Combined Tibial Deflexion Osteotomy and Anterior Cruciate Ligament Reconstruction Improves Knee Function and Stability: A Systematic Review.

IMPORTANCE: Patients with excessive posterior tibial slope (PTS) may have higher risks of anterior cruciate ligament (ACL) reconstruction (ACL-R) failure, and clinical outcomes after revision ACL-R procedures are typically poor. OBJECTIVE: To perform a systematic review of the literature summarizing the clinical and radiological outcomes of the surgical treatment of ACL insufficiency in the setting of excessive PTS using a tibial deflexion osteotomy combined with ACL-R. EVIDENCE REVIEW: A systematic review of the literature was performed using PubMed, Cochrane Library, and OVID Medline databases from 1990 to present. Inclusion criteria were: studies of outcomes of isolated tibial deflexion osteotomies performed with primary or revision ACL-R in the English language. Data extracted included study demographic information, type of tibial deflexion osteotomy and concomitant procedures, radiological outcomes, patient reported outcome scores, and postoperative complications FINDINGS: Six studies, with 133 knees were identified. All included studies were retrospective case series, with a weighted mean follow-up of 3.39 years. In 106 of 133 (79.7%) knees, tibial deflexion osteotomy was performed concomitantly with an ACL-R, whereas in 27 of 133 (20.3%) knees the procedures were staged. 22, 45, and 66 of 133 knees (16.5%, 33.8%, and 49.6%) underwent primary, 1st revision, and 2nd or greater revision ACL-R, respectively. 3 of 133 (2.25%) knees demonstrated recurrent ACL graft failure at final follow-up. On average, PTS decreased from 15.2 degrees preoperatively to 7.1 degrees postoperatively. Mean International Knee Documentation Committee (IKDC), Lysholm, and Tegner scores increased from 42.5, 46.4, and 4.2 preoperatively to 71.8, 89.0, and 6.7 postoperatively. CONCLUSIONS: The results of this review suggest that combined ACL-R and tibial deflexion osteotomy may be effective in decreasing PTS and improving knee function and stability. STUDY DESIGN: Systematic Review; Level of evidence 4.

Outcomes of associated both-column acetabular fractures with and without a posterior wall fracture- A retrospective observational cohort study.

Aims & objectives: Our study sought to determine if posterior wall (PW) involvement in associated both-column acetabular fractures (ABCAFs) is associated with different clinical outcomes, primarily rate of conversion to total hip arthroplasty (THA), in comparison to ABCAFs with no PW involvement. Materials & methods: This retrospective observational cohort study was performed at two academic Level 1 trauma centers. Two study groups were identified. The first study group consisted of 18 patients who sustained an ABCAF with PW involvement (+PW). The second study group consisted of 26 patients who sustained an ABCAF with no PW involvement (-PW). All patients achieved a minimum 12-months of follow-up and/or received a THA conversion procedure at a time remote to their index open reduction internal fixation (ORIF) procedure. The primary outcome of this study was subsequent conversion to THA on the injured hip. The secondary outcome was the presence of post-operative pain at ≥6 months and/or complications. Results: No difference in rate of conversion to THA between + PW (n = 4, 22.2%) and -PW (n = 3, 11.5%) groups was demonstrated (p = 0.419). Similarly, no differences were seen between groups regarding complication rate (p = 0.814) and post-operative pain (p = 0.142). Conclusion: Involvement of the PW does not appear to create worse clinical outcomes in comparison to no involvement in ABCAFs particularly as it relates to ipsilateral joint replacement.

Anatomic vs. reverse shoulder arthroplasty for the treatment of Walch B2 glenoid morphology: a systematic review and meta-analysis.

Background: Walch B2 glenoid morphology with glenohumeral osteoarthritis is a difficult degenerative pattern to manage for shoulder surgeons. Anatomic total shoulder arthroplasty (TSA) in combination with eccentric reaming or bone grafting are the traditional methods of treatment. Newer approaches such as TSA with posteriorly augmented glenoid components and reverse shoulder arthroplasty (RSA) may offer better stability for the posteriorly subluxated biconcave B2 wear pattern. The aim of this systematic review is to compare mid-term surgical and functional outcomes of Walch B2 glenoids without significant rotator cuff pathology treated with TSA and RSA. Methods: The review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by searching the MEDLINE (PubMed) and Embase (Elsevier) databases. Inclusion criteria were clinical studies that evaluated the outcomes and complications of TSA or RSA in the setting of B2 glenoid morphology without significant rotator cuff pathology. Data relevant to TSA and RSA surgical outcomes were extracted and compiled, and outcomes were compared. A meta-analysis of proportions of complication and revision rates among TSA and RSA groups was performed. Results: Overall, 16 articles were included with 414 TSAs and 78 RSAs. The average follow-up duration was 54.1 ± 14.8 months for patients undergoing TSA and 44.8 ± 10.1 months for patients undergoing RSA. The TSA group was further subdivided based on the use of eccentric reaming (135 TSAs), an augmented glenoid component (84 TSAs), or bone grafting (11 TSAs) or was unspecified (184 TSAs). Overall, patients undergoing TSA and RSA demonstrated mean improvements of 50.1 ± 8.5° and 64.7 ± 5.2° in active flexion, 58.5 ± 10.3° and 68.9 ± not reported° in active abduction, and 31.3 ± 5.7° and 29.0 ± 10.2° in active external rotation, respectively. In regard to functional outcome scores, patients undergoing TSA and RSA showed mean Constant score improvements of 38.8 ± 5.3 and 46.6 ± 3.1 points and American Shoulder and Elbow Surgeons score improvements of 48.2 ± 1.0 and 49.2 ± 25.3 points, respectively. Results of the meta-analysis with mid-term follow-up data demonstrated pooled complication rates of 9% (95% confidence interval [CI], 1%-22%) for TSA and 6% (95% CI, 0%-28%) for RSA and pooled revision rates of 2% (95% CI, 0%-8%) for TSA and 1% (95% CI, 0%-15%) for RSA. Conclusion: In the setting of Walch B2 glenoid morphology, TSA with eccentric reaming or an augmented component yields comparable outcomes to RSA. Based on the patient's age, activity level, and expectations, both TSA and RSA can be considered a reasonable option to treat Walch B2 glenoid morphology.

Epidemiology, Clinical Assessments, and Current Treatments of Nonunions.

PURPOSE OF REVIEW: The failure of bony union following a fracture, termed a fracture nonunion, has severe patient morbidity and economic consequences. This review describes current consensuses and future directions of investigation for determining why, detecting when, and effective treatment if this complication occurs. RECENT FINDINGS: Current nonunion investigation is emphasizing an expanded understanding of the biology of healing. This has led to assessments of the immune environment, multiple cytokines and morphogenetic factors, and the role of skeletogenic stem cells in the development of nonunion. Detecting biological markers and other objective diagnostic criteria is also a current objective of nonunion research. Treatment approaches in the near future will likely be dominated by the development of specific adjunct therapies to the nonunion surgical management, which will be informed by an expanded mechanistic understanding of nonunion biology. Current consensus among orthopedists is that improved diagnosis and treatment of nonunion hinges first on discoveries at the bench side with later translation to the clinic.

Predictors of Symptomatic Implant Removal After Open Reduction and Internal Fixation of Tibial Plateau Fractures: A Retrospective Case-Control Study.

A retrospective case-control study was conducted at a level I trauma center to assess whether radiographic details of tibial plateau fixation can predict symptomatic implant removal. Nine hundred fifty-one tibial plateau fractures were treated with open reduction and internal fixation from 2007 to 2016. Eighty-two (9%) were treated with implant removal for localized pain over the implant. A control group was selected from the remaining patients using cumulative sampling. Records and radiographs were reviewed for predictors hypothesized to be associated with implant removal. Based on the authors' multivariable model, implant removal was associated with each additional protruding screw (adjusted odds ratio, 1.32; 95% confidence interval, 1.13-1.55; P<.001), bicondylar fractures (adjusted odds ratio, 2.13; 95% confidence interval, 1.11-4.11; P=.02), and lower body mass index (P=.05). Associations that approached significance were observed with decreased age (adjusted odds ratio, 0.82 per 10 years; 95% confidence interval, 0.66-1.01; P=.06) and closed fractures (adjusted odds ratio, 0.34; 95% confidence interval, 0.10-1.19; P=.09). The model discriminated fractures requiring implant removal with moderate accuracy (area under the curve=0.71). Each additional screw that radiographically protrudes beyond the far cortex increases the odds of symptomatic implant removal by 32%. Bicondylar fractures and lower body mass index are also associated with symptomatic implant removal. These findings might help inform patients and guide fixation techniques to reduce the likelihood of symptomatic implant removal. [Orthopedics. 2020;43(3):161-167.].

Variations in the Organisms Causing Deep Surgical Site Infections in Fracture Patients at a Level I Trauma Center (2006-2015).

OBJECTIVES: To quantify the current bacteriology of deep surgical site infections (SSIs) after fracture surgery at 1 institution and to compare those data with historical controls at the same institution, assessing variations in infecting organisms over the past decade. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: Two hundred forty-three patients requiring surgical intervention for deep SSI between January 2011 and December 2015 were compared with 211 patients requiring surgical intervention for deep SSI between December 2006 and December 2010. INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Bacteria were categorized as Staphylococcus aureus, coagulase-negative staphylococci (CoNS), Streptococcus, Enterococcus, gram-negative rods (GNR), gram-positive rods, anaerobes, or negative cultures. The proportion of each bacterial type was determined and compared with previously published data from the same trauma center (December 2006 to December 2010). RESULTS: Patients most commonly had S. aureus infections (48%), followed by GNR (40%) and CoNS (19%). The proportion of CoNS species (26% vs. 12%, P < 0.01) in infected patients was significantly higher during the current study period compared with historical controls. The proportion of S. aureus species in infected patients was significantly less during the current study period (39% vs. 56%, P < 0.01). The reduction in the proportion of S. aureus species in infected patients was driven by a decrease in the proportion of methicillin-resistant S. aureus (MRSA) in the overall sample. CONCLUSIONS: Bacteriology of deep SSI of fractures has changed substantially over the past decade at our center, specifically the proportions of GNR, CoNS, and MRSA. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Knee Stiffness Surgery After Tibial Plateau Fracture Fixation.

OBJECTIVE: To determine the risk factors for knee stiffness surgery after tibial plateau fixation. DESIGN: Retrospective observational cohort study. SETTING: Academic Level I trauma center. PATIENTS/PARTICIPANTS: A study group of 110 patients who underwent knee stiffness surgery (manipulation while under anesthesia, arthroscopic lysis of adhesion, or quadricepsplasty) at a time remote from open reduction and internal fixation of tibial plateau fractures and a control group of 319 patients with tibial plateau fractures treated with open reduction and internal fixation who did not undergo knee stiffness surgery and who had either a minimum of 1 year of follow-up or clearly documented range of motion ≥110 degrees with a minimum of 90 days of follow-up. INTERVENTION: Each case was assessed from the time of index admission through study event, end of minimum follow-up, or achievement of ≥110 degrees range of motion. MAIN OUTCOME MEASUREMENTS: Knee stiffness surgery. RESULTS: Total number of weeks in an external fixator (odds ratio, 1.5 per week; 95% confidence interval, 1.3-1.7; P < 0.001) and the presence of bilateral tibial plateau fractures (odds ratio, 3.3; 95% confidence interval, 1.2-9.1; P = 0.02) were significant predictors of knee stiffness intervention. CONCLUSION: Clinicians should be aware that the time spent in external fixation and the presence of bilateral tibial plateau injuries are strong risk factors for requiring subsequent surgery to treat knee stiffness. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is Lateral Femoral Nailing Associated With Increased Intensive Care Unit Days? A Propensity-Matched Analysis of 848 Cases.

OBJECTIVE: The purpose of this study is to determine if lateral patient position during femoral nailing is associated with increases in intensive care unit (ICU) length of stay (LOS) or ventilator days when compared with femoral nailing in a supine position. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Patients with femoral shaft fractures treated with intramedullary fixation were identified. Propensity matching was performed to minimize selection bias using factors thought to be associated with surgeon selection of supine nailing at our institution (Injury Severity Score, Abbreviated Injury Score brain, and bilateral fractures). After matching, 848 patients were included in the analysis. INTERVENTION: Femoral nailing in the lateral position compared with the supine position. MAIN OUTCOME MEASUREMENTS: Our primary outcome measure was ICU LOS. Ventilator days were the secondary outcome. RESULTS: Treating patients with femoral nailing in the lateral position was associated with a 1.88 days (95% confidence interval, 0.73-3.02; P = 0.001) reduction in ICU LOS in our adjusted model. Intramedullary nailing in the lateral position was associated with a 1.29 days (95% confidence interval, -0.12 to 2.69) decrease in postoperative time on a ventilator. However, this finding was not statistically significant (P = 0.07). CONCLUSION: Lateral femoral nailing was associated with decreased ICU LOS (P = 0.001) even after accounting for selection bias using propensity score matching. Our data indicate that lateral femoral nailing is likely not associated with the increased risk of pulmonary complication. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.