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High-energy tibial plateau fractures present a therapeutic challenge to the orthopaedic trauma surgeon, both in terms of the osseous injury as well as the concomitant soft-tissue insult. Surgical treatment has evolved to address these fractures in a more biologically favourable manner without further compromising the soft tissues. We present a summary of these injuries and outline the contemporary approaches to treatment. Potential complications and their avoidance are also discussed. Outcomes following these injuries are reviewed to assist with determination of treatment goals. [ABSTRACT FROM AUTHOR]

Distal radius fractures are the most common upper extremity injury. Patients referred to safety-net tertiary facilities following a fracture experience significant delays in treatment because of financial and language barriers as well as poor access to care at outlying community hospitals. This delay in treatment can affect postoperative functional outcomes and complication rates because of failure to restore anatomic alignment. The purpose of this multicenter study was to assess for risk factors associated with delayed fixation of distal radius fractures and evaluate the impact of delayed treatment on radiographic alignment. Patients with a distal radius fracture treated surgically during a 2-year period were identified. Measures included time from injury to surgery, demographic information, fracture classification, and radiographic parameters. The effect of surgery delay on radiographic outcomes was assessed with delayed surgery defined as 11 or more days out from injury. A total of 183 patients met study inclusion criteria. Medicaid and indigent patients were more likely to experience a delay in surgical treatment. Specifically, 70% of these patients were treated in a delayed fashion. Delayed treatment of 11 days or more was associated with worse radial height and inclination on postoperative radiographic imaging. Medicaid and indigent patients are more likely to experience delayed fixation in the treatment of distal radius fractures. This delayed surgery negatively affects postoperative radiographic outcomes. These findings suggest a need to improve access to care for Medicaid and indigent patients and to proceed with operative intervention within 10 days for distal radius fractures. [ Orthopedics . 2024;47(2):e93-e97.].

Objectives: To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population., Design: Retrospective case series., Setting: Eight, academic, level 1 trauma centers., Patients Selection Criteria: Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019., Outcome Measures and Comparisons: Success rate of nonunion surgery., Results: Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate., Conclusions: This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Dr. J.R. Hsu reports consultancy for Globus Medical and personal fees from Smith & Nephew speakers' bureau. The remaining authors report no conflict of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture)., Methods: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications., Results: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups., Conclusions: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.)., (Copyright © 2024 Massachusetts Medical Society.)

Purpose: The purpose of this study was to examine the outcomes of anterior cruciate ligament (ACL) reconstruction using quadrupled hamstring (QH) autograft in a cohort of National Collegiate Athletic Association (NCAA) Division I football players., Methods: A retrospective analysis was performed on NCAA Division I football players at a single institution who had transtibial ACL reconstruction using QH autograft between 2001 and 2016. Primary outcomes were ACL reinjury and return to play (RTP). Secondary outcomes were position, percent of eligibility used after surgery, graft diameter, Tegner-Lysholm scores, concomitant injuries/surgeries, and postcollegiate professional play., Results: Between 2001 and 2016, 34 players had QH autograft ACL reconstruction, and 29 players achieved RTP. Of the 29, 2 (6.9%) sustained ACL reinjuries. The average RTP was 318 days (range 115-628) after surgery. Players used 79.5% of their remaining collegiate eligibility after surgery. Nine players sustained multiligamentous knee injuries. This did not have a significant effect on RTP (P = 0.709; mean 306±24 days for isolated ACL, mean of 353±51 for 2 ligaments, mean of 324±114 for 3 + ligaments) and none sustained reinjury. Associated meniscal injuries were sustained by 28, and 8 sustained chondral injuries. The mean postoperative Tegner-Lysholm score was 90.7 of 100, with mean follow-up of 102 months. Of these players, 18 went on to play professionally, with 17 joining National Football League rosters and 1 an arena team roster., Conclusion: QH demonstrated an ACL reinjury and RTP rates similar to those in previously published, predominantly bone-patella tendon-bone ACL reinjury data in elite athletes. This study demonstrates that QH autograft may be a viable option in elite athletes., Level of Evidence: IV, case series., (Copyright © 2021 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

Background: Heterotopic ossification (HO) is a frequent complication following hip surgery. Using data from the Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial, we aimed to (1) determine the prevalence of HO following total hip arthroplasty (THA) for femoral neck fracture in patients ≥50 years of age, (2) identify whether HO is associated with an increased risk of revision surgery within 24 months after the fracture, and (3) determine the impact of HO on functional outcomes., Methods: We performed a multivariable Cox regression analysis using revision surgery as the dependent variable and HO as the independent variable. We compared Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores between participants with and those without HO at 24 months., Results: Of 1,441 participants in the study, 287 (19.9%) developed HO within 24 months. HO was not associated with subsequent revision surgery. Grade-III HO was associated with statistically significant and clinically relevant deterioration in the total WOMAC score, which was mainly related to the function component of the score, compared with grade I or II., Conclusions: The impact of grade-III HO on the functional outcomes and quality of life after THA for hip fracture is clinically important, and HO prophylaxis for selected high-risk patients may be appropriate., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemiarthroplasty (HEALTH) trial was supported by research grants from the Canadian Institutes of Health Research (CIHR) (MCT-90168), National Institutes of Health (NIH) (1UM1AR063386-01), ZorgOnderzoek Nederland-medische wetensehappen (ZonMw) (17088.2503), Sophies Minde Foundation for Orthopaedic Research, McMaster Surgical Associates, and Stryker Orthopaedics. The funding sources had no role in design or conduct of the study; the collection, management, analysis, or interpretation of the data; or the preparation, review, or approval of the manuscript. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version of the article, one or more of the authors checked “yes” to indicate that the author had a relevant financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/JBJS/G429)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

Importance: Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist., Objective: To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections., Design, Setting, and Participants: This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers., Interventions: A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder., Main Outcomes and Measures: The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence., Results: The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections., Conclusions and Relevance: Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin., Trial Registration: ClinicalTrials.gov Identifier: NCT02227446.

Background: Surgical specialties face unique challenges caused by SARS-COV-2 (COVID-19). These disruptions will call on clinicians to have greater consideration for non-operative treatment options to help manage patient symptoms and provide therapeutic care in lieu of the traditional surgical management course of action. This study aimed to summarize the current guidance on elective surgery during the COVID-19 pandemic, assess how this guidance may impact orthopaedic care, and review any recommendations for non-operative management in light of elective surgery disruptions., Methods: A systematic search was conducted, and included guidance were categorized as either "Selective Postponement" or "Complete Postponement" of elective surgery. Selective postponement was considered as guidance that suggested elective cases should be evaluated on a case-by-case basis, whereas complete postponement suggested that all elective procedures be postponed until after the pandemic, with no case-by-case consideration. In addition, any statements regarding conservative/non-operative management were summarized when provided by included reports., Results: A total of 11 reports from nine different health organizations were included in this review. There were seven (63.6%) guidance reports that suggested a complete postponement of non-elective surgical procedures, whereas four (36.4%) reports suggested the use of selective postponement of these procedures. The guidance trends shifted from selective to complete elective surgery postponement occurred throughout the month of March. The general guidance provided by these reports was to have an increased consideration for non-operative treatment options whenever possible and safe. As elective surgery begins to re-open, non-operative management will play a key role in managing the surgical backlog caused by the elective surgery shutdown., Conclusion: Global guidance from major medical associations are in agreement that elective surgical procedures require postponement in order to minimize the risk of COVID-19 spread, as well as increase available hospital resources for managing the influx of COVID-19 patients. It is imperative that clinicians and patients consider non-operative, conservative treatment options in order to manage conditions and symptoms until surgical management options become available again, and to manage the increased surgical waitlists caused by the elective surgery shutdowns., Competing Interests: Conflict of interest statement: Mark Phillips: Employer received grant support from Bioventus Yaping Chang: Nothing to disclose Robert D. Zura: Consultant for Osteocentric and Bioventus Samir Mehta: Paid presenter/speaker for DePuy Synthes, GE Healthcare, NuVasive, and Smith and Nephew. Paid consultant for Smith & Nephew, and DePuy Synthes. Receives publishing royalties from Wolters Kluwer Health-Lippincott Williams & Wilkins. Board member for the Pennsylvania Orthopaedic Society and Current Opinion in Orthopedics. Peter V. Giannoudis: Nothing to disclose Peter A. Nolte: Nothing to disclose Mohit Bhandari: Personal fees from AgNovos Healthcare, Sanofi Aventis, Stryker, Pendopharm, Bioventus, grants from DJ Orthopaedics, Acumed, (© The Author(s), 2020.)

Background: Globally, hip fractures are among the top 10 causes of disability in adults. For displaced femoral neck fractures, there remains uncertainty regarding the effect of a total hip arthroplasty as compared with hemiarthroplasty., Methods: We randomly assigned 1495 patients who were 50 years of age or older and had a displaced femoral neck fracture to undergo either total hip arthroplasty or hemiarthroplasty. All enrolled patients had been able to ambulate without the assistance of another person before the fracture occurred. The trial was conducted in 80 centers in 10 countries. The primary end point was a secondary hip procedure within 24 months of follow-up. Secondary end points included death, serious adverse events, hip-related complications, health-related quality of life, function, and overall health end points., Results: The primary end point occurred in 57 of 718 patients (7.9%) who were randomly assigned to total hip arthroplasty and 60 of 723 patients (8.3%) who were randomly assigned to hemiarthroplasty (hazard ratio, 0.95; 95% confidence interval [CI], 0.64 to 1.40; P = 0.79). Hip instability or dislocation occurred in 34 patients (4.7%) assigned to total hip arthroplasty and 17 patients (2.4%) assigned to hemiarthroplasty (hazard ratio, 2.00; 99% CI, 0.97 to 4.09). Function, as measured with the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total score, pain score, stiffness score, and function score, modestly favored total hip arthroplasty over hemiarthroplasty. Mortality was similar in the two treatment groups (14.3% among the patients assigned to total hip arthroplasty and 13.1% among those assigned to hemiarthroplasty, P = 0.48). Serious adverse events occurred in 300 patients (41.8%) assigned to total hip arthroplasty and in 265 patients (36.7%) assigned to hemiarthroplasty., Conclusions: Among independently ambulating patients with displaced femoral neck fractures, the incidence of secondary procedures did not differ significantly between patients who were randomly assigned to undergo total hip arthroplasty and those who were assigned to undergo hemiarthroplasty, and total hip arthroplasty provided a clinically unimportant improvement over hemiarthroplasty in function and quality of life over 24 months. (Funded by the Canadian Institutes of Health Research and others; ClinicalTrials.gov number, NCT00556842.)., (Copyright © 2019 Massachusetts Medical Society.)

Outcomes following ankle fracture surgery have been well studied; however, factors associated with surgical wound healing specifically are less clear. We aimed to study the relationship between wound healing and body mass index, as well as other variables following surgical treatment of ankle fractures. There were 127 consecutive, isolated, closed, malleolar ankle fractures treated with open reduction and internal fixation at a level-1 trauma center from 2008 to 2012. Patient, injury, and treatment variables were recorded and clinical records were reviewed to identify wound complications. There were 6 major and 18 minor wound complications. The overall rate of wound complication of any type was significantly lower in obese patients at 11.7% (7/60) compared with 25.4% (17/67, P < .05) in nonobese patients. When controlling for other variables obesity was associated with a significantly lower risk of developing a wound complication (OR 0.267, 95% CI 0.087-0.822), as was low energy mechanism (OR 0.246, 95% CI 0.067-0.906). No other covariates tested were associated with an increased risk of a wound infection. Ankle anatomy may present a unique situation whereby obesity may be protective against wound complications. Further studies are needed to confirm this clinical observation, and to demonstrate the mechanism through which this may occur., Levels of Evidence: Therapeutic, Level IV: Retrospective.

Background: Proximal humerus fractures are common injuries and nonsurgical treatment has proven to yield good to excellent clinical results. A small percentage of these fractures go on to delayed or nonunion and the incidence and risk factors for this complication are poorly understood. We hypothesize that adjacent joint stiffness of the glenohumeral joint might lead to an increased rate of nonunion for proximal humerus fractures., Methods: A search of the entire Medicare database from 2005 to 2011 was performed to identify 38,754 patients who sustained a proximal humerus fracture including 13,802 with co-existing ipsilateral shoulder osteoarthritis (OA) and 24,952 with co-existing diagnosis of rheumatoid arthritis (RA). A cohort of 301,987 patients served as a control. Medical co-morbidities and fracture complications were compared between the cohorts., Results: The incidence of delayed union at 3 and 6 months for OA and RA groups were significantly increased compared to control at 0.79% and 1.74%, and 0.67% and 1.86%, respectively (p < 0.001). Nonunion rates were also significantly increased (p < 0.001) in the OA and RA cohorts at 9 months and 1 year with incidences of 2.39%, 2.89% and 2.59% and 3.08%, Respectively. The incidence of nonunion in the control cohort at the same time points was 1.13% and 1.35%., Conclusions: The coexistence of shoulder OA or a diagnosis of RA nearly doubled in the incidence of proximal humerus nonunion. This is the first study investigating this association in the shoulder and should be considered along with traditional nonunion risk factors in the treatment algorithm., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Calcaneal tuberosity fractures comprise only 1% to 2% of all calcaneal fractures. Treatment of these injuries has traditionally included open reduction and internal fixation with various means including lag screws, suture anchors, and K-wires. This article reports on a series of cases treated with excision of the tuberosity fragment with repair of the Achilles tendon supplemented by a flexor hallucis longus tendon transfer.

Objective: We investigated tissue turnover in healthy and osteoarthritic cartilage. We challenge long held views that osteoarthritis (OA) is dominated by a similar turnover process in all joints and present evidence that hip and knee cartilage respond very differently to OA., Methods: d- and l-Aspartate (Asp) were quantified for whole cartilage, collagen and non-collagenous components of cartilage obtained at the time of joint replacement. We computed the Asp racemization ratio (Asp-RR = d/d + l Asp), reflecting the proportion of old to total protein, for each component., Results: Compared with hip OA, knee OA collagen fibrils (P < 0.0001), collagen (P = 0.007), and non-collagenous proteins (P = 0.0003) had significantly lower age-adjusted mean Asp-RRs consistent with elevated protein synthesis in knee OA. Knee OA collagen had a mean hydroxyproline/proline (H/P) ratio of 1.2 consistent with the presence of type III collagen whereas hip OA collagen had a mean H/P ratio of 0.99 consistent with type II collagen. Based on Asp-RR, the relative age was significantly different in knee and hip OA (P < 0.0005); on average OA knees were estimated to be 30 yrs 'younger', and OA hips 10 yrs 'older' than non-OA., Conclusions: The metabolic response to OA was strikingly different by joint site. Knee OA cartilage evinced an anabolic response that appeared to be absent in hip OA cartilage. These results challenge the long held view that OA cartilage is capable of only minimal repair and that collagen loss is irreversible., (Copyright © 2015 Osteoarthritis Research Society International. Published by Elsevier Ltd. All rights reserved.)

Background: While acute trauma is a major cause of osteoarthritis, its etiology is poorly understood. We sought to determine whether xanthine oxidase (XO), a major producer of reactive oxygen species, plays a role in the early events of acute joint injury., Methods: We analyzed synovial fluid from 23 subjects with recent severe acute knee injury. As a control we evaluated SF from 23 individuals with no or minimal knee osteoarthritis. We measured XO activity, reactive oxygen+reactive nitrogen species (ROS+RNS), protein oxidative damage (carbonyl), the type II collagen synthesis marker procollagen II c-propeptide (CPII) and the type II collagen degradation marker collagen type II telopeptide (CTx-II). We also measured the proinflammatory cytokine IL-6., Results: XO and ROS+RNS were higher (p=0.02 and p=0.001 respectively) in acute injury than control and were strongly positively associated (r=0.62, p=0.004). Carbonyl was higher in acute injury than control (p=0.0002) and was positively correlated with XO (r=0.68, p=0.0007) as well as with ROS+RNS (r=0.71, p=0.004). CPII was higher in acute injury than control (p<0.0001) and was negatively correlated with XO (r=-0.49, p=0.017). While CTxII was not significantly higher in acute injury than control, it was positively correlated with CPII (r=0.71, p=0.0002). IL-6 was higher in acute injury than control (p<0.0001)., Conclusions: These results are consistent with a potentially injurious effect of XO activity in acute joint injury characterized by excess free radical production and oxidative damage. These effects are associated with an inhibition of type II collagen production that may impede the ability of the injured joint to repair., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Objective: The inflammatory response following an articular fracture is thought to play a role in the development of posttraumatic arthritis (PTA) but has not been well characterized. The objective of this study was to characterize the acute inflammatory response, both locally and systemically, in joint synovium, synovial fluid (SF), and serum following articular fracture of the ankle. We hypothesized that intraarticular fracture would alter the synovial environment and lead to increased local and systemic inflammation., Methods: Synovial tissue biopsy specimens, SF samples, and serum samples were collected from patients with an acute articular ankle fracture (n = 6). Additional samples (normal, ankle osteoarthritis [OA], and knee OA [n = 6 per group]) were included for comparative analyses. Synovial tissue was assessed for synovitis and macrophage count. SF and serum were assessed for cytokines (interferon-γ [IFNγ], interleukin-1β [IL-1β], IL-6, IL-8, IL-10, IL-12p70, and tumor necrosis factor α) and chemokines (eotaxin, eotaxin 3, IFNγ-inducible 10-kd protein, monocyte chemotactic protein 1 [MCP-1], MCP-4, macrophage-derived chemokine, macrophage inflammatory protein 1β, and thymus and activation-regulated chemokine)., Results: Synovitis scores were significantly higher in ankle fracture tissue compared with normal ankle tissue (P = 0.007), and there was a trend toward an increased abundance of CD68+ macrophages in ankle fracture synovium compared with normal knee synovium (P = 0.06). The concentrations of all cytokines and chemokines were elevated in the SF of patients with ankle fracture compared with those in SF from OA patients with no history of trauma. Only the concentration of IL-6 was significantly increased in the serum of patients with ankle fracture compared with normal serum (P = 0.027)., Conclusion: Articular fracture of the ankle increased acute local inflammation, as indicated by increased synovitis, increased macrophage infiltration into synovial tissue, and increased SF concentrations of biomarkers of inflammation. Characterizing the acute response to articular fracture provides insight into the healing process and may help to identify patients who may be at greater risk of PTA., (© 2015, American College of Rheumatology.)

Objective: To describe pelvic bone osteomyelitis in the prostate cancer survivor, to report on clinical presentation and treatment, and to suggest an algorithmic approach to managing this syndrome complex., Materials and Methods: A retrospective chart review from January 2011 to June 2014 was performed to identify prostate cancer patients with pubic symphysis osteomyelitis at a tertiary-care academic medical center with emphasis on genitourinary cancer survivorship. Data on clinical presentation and outcomes were reviewed., Results: Ten patients were diagnosed with having osteomyelitis of the pubic symphysis with or without extension into the pubic rami. Three patients had associated rectal fistulas. Four patients had radical prostatectomy, 5 patients received radiotherapy, and 1 patient received high-intensity focused ultrasound as the primary treatment for prostate cancer. The most common presenting symptoms were pelvic and suprapubic pain, difficulty in walking, and recurrent urinary infections at a median of 7 years after prostate cancer treatment (range, 1.5-16 years). Eight of the 10 patients underwent pubic bone debridement with urinary and fecal diversion when needed. Two patients continue to be managed conservatively with suppressive antibiotics owing to low disease burden. Complete resolution of symptoms was noted in patients undergoing operative intervention, without any pelvic ring instability due to pubic bone resection., Conclusion: The combination of pelvic pain, difficulty with ambulation, and recurrent infections in a prostate cancer survivor should prompt investigation for pubic bone osteomyelitis-a poorly recognized syndrome complex that is best managed in a multidisciplinary setting., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment., Design: Web-based reliability study., Setting: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey., Participants: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns., Main Outcome Measurements: Fleiss kappa (κ) was used to assess the reliability of agreement between the surgeons., Results: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, κ = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, κ = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), κ = 0.79) was substantial and the agreement about a fractured body (Body (B), κ = 0.57) or process was moderate (Process (P), κ = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (κ = 0.57) with a 73% PA., Conclusions: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions.

The purpose of this case report is to describe a novel use of computer assistance in identifying and restoring the mechanical axis in the treatment of a periprosthetic distal femur fracture in a 76-year-old female patient with a total knee arthroplasty.

Lead toxicity associated with extra-articular retained missiles (EARMs) is an uncommon yet potentially devastating complication of gunshot wounds. While the risk of lead toxicity with intra-articular retained missiles is well-known, EARMs are routinely permitted to remain in tissues indefinitely without surveillance for lead toxicity. We present a 34 year-old man who was found to have symptomatic lead toxicity 14 years after sustaining a gunshot-associated femoral fracture with retention of lead bullet fragments. A fluid-filled cyst containing two large lead bullet fragments was identified intraoperatively. Whole-blood lead concentration decreased after removal of the lead-filled cyst. Cyst formation and concomitant bone fracture are two of the risk factors for lead toxicity in patients with EARMs after gunshot wounds. Recognizing risk factors for EARM-associated elevation in lead levels is important as the adverse effects of increased lead burden may be asymptomatic and difficult to diagnose, yet debilitating and potentially lethal.

We conducted a retrospective, single-center (tertiary referral center with associated level I trauma center) review to evaluate the outcome of open reduction and internal fixation (ORIF) with intramedullary (IM) clavicle pin of displaced clavicular fractures. Sixty-eight displaced midshaft clavicle fractures in 68 patients underwent ORIF with IM clavicle pins. Patients were identified through a perioperative database by searching for Current Procedural Terminology (CPT) codes. Union was the primary outcome. Secondary outcomes included time to union, pain, incidence of nonunion and delayed union, postoperative range of motion, and incidence of complications. Sixty-six fractures (97%) went on to union. Complications included painful hardware (44%), deep and superficial wound infections (10%), and hardware failure (4%), including pin breakage and extrusion. Postoperative shoulder pain was present in 10% of patients and limited shoulder range of motion in 12%. IM pin fixation can provide good outcomes, even for fractures with a significant amount of shortening and comminution.

Background: Tibial plateau fractures with associated compartment syndrome are severe injuries with elevated infection rates. The objective of this article was to analyze whether there is an association between infection and the timing of definitive fracture fixation in relation to fasciotomy closure or coverage., Methods: Eighty-one tibial plateau fractures, complicated by compartment syndrome, were treated with four-compartment fasciotomies and definitive fracture fixation before, at, or after fasciotomy closure or coverage., Results: Thirty extremities were treated with definitive fixation before fasciotomy closure. Seven (23%) of these extremities developed an infection. Twenty-six extremities were treated with definitive internal fixation at the time of fasciotomy closure of which three (12%) developed an infection. Twenty-five extremities were treated definitively after fasciotomy closure of which four (16%) developed an infection. There was no significant difference in the rate of infection among the groups (p = 0.5012)., Conclusions: This study demonstrated no statistical difference in the rate of infection when tibial plateau fractures with four-compartment fasciotomies were treated with open reduction and internal fixation before fasciotomy closure, at fasciotomy closure, or after fasciotomy closure. Based on the data presented herein, it seems that definitive fracture treatment can be determined by the condition of patient and by surgeon preference and experience without exposing the patient to the additional risk of infection.

Concomitant fractures of the pelvic ring and proximal femur in the setting of low-energy trauma are rare but not mutually exclusive. An 82-year-old woman, without prior hip pain, presented to our institution after a fall from standing height. Ipsilateral pubic rami and sacral ala fractures were diagnosed with plain radiographs and computed tomography scanning, respectively, and corroborated by physical examination. No further imaging was performed in the emergency department. However, with adequate in-house pain control, the patient's complaints and physical examination were also indicative of a hip fracture. A subsequent magnetic resonance imaging study revealed a nondisplaced ipsilateral intertrochanteric femur fracture. Previously, it has been reported that occult fractures of the hip and pelvic ring appear to be mutually exclusive. Moreover, if acute fractures of the pubic ramus are identified, it has been recommended that no further investigation is warranted to rule out fracture of the hip. This case report demonstrates that low-energy pelvic ring and hip fractures can occur together. Sound clinical acumen is imperative and must supercede literature reports when providing patient care.

This article reviews information on the hazards of cornstarch powder on medical gloves. Dusting powders were first applied to latex gloves to facilitate donning. After 1980, manufacturers devised innovative techniques without dusting powder. It has been well documented that these powders on gloves present a health hazard to patients and health care workers by 5 different mechanisms. First, the glove cornstarch has documented detrimental effects on wound closure techniques. Second, this powder potentiates wound infection. Third, cornstarch induces peritoneal adhesion formation and granulomatous peritonitis. Finally, these powders serve as carriers as latex allergen and they precipitate a life-threatening allergic reaction in sensitized patients. These well-documented hazards of glove powder have caused the United Kingdom and Germany to ban cornstarch powder on medical gloves over 10 years ago.

Background: Traditionally, management of exposed hardware has included irrigation and débridement, intravenous antibiotics, and likely removal of the hardware. Increasingly, the goal of wound closure without hardware removal using plastic surgical techniques of soft-tissue reconstruction has been emphasized. Identification of parameters for retaining exposed hardware may assist surgeons with management decisions and outcomes., Methods: A current literature review was performed to identify parameters with prognostic relevance for management of exposed hardware before soft-tissue reconstruction., Results: The following parameters were identified as important for the potential salvage of exposed hardware with soft-tissue coverage: hardware location, infection, duration of exposure, and presence of hardware loosening., Conclusions: Management of exposed hardware has included the removal of the hardware. However, if certain criteria are met--specifically, stable hardware, time of exposure less than 2 weeks, lack of infection, and location of hardware--salvage of the hardware with plastic surgical soft-tissue coverage may be a therapeutic option.

Introduction: Certain amino acids within proteins have been reported to change from the L form to the D form over time. This process is known as racemization and is most likely to occur in long-lived low-turnover tissues such as normal cartilage. We hypothesized that diseased tissue, as found in an osteoarthritic (OA) joint, would have increased turnover reflected by a decrease in the racemized amino acid content., Methods: Using high-performance liquid chromatography methods, we quantified the L and D forms of amino acids reported to racemize in vivo on a biological timescale: alanine, aspartate (Asp), asparagine (Asn), glutamate, glutamine, isoleucine, leucine (Leu), and serine (Ser). Furthermore, using a metabolically inactive control material (tooth dentin) and a control material with normal metabolism (normal articular cartilage), we developed an age adjustment in order to make inferences about the state of protein turnover in cartilage and meniscus., Results: In the metabolically inactive control material (n = 25, ages 13 to 80 years) and the normal metabolizing control material (n = 19, ages 17 to 83 years), only Asp + Asn (Asx), Ser, and Leu showed a significant change (increase) in racemization with age (P < 0.01). The age-adjusted proportions of racemized to total amino acid (D/D+L expressed as a percentage of the control material) for Asx, Ser, and Leu when compared with the normal articular cartilage control were 97%, 74%, and 73% in OA meniscal cartilage and 97%, 70%, and 78% in OA articular cartilage. We also observed lower amino acid content in OA articular and meniscal cartilages compared with normal articular cartilage as well as a loss of total amino acids with age in the OA meniscal but not the OA articular cartilage., Conclusions: These data demonstrate comparable anabolic responses for non-lesioned OA articular cartilage and OA meniscal cartilage but an excess of catabolism over anabolism for the meniscal cartilage.

Introduction: Aging proteins undergo non-enzymatic post-translational modification, including isomerization and racemization. We hypothesized that cartilage with many long-lived components could accumulate non-enzymatically modified amino acids in the form of isomerized aspartate and that its liberation due to osteoarthritis (OA)-related cartilage degradation could reflect OA severity., Methods: Articular cartilage and synovial fluid were obtained from 14 randomly selected total knee arthroplasty cases (56 to 79 years old) and non-arthritis cartilage from 8 trauma cases (51 to 83 years old). Paired lesional cartilage and non-lesioned OA cartilage were graded histologically using a modified Mankin system. Paired cartilage and synovial fluids were assayed for isomerized aspartate, phosphate-buffered saline/EDTA (ethylenediaminetetraacetic acid) extractable glycosaminoglycans, and total protein. Macroscopically normal non-lesioned OA cartilage was separated into superficial and deep regions when cartilage thickness was at least 3 mm (n = 6)., Results: Normalized to cartilage wet weight, normal cartilage and deep non-lesioned OA cartilage contained significantly (P < 0.05) more isomerized aspartate than superficial non-lesioned OA cartilage and lesioned cartilage. Synovial fluid isomerized aspartate correlated positively (R2 = 0.53, P = 0.02) and glycosaminoglycans correlated negatively (R2 = 0.42, P = 0.04) with histological OA lesion severity. Neither synovial fluid isomerized aspartate nor glycosaminoglycans nor total protein correlated with histological scores of non-lesioned areas., Conclusions: We show for the first time that human cartilage and synovial fluid contain measurable quantities of an isomerized amino acid and that synovial fluid concentrations of isomerized aspartate reflected severity of histological OA. Further assessment is warranted to identify the cartilage proteins containing this modification and to assess the functional consequences and biomarker applications of this analyte in OA.

Free vascularized fibula graft surgery has been shown to be successful in the treatment of osteonecrosis of the femoral head. Refinements in the surgical technique have greatly decreased patient morbidity and overall surgical time. Careful placement of the hip incision is one such refinement. Specific bony landmarks to map out the location of the incision and a simple technique for incision placement are described. An accurately placed 10- to 15-cm incision will allow access to both the proximal femur and the ascending branch of the lateral femoral circumflex artery and veins.

Pneumatic tourniquets about the thigh are commonly employed in lower extremity orthopaedic surgery to maintain a bloodless operative field. The purpose of this study was to determine whether the position of the knee at the time of tourniquet inflation has an impact on knee range of motion (ROM). Passive ROM of the knees of 30 patients was measured with the tourniquet deflated, with the tourniquet inflated while the knees were in extension, and with the tourniquet inflated while the knees were in flexion. The average knee ROM with a deflated tourniquet was 143.0 degrees with a standard deviation of 8.1 degrees (range, 125 degrees -160 degrees ). When the tourniquet was inflated with the knees in extension, the average knee ROM was 143.0 degrees with a standard deviation of 7.8 degrees (range, 125 degrees -159 degrees ). When the tourniquet was inflated with the knees in flexion, the average knee ROM was 143.7 degrees with a standard deviation of 7.8 degrees (range, 124 degrees -160 degrees ). There was a statistically significant difference between the ROM of knees with tourniquet inflation in flexion versus extension (p = .0011.) Although there was a statistical difference, it was concluded that a difference of approximately 1 degrees in knee ROM is not clinically relevant.

Post-traumatic arthritis is a frequent consequence of articular fracture. The mechanisms leading to its development after such injuries have not been clearly delineated. A potential contributing factor is decreased viability of the articular chondrocytes. The object of this study was to characterise the regional variation in the viability of chondrocytes following joint trauma. A total of 29 osteochondral fragments from traumatic injuries to joints that could not be used in articular reconstruction were analysed for cell viability using the fluorescence live/dead assay and for apoptosis employing the TUNEL assay, and compared with cadaver control fragments. Chondrocyte death and apoptosis were significantly greater along the edge of the fracture and in the superficial zone of the osteochondral fragments. The middle and deep zones demonstrated significantly higher viability of the chondrocytes. These findings indicate the presence of both necrotic and apoptotic chondrocytes after joint injury and may provide further insight into the role of chondrocyte death in post-traumatic arthritis.

The purpose of the study was to determine the attitudes of members of the Orthopaedic Trauma Association (OTA) concerning the use and efficacy of bone growth stimulators. A questionnaire regarding bone growth stimulators was sent to the active members of the OTA. Descriptive statistics was performed using frequencies and percentages. All analyses were performed using Stata for Linux, version 8.0 (Intercooled Stata, Stata Corporation; College Station, TX). A response rate of 43% was obtained. Respondents indicated that they only occasionally used bone stimulators for the treatment of acute fractures and stress fractures. A majority of respondents have utilized stimulators for the treatment of delayed unions and nonunions. It was concluded that many members of the OTA utilize bone stimulators for delayed unions and nonunions, but not routinely for the treatment of acute fractures or stress fractures.

Approaches to internal fixation have become more biologic. Greater emphasis is placed on vascularity and soft tissue integrity. Locked plates, analogous to rigid internal fixators, can provide relative stability favorable to secondary fracture healing. If applied appropriately, they can avoid soft tissue compromise. The key to this new generation of plates is the locking mechanism of the screw to the plate, which provides angular stability and avoids compression of the plate to the periosteum. Favorable biomechanical and clinical results continue to expand the number of appropriate indications for use of locked plating devices, although exact indications for their use have yet to be precisely defined.

Intramedullary fixation of fibular fractures has been reported in the literature. Its advantages include ease of fixation as well as minimal soft tissue disruption. Various implants have been described, including the Inyo nail and Rush rods. Several studies have examined their use in older people with osteoporotic bone as well as in instances where soft tissue preservation is of concern. To our knowledge, no technique has been described using flexible titanium elastic nails (TENS) (Synthes; Paoli, PA). We illustrate such a technique as well as a case report that demonstrates our experience. Insertion of flexible titanium elastic nails requires attention to detail with preservation of the peroneal tendons and their sheath. While such a construct cannot control rotation, it can preserve length as well as prevent varus and valgus displacement. Future endeavors could focus on the biomechanical principles of intramedullary fibular fixation with TENS nails.

Plate and screw fixation devices are essential in the orthopaedic surgical management of various fractures. Production of these devices has been nearly perfected, with few manufacturing defects reported. Assuming that all implants have been machined properly may cause a surgeon to overlook a manufacturing defect and may potentially result in a poor patient outcome. We report a case of the imperfect manufacturing of a less invasive stabilization system (LISS) plate screw hole. This resulted in a loss of fixation of a single locking screw to the plate in the treatment of a distal femoral fracture. Prompt recognition of the defect helped avoid a potential adverse outcome for the patient. When these issues arise, open dialogue with industry is crucial to promptly identify a solution and enhance patient care. This case highlights the manufacturing company's outstanding quality control and prompt solution of such an occurrence. It is the purpose of this report to raise surgeons' awareness of potential manufacturing problems with implants and prevent negative consequences as a result.

The purpose of this report is to describe a crisis in healthcare, disabling back injuries in US healthcare workers. In addition, outlined is the proven solution of safe, mechanized, patient lifting, which has been shown to prevent these injuries. A "Safe Patient Handling--No Manual Lift" policy must be immediately instituted throughout this country. Such a policy is essential to halt hazardous manual patient lifting, which promotes needless disability and loss of healthcare workers, pain and risk of severe injury to patients, and tremendous waste of financial resources to employers and workers' compensation insurance carriers. Healthcare workers consistently rank among top occupations with disabling back injuries, primarily from manually lifting patients. Back injury may be the single largest contributor to the nursing shortage. Reported injuries to certified nursing assistants are three to four times that of registered nurses. A national healthcare policy for "Safe Patient Handling--No Manual Lift" is urgently needed to address this crisis. Body mechanics training is ineffective in prevention of back injury with patient lifting. Mandated use of mechanical patient lift equipment has proven to prevent most back injury to nursing personnel and reduce pain and injury to patients associated with manual lifting. With the national epidemic of morbid obesity in our country, innovative devices are available for use in emergency medical systems and hospitals for patient lifting and transfer without injury to hospital personnel. The US healthcare industry has not voluntarily taken measures necessary to reduce patient handling injury by use of mechanical lift devices. US healthcare workers who suffer disabling work-related back injuries are limited to the fixed, and often inadequate, relief which they may obtain from workers' compensation. Under workers' compensation law, healthcare workers injured lifting patients may not sue their employer for not providing mechanical lift equipment. Discarding healthcare workers disabled by preventable back injuries is an abuse which legislators must remedy. In addition, Medicare reimbursement policies must also be updated to allow the disabled community to purchase electrically operated overhead ceiling lifts. The US lags far behind countries with legislated manual handling regulations and "No Lifting" nursing policies. England and Australia have had "No Lifting" nursing policies in place since 1996 and 1998, respectively. The National Occupational Research Agenda (NORA) recognized a model in 2003 for reduction of back injuries to nursing staff in US healthcare facilities. Also in 2003, the American Nurses Association called for elimination of manual patient handling because it is unsafe and causes musculoskeletal injuries to nurses. The first state legislation for safe patient handling passed both houses in California but was vetoed by the Governor in September 2004. California and other states are preparing to (re)introduce legislation in January 2005. A national, industry-specific policy is essential to quell the outflow of nursing personnel to disability from manual patient lifting.

Objective: To compare the biomechanical stability of extraarticular proximal tibia fractures reconstructed using a double-plate construct, locking plate system, hybrid external fixator, and single lateral periarticular plate, all from the same manufacturer., Design: Standardized proximal tibial fractures (AO classification 41-A3.2 and A3.3) in synthetic tibiae were stabilized using one of the four constructs. Load versus proximal fragment translation and rotation were monitored in each case. Fixation was evaluated for moderately unstable and completely unstable fractures simulated by wedge and gap osteotomies of the proximal femur., Setting: Academic medical center biomechanical engineering laboratory., Main Outcome Measurements: Proximal fragment axial displacement, varus rotation, and posterior rotation versus applied load for each of the constructs., Results: The double-plate construct was significantly stiffer than all other constructs with regard to resistance to axial displacement, varus rotation, and posterior rotation for both types of unstable fractures. With regard to axial stiffness, the double-plate construct was statistically similar to an intact tibia for moderately stable fractures. The locking plate and the external fixator were similar for stabilization of moderately unstable fractures, whereas the locking plate and the periarticular plate were significantly stiffer than the external fixator construct for completely unstable fractures., Conclusion: For axial load applied to a wedge or gap osteotomy of the proximal tibia, the double-plate construct provided significantly more rigidity than the other constructs. The locking plate, periarticular plate, and hybrid external fixator tested provided similar rigidity for the wedge osteotomy, but for the gap osteotomy the external fixator could not support 600N without complete closure of the gap.

Gunshot wounds to the pelvis can result in injuries to various organ systems. These injuries require the care of a multispecialty trauma team at a trauma center. Orthopaedic care includes wound treatment, fracture stabilization, and infection prophylaxis. Wound care is determined by the personality of the injury, and not solely based on the velocity of the missile. Antibiotic treatment usually is indicated for patients with gunshot wounds to the pelvis, but is controversial in patients with low-energy wounds. Fractures are treated based on their stability. Regional consideration of pelvic gunshot wounds includes injuries with associated abdominal viscus injury, intraarticular bullets, and retained bullets in the spinal canal.

With the advent of percutaneously placed lag screws for fixation of acetabular fractures, this study evaluated the strength of lag screw fixation compared with traditional fixation techniques of transverse acetabular fractures. Ten formalin-treated human, cadaveric pelvic specimens with bilateral, transtectal transverse acetabular fractures were used for this study. The right acetabular fractures were fixed with a five-hole plate and four screws with the central hole spanning the posterior fracture site. The left acetabular fractures were fixed with two lag screws, one each in the anterior and posterior columns, or with a screw and wire construct stabilizing both columns. The specimens were loaded to implant failure. Stiffness, yield strength, maximum load at failure, and site of failure was recorded. The plate and screw construct showed significantly greater yield and maximum strength when compared with the two lag screws. The stiffness of the lag screw method was 39% higher than that of the plating method, but this result was not statistically significant. In addition, the plate and screw method provided significantly greater maximum strength than the screw and wire technique. The quadrilateral plate seemed to be the weakest area of fixation because 83% of the implant failures occurred in this region. In patients in whom the risks of formal open reduction and internal fixation of acetabular fractures outweigh the possible benefits, such as in patients with burns or degloved skin, the advent of computer-assisted and fluoroscopically guided percutaneous surgical techniques have been instrumental. This study showed there is greater strength of fixation with a plate and screw construct, possibly secondary to supplementary fixation distal to the quadrilateral plate. However, lag screw fixation provided relatively greater stiffness, which may account for its clinical success. Percutaneous lag screw fixation of appropriate transverse acetabular fractures is a viable option.

A constrained acetabular liner occasionally is used in management of chronic instability after total hip arthroplasty. If dislocation occurs out of a constrained liner, open reduction is indicated. A case is presented of closed reduction of a femoral component into a constrained liner.

Tumor-induced osteomalacia is a rare clinical entity that is associated with soft-tissue or skeletal tumors. We present a case report of a patient with a chest wall mesenchymal chondrosarcoma who presented with bone pain. The patient had skeletal changes in the femoral neck and fibula consistent with osteomalacia and laboratory values suggesting phosphate diabetes. The patient was treated with tumor resection and phosphate supplementation with reversal of the signs and symptoms of osteomalacia. Tumor-induced osteomalacia is vitamin-D-resistant and often reversed by complete removal of the tumor. Most commonly, the causative tumors are of vascular, mesenchymal, or fibrous origin. The osteomalacia is associated with bone pain, muscle weakness, and radiographic changes. Tumor-induced humoral factors have been implicated in causing the osteomalacia, but the definite etiology has yet to be determined. Current treatment includes complete tumor resection and electrolyte supplementation.

Cornstarch is currently the only powder used in the manufacture of surgical and examination gloves. The purpose of this study was to determine if cornstarch damages local tissue defenses in contaminated wounds. It was found that in contaminated wounds, cornstarch enhanced the growth of bacteria and elicited exaggerated inflammatory responses as measured by wound induration. As a result of this investigation, we do not recommend the use of gloves with cornstarch powders.

Holes in surgical gloves are considered to be an important source of transmission of pathogens between surgeon and patient. Two new glove hole detectors have been devised to alert the surgeon to the presence of holes. These devices have been evaluated using six powder-free and seven powdered varieties of surgical gloves that were either dry or exposed to hydration. Eight of the 13 surgical gloves hydrated rapidly with water, altering their resistance to the conduction of electricity. Because the Barrier Integrity Monitor¿ only has a hydration monitor, 68 false positives occurred during the evaluation, indicating to the surgeon that he/she should change gloves unnecessarily because the glove had no hole. In contrast, the Surgic Alert Monitor¿ (SAM¿) had a hydration alarm as well as a glove hole detection alarm. During the 104 tests, the SAM¿ device showed no false positives. In the testing of five of the rapidly hydrating types of surgical gloves, the SAM¿ device could not reliably detect holes. On the basis of this study, the SAM¿ device, in conjunction with gloves that resist hydration, appeared to be a reliable hole detection monitor.