Does Flipping From Prone to Supine for Medial Malleolar Fixation of Trimalleolar Ankle Fractures Improve Results?

There has been a paradigm shift towards fixing the posterior malleolus in trimalleolar ankle fractures. This study evaluated whether a surgeon's preference to intraoperatively flip or not flip patients from prone to supine for medial malleolar fixation following repair of fibular and posterior malleoli impacted surgical outcomes. A retrospective patient cohort treated at a large urban academic center and level 1 trauma center was reviewed to identify all operative trimalleolar ankle fractures initially positioned prone. One hundred and forty-seven patients with mean 12-month follow-up were included and divided based on positioning for medial malleolar fixation, prone or supine (following closure, flip and re-prep, and drape). Data was collected on patient demographics, injury mechanism, perioperative variables, and complication rates. Postoperative reduction films were reviewed by orthopedic traumatologists to grade the accuracy of anatomic fracture reduction. Overall, 74 (50.3%) had the medial malleolus fixed prone, while 73 (49.7%) were flipped and fixed supine. No differences in demographics, injury details, and fracture type existed between the groups. The supine group had a higher rate of initial external fixation (p = .047), longer operative time in minutes (p < .001), and a higher use of plate and screw constructs for medial malleolar fixation (p = .019). There were no differences in clinical and radiographic outcomes and complication rates. This study demonstrated that intraoperative change in positioning for improved medial malleolar visualization in trimalleolar ankle fractures results in longer operative times but similar radiographic and clinical results. The decision of operative position should be based on surgeon comfort.

Management of Large Segmental Bone Defects at the Knee With Intramedullary Stabilized Antibiotic Spacers During Two-Stage Treatment of Endoprosthetic Joint Infection.

BACKGROUND: Following debridement of infected prostheses that require reconstruction with an endoprosthetic replacement (EPR), instability related to segmental residual bone defects present a challenge in management with 2-stage reimplantation. METHODS: We retrospectively reviewed all patients treated for revision total joint or endoprosthetic infection at the knee from 1998 to 2018. At our institution, patients with skeletal defects >6 cm following explant of prosthesis and debridement (stage 1) were managed with intramedullary nail-stabilized antibiotic spacers. Following stage 1, antimicrobial therapy included 6 weeks of intravenous antibiotics and a minimum of 6 weeks of oral antibiotics. Following resolution of inflammatory markers and negative tissue cultures, reimplantation (stage 2) of an EPR was performed. RESULTS: Twenty-one patients at a mean age of 54 ± 21 years were treated for prosthetic joint infection at the knee. Polymicrobial growth was detected in 38% of cases, followed by coagulase-negative staphylococci (24%) and Staphylococcus aureus (19%). Mean residual skeletal defect after stage 1 treatment was 20 cm. Prosthetic joint infection eradication was achieved in 18 (86%) patients, with a mean Musculoskeletal Tumor Society score of 77% and mean knee range of motion of 100°. Patients with polymicrobial infections had a greater number of surgeries prior to infection (P = .024), and were more likely to require additional debridement prior to EPR (odds ratio 12.0, P = .048). CONCLUSION: Management of large segmental skeletal defects at the knee following explant using intramedullary stabilized antibiotic spacers maintain stability and result in high rates of limb salvage with conversion to an endoprosthesis.

Supplemental Bone Grafting in Giant Cell Tumor of the Extremity Reduces Nononcologic Complications.

BACKGROUND: Giant cell tumors (GCTs) are treated with resection curettage and adjuvants followed by stabilization. Complications include recurrence, fracture, and joint degeneration. Studies have shown treatment with polymethylmethacrylate (PMMA) may increase the risk of joint degeneration and fracture. Other studies have suggested that subchondral bone grafting may reduce these risks. QUESTIONS/PURPOSES: Following standard intralesional resection-curettage and adjuvant treatment, is the use of bone graft, with or without supplemental PMMA, (1) associated with fewer nononcologic complications; (2) associated with differences in tumor recurrence between patients treated with versus those treated without bone grafting for GCT; and (3) associated with differences in Musculoskeletal Tumor Society (MSTS) scores? METHODS: Between 1996 and 2014, 49 patients presented with GCT in the epiphysis of a long bone. Six patients were excluded, four who were lost to followup before 12 months and two because they presented with displaced, comminuted, intraarticular pathologic fractures with a nonreconstructable joint surface. The remaining 43 patients were included in our study at a mean followup of 59 months (range, 12-234 months). After resection-curettage, 21 patients were reconstructed using femoral head allograft with or without PMMA (JB) and 22 patients were reconstructed using PMMA alone (FRP, KSB); each surgeon used the same approach (that is, bone graft or no bone graft) throughout the period of study. The primary study comparison was between patients treated with bone graft (with or without PMMA) and those treated without bone graft. RESULTS: Nononcologic complications occurred less frequently in patients treated with bone graft than those treated without (10% [two of 21] versus 55% [12 of 22]; odds ratio, 0.088; 95% confidence interval [CI], 0.02-0.47; p = 0.002). Patients with bone graft had increased nononcologic complication-free survival (hazard ratio, 4.59; 95% CI, 1.39-15.12; p = 0.012). With the numbers available, there was no difference in tumor recurrence between patients treated with bone graft versus without (29% [six of 21] versus 32% [seven of 22]; odds ratio, 0.70; 95% CI, 0.1936-2.531; p = 0.586) or in recurrence-free survival among patients with bone graft versus without (hazard ratio, 0.94; 95% CI, 0.30-2.98; p = 0.920). With the numbers available, there was no difference in mean MSTS scores between patients treated with bone graft versus without (92% ± 2% versus 93% ± 1.4%; mean difference 1.0%; 95% CI, -3.9% to 6.0%; p = 0.675). CONCLUSIONS: Compared with PMMA alone, the use of periarticular bone graft constructs reduces postoperative complications apparently without increasing the likelihood of tumor recurrence. LEVEL OF EVIDENCE: Level III, therapeutic study.

Severe Obesity Worsens 30-Day Surgical Outcomes and Projected Costs in Operative Femoral Shaft and Tibial Shaft Fractures.

OBJECTIVE: To assess the impact of severe obesity on 30-day adverse event rates, hospital length of stay (LOS), readmissions, and projected costs after operative fixation of tibia and femur fractures. METHODS: An analysis of the American College of Surgeons National Surgical Quality Improvement Project database from 2012 to 2019 of isolated femoral shaft and tibial shaft fracture fixation cases was conducted. Adverse events, LOS, readmission rates, and operative time were queried for severe obesity, defined as body mass index greater than 40, compared with other patients. Student t tests were used to assess continuous variables. Fisher exact test and odds ratios were used for categorical variables. A cost-analysis was also performed to quantify the effect of severe obesity on projected health care expenditures. RESULTS: A total of 10,436 patients were included with 7.0% of patients categorized as severely obese. Severely obese patients had higher infectious complication rates (9.0% vs. 6.7%, P = 0.013, OR 1.36, 95% CI 1.04-1.78), readmission rates (7.9% vs. 5.6%, P-value = 0.008, OR 1.44, 95% CI 1.08-1.91), longer LOS (5.8 days SD ±10.2 vs. 5.0 days SD ±7.9 days, P-value = 0.008), and longer operative times (mean 115 minutes ± 56 minutes SD vs. 103 minutes SD ±54 minutes, P-value = <0.001). Severe obesity resulted in an estimated $4258.07 additional health care expenditures per patient compared with nonobese patients. This amounted to a projected added total expenditure of $3.09 million USD in the overall cohort. CONCLUSION: Severe obesity is associated with significantly worse 30-day outcomes and higher readmission rates for patients undergoing operative fixation of tibial shaft and femoral shaft fractures. Health policy considerations should be made to incentivize care for this patient population, particularly in trauma where modification of risk factors before surgery is often not feasible. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Radiographic Scoring of Humeral Shaft Fractures Helps Identify Patients at Risk of Surgery for Delayed Union.

OBJECTIVES: Assessing external validity and clinical relevance of modified radiographic union score (mRUS) to predict delayed union in closed humeral shaft fractures initially treated with conservative management. DESIGN: Retrospective cohort. SETTING: Single urban academic level 1 trauma center. PATIENTS: Patients undergoing initial nonoperative treatment of a humeral shaft fracture with a minimum of 3 months follow-up and at least one set of follow-up orthogonal x-rays within 12-weeks of injury. MAIN OUTCOME MEASUREMENTS: Interobserver and intraobserver reliability of the (mRUS) system for humeral shaft fractures, and establishing an mRUS threshold at 6 and 12 weeks postinjury to predict surgery for delayed union. RESULTS: mRUS demonstrated substantial interobserver agreement on all assessments. Intraobserver agreement was nearly perfect for all reviewers on repeat assessment. mRUS of ≤7 at 6 ± 1 weeks follow-up was associated with surgery for delayed union with an odds ratio of 4.88 (95% CI, 2.52-9.44, P < 0.01), sensitivity of 0.286, and specificity of 0.924. At 12 ± 1 weeks follow-up, the same threshold demonstrated a stronger association with an odds ratio of 14.7 (95% CI, 4.9-44.1, P < 0.01), sensitivity of 0.225, and specificity of 0.981. CONCLUSIONS: The mRUS for humeral shaft fractures is reliable and reproducible providing an objective way to track subtle changes in radiographs over time. An mRUS of ≤7 at 6 or 12 weeks postinjury is highly specific for delayed union. This can be helpful when counseling patients about the risk of nonunion and potential early surgical intervention. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Linea Aspera as Rotational Landmark for Tumor Endopostheses: A Computed Tomography Study.

This computed tomography study examined the reliability of the linea aspera as a rotational landmark in tumor endoprosthetic replacement by determining its cross-sectional location on the femur.

Are patient demographics different for early-onset and late-onset Blount disease? Results based on meta-analysis.

Early-onset and late-onset Blount disease has been described with some clinical overlap between the two forms. Using PRISMA guidelines, we searched for articles that included demographics of patients with both types of Blount disease. On the basis of 24 articles that met our inclusion criteria, patients with early-onset Blount disease were more likely to have bilateral involvement [odds ratio (OR) 4.30, 95% confidence interval (CI) 2.27-8.17] and less likely to be Black (OR 0.20, 95% CI 0.08-0.53) or male (OR 0.32, 95% CI 0.13-0.78). Our results confirm that differences based on laterality, race, and sex exist between the two forms of Blount disease.