The Effect of Sacrificing the Posterior Cruciate Ligament in Total Knee Arthroplasties That Use a Highly Congruent Polyethylene Component.

BACKGROUND: There is continued debate regarding retention versus sacrificing of the posterior cruciate ligament (PCL) in total knee arthroplasty (TKA). We sought to determine if there was a difference in range of motion (ROM) after TKA between patients with PCL sacrifice versus PCL retention when using a highly congruent polyethylene insert. METHODS: We conducted an Institutional Review Board approved retrospective study of consecutive patients receiving TKA using the same implant with a highly congruent polyethylene component implanted by one surgeon from November 2013 to January 2016. Patients were placed in 2 groups based on whether the PCL was intact or released at the time of surgery. Patient charts were reviewed for age, body mass index, PCL status at surgery (incompetent, kept intact, or released), and preoperative/postoperative knee ROM. RESULTS: Both groups were similar in average age (60.5 vs 60.6, respectively) and body mass index (33.3 vs 32.6, respectively). Postoperative tibial slope (5.5° PCL release, 6.6° PCL retained, P = .028) was the only alignment variable reaching significance; all other alignment and motion variables were similar. CONCLUSION: Results indicate that the PCL can be successfully retained with the use of a congruent bearing design, with no evident limitation in postoperative ROM or loss of stability due to the bearing in comparison to patients who undergo PCL release.

Tibial Shaft and Pilon Fractures With Associated Syndesmotic Injury: A Matched Cohort Assessment.

OBJECTIVE: To determine the outcomes of pilon and tibial shaft fractures with syndesmotic injuries compared with similar fractures without syndesmotic injury. DESIGN: Retrospective case-control study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: All patients over a 5-year period (2012-2017) with tibial shaft or pilon fractures with a concomitant syndesmotic injury and a control group without a syndesmotic injury matched for age, OTA/AO fracture classification, and Gustilo-Anderson open fracture classification. INTERVENTION: Preoperative or intraoperative diagnosis of syndesmotic injury with reduction and fixation of both fracture and syndesmosis. MAIN OUTCOME MEASUREMENT: Rates of deep infection, nonunion, unplanned reoperation, and amputation in patients with a combined syndesmotic injury and tibial shaft or pilon fracture versus those without a syndesmotic injury. RESULTS: A total of 30 patients, including 15 tibial shaft and 15 pilon fractures, were found to have associated syndesmotic injuries. The matched control group comprised 60 patients. The incidence of syndesmotic injury in all tibial shaft fractures was 2.3% and in all pilon fractures was 3.4%. The syndesmotic injury group had more neurologic injuries (23.3% vs. 8.3% P = 0.02), more vascular injuries not requiring repair (30% vs. 15%, P = 0.13), and a higher rate compartment syndrome (6.7% vs. 0%, P = 0.063). Segmental fibula fracture was significantly more common in patients with a syndesmotic injury (36.7% vs. 13.3%, P = 0.04). Fifty percent of the syndesmotic injury group underwent an unplanned reoperation with significantly more unplanned reoperations (50% vs. 27.5%, P = 0.04). The syndesmotic group had a significantly higher deep infection rate (26.7% vs. 8.3% P = 0.047) and higher rate of amputation (26.7% vs. 3.3% P = 0.002) while the nonunion rate was similar (17.4% vs. 16.7% P = 0.85). CONCLUSIONS: Although syndesmotic injuries with tibial shaft or pilon fractures are rare, they are a marker of a potentially limb-threatening injury. Limbs with this combined injury are at increased risk of deep infection, unplanned reoperation, and amputation. The presence of a segmental fibula fracture should raise clinical suspicion to evaluate for syndesmotic injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

An Analysis of Symptomatic Meniscal Re-Tear Incidence in Two Age Populations: Differences in Older versus Younger Adults.

A symptomatic meniscal tear is one of the most common problems treated by an orthopaedic surgeon. Treatment ranges from observation to complete meniscectomy. Prior research has shown that contact stresses increase within the joint compartment after partial meniscectomy, thus leading to arthritis of the compartment. The purpose of the current study was to determine the incidence of meniscal re-tears in two populations of patients and identify potential factors predisposing to re-tear. A retrospective review of our relational database identified 1,930 arthroscopic partial meniscectomies from 1993 to 2003. Meniscectomies were divided into two groups, 430 patients < 45 years of age (YOUNG) and 712 patients ≥ 45 (OLD). Age, onset date, Lysholm, Tegner, tear type, radial and circumferential location, as well as degree and location of chondromalacia, were analyzed. Of the YOUNG group, 1.16% experienced re-tears, versus 0.42% of the OLD group. From the younger re-tear group, 80% were chronic and 20% had grade 2 chondromalacia in one compartment. The YOUNG re-tear group was slightly more active with higher Tegner (5.6 vs. 4.3) and Lysholm (66.2 vs. 60) scores than the rest of the YOUNG group. The OLD re-tear group was less active with a lower Tegner (2.5 vs. 4.1) and Lysholm (62 vs. 66) score compared with the rest of the older group. In this study, patients under 45 years and with chronic tears had slightly higher incidence of re-tears. Results indicated that the lateral meniscus is more likely to re-tear.

Soft Drink Consumption and Mental Health in Adolescents: A Longitudinal Examination.

PURPOSE: Previous studies showed associations between soft drink consumption and mental health problems in adolescents, but the direction of these effects is unknown. This study examines the hypotheses that soft drink consumption predicts aggression and depressive symptoms over time and that these mental health problems predict soft drink consumption. METHODS: Interviews were conducted with 5,147 children and their caregivers from three sites at child ages 11, 13, and 16. At each time point, youth reported on their frequency of consuming soft drinks, aggressive behavior, and depressive symptoms. An autoregressive cross-lagged path model tested reciprocal relationships between soft drink consumption, aggressive behavior, and depressive symptoms over time. RESULTS: More frequent consumption of soft drinks was associated with more aggressive behavior at each time point and depressive symptoms at ages 11 and 13 (r = .04 to .18, p ≤ .002). After adjusting for covariates and stability of each behavior over time, soft drink consumption at ages 11 and 13 predicted more aggressive behavior at the next time point (ß = .08 and .06, p < .001). Aggressive behavior at age 13 also predicted more soft drink consumption at age 16 (ß = .06, p = .002). Soft drink consumption at age 13 predicted fewer depressive symptoms (ß = -.04, p = .007), but depressive symptoms did not predict soft drink consumption. CONCLUSIONS: More frequent consumption of soft drinks may contribute to aggressive behavior in adolescents over time; there is some support for reciprocal relationships. There is no evidence for soft drink consumption contributing to adolescents' depression. Future research should examine longitudinal effects over shorter intervals.

The rising use of total hip arthroplasty for femoral neck fractures in the United States.

BACKGROUND: We examined the trends in the treatment of femoral neck fractures with arthroplasty in the United States from 2004-2013. METHODS: We used the National Inpatient Sample database in conjunction with codes from the International Classification of Diseases, Ninth Revision, to identify patients receiving hemiarthroplasty (HA) or total hip arthroplasty (THA) for the treatment of closed femoral neck fracture from 2004-2013. We evaluated the trend of these 2 treatments along with demographics, comorbidities, length of stay and same admission mortality. RESULTS: Our study identified 1,059,414 patients who underwent arthroplasty for the treatment of femoral neck fracture. We found a 42% increase in the use of THA during the study period from 8.4% in 2004 to 12.9% in 2013. While the large majority of patients received HA (87.1%), there was an overall decline in the use of HA (89,132 in 2004 to 85,635 in 2013) and increase in the use of THA (8,177 in 2004 to 11,375 in 2013). Patients receiving THA were younger (mean age 74.7 THA vs. 80.4 HA, p < 0.001) with fewer comorbidities, higher likelihood of discharge to home (24% THA vs. 10% HA, p < 0.001) and lower inpatient mortality rates (1.5 % THA vs. 2.4 % HA, p < 0.001) in comparison to HA. CONCLUSION: There has been a significant increase in the use of THA over the last decade. Patients receiving THA were younger and healthier with fewer comorbidities, less likely to sustain a same admission mortality and more likely to discharge to home in comparison to HA patients.

Open Fractures: Are We Still Treating the Same Types of Infections?

Background: To analyze the rate of methicillin-resistant Staphylococcus aureus (MRSA), gram-negative, and polymicrobial infections in open fractures, measure the efficacy of the current open fracture antibiotic regimen against these infections, identify the most effective agent(s) to cover these infections, and analyze risk factors for infection. Methods: We examined retrospectively 451 patients with open fractures from January 2008 to December 2012 who were treated at our facility. Positive cultures during surgical debridement after wound closure defined an infection. Infecting organisms and their antibiotic sensitivities were identified through microbiology culture reports. Rates of MRSA, gram-negative, and polymicrobial infections were determined. The efficacy of the current regimen (cefazolin and gentamicin) was calculated against gram-positive and gram-negative organisms. Efficacy profiles against infectious organisms were calculated for all commonly tested antibiotics. Patient factors, injury characteristics, and treatment options were analyzed to determine risk factors for infection. Results: Ninety patients (20%) were identified as infected at surgical debridement. Of those 90, 21 (23.3%) were diagnosed with MRSA, 56 (62.2%) were found to have a gram-negative infection, and 46 (51.1%) had polymicrobial infections. Cephalosporins and ß-lactam agents had a 59.2% efficacy rate against gram-positive bacteria and gentamicin showed a 94% sensitivity rate against gram-negative bacteria. Vancomycin (95.8% sensitivity) demonstrated the highest sensitivity for all gram-positive organisms. Amikacin (98.8% sensitivity), meropenem (96.3% sensitivity), and gentamicin (94.2% sensitivity) demonstrated excellent efficacy for all gram-negative organisms. Immuno-compromised status and Gustilo-Anderson type were the only independently predictive risk factors for infection in a multivariable model. Conclusions: Based on this analysis, the rate of MRSA, gram-negative, and polymicrobial infections in open fractures is high and increasing compared with historical cohorts. With the sensitivity of early generation cephalosporins being relatively poor against gram-positive organisms, the present antibiotic regimen for open, long-bone fractures may need to be reconsidered with these emerging trends.

A Meta-Analysis of Arthroscopic Meniscal Repair: Inside-Out versus Outside-In versus All-Inside Techniques.

Meniscal repair has been introduced to preserve knee function and limit the accelerated degenerative changes associated with meniscal tissue resection. Arthroscopic techniques have evolved to improve morbidity. However, there are few clinical outcome studies in the peer-reviewed literature that compare the use of these approaches. Therefore, our purpose was to perform a meta-analysis of the existing literature on arthroscopic meniscal repair techniques. Specifically, we evaluated differences in: (1) operating time; (2) incidence of postoperative meniscal healing; (3) functional outcomes, using various scoring systems; and (4) incidence of complications. We searched the peer-reviewed literature using SCOPUS, Medline, EMBASE, and Web of Science. Eight studies were eligible for the meta-analysis. These included one prospective, randomized trial (level I), three prospective, comparative studies (level II), and four retrospective, comparative studies (level III). There were a total of 476 patients who had a mean follow-up between 3 and 156 months. When evaluating objective outcomes, the inside-out technique had a significantly higher mean operating time than the all-inside technique. The inside-out and all-inside techniques had comparable meniscal healing rates, but the outside-in repair had a significantly higher rate of meniscal healing than the all-inside repair. Upon assessment of functional outcomes, the inside-out and all-inside methods had comparable International Knee Documentation Committee and Tegner activity scores, but the all-inside method had greater improvements in Lysholm scores. The inside-out and all-inside repairs had similar overall complication rates. All-inside repair may demonstrate lower operating times, but the outside-in repair may have superior meniscal healing rates. Functional outcomes are overall comparable between the techniques. However, there are limited clinical data on the outcome differences between these procedures, and further comparative studies with longer follow-up are needed.

Planning C2 pedicle screw placement with multiplanar reformatted cervical spine computed tomography.

OBJECT: Careful preoperative planning with thin-slice computed tomography (CT) scan is useful for hardware placement at C2. Prior studies have shown considerable variability in the proportion of C2 vertebrae considered safe for pedicle screw placement, depending on the imaging technique used. Our work sought to more carefully define that proportion using a refined imaging technique on a large number of submillimeter CT scans. MATERIALS AND METHODS: We reviewed 150 submillimeter cervical spine studies randomly selected from CT scans performed at a Level 1 trauma center. OsiriX™ image analysis software was used to propagate a 5-mm cylinder through the plane of the pedicle on paracoronal reformatted CT scans. Hounsfield unit attenuation was used to determine whether the cylinder violated the pedicle. Binomial data were generated to determine the proportion of pedicles that would allow safe screw placement. RESULTS: We analyzed 300 pedicles in 150 patients. Using a standard C2 pedicle starting point, 32% of pedicles were breached by the 5-mm diameter cylinder. When screw trajectory was adjusted by moving the cylinder to fit the pedicle isthmus, establishing an optimized starting point, only 14% of pedicles were breached. Average pedicle length was 27.3 mm for screws that would have crossed the isthmus versus 13.2 mm for screws that would have stopped short due to potential breach. CONCLUSIONS: Findings of the current work suggest that preoperative imaging analysis or navigation can be useful adjuncts when anatomical variants are present.

Intraoperative Evaluation of the Anatomic Lateral Distal Femoral Angle and Its Variation due to Positioning.

BACKGROUND/PURPOSE: Preoperative evaluation of the contralateral anatomic lateral distal femoral angle (aLDFA) at our institution is used to judge coronal plane alignment. In our study, we investigated 4 different techniques for obtaining an anteroposterior intraoperative fluoroscopic image of the distal femur to determine which technique provides (1) the greatest interobserver reliability; (2) the lowest variability from the previously published population mean; and (3) the lowest side-to-side variability. METHODS: Inclusion criteria included lower extremity injuries needing fixation that required intraoperative fluoroscopy with an intact femur and an intact extensor mechanism (N = 100). Fluoroscopic images were obtained of the distal femur in 4 positions differentiated by the position of the limb and the orientation of the C-arm beam to the femoral shaft. RESULTS: All measurement techniques resulted in mean measurements within one degree of 81 degrees. Variance between measurements was small among patients with all views, but images that involved a true anteroposterior with the beam perpendicular to the femur had the lowest rate of measurements that were <78 or >84 degrees. CONCLUSION: Side-to-side differences in patients were <2 degrees on average with every image used. With the best-performing images, 20% of patients had an aLDFA > 3 degrees different from the population mean of 81 degrees and 3% of patients were >5 degrees different. Although restoring aLDFA to 81 degrees will be within 3 degrees of the contralateral side the vast majority of the time, matching the aLDFA to the injured side will be the most accurate reconstruction.

Risk Factors for Kidney Dysfunction With the Use of Gentamicin in Open Fracture Antibiotic Treatment.

OBJECTIVES: To evaluate all patients who received gentamicin for open fracture treatment and determine the incidence of, and risk factors for, kidney injury in this population. DESIGN: Retrospective, case control. SETTING: Single institution; Level 1 trauma center. PATIENTS/PARTICIPANTS: A retrospective chart review identified patients who received gentamicin for open fracture antibiotic treatment from January 2008 to December 2012. Overall, 371 patients met the inclusion criteria and were categorized into 2 groups using risk, injury, failure, loss of kidney function, and end-stage kidney disease criteria: normal kidney function (74.9%) versus abnormal kidney function (25.1%). INTERVENTION: Use of gentamicin in open fracture antibiotic treatment. MAIN OUTCOME MEASUREMENTS: Kidney function; injury and treatment characteristics (eg, mechanism of injury; Gustilo-Anderson classification; number of surgical debridements, timing of definitive wound coverage, and type of wound coverage); and patient information (eg, age, height, weight, and body mass index, tobacco use, diabetes mellitus, human immunodeficiency virus, hepatitis, and current chemotherapy treatment). RESULTS: Those with abnormal kidney function had lower baseline creatinine (P < 0.001) and higher injury severity scores (16.5 vs. 11.8, P < 0.001) and were more likely to require intensive care unit admission (P < 0.001) than the normal group. Female sex (P = 0.015), and higher weight (P = 0.004), ICU admission (P < 0.001), and use of CT contrasted imaging (P < 0.001) were independently associated with abnormal kidney function. Abnormal kidney function incidence also sharply increased with age. CONCLUSIONS: Females and heavier individuals are at-risk of kidney injury while receiving gentamicin. ICU admission and concurent CT contrasted imaging are strongly associated with kidney injury in patients receiving gentamicin for open fracture treatment, and gentamicin should be avoided in those >60 years of age. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Stability of the Syndesmosis After Posterior Malleolar Fracture Fixation.

BACKGROUND: We sought to define the rate of syndesmotic instability after anatomic reduction of the posterior malleolus when posterior stabilization of a trimalleolar or trimalleolar equivalent ankle fracture was chosen vs when a supine position and initially conservative management of the posterior elements was chosen. METHODS: The types of syndesmotic and posterior malleolar fixation used to treat adult patients with ankle fractures involving the posterior malleolus at our level I trauma center were retrospectively assessed (N = 198). Specifically, both bimalleolar and trimalleolar fractures were included. Exclusion criteria included pilon fractures, trimalleolar fractures with Chaput fragments, and neurologic injury. Demographics, fracture classification, initial operative position, medial clear space, and posterior malleolar fragment size were recorded for each fracture. RESULTS: In total, 151 patients (76.3%) were initially positioned supine, 27.2% of whom had syndesmotic instability requiring operative stabilization. Almost 25% of supine patients also underwent posterior malleolar stabilization for posterior instability. Overall, 73 (48.3%) patients who were initially treated in the supine position needed some form of additional stabilization. Forty-seven patients (23.7%) were initially positioned prone. Syndesmotic stability was restored in 97.9% of these patients. This 2.1% rate of instability vastly differs from the 13-fold higher syndesmotic instability rate observed in the supine group ( P < .001). CONCLUSION: Our data demonstrate that the rate of syndesmotic instability was reduced in trimalleolar and trimalleolar equivalent fractures when prone positioning and direct fixation of the posterior malleolus were first performed. Using traditional preoperative estimates of posterior stability to determine the need for posterior malleolar fixation may be inadequate since almost a quarter of patients treated supine received posterior stabilization. LEVEL OF EVIDENCE: Level III, retrospective comparative series.

Chronic Physical Health Conditions and Emotional Problems From Early Adolescence Through Midadolescence.

OBJECTIVE: Chronic physical health conditions are highly prevalent in youth, frequently persisting into adulthood and contributing to the current and future health care burden in the United States. Our study evaluated associations of chronic physical health conditions with depressive and physiological anxiety symptoms in a community sample of youth and examined how those associations changed from early to midadolescence. METHODS: In this longitudinal study of 5147 youth, students and their caregivers were interviewed when youth were in grades 5 (mean age = 11), 7 (mean age = 13), and 10 (mean age = 16). Caregivers reported family sociodemographics, youth race/ethnicity, and youth chronic physical health history at baseline. Youth reported their depressive symptoms at each time point and their physiological anxiety symptoms at grades 7 and 10. RESULTS: At age 11, 28.5% had experienced a chronic physical health condition. Having any chronic physical health condition was related to elevated depressive symptoms at age 11 (2.05 ± 0.05 vs 1.89 ± 0.03; mean ± standard error; P < .01) and anxiety symptoms at age 16 (2.72 ± 0.06 vs 2.55 ± 0.04; P < .05). Experiencing multiple conditions was also related to experiencing more depressive symptoms (b = 0.13; P < .01) and physiological anxiety symptoms (b = 0.13; P < .05). After adjusting for previous mental health symptoms, having any condition still predicted anxiety at age 16. CONCLUSIONS: Children with chronic physical health conditions have an increased risk of depressive symptoms and physiological anxiety symptoms, especially in early and midadolescence. Repeated screening for these symptoms may help identify children in need of interventions.

Generating stability in elderly acetabular fractures-A biomechanical assessment.

BACKGROUND & OBJECTIVES: As the overall health and life expectancy increases in the United States, the incidence of fragility fractures in elderly patients also continues to increase. Given their medical comorbidities and decreased bone mineral density, acetabular fractures in the elderly population present a significant challenge to the orthopaedic trauma surgeon. The anterior column posterior hemitransverse (ACPHT) fracture pattern is a common fracture pattern in this population, and is often associated with central subluxation/dislocation of the femoral head with articular impaction. This study sought to delineate the most stable fixation construct in ACPHT fracture patterns in the elderly population. MATERIALS AND METHODS: The sample consisted of 3 groups of synthetic hemipelves (N=15), which were tested in order to compare stiffness by measuring motion at fracture lines under applied loads. The three groups of unique quadrilateral plate fixation were as follows: a specialty quadrilateral surface plate; 4 long peri-articular screws parallel to the quadrilateral surface into the ischium,; and an 8 hole infrapectineal buttress plate. Digital imaging system measured construct motion under load. Construct stiffness was estimated by linear regression of load between 50 and 850N versus average relative motion (average of relative motion at 200 points along the line of the osteotomy). Permanent deformation was estimated as the magnitude of relative motion upon unloading. RESULTS: Using ANOVA with Tukey's test to determine construct stiffness in loading, the group long peri-articular screws was found to have significantly higher stiffness than either of the other groups. Maximal fracture displacement was located at the intersection of the low transverse fracture line in the posterior column and the free quadrilateral surface fragment. CONCLUSIONS: Results indicate that the best fixation construct for this ACPHT acetabular fracture pattern includes independent lag screws across the anterior column and a pelvic brim plate with long periarticular screws maximizing posterior column fixation and preventing medialization of the free quadrilateral fragment. Although there are potential patient considerations that may complicate the placement of all 4 long screws, in most patients one or more of these screws can be safely placed in order to help prevent secondary displacement.

Extent and Morbidity of Lateralization of a Trochanteric Fixation Nail Blade.

This study examined the incidence and risk factors associated with lateral helical blade migration and trochanteric pain with the trochanteric fixation nail. A retrospective review was performed of 141 cases of pertrochanteric femur fracture treated with a trochanteric fixation nail at a level I trauma center over a period of 42 months. Exclusion criteria included follow-up of less than 60 days, preexisting osteonecrosis of the femoral head, and prophylactic trochanteric fixation nail treatment. Patient demographics, operative findings, and radiographic findings were recorded. Medical records were reviewed to identify symptomatic hardware. Overall, 27 patients (19.1%) were symptomatic, and 3 (2.1%) required revision surgery for blade prominence. Of the patients, 42 (30%) had lateralization of greater than 1 cm, and 16 of these (38.1%) were symptomatic (P<.02). A risk factor for lateralization was AO classification, with 46.1% of type A2 fractures showing lateralization of greater than 1 cm. The quality of calcar reduction nearly reached statistical significance, and 44.8% of patients who had inadequate reduction had lateralization of greater than 1 cm compared with 26.4% of patients who had adequate reduction (P=.054). Lateralization of greater than 1 cm was directly associated with the presence of symptoms (P<.001) and removal of hardware because of trochanteric pain (P=.007). Multivariate analysis showed that increasing tip-apex distance, inadequate calcar reduction, and greater fracture severity were predictive of excessive lateralization of greater than 1 cm. Nearly 20% of patients had lateral hip pain associated with cephalomedullary fixation. Final lateralization of the helical blade of greater than 1 cm was a very strong predictor of symptoms. During preoperative counseling, surgeons should caution patients about this relatively frequent and likely underreported complication. [Orthopedics. 2017; 40(5):e886-e891.].

Correlates of Depressive Symptoms in Older Adults with Diabetes.

Investigators examined correlates of depressive symptoms within a sample of older adults with diabetes. Participants completed a structured telephone interview with measures including depressive symptoms, health conditions, cognitive function, and diabetes distress. Correlations and hierarchical linear regression models were utilized to examine bivariate and covariate-adjusted correlates of depressive symptoms. The sample included 246 community-dwelling adults with diabetes (≥ 65 years old). In bivariate analyses, African Americans, individuals with specific health issues (neuropathy, stroke, respiratory issues, arthritis, and cardiac issues), and those with higher levels of diabetes distress reported more depressive symptoms. Older age, higher education, more income, and better cognitive function were inversely associated with depressive symptoms. In the final covariate-adjusted regression model, stroke (B = .22, p < .001), cognitive function (B = -.14, p < .01), and higher levels of diabetes-related distress (B = .49, p < .001) each were uniquely associated with more depressive symptoms. Diabetes distress partially mediated the associations between cardiac issues and depressive symptoms and between cognitive function and depressive symptoms. Findings suggest that interventions targeted at helping older adults manage their diabetes-related distress and reducing the likelihood of experiencing additional health complications may reduce depressive symptoms within this population.