Delayed debridement of open tibia fractures beyond 24 and 48 h does not appear to increase infection and reoperation risk.

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

Preliminary Report: Pediatric Femur Fractures: Single Incision Intramedullary Stabilization Technique.

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

Comparison of older and newer generations of ActiGraph accelerometers with the normal filter and the low frequency extension.

BACKGROUND: Many studies used the older ActiGraph (7164) for physical activity measurement, but this model has been replaced with newer ones (e.g., GT3X+). The assumption that new generation models are more accurate has been questioned, especially for measuring lower intensity levels. The low-frequency extension (LFE) increases the low-intensity sensitivity of newer models, but its comparability with older models is unknown. This study compared step counts and physical activity collected with the 7164 and GT3X + using the Normal Filter and the LFE (GT3X+N and GT3X+LFE, respectively). FINDINGS: Twenty-five adults wore 2 accelerometer models simultaneously for 3 days and were instructed to engage in typical behaviors. Average daily step counts and minutes per day in nonwear, sedentary, light, moderate, and vigorous activity were calculated. Repeated measures ANOVAs with post-hoc pairwise comparisons were used to compare mean values. Means for the GT3X+N and 7164 were significantly different in 4 of the 6 categories (p<.05). The GT3X+N showed 2041 fewer steps per day and more sedentary, less light, and less moderate than the 7164 (+25.6, -31.2, -2.9 mins/day, respectively). The GT3X+LFE showed non-significant differences in 5 of 6 categories but recorded significantly more steps (+3597 steps/day; p<.001) than the 7164. CONCLUSION: Studies using the newer ActiGraphs should employ the LFE for greater sensitivity to lower intensity activity and more comparable activity results with studies using the older models. Newer generation ActiGraphs do not produce comparable step counts to the older generation devices with the Normal filter or the LFE.

Single incision power optimizing cost-effective (SPOC) distal biceps repair.

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

The Vascularity and Osteogenesis of a Vascularized Flap for the Treatment of Scaphoid Nonunion: The Pedicle Volar Distal Radial Periosteal Flap.

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

Dogs and Orthopaedic Injuries: Is There a Correlation With Breed?

OBJECTIVES: To identify the incidence of orthopaedic injuries secondary to dog bites, determine the responsible breeds, and assess the severity of injury by dog breed. DESIGN: Retrospective. SETTING: Single Level I trauma center. PATIENTS: Ninety-five patients treated for a dog bite that resulted in an orthopaedic injury between January 2010 and July 2016. INTERVENTION: Patients were treated according to their specific orthopaedic injury. MAIN OUTCOME MEASUREMENTS: Dog breed and type of orthopaedic injury. RESULTS: Thirty-nine percent of all dog bite-related emergency department visits resulted in an orthopaedic injury requiring specialist treatment. Of the 95 patients, 50% were the result of a pit bull terrier bite and 22% by a law enforcement dog. A total of 32% were attacked by multiple dogs. There was a 51% incidence of severe injury (amputation or fracture) with a significant association with breed. CONCLUSIONS: Thirty-nine percent of all dog bite-related emergency department visits at our facility resulted in an injury requiring orthopaedic treatment. Pit bull terrier bites were responsible for a significantly higher number of orthopaedic injuries and resulted in an amputation and/or bony injury in 66% of patients treated, whereas bites from law enforcement dogs and other breeds were less associated with severe injuries. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bilateral Internal Iliac Artery Embolization Results in an Unacceptably High Rate of Complications in Patients Requiring Pelvic/Acetabular Surgery.

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

Short Versus Long Intramedullary Nails in the Treatment of Pertrochanteric Hip Fractures: Incidence of Ipsilateral Fractures and Costs Associated With Each Implant.

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

Demographic factors in hip fracture incidence and mortality rates in California, 2000-2011.

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

Biomechanical Comparison of Fracture Risk Created by 2 Different Clavicle Tunnel Preparations for Coracoclavicular Ligament Reconstruction.

BACKGROUND: An anatomic reconstruction of coracoclavicular (CC) ligaments typically requires drilling tunnels in the clavicle. An increase in fracture complications has been associated with graft tunnel position. A method of drilling clavicle tunnels that would better re-create anatomic function of the CC ligaments without increasing fracture risk would be an improvement. PURPOSE: To evaluate the feasibility of a novel single anterior-to-posterior tunnel technique and compare the biomechanical properties to the 2-tunnel technique in CC ligament reconstruction. The hypothesis was that the single tunnel will yield similar loads to failure as the 2-tunnel technique and better reproduce the native anatomy of the conoid and trapezoid ligaments. STUDY DESIGN: Controlled laboratory study. METHODS: Eight fresh-frozen matched pairs of human clavicles underwent testing. In 1 specimen of the matched pair, 2 bone tunnels were created as previously described. In the other, a single tunnel was placed obliquely from anterior to posterior. The relative position of the tunnels in relation to the conoid tuberosity was recorded. Specimens were tested on a materials testing machine. The ultimate load to failure, linear stiffness, distance of the conoid tuberosity to the conoid tunnel exit point, and mode of failure were recorded. RESULTS: The ultimate load to failure in the single-tunnel group and the 2-tunnel group was 457.2 ± 139.8 and 488.8 ± 170.6, respectively. There was no significant difference (P = .5). The linear stiffness in the single-tunnel group and the 2-tunnel group was 94.6 ± 31.3 and 79.8 ± 33.5, respectively. There was no significant difference (P = .2). The 2-tunnel group had a significantly longer average maximum distance from the conoid tuberosity to the conoid tunnel exit point than the single-tunnel group (6.0 ± 2.1 vs 0.8 ± 1.9 mm; P = .05). The single-tunnel group was consistently more anatomic with regard to its relationship to the conoid tuberosity than the 2-tunnel group. CONCLUSION: The single anterior-to-posterior clavicle tunnel had similar biomechanical properties to the 2-tunnel technique. However, the single-tunnel technique better reproduced the anatomic footprint of the conoid ligament. Utilizing this single-tunnel technique may yield an anatomic advantage that may also reduce the rate of complications caused by posterior wall blowout. CLINICAL RELEVANCE: Acromioclavicular joint injuries are common in collision sports. Surgical management is often indicated to reconstruct the joint. This study assesses the feasibility of a novel surgical approach.