Effect of Antibiotic Administration Before Joint Aspiration on Synovial Fluid White Blood Cell Count in Native Joint Septic Arthritis.

Background: This study was performed to assess the impact of preaspiration antibiotics on synovial fluid analysis and timing of operative treatment in native-joint septic arthritis. Methods: We performed a retrospective record review of adult patients from an urban level 1 trauma center with native joint septic arthritis in 2015-2019, identified by means of codes from the International Classification of Diseases (Ninth Revision and Tenth Revision). Univariate and multivariate analyses were performed to determine whether antibiotics were associated with lower synovial fluid white blood cell counts (WBCs), the percentage of polymorphonuclear neutrophil (PMNs), and rate of culture positivity. Secondary analysis included time elapsed from aspiration to surgery. Results: Of the 126 patients with septic joints included, nearly two-thirds (n = 80 [63.5%]) received antibiotics before joint aspiration. The synovial fluid WBC count, percentage of PMNs, and rate of culture positivity were significantly lower in patients who received preaspiration antibiotics than in those who did not (mean WBC count, 51 379.1/µL [standard deviation, 52 576.3/µL] vs 92 162.7/µL [59 330.6/µL], respectively [P < .001]; PMN percentage, 83.6% [20.5%] vs 91.9% [6.0%; P = .01]; and culture positivity, 32.5% vs 59.1% [P = .008]). Multivariable analyses revealed that these associations remained after controlling for potential confounders (change in PMNs, -42 784.60/µL [95% confidence interval, -65 355/µL to -20 213.90/µL [P < .001]; change in PMNs, -7.8% [-13.7% to -1.8%] [P = .01]; odds ratio, 0.39 [.18-.87; P = .02). Patients with a synovial fluid WBC count ≤50 000/µL experienced significant delay in time from joint aspiration to operative intervention (mean [standard deviation], 10.5 [11.3] vs 17.9 [17.2] hours; P = .02). Conclusions: The administration of antibiotics before joint aspiration for suspected septic arthritis appears to decrease the synovial fluid WBC count, the percentage of PMNs, and the rate of culture positivity. Efforts to limit antibiotic administration before joint aspiration are important to minimize diagnostic dilemmas and circumvent treatment delays.

Incidence of Complications and Revision Surgery After High Tibial Osteotomy: A Systematic Review.

BACKGROUND: High tibial osteotomy (HTO) is a well-recognized procedure for its effectiveness in treating symptomatic early knee arthritis and malalignment. Although there are numerous systematic reviews evaluating the management and outcomes after HTO, there are few investigations on complications of this procedure. PURPOSE: To systematically review the literature to determine the incidence of intraoperative and postoperative complications associated with medial opening wedge and lateral closing wedge HTOs. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: The Cochrane Database of Systematic Reviews, PubMed, Embase, and MEDLINE databases were queried for studies reporting complications associated with HTO with or without concomitant procedures. Data including patient characteristics, procedure type, concomitant procedures, follow-up time, and postoperative imaging were extracted. Rates of intra- and postoperative complications, reoperations, and conversion to arthroplasty were recorded. RESULTS: A total of 71 studies were included for analysis, comprising 7836 patients. The overall intraoperative complication rate during HTO was 5.5% (range, 0%-29.3%), and the overall postoperative complication rate was 6.9% (range, 0%-26.6%). The most common intraoperative complication was lateral hinge fracture (incidence, 9.1%; range, 0%-30.4%) in medially based HTOs and peroneal nerve injury in laterally based HTOs (incidence, 3.2%; range, 0%-8.7%). The overall incidence of neurovascular injury after medially or laterally based HTOs was 1.1% (range, 0%-18.9%). The most common postoperative complication was superficial infection (incidence, 2.2%; range, 0%-13%). Of the included studies, 62 included postoperative radiographic analysis, and among those, the incidence of nonunion was 1.9% (range, 0%-15.5%), loss of correction was 1.2% (range, 0%-34.3%), and implant failure was 1.0% (range, 0%-10.2%). Among studies reporting revision surgeries, the overall reoperation rate was 15.5% (range, 0%-70.7%), with the most common type of reoperation being hardware removal (incidence, 10.0%; range, 0%-60%). CONCLUSION: Intraoperatively, medially based HTOs are associated with a 1 in 11 risk of lateral hinge fracture and laterally based HTOs with a 1 in 30 risk of peroneal nerve injury. Postoperative complication rates in the range of 10% to 15% can be expected, including infection (2.9%), loss of correction (1.2%), and nonunion (1.9%). Patients should also be counseled that the reoperation rate is approximately 15%, with hardware removal being the most common procedure.

Predictors of Hardware Removal in Orthopaedic Trauma Patients Undergoing Syndesmotic Ankle Fixation With Screws.

Background: Indications for removal of syndesmotic screws are not fully elucidated. This study aimed to determine factors related to elective syndesmotic screw removal. Methods: Patients who underwent fixation of ankle syndesmotic injuries were included. Screw removal was offered after a minimum of 12 weeks after surgery for pain, stiffness or patient desire to remove painful or broken hardware. Patient demographics, surgical data, distance of the syndesmotic screw from the joint, location of the screw at the physeal scar, and number of syndesmotic screws placed were collected for all patients. Bivariate and multivariate analyses were performed to determine the relationship between patient characteristics and screw removal and independent predictors of hardware removal. Results: Of 160 patients, 60 patients (38%) with an average age of 36.1 (range: 18-84) years underwent elective syndesmotic screw removal at a mean of 7 (range, 3-47) months after initial fixation. The most common reason for screw removal (50/60 patients) was ankle stiffness and pain (83%). Patients who underwent screw removal were more likely to be younger (36.1 years ± 13.0 vs 46.6 years ± 18.2, P < .001) and have a lower ASA score (2 ± 0.8 vs 2.1 ± 0.7, P = .003) by bivariate analysis. Of patients who underwent screw removal, 21.7% (13/60) had a broken screw at the time of removal. Whether the screw was placed at the physeal scar was not significantly associated with patient decision for hardware removal (P = .80). Conclusion: Younger and healthier patients were more likely to undergo elective removal of syndesmotic hardware. Screw distance from joint and screw placement at the physeal scar were not significantly associated with hardware removal. Level of Evidence: Level III, retrospective cohort study.

Heterotopic Ossification Remodeling After Acetabular Surgery: A Natural History Case Report.

CASE: A 30-year-old woman presented with a transverse plus posterior wall acetabular fracture and underwent operative fixation through a Kocher-Langenbeck approach. Shared decision was made for no heterotopic ossification (HO) prophylaxis. The patient developed symptomatic HO and was scheduled for resection, which was delayed because of the pandemic. She returned with interval remodeling of HO and symptom resolution. No surgery was required. CONCLUSION: HO is a common complication after acetabular injury. Resection is the treatment of choice for symptomatic HO. We are not aware of other reports of spontaneous remodeling of symptomatic HO such that it no longer required surgery.

How to place a cephalomedullary screw when visualization is obscured by the jig in peritrochanteric hip fractures using "peek radiographs."

Lag screw positioning can be difficult to discern intraoperatively on lateral fluoroscopic imaging during intramedullary fixation of proximal femur fractures in some nailing systems due to the drill guide handle obstructing the view. We have described a method of obtaining non-obstructed lateral-oblique "peek" views that reliably assist in obtaining adequate tip-apex distance (TAD) measurements when using intramedullary fixation for these fractures. The purpose of this study was (1) to describe an intraoperative radiographic technique to obtain non-obscured views for appropriate center-center placement of the lag screw(s) within the femoral head during jig-aided cephalomedullary nailing of peritrochanteric hip fractures and (2) to present a case series detailing the radiographic results using this technique. This clinical series of sixty-five patients with intertrochanteric or subtrochanteric proximal femur fractures stabilized with a cephalomedullary nail had an average TAD of 15.1 ± 3.3mm (range: 9.4mm-26.2mm). This suggests that our technical trick of obtaining "peek" radiographs intraoperatively may aid in a precise lag-screw placement.

Is Patellar Instability a Contraindication to Semiextended Tibial Nailing?: A Case Report.

CASE: We report a 40-year-old woman with undiagnosed patellofemoral instability that worsened 8 months after intramedullary nailing of a distal left tibia fracture in the semiextended position through a partial medial parapatellar approach. Patella stability and asymptomatic knee function were restored after IM nail removal, medial patellofemoral ligament repair, and left tibial tubercle transposition. CONCLUSION: The optimal surgical approach for tibial IM nailing in patients with chronic patellar instability has not been described. Clinicians should be cognizant of the potential for worsening patellofemoral instability in these patients when using the medial parapatellar approach in the semiextended position.

Is fixation of the medial malleolus necessary in unstable ankle fractures?

INTRODUCTION: It is unclear whether the medial malleolus in unstable bi- and tri- malleolar ankle fractures without medial talar displacement should be addressed surgically. This study reviews a fixation protocol for the medial malleolar component of unstable bi- or tri- malleolar ankle fractures. MATERIALS AND METHODS: Two hundred fifty-seven patients who sustained bi- (AO/OTA 44-B2) or tri- (AO/OTA 44-B3) malleolar ankle fractures between January 2005 and August 2019 at two Level 1 trauma centers were retrospectively identified. Medial malleolar fractures were defined as anterior, supra or intercollicular fractures based on the exit of the posterior fracture line. Fixation of the medial malleolar component was performed based on surgical algorithm. Only large or significantly displaced medial malleolar fractures were fixed if the soft tissues were amenable. Primary outcome measure was the presence of medial-sided ankle pain after operative or non-operative treatment of the medial malleolar fracture after a minimum follow up of 6 months. Presence of pain was defined by a pain score of 3 or higher on a 10-point VAS pain score at the site of the medial malleolar fracture. RESULTS: Significantly more patients in the supracollicular group reported the presence of pain when this type was not fixed versus fixed (28 vs 14%, p = 0.0094). Significantly more patients in the anterior collicular subgroup reported the presence of pain when this type was fixed versus not fixed (40 vs 10%, p = 0.0438). There was no difference in the number of patients reporting pain in the intercollicular group when comparing those who were fixed versus not fixed, (21 vs 22%, p = 1.000). CONCLUSIONS: When examining post-operative pain, not all medial malleolar fractures require fixation when appropriately selected based on fracture pattern. Only 10% of patients with anterior collicular fractures reported pain after non operative management. Unsurprisingly, more patients in the supracollicular fractures reported pain without surgery compared to with surgery. Fracture pattern should be considered in the treatment algorithm for the medial malleolar component in bi- and tri- malleolar fractures.

Impingement and perforation of the anterior femoral cortex in cephalomedullary nailing: Systematic review and surgical techniques.

BACKGROUND: Anterior femoral cortical impingement and perforation are known risks of cephalomedullary nailing. The incidence of and risk factors for these findings have not been fully established in the literature. The purpose of this review was to answer: (1) What is the incidence of anterior femoral cortical impingement and perforation associated with cephalomedullary nailing of proximal femur fractures? (2) How does incidence vary by nail radius of curvature (ROC)? (3) What populations are at increased risk of impingement and perforation? (4) What surgical techniques prevent their occurrence? HYPOTHESIS: Our hypothesis was that impingement would be a relatively common finding following cephalomedullary nailing, and perforation would be much less frequent but still an appreciable risk. Secondarily, nails with a larger ROC would have a higher rate of impingement. PATIENTS AND METHODS: In this systematic review, PubMed, MEDLINE, and Cochrane databases were searched for articles from 1990-2020 written in English using the terms "cephalomedullary nail" or "femoral nail" and "perforation" or "impingement", and similar words. Inclusion criteria were studies discussing the complication of anterior femoral cortical impingement or perforation associated with the use of a cephalomedullary nail. Fourteen studies met inclusion criteria. Rates of anterior femoral cortical impingement or perforation, patient demographics, nail type, and ROC were extracted. Surgical techniques to prevent perforation were qualitatively reviewed. RESULTS: The rate of anterior cortical impingement with long cephalomedullary nails was 17.2% (192/1117 patients) and with short nails was 29.2% (176/602). The rate of anterior cortical perforation with long nails was 1.0% (11/1116) and with short nails was 0% (0/234). Long nails with ROC>150cm showed an impingement rate of 10.9% (62/567) and perforation rate of 1.1% (7/617 patients). Nails with ROC 150cm or 100cm had an impingement rate of 1.1% (1/93) and perforation rate of 0% (0/93). DISCUSSION: Impingement and perforation of the anterior femoral cortex during cephalomedullary nailing are appreciable risks that surgeons should anticipate and avoid, especially in certain populations and with nails with larger ROC. Surgeons may consider use of long nails with ROC 150cm and below, given a nearly 10-fold lower incidence of impingement and no reported perforations. LEVEL OF EVIDENCE: Therapeutic, level IV.

Anterior Compartment Neurovascular Bundle Entrapment in a Minimally Displaced Distal Tibial Fracture: A Case Report.

CASE: A 29-year-old woman presented with a low-energy, minimally displaced pilon fracture with progressive pain and paresthesias in the affected foot, ultimately requiring open reduction and internal fixation. Intraoperatively, the deep peroneal nerve and anterior tibial artery and vein were entrapped within the fracture. After freeing the bundle and fixing the fracture, the paresthesias improved and ultimately resolved. CONCLUSION: Injury to the anterior leg compartment neurovascular structures should be considered in low-energy, minimally displaced pilon fractures. In this instance, progressive neurologic symptoms not consistent with the radiographic findings indicated the patient for surgical exploration and fixation.

Patient Perceptions of Telehealth Orthopedic Services in the Era of COVID-19 and Beyond.

The coronavirus disease 2019 (COVID-19) pandemic necessitated an unprecedented increase in the use of telehealth services in orthopedics. Patient attitudes toward and satisfaction with virtual orthopedic services remain largely unexplored. A prospective study of all orthopedic patients at a tertiary academic medical center who had a telehealth appointment between April 1, 2020, and May 5, 2020, was performed to assess patients' experience with a validated 21-item telehealth satisfaction questionnaire. The survey contained statements designed to assess patients' level of agreement with numerous aspects of telehealth, including convenience, the surgeon's ability to engage in care, ease of use, and future use of telehealth. Most respondents (86.7%) were satisfied with the telehealth system. The majority of patients expressed that the system is easy to use (90.0%), is convenient (86.7%), and saves them time (83.3%). Nearly all (95%) patients agreed that their surgeon could answer their questions with the use of this technology, although nearly half (46.6%) identified the lack of physical contact during the examination as problematic. Only 46.7% of patients agreed that telehealth should be a standard form of health care delivery in the future; these patients were found to have significantly longer commute times compared with those who did not (52.1±58.2 vs 28.3±19.2, P=.03). Patient perspectives on the widespread adoption of telehealth, such as ease of use, privacy protection, and convenience, showed that these anticipated barriers may be some of the greatest advantages of telehealth. The COVID-19 pandemic may have provided the momentum for telehealth to become a mainstay of orthopedic health care delivery in the future. [Orthopedics. 2021;44(5):e668-e674.].

Public perceptions and disparities in access to telehealth orthopaedic services in the COVID-19 era.

BACKGROUND: We used online crowdsourcing to explore public perceptions and attitudes towards virtual orthopaedic care, and to identify factors associated with perceived difficulty navigating telehealth services during the COVID-19 pandemic. METHODS: A modified version of the validated Telemedicine Satisfaction and Usefulness Questionnaire was completed by 816 individuals using crowd-sourcing methods. Multivariable logistic regression modelling was used to determine population characteristics associated with perceived difficulty using telehealth technology. RESULTS: Most respondents (85%) believed that telehealth visits would be a convenient form of healthcare delivery, and 64% would prefer them over in-person office visits. The majority (92%) agreed that telehealth would save them time, but 81% had concerns regarding the lack of physical contact during a musculoskeletal examination. More respondents would feel comfortable using telehealth for routine follow-up care (81%) compared to initial assessment visits (59%) and first postoperative appointments (60%). Roughly 1 in 15 (7%) expressed difficulty with using telehealth; these respondents were more often unmarried, lower-income, and more medically infirm, and reported greater symptoms of depression. After multivariable adjustment, lower income and poor health were retained as predictors of difficulty with navigating telehealth technology (p = 0.027,p = 0.036, respectively). CONCLUSION: The majority of the public appears receptive to telehealth for orthopaedic care for both new patient visits and follow-up appointments. The finding that people with multiple chronic conditions and psychosocial needs struggle to engage with telehealth suggests that those who arguably stand to benefit the most from continued care are the ones being unintentionally left out of this digitization boom.

Inflammatory and Coagulative Considerations for the Management of Orthopaedic Trauma Patients With COVID-19: A Review of the Current Evidence and Our Surgical Experience.

Mounting evidence suggests that the pathogenesis of coronavirus disease 2019 (COVID-19) involves a hyperinflammatory response predisposing patients to thromboembolic disease and acute respiratory distress. In the setting of severe blunt trauma, damaged tissues induce a local and systemic inflammatory response through similar pathways to COVID-19. As such, patients with COVID-19 sustaining orthopaedic trauma injuries may have an amplified response to the traumatic insult because of their baseline hyperinflammatory and hypercoagulable states. These patients may have compromised physiological reserve to withstand the insult of surgical intervention before reaching clinical instability. In this article, we review the current evidence regarding pathogenesis of COVID-19 and its implications on the management of orthopaedic trauma patients by discussing a case and the most recent literature. LEVEL OF EVIDENCE:: Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Hospital Stays and Medical Expenses Increase Nationwide Among Patients With Septic Arthritis of the Shoulder Who Inject Drugs.

The authors determined the proportion of patients nationwide with septic arthritis of the shoulder who inject drugs, evaluated differences in hospitalization outcomes and charges between patients with and without injection drug use (IDU), and quantified demographic trends among patients with IDU from 2000 to 2013. Nationally representative data of patients with a principal discharge diagnosis of shoulder septic arthritis were obtained from the Nationwide Inpatient Sample 2000-2013. Using published algorithms, the authors classified septic arthritis of the shoulder as related or unrelated to IDU. They compared length of stay, leaving against medical advice, number of procedures, and mortality rates between the 2 groups, using regression models to control for age, sex, and race. Fifteen percent (95% confidence interval [CI], 13.6%-16.5%) of septic arthritis cases were associated with IDU. From 2000 to 2013, shoulder septic arthritis associated with IDU increased 4-fold. After controlling for age, sex, and race, individuals who inject drugs stayed in the hospital for 3.7 more days (95% CI, 2.4-5.0), incurred an average of $13,250 more charges for medical care (95% CI, $2635-$23,866), and were 5.54 times more likely (95% CI, 3.22-9.55) to leave against medical advice than those without IDU. From 2000 to 2013, there was an increase in the proportion of patients with IDU-related septic arthritis of the shoulder between 35 and 54 years old and 55 and 64 years old, and an increase in the proportion who were white. Injection drug use-related shoulder septic arthritis is linked to suboptimal inpatient outcomes and greater resource use. [Orthopedics. 2020;43(4):e270-e277.].

Magnetic Resonance Imaging of Trauma Patients Treated With Contemporary External Fixation Devices: A Multicenter Case Series.

OBJECTIVES: To report the safety and clinical outcomes of placing current magnetic resonance imaging (MRI) components inside and outside the MRI bore during MRIs. DESIGN: Retrospective case series. SETTING: Four trauma centers (3 Level I and 1 Level II), from January 2005 to January 2015. PATIENTS: All patients who had MRIs with external fixators in place either inside or outside the MRI bore. INTERVENTION: MRI of patients with external fixator in place. MAIN OUTCOME MEASUREMENTS: Adverse events were defined as catastrophic pullout of the external fixator during the MRI, thermal injury to the skin, severe field distortions precluding the intended imaging, alterations of the magnetic field, or visible structural damage to the magnet casing. RESULTS: Thirty-eight patients with 44 external fixators were identified who had MRI with the fixator inside or outside the MRI bore. Twelve patients with 13 external fixators had MRI with the external fixator inside the MRI bore. Twenty-seven patients with 32 external fixators had MRI with the external fixator outside the MRI bore. There were no adverse events. CONCLUSIONS: Although no universal guidelines exist, there are circumstances in which obtaining MRIs of patients with external fixators can be safe. This is the first clinical series with the primary outcome of safety when placing modern external components both inside and outside an MRI bore during a scan. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Functional Outcomes of Elderly Patients With Nonoperatively Treated Acetabular Fractures That Meet Operative Criteria.

OBJECTIVES: To report functional outcomes of displaced acetabular fractures treated nonoperatively in the geriatric patient population. DESIGN: Retrospective case series. SETTING: Two Level I trauma centers. PATIENTS: Twenty-seven patients 60 years of age or older who sustained displaced acetabular fractures during an 11-year period. INTERVENTION: Nonoperative treatment. MAIN OUTCOME MEASUREMENTS: Primary outcome measurements were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and Short Form 8 (SF-8) scores. Secondary outcome measurements were conversion to open reduction and internal fixation or total hip arthroplasty and 1-year mortality. RESULTS: Twenty-six patients completed the WOMAC and SF-8 surveys. The overall WOMAC score was 12.9 ± 15.6 (range, 0-59.4). The average physical SF-8 was 51.1 ± 8.7 (range, 30.4-58.6), and the average mental SF-8 was 55 ± 6.2 (range, 30.4-58.6). The 1-year mortality rate was 24%. Conversion of treatment occurred in 15% of patients. CONCLUSIONS: Elderly patients with fracture patterns that would qualify for operative treatment in younger healthy patients had surprisingly good outcome scores when treated nonoperatively. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Balancing Life and Work in a 2-Physician Relationship: Redefining the "Power Couple".

Balancing the requirements of work and personal life can be a struggle. It is challenging to do on your own, but even more difficult when partnered with someone with similar career goals. Often times, career choices are prioritized over personal ones, which puts stress on interpersonal relationships and time spent with our partner. Despite this struggle, it seems that 2-physician relationships are becoming more common-and they are succeeding. This article reviews the successes and challenges of the 2-physician relationship.

Effect of surgical treatment on mortality after acetabular fracture in the elderly: a multicenter study of 454 patients.

OBJECTIVES: Controversy exists regarding the effect of operative treatment on mortality after acetabular fracture in elderly patients. Our hypothesis was that operative treatment would confer a mortality benefit compared with nonoperative treatment even after adjusting for comorbidities associated with death. DESIGN: Retrospective study. SETTING: Three University Level I Trauma Centers. PATIENTS/PARTICIPANTS: All patients aged 60 years and older with acetabular fractures treated from 2002 to 2009 were included in the study. Four hundred fifty-four patients were identified with an average age of 74 years. Sixty-seven percent of the study group was male and 33% female. INTERVENTION: One of 4 treatments: nonoperative management with early mobilization, percutaneous reduction and fixation, open reduction and internal fixation, acute total hip arthroplasty. MAIN OUTCOME MEASUREMENTS: Kaplan-Meier survival curves were created, and Cox proportional hazards models were used to calculate unadjusted and adjusted hazard ratios (HRs) for covariates of interest. RESULTS: In contrast to previous smaller studies, the overall mortality was relatively low at 16% at 1 year [95% confidence interval (CI), 13-19]. Unadjusted survivorship curves suggested higher 1-year mortality rates for nonoperatively treated patients (21% vs. 13%, P < 0.001); however, nonoperative treatment was associated with other risk factors for higher mortality. By accounting for these patient risk factors, our final multivariate model of survival demonstrated no significant difference in hazard of death for nonoperative treatment (0.92, P = 0.6) nor for any of the 3 operative treatment subgroups (P range, 0.4-0.8). As expected, we did find a significantly increased hazard for factors such as the Charlson comorbidity index [HR, 1.25 per point (95% CI, 1.16-1.34)] and age [HR, 1.08 per year of age more than 70 years (95% CI, 1.05-1.11)]. In addition, associated fracture patterns (compared with elementary patterns) significantly increased the hazard of death with a ratio of 1.51 (95% CI, 1.10-2.06). CONCLUSIONS: The operative treatment of acetabular fractures does not increase or decrease mortality, once comorbidities are taken into account. The reasons for this are unknown. Regardless of the causes, the decision for operative versus nonoperative treatment of geriatric acetabular fractures should not be justified based on the concern for increased or decreased mortality alone. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Semi-extended nailing of metaphyseal tibia fractures: alignment and incidence of postoperative knee pain.

OBJECTIVES: To review a large series of tibial metaphyseal fractures treated with nailing in semi-extension (20-30 degrees) using a superomedial portal. To report on the quality and maintenance of reduction. To compare knee pain at final follow-up with a group nailed in hyperflexion (>90 degrees) with a standard inferior incision and parapatellar approach. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENTS: One hundred eighty-five consecutive tibia fractures were treated with intramedullary nails. Eighty-four patients with fractures affecting the proximal (50) or distal (34) metaphysis were nailed with the knee in semi-extension. One hundred one with diaphyseal fractures were nailed in standard hyperflexion and were used as a comparison group. OUTCOME MEASURES: Knee pain was recorded at the final follow-up and graded on a 0-3 scale as per Court-Brown. Alignment was measured on full-length biplanar radiographs immediately postoperative and compared with the same radiographs at union. RESULTS: There was no statistical difference in the number of patients without knee pain at union (P = 0.7). Radiographic angulation at the fracture was <5 degrees in all patients immediately postoperative, and no patient lost reduction. The average follow-up was 2.3 years. CONCLUSIONS: Knee pain after semi-extended tibial nailing was similar in frequency compared with standard nailing. There were no significant angulatory deformities, and no losses of reduction for both proximal and distal metaphyseal fractures nailed with the semi-extended technique. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Do locking screws work in plates bent at holes?

OBJECTIVES: To assess whether plate bending at a hole significantly changes the biomechanical properties of a locked screw. METHODS: Coronal plane bends of 5-, 15-, or 45-degree angles were placed in 3.5-mm locking compression plates with the apex at a locking hole. An additional 45-degree angle test group was created in which a threaded screw head insert was placed before bending. Ten plates were tested in each group and compared with nonbent controls in a stepwise cyclic loading protocol. RESULTS: Statistically significant differences in protocol survival were shown between the control group and the 15-degree angle (P = 0.006) and 45-degree angle (P = 0.0007) groups. An apparent decrease in protocol survival in the 5-degree angle group did not reach statistical significance (P = 0.17). The average number of cycles survived was significantly different between the control group and the 15-degree angle (P = 0.027) and 45-degree angle (P = 0.0002) groups. The mean cycles to failure for the 5-degree angle group was 16% lower than for controls but did not reach statistical significance (P = 0.37). The test group bent to an angle of 45 degrees after placement of a threaded screw head insert showed no difference in protocol survival or in mean number of cycles survived compared with the regular 45-degree angle group. CONCLUSION: Bending of a 3.5-mm locking compression plate by more than 5 degrees at a locking hole results in a statistically significant decrease in survival of the corresponding locked screw. This effect cannot be prevented by the placement of a threaded screw head insert before bending.

Knee pain correlates with union after tibial nailing.

OBJECTIVES: The purpose of this study is to evaluate the change in quantitatively scored knee pain during union. DESIGN: This is a retrospective review of prospectively collected data over a 15-year period. SETTING: Academic medical center. PATIENTS: All patients treated with an intramedullary nail were evaluated for knee pain and union. Four hundred twenty-eight patients with 443 tibia fractures were included. INTERVENTION: All tibia fractures were treated with an intramedullary nail. OUTCOMES: Patient-based knee pain was scored from 0 to 3. Fracture union was also graded using a modified Hammer score based on cortical bridging and remodeling. RESULTS: We found a significant inverse association between pain and union score (P < 0.01). In contradistinction, there was not a correlation between time from surgery and pain (P = 0.13). Because union score and time were related, a model was created with both parameters. This model demonstrated a statistical correlation with union score (P < 0.01), but not for time from surgery (P = 0.18). CONCLUSIONS: We postulated that knee pain may correlate with either union or time from surgery. We found a statistically significant, negative correlation between knee pain and fracture union. There was no such association between pain and time from surgery.