Surgeon preferences regarding antibiotic prophylaxis for ballistic fractures.

BACKGROUND: Scant evidence exists to support antibiotic use for low velocity ballistic fractures (LVBF). We therefore sought to define current practice patterns. We hypothesized that most surgeons prescribe antibiotics for LVBF, prescribing is not driven by institutional protocols, and that decisions are based on protocols utilized for blunt trauma. MATERIALS AND METHODS: A web-based questionnaire was emailed to the membership of the Orthopaedic Trauma Association (OTA). The questionnaire included demographic information and questions about LVBF treatment practices. Two hundred and twenty surgeons responded. One hundred and fifty-four (70 %) respondents worked at a Level-1 trauma center, 176 (80 %) had received fellowship education in orthopaedic trauma and 104 (47 %) treated at least 10 ballistic fractures annually. Responses were analyzed with SAS 9.3 for Windows (SAS Institute Inc, Cary, NC). RESULTS: One hundred eighty-six respondents (86 %) routinely provide antibiotics for LVBF. Those who did not were more apt to do so for intra-articular fractures (8/16, 50 %) and pelvic fractures with visceral injury (10/16, 63 %). Most surgeons (167, 76 %) do not believe the Gustilo-Anderson classification applies to ballistic fractures, and (20/29, 70 %) do not base their antibiotic choice on the classification system. Few institutions (58, 26 %) have protocols guiding antibiotic use for LVBF. CONCLUSIONS: Routine antibiotic use for LVBF is common; however, practice is not dictated by institutional protocol. Although antibiotic use generally follows current blunt trauma guidelines, surgeons do not base their treatment decisions the Gustilo-Anderson classification. Given the high rate of antibiotic use for LVBF, further study should focus on providing evidence-based treatment guidelines.

Treatment of Acute Jones Fractures Without Weightbearing Restriction.

Jones fractures are reportedly prone to nonunion and generally treated with a period of non-weightbearing or operative treatment. Extended non-weightbearing can have adverse effects, and operative treatment poses various risks. We report the clinical results of patients treated without weightbearing restriction. All patients treated for metatarsal fractures by a single surgeon from January 1, 2000 to December 31, 2009 were identified through the clinical billing records by International Classification of Diseases, ninth revision, code. Through a radiographic and medical record review, 27 consecutive patients with acute Jones fractures treated without weightbearing restriction were identified. The demographic information and clinical and radiographic results were recorded. Of the 27 patients, 24 (89%) had achieved clinical union at a mean of 8.0 ± 2.6 weeks. Complete radiographic union was noted in 13 (48%) patients, and 13 (48%) others had made significant progress toward radiographic union but had not yet reached it. Two (8.3%) patients were lost to follow-up. One patient (4%) developed nonunion. Patients with acute Jones fractures can be treated without weightbearing restriction. This protocol results in rapid clinical union and a low rate of nonunion.

Intraosseous Shelf Plate Fixation for Depressed Articular Fragments in Tibial Plateau Fractures: A Technical Trick and Case Series.

SUMMARY: Tibial plateau fractures with severely displaced articular injuries and significant deformity to the surrounding metaphyseal bone (including the hyperextension varus bicondylar pattern) can be challenging to stabilize due to resulting large bone voids uncontained by metaphyseal cortex. The purpose of this report was to describe a technique to support the plateau articular surface in these cases and report on outcomes of a small series. This technique uses a small or mini fragment plate, contoured to function as an intraosseous shelf plate, with the "shelf" portion inserted into the bone beneath the articular surface to support it. This technique provides fixed-angle support to the fragment. There are some advantages of this technique compared to structural allograft, large volume ceramic bone void filler, a spine cage, or other trabecular metal object, including the ability to remove the plate later, ability to tension the plate against the depressed articular surface, ability to place screws or other allograft near the implant, wide availability of the implant, and familiarity of orthopaedic trauma surgeons with placing plates and screws to hold reductions. The technique is particularly useful in patterns with uncontained articular depression and a large metaphyseal void.

Radiographic Accuracy of Identifying Anterolateral Tibial Plafond Involvement in Pronation Abduction Ankle Fractures.

OBJECTIVES: To evaluate the incidence of anterolateral tibial plafond involvement in pronation-abduction (PAB) ankle fractures and analyze the accuracy of radiographs in detecting anterolateral tibial plafond involvement, impaction, and predicting the need for direct visualization and an articular reduction. METHODS: Design: A multi-institutional retrospective chart review. SETTING: Five level 1 trauma centers in the United States. PATIENT SELECTION CRITERIA: Adult patients with PAB ankle fractures (OTA/AO 44B2.3, 44C2.2, 44C2.3) from 2020-2022 were reviewed by 7 fellowship-trained orthopedic trauma surgeons. They were queried about the presence of anterolateral tibial plafond involvement and impaction, and whether they would need direct visualization and an articular reduction using both radiographs and CT. OUTCOME MEASUREMENTS AND COMPARISONS: The presence of anterolateral tibial plafond impaction was tabulated separately using radiographs and CT scans. The accuracy of radiographs and changes in surgical plan after CT review were calculated using CT as the gold standard. RESULTS: 61 fractures in 61 patients were evaluated with CT and/or plain radiographs. Using plain radiographs, anterolateral tibial plafond involvement and impaction were identified in 61% and 36% of cases, respectively. In the 38 fractures with both plain radiographs and CT scans, anterolateral tibial plafond involvement was identified in 66% of radiographs and 74% of CT scans (p = 0.4). Plafond impaction was identified in 42% of plain radiographs and 37% of CT scans (p = 0.62). There was no difference in the rate of involvement between radiographs and CT scan. The diagnosis of anterolateral tibial plafond impaction using plain radiographs was correct in 74% of fractures when compared to CT imaging, resulting in a sensitivity of 71%, a specificity of 75%, a positive predictive value (PPV) of 62%, and a negative predictive value (NPV) of 82%. Plain radiographs correctly predicted the need for direct visualization and an articular reduction in 74% of cases and had a PPV of 59% and a NPV of 86%. CONCLUSIONS: Anterolateral tibial plafond involvement and impaction was present on CT in 74% and 37% of pronation-abduction (PAB) ankle fractures, respectively. Plain radiographs had higher NPV for identifying impaction and the need for articular reduction than they did sensitivity, specificity or PPV. CT is an important tool for preoperative planning that should be considered when planning for operative fixation of PAB ankle fractures. LEVEL OF EVIDENCE: Prognostic level III. See Instructions for Authors for a complete description of levels of evidence.

Radiofrequency ablation in the treatment of osteoid osteoma: results and complications.

BACKGROUND: Percutaneous radiofrequency ablation (RFA) for treatment of osteoid osteoma is effective and avoids the potential complications of open surgical resection. This study evaluates the efficacy of RFA at a single tertiary-care pediatric hospital and highlights an important complication. MATERIALS AND METHODS: The medical records of 21 cases of RFA in 21 children between 2004 and 2010 were reviewed retrospectively for demographic data, lesion site, access point and technique for ablation, clinical outcome and complications. RESULTS: Clinical follow-up was available for 17/21 children (81%) at an average of 17.0 months (range 0.5-86.1 months). No persistence or recurrence of pre-procedural pain was noted. Two children (9.5%) had a complication, including a burn to the local skin and muscle requiring local wound care, and a late subtrochanteric femur fracture treated successfully with open reduction internal fixation. CONCLUSION: RFA is a safe and effective alternative to surgical resection of the osteoid osteoma nidus. When accessing the proximal femur, the risk of late post-procedural fracture must be considered and discussed with the family. An understanding of biomechanical principles in the proximal femur might provide an effective strategy for limiting this risk.

A Central Collinear Start Point for Reconstruction Nailing of Femur Fractures: A Technical Trick and Case Series.

SUMMARY: Selecting the optimal entry point for reconstruction nailing is critical to avoid iatrogenic malalignment and optimize mechanical stability. In-line nailing is familiar to surgeons and desirable for its on-axis position. However, there are several potential drawbacks. We describe a modified entry point and present an accompanying clinical series emphasizing an entry point in line with the medullary canal and central on the femoral neck. This central collinear start point is anterior to the traditional piriformis start point and may obviate some of the potential drawbacks with traditional piriformis nailing.

Negative-Pressure Wound Therapy in Foot and Ankle Surgery.

Negative Pressure Wound Therapy (NPWT) is frequently utilized to manage complex wounds, however its mechanisms of healing remain poorly understood. Changes in growth factor expression, micro- and macro-deformation, blood flow, exudate removal, and bacterial concentration within the wound bed are thought to play a role. NPWT is gaining widespread usage in foot and ankle surgery, including the management of traumatic wounds; diabetic and neuropathic ulcers; wounds left open after debridement for infection or dehiscence; high-risk, closed incisions; tissue grafts and free flaps. This article reviews the rationale for NPWT, its proposed mechanisms of action, and the evidence regarding its clinical applications within the field of foot and ankle surgery. Level of Evidence: Level V, expert opinion.

Gel scaffolds of BMP-2-binding peptide amphiphile nanofibers for spinal arthrodesis.

Peptide amphiphile (PA) nanofibers formed by self-assembly can be customized for specific applications in regenerative medicine through the use of molecules that display bioactive signals on their surfaces. Here, the use of PA nanofibers with binding affinity for the bone promoting growth factor BMP-2 to create a gel scaffold for osteogenesis is reported. With the objective of reducing the amount of BMP-2 used clinically for successful arthrodesis in the spine, amounts of growth factor incorporated in the scaffolds that are 10 to 100 times lower than that those used clinically in collagen scaffolds are used. The efficacy of the bioactive PA system to promote BMP-2-induced osteogenesis in vivo is investigated in a rat posterolateral lumbar intertransverse spinal fusion model. PA nanofiber gels displaying BMP-2-binding segments exhibit superior spinal fusion rates relative to controls, effectively decreasing the required therapeutic dose of BMP-2 by 10-fold. Interestingly, a 42% fusion rate is observed for gels containing the bioactive nanofibers without the use of exogenous BMP-2, suggesting the ability of the nanofiber to recruit endogenous growth factor. Results obtained here demonstrate that bioactive biomaterials with capacity to bind specific growth factors by design are great targets for regenerative medicine.

Effects of lumbar disk herniation on the careers of professional baseball players.

Outcomes after lumbar disk herniation in baseball athletes are currently unknown. It has been postulated that the repetitive torque-producing motions of a baseball player may have negative implications after a disk injury. Sixty-nine lumbar disk herniations (40 treated operatively, 29 nonoperatively) in 64 professional baseball players were identified, and important outcome measures including successful return to play, time to recovery, career longevity, and performance based on vital statistics to each position were documented. Ninety-seven percent of baseball athletes successfully returned to play at an average of 6.6 months after diagnosis. Athletes treated operatively required significantly more time to return to play than those managed nonoperatively (8.7 vs 3.6 months, respectively; P<.0001).