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Surgical debridement is critical to the treatment of open tibia fractures, although the effects of delayed debridement have not been well-established. Other factors such as Gustilo-Anderson type, prompt initiation of antibiotics, and time to definitive closure may be more predictive of infection than time to surgery. We sought to determine the effect of a prolonged delay to surgical debridement with respect to infection and reoperation rates for open tibia fractures. All open diaphyseal tibia fractures with > 12-week follow-up were evaluated. Patient demographics, Gustilo-Anderson type, and rates of deep infection and all-cause reoperation were recorded. Patients were divided into 3 groups based on time to surgery: early ( 48 h). Univariate and multivariate analyses were performed to evaluate the relationship between time to surgery, fracture type, infection, and reoperation. In total, 96 open tibia fractures with average follow-up of 59.3 weeks and infection rate of 13.5% were included. Infection rates for the early, delayed, and late groups were 13.3%, 17.2%, and 9.1%, respectively (p = 0.70). Reoperation rates for the early, delayed, and late groups were 29.8%, 31.0%, and 22.7%, respectively (p = 0.80). The groups did not vary in proportion of Gustilo-Anderson fracture types; infection rates between Gustilo-Anderson types were similar (p = 0.57). Type IIIA-C fractures required more reoperations than other fracture types (p = 0.01). Delayed surgical debridement of open tibia fractures did not result in greater rates of infection or reoperation. Gustilo-Anderson classification was more predictive of reoperation, with Type IIIA-C injuries having a significantly higher reoperation rate.

Surgical debridement is critical to the treatment of open tibia fractures, although the effects of delayed debridement have not been well-established. Other factors such as Gustilo-Anderson type, prompt initiation of antibiotics, and time to definitive closure may be more predictive of infection than time to surgery. We sought to determine the effect of a prolonged delay to surgical debridement with respect to infection and reoperation rates for open tibia fractures.All open diaphyseal tibia fractures with 12-week follow-up were evaluated. Patient demographics, Gustilo-Anderson type, and rates of deep infection and all-cause reoperation were recorded. Patients were divided into 3 groups based on time to surgery: early ( 24 h), delayed (24-48 h), and late ( 48 h). Univariate and multivariate analyses were performed to evaluate the relationship between time to surgery, fracture type, infection, and reoperation.In total, 96 open tibia fractures with average follow-up of 59.3 weeks and infection rate of 13.5% were included. Infection rates for the early, delayed, and late groups were 13.3%, 17.2%, and 9.1%, respectively (p = 0.70). Reoperation rates for the early, delayed, and late groups were 29.8%, 31.0%, and 22.7%, respectively (p = 0.80). The groups did not vary in proportion of Gustilo-Anderson fracture types; infection rates between Gustilo-Anderson types were similar (p = 0.57). Type IIIA-C fractures required more reoperations than other fracture types (p = 0.01).Delayed surgical debridement of open tibia fractures did not result in greater rates of infection or reoperation. Gustilo-Anderson classification was more predictive of reoperation, with Type IIIA-C injuries having a significantly higher reoperation rate.

Objectives:To identify the incidence of orthopaedic injuries secondary to dog bites, determine the responsible breeds, and assess the severity of injury by dog breed.Design:Retrospective.Setting:Single Level I trauma center.Patients:Ninety-five patients treated for a dog bite that resulted in an ort

The single incision power optimizing cost-effective (SPOC) distal biceps repair was developed to achieve an anatomic repair of distal biceps tendon injuries using an anterior approach, without the use of costly implants. In addition, the technique can be performed with common surgical instruments and minimizes damage to the structural integrity of the radial tuberosity. An anatomic reattachment site has been correlated to a normal return of supination strength from full pronation to full supination (Bain et al. J Shoulder Elbow Surg 9:120–6, 2000). In cadaveric studies, it has been demonstrated that distal biceps tendons repaired anterior to the anatomic footprint can minimize supination strength by acting as pronators as the forearm supinates beyond neutral toward supination (Tanner et al. J Shoulder Elbow Surg 22:305–11, 2013). The SPOC technique has been used at our institution since 2008 in over 130 consecutive cases and maximizes supination strength, as demonstrated by Biodex testing, throughout the entire arc of forearm rotation by achieving an anatomic reattachment of the distal biceps tendon (Schmidt et al. J Bone Joint Surg Am 97:2014–23, 2015).

Both short intramedullary nails (SIMNs) and long intramedullary nails (LIMNs) are routinely used in the surgical treatment of pertrochanteric hip fractures. The purpose of this study was to assess the incidence of ipsilateral femur fractures after the surgical treatment of hip fractures and the overall costs associated with each implant.Retrospective cohort study.Level I trauma center and 2 community hospitals.A total of 609 patients with pertrochanteric hip fractures treated with an SIMN or LIMN from 2005 to 2011.Review of patient demographics and clinical outcomes over a 5-year follow-up period.Ipsilateral femur refracture rates were recorded for both groups, and a cost analysis was then performed to compare SIMNs and LIMNs while accounting for their observed refracture rates and surgical/hospital costs to determine the overall cost of each implant.Union rates were equivalent between groups and averaged over 97%. The incidence of ipsilateral femur fractures in both groups steadily increased with greater follow-up time to reach nearly 10% at 5 years. Although only 47% of all nails were locked distally, 15 of the 16 refractures occurred in nails that were not distally locked. Cost analysis revealed no significant difference in the use of short versus LIMNs over a 5-year period (P = 0.76).The incidence of ipsilateral femur refractures steadily rose with greater follow-up in both SIMN and LIMNs. Distally locking the initial fixation seems to protect against future femur fractures and may also affect the refracture location when using LIMNs. No differences in overall costs were seen at 1, 2, or 5 years between SIMNs and LIMNs.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To assess complication rates in patients undergoing open reduction internal fixation (ORIF) of pelvic/acetabular fractures with and without pelvic angiography embolization (PAE). DESIGN Retrospective case series. SETTING Level 1 Trauma Center. PATIENTS/PARTICIPANTS One hundred eleven patients with pelvic or acetabular fractures that required orthopaedic fixation. INTERVENTION Retrospective analysis of outcomes in patients who underwent ORIF of pelvic/acetabular fractures with and without PAE. MAIN OUTCOME MEASUREMENTS Comparison of surgical wound infections, necrosis, and/or fracture nonunions between the PAE group and a control group (no PAE). RESULTS Final study groups consisted of 50 patients in the PAE group and 61 patients in the control group. Ninety-six percent of patients underwent nonselective PAE. Significantly higher complications were noted in the PAE group than in the control group (20% compared with 4.9%; P = 0.020). In addition, posterior surgical approaches combined with internal iliac artery embolization represented the highest complication rate. CONCLUSIONS Patients requiring PAE and pelvic/acetabular ORIF should undergo a multidisciplinary treatment approach with the trauma surgeon, interventional radiologist, and orthopaedic surgeon before PAE being performed to decrease complications and avoid nonselective bilateral internal iliac artery embolization. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Vascularized periosteal flaps from the distal radius have been previously proposed. The purpose of this study was to investigate the vascularity and osteogenic potential of a vascularized volar distal radial periosteal flap for the treatment of scaphoid nonunion. Methods: In 5 fresh frozen cadavers, a rectangular periosteal flap was elevated from the distal radius with the pedicle just proximal to the watershed line. Latex dye was injected into the radial artery proximally and the vascularity of the flap characterized by microscopic evaluation. Patients with scaphoid nonunion were then treated with open reduction, internal fixation, and distal radius cancellous bone graft. Two groups of patients with midwaist nonunion scaphoid were then evaluated. The first group received the vascularized periosteal flap and the second group received a nonvascularized periosteal flap. A third group of proximal pole nonunions also received the vascularized flap. Results: Cadaveric dissections revealed that all of the injected flaps demonstrated vascularity to the distal edge of the flap. Vascularized flaps formed visible bone on imaging in 55% of cases. None of the nonvascularized flaps formed visible bone. In group 1, 12/12 midwaist nonunions united. In group 2, union was achieved in 6/6 of patients who completed the follow-up. In group 3, 6/7 proximal pole fractures united. Conclusions: Previously proposed vascularized periosteal flaps from the distal radius appear to possess notable osteogenic potential that may be of interest to surgeons treating scaphoid nonunion.

Background The purpose of this study was to review the results of a single anterior incision distal biceps tendon repair that reattaches the tendon to its posterior anatomic insertion site. We hypothesize this repair maximizes the supination torque of the biceps muscle throughout the full arc of forearm rotation. Methods A consecutive series of patients with distal biceps tears were treated using a technique that reattaches the distal biceps tendon to the posterior radial surface similar to a 2-incision repair, which optimizes the biceps moment arm in all forearm positions including maximum supination. This method of distal biceps reattachment has been utilized in our practice since December 2008 on 40 distal biceps tendon repairs. Biodex testing was used to quantify the peak supination torque, the supination work, and the power of supination at each degree of forearm rotation and included on patients with a minimum clinical follow up of 12 months. Range of motion was also recorded. Results Thirty patients met the inclusion criteria. Three patients, 2 of whom were lost to follow-up and 1 with bilateral repairs, were not included in this study. Seventeen of the remaining 27 patients completed strength testing using a Biodex Isokinetic Testing machine. Supination strength averaged 91% and 91% of the uninjured side at 60 and 120 deg/sec, respectively. Twenty-five (93%) patients reported no pain and had returned to work or normal activities. Conclusion A single anterior incision distal biceps tendon repair that maximizes supination torque throughout full forearm rotation has been utilized. No specialized anchors or equipment are required.

Background Hip fractures result in both health and cost burdens from a public health perspective and have a major impact on the health care system in the USA. The purpose was to examine whether there were systematic differences in hip fracture incidence and 30-, 90-, and 365-day mortality after hip fracture in the California population as a function of age, gender, and race/ethnicity from 2000–2011. Methods This was a population-based study from 2000 to 2011 using data from the California Office of Statewide Health and Planning and Development (OSHPD, N = 317,677), California State Death Statistical Master File records (N = 224,899), and the US Census 2000 and 2010. There were a total of 317,677 hospital admissions for hip fractures over the 12-year span and 24,899 deaths following hip fractures. All participants without linkage (substituted for social security) numbers were excluded from mortality rate calculations. Variation in incidence and mortality rates across time, gender, race/ethnicity, and age were assessed using Poisson regression models. Odds ratio and 95 % confidence intervals are provided. Results The incidence rate of hip fractures decreased between 2000 and 2011 (odds ratio (OR) = 0.98, 95 % confidence interval (CI) 0.98, 0.98). Mortality rates also decreased over time. There were gender, race/ethnicity, and age group differences in both incidence and mortality rates. Conclusions Males were half as likely to sustain a hip fracture, but their mortality within a year of the procedure is almost twice the rate than women. As age increased, the prevalence of hip fracture increased dramatically, but mortality did not increase as steeply. Caucasians were more likely to sustain a hip fracture and to die within 1 year after a hip fracture. The disparities in subpopulations will allow for targeted population interventions and opportunities for further research.

Background Pediatric femoral shaft fractures are common injuries that have seen a trend toward surgical stabilization. Traditionally these fractures have been stabilized with flexible intramedullary nails performed through a 2-incision technique. We proposed that a single incision technique would offer equivalent outcomes with the potential for improved cosmesis and a reduced infection risk. Methods A retrospective review was performed of 112 consecutive cases of pediatric femoral shaft fractures, 66 cases were excluded, leaving 23 cases utilizing the single incision technique and 23 utilizing the standard 2-incision technique. Electronic medical records were then reviewed for demographic information, and a PAC system was employed to classify the fractures according to the AO classification and determine the time to fracture union. Results No significant difference was found in fracture healing times with a mean union time of 62.4 and 50.3 days in the single and double incision groups, respectively (P=0.38). One complication of superficial infection was noted in the 2-incision group; however, this was not statistically significant, and no malunions or nonunions were detected in either group. Conclusions A single incision technique for intramedullary stabilization of pediatric femoral shaft fractures is a viable option with an equivalent time to fracture union and no observed difference in the complication rate. Furthermore, the technique may offer benefits with regard to infection risk and cosmesis.

Acromioclaviclular (AC) joint injuries are common, especially in athletes.8,12 For injuries involving complete disruption of the coracoclavicular (CC) ligaments and greater than 100% increase in the CC distance, surgical intervention is often indicated. Currently, there are multiple surgical techniques utilized to address these injuries, which includes reconstruction of the CC ligaments with tendon grafts. The important role of the anatomic reconstruction of the CC ligaments in AC joint separations has been increasingly recognized. Anatomic CC ligament reconstruction techniques have been shown to be biomechanically superior to other, nonanatomic, methods in several studies.3,9 From a biomechanical perspective, the importance of the CC ligaments in controlling superior and horizontal translations has been well elucidated.5,7 An anatomic reconstruction technique popularized by Mazzocca et al9 requires drilling 2 tunnels from superior to inferior, each at a fixed distance from the distal end of the clavicle, in an attempt to reproduce the native CC ligaments. The tendon graft is looped around the coracoid and passed through the 2 tunnels drilled in the clavicle, and fixation of the graft is maintained with 2 biotenodesis screws. This relatively straightforward technique has demonstrated good results in several biomechanical and clinical studies and has been widely adopted in recent years.1,3 However, as awareness of the anatomic CC ligament reconstruction method increases and as more surgeons have adopted this technique, it has become evident that there is the potential for complications.2,14 Many of the complications have in part been attributed to malposition of the clavicle tunnels. In a study performed by Rios et al,11 the position of the clavicle tunnels established by Mazzocca et al9 was refined, based on further evaluation of clavicular anatomy. These authors established ratios of the total clavicular length for each of the CC ligament attachments. They recommended placing the conoid tunnel at 30% of the clavicular length in the posterior half on the superior clavicle and the trapezoid tunnel at 17% of the clavicular length centered in the midportion of the clavicle. Although these ratios are widely utilized by surgeons, there is recent evidence to suggest that using a 30% ratio for the conoid tunnel may not yield an anatomic conoid.13,16 Xue et al16 performed an anatomic study similar to Rios et al11 that was specific to a Chinese population. Ratios were calculated that represented the distance from the clavicular landmarks to each footprint center divided by clavicular length. They determined the ratios of the distance to the conoid center and to the trapezoid center divided by clavicular length to be 25.5% and 15.6%, respectively. In a recent study, Cook et al2 reported early failure of anatomic CC ligament reconstructions in 28% of patients. They determined that conoid tunnel placement at a ratio of 30% was a significant risk factor in the reconstructions that failed. There were no failures in their study when the conoid ratio was less than 25%. The authors further emphasized the importance of the conoid ligament over the trapezoid for maintenance of reduction. This conclusion has been supported by other biomechanical studies that have shown the conoid to be the most important ligament resisting translation.5 A method of drilling clavicle bone tunnels that better reproduces the anatomic footprint of the conoid ligament while avoiding the risk of posterior wall blowout would be optimal. The purpose of this study was to evaluate the feasibility of a novel single-tunnel technique and compare the biomechanical properties of matched pairs of human cadaveric clavicles to the accepted standard of a 2-tunnel technique for CC ligament reconstruction. The hypothesis was that the single-tunnel technique will yield similar loads to failure as the 2-tunnel technique and better reproduce the anatomic footprint of the conoid ligament.