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Background. A 72-year-old man with a history of delayed presentation for severe right lower extremity burns underwent through- knee amputation complicated by periprosthetic distal femur osteomyelitis. Subsequent transfemoral amputation was complicated by Stage IVB Cierny-Mader osteomyelitis despite appropriate medical and surgical treatment. Methods. Due to the presence of threatened proximal femur intramedullary nail from prior intertrochanteric femur fracture, inability to further shorten femur, and lack of local soft-tissue options, we performed soft tissue reconstruction with free gracilis flap. The free gracilis flap was pulled proximally through the femoral canal to obliterate intramedullary dead space and provide distal femoral stump coverage. Results. The stump was fully healed upon 6-month follow-up with computerized tomography demonstrating continued presence of gracilis flap within the femoral canal and no evidence of osteomyelitis. At 1-year follow-up, the patient was ambulatory using a prosthetic without recurrence of osteomyelitis. Conclusions. Previous descriptions of intramedullary free muscle flaps for the treatment of osteomyelitis are limited in number, with its function being limited to dead-space obliteration. This report presents intramedullary free gracilis flap to be a viable option in above-knee amputees for combined dead space obliteration and stump resurfacing in the context of recurrent osteomyelitis. [ABSTRACT FROM AUTHOR]

Although operative treatment of displaced, intra-articular fractures of the calcaneus in adults is generally accepted as standard practice, operative treatment for the same fractures in the skeletally immature remains controversial, potentially because the outcome for fracture types (intra- vs. extra-articular) and severity (displaced vs. nondisplaced) have been confounded in studies of children. We review herein the results of 21 displaced, intra-articular fractures in 18 skeletally immature patients, who were treated with open reduction and internal fixation using a standard surgical approach and protocol developed for adults. The average pre-operative Böhler's angle on the injured side was -5° (range: -35 - +35) compared to 31° (range: +22 - +47) on the uninjured side, indicating substantial displacement. There were no post-operative infections or wound healing problems, and all but one patient was followed to union (average follow- up: 1.5 years; range: 0.30-4.3 years). Maintenance of reduction was confirmed on follow-up radiographs with an average Böhler's angle of 31° (range: +22 - +49). We demonstrate that results for operative fixation of displaced, intra-articular calcaneal fractures in the skeletally immature are comparable to those in adults when the treatment protocol is the same. [ABSTRACT FROM AUTHOR]

The objective of this study was to determine the validity and inter-rater reliability of radiographic assessment of sagittal deformity of femoral neck fractures., Design: This is a retrospective cohort study., Setting: Level 1 trauma center., Patients/participants: Thirty-one patients 65 years or older who sustained low-energy, Garden type I/II femoral neck fractures imaged with biplanar radiographs and either computed tomography or magnetic resonance imaging were included., Main Outcome Measurements: Preoperative sagittal tilt was measured on lateral radiographs and compared with the tilt identified on advanced imaging. Fractures were defined as "high-risk" if posterior tilt was ≥20 degrees or anterior tilt was >10 degrees., Results: Of 31 Garden type I/II femoral neck fractures, advanced imaging identified 10 high-risk fractures including 8 (25.8%) with posterior tilt ≥20 degrees and 2 (6.5%) with anterior tilt >10 degrees. Overall, there was no significant difference between sagittal tilt measured using lateral radiographs and advanced imaging ( P = 0.84), and the 3 raters had good agreement between their measurements of sagittal tilt on lateral radiographs (interclass correlation coefficient 0.79, 95% confidence interval [0.65, 0.88], P < 0.01). However, for high-risk fractures, radiographic measurements from lateral radiographs alone resulted in greater variability and underestimation of tilt by 5.2 degrees (95% confidence interval [-18.68, 8.28]) when compared with computed tomography/magnetic resonance imaging. Owing to this underestimation of sagittal tilt, the raters misclassified high-risk fractures as "low-risk" in most cases (averaging 6.3 of 10, 63%, range 6 - 7) when using lateral radiographs while low-risk fractures were rarely misclassified as high-risk (averaging 1.7 of 21, 7.9%, range 1 - 3, P = 0.01)., Conclusions: Lateral radiographs frequently lead surgeons to misclassify high-risk sagittal tilt of low-energy femoral neck fractures as low-risk. Further research is necessary to improve the assessment of sagittal plane deformity for these injuries., Level of Evidence: Level IV diagnostic study., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Orthopaedic Trauma Association.)

Background: Previous retrospective research found that the presence or absence of bridging callus within 4 months postoperatively discriminated accurately between eventual union and nonunion of fractures of the tibial shaft. However, there remains no consensus regarding early prognostication of long bone nonunion. We prospectively assessed the accuracy and reliability of the presence of any bridging callus within 4 months in a cohort that was expanded to include both tibial and femoral shaft fractures., Methods: We identified 194 consecutive fractures of the shaft of the tibia (OTA/AO type 42-A, B, or C) and femur (OTA/AO type 32-A, B, or C) that were treated with intramedullary nailing. Exclusions for inadequate follow-up (55), extended delay prior to nailing (10), and skeletal immaturity (3) resulted in a study population of 126 fractures (56 tibiae and 70 femora) in 115 patients. Digital radiographs made between 3 and 4 months postoperatively were independently assessed by 3 orthopaedic traumatologists. The accuracy of assessment of the presence of any bridging callus, bicortical bridging, and tricortical bridging to predict union or nonunion was assessed with chi-square analysis and by interobserver reliability (kappa statistic)., Results: The nonunion rate was 4% (5 of 126 fractures). The presence of any bridging callus by 4 months accurately predicted union (121 of 122 fractures) and its absence predicted nonunion (4 of 4 fractures). There was 1 incorrect prediction of union for a fracture that failed to unite (p < 0.001). Bicortical or greater bridging predicted union when present (116 of 116 fractures) and nonunion when absent (5 of 10 fractures), incorrectly predicting that 5 healing fractures would go on to nonunion (p < 0.001). Tricortical or greater bridging predicted union when present (103 of 103 fractures) and nonunion when absent (5 of 23 fractures), incorrectly predicting that 18 healing fractures would go on to nonunion (p < 0.001). Interobserver reliability was calculated for any bridging (kappa value, 0.91), bicortical bridging (kappa value, 0.79), tricortical bridging (kappa value, 0.71), and the exact number of cortices bridged (kappa value, 0.67)., Conclusions: The presence of any bridging callus within 4 months accurately predicts the final healing outcome for tibial and femoral shaft fractures treated with intramedullary nailing. This criterion is simple and reliable, and only standard radiographs are needed to make the determination. Basing the prognosis on the bridging of additional cortices risks overestimation of the nonunion rate and is associated with relatively poor reliability.