Imaging of Postoperative Infection at the Knee Joint.

Postoperative infections of the knee are uncommon but may occur with joint arthroplasties, fracture fixation, or after arthroscopic procedures. The ultimate diagnosis is made by joint aspiration or tissue sampling. Joint aspiration and tissue sampling can be performed under imaging guidance or intraoperatively. Imaging is an important adjunct to clinical and laboratory findings and should start with radiographs. Cross-sectional imaging including magnetic resonance (MR) imaging, computed tomography (CT), nuclear studies, and ultrasound (US) are frequently used if the diagnosis is in doubt and to evaluate the extent of disease. We discuss the current algorithm in the diagnosis of various postoperative infections of the knee joint. The article addresses the utility of radiography, MR imaging, CT, US, and the most commonly used nuclear studies in the diagnosis of various postoperative knee infections and the imaging appearances of these infections on each of these diagnostic modalities.

Republication of "Ankle Fracture-Dislocations: A Review".

Ankle fractures are common musculoskeletal injuries that may result in tibiotalar joint dislocations. Ankle fracture-dislocations occur via similar mechanisms as ankle fractures, although the persistence or magnitude of the deforming force is sufficient to disrupt any remaining bony or soft-tissue stability. Ankle fracture-dislocations likely represent distinct clinical entities, as the pathology, management, and patient outcomes following these injuries differ from those seen in more common ankle fractures without dislocation. Ankle fracture-dislocations have higher rates of concomitant injury including open fractures, chondral lesions, and intra-articular loose bodies. Long-term outcomes in ankle fracture-dislocations are worse than ankle fractures without dislocation. Higher rates of posttraumatic osteoarthritis and chronic pain have also been reported. In this review, we discuss the current literature regarding the history, management, and outcomes of ankle-fracture dislocations and highlight the need for future study.

Inpatient soft tissue protocol and wound complications in calcaneus fractures.

BACKGROUND: Operative treatment of calcaneus fractures is associated with the risk of early wound complications. Though accepted practice dictates surgery should be delayed until soft tissues recover from the initial traumatic insult, optimal timing of surgery has not been delineated. METHODS: A retrospective chart and radiographic review at a level I trauma center was performed to determine if an aggressive inpatient soft tissue management protocol designed to decrease the time delay from injury to surgery is effective at reducing complications. Ninety-seven patients (17 female, 80 male; mean age, 39.7±14.0 years) with 102 calcaneus fractures treated between October 1995 and January 2005 were identified. Differences in complication rates and quality of reduction between the inpatient and outpatient treatment groups were analyzed. Quality of reduction was determined by measuring postoperative Bohler's angle and posterior facet articular step-off. RESULTS: Mean time from injury to surgery was 6.2 days for the inpatient group and 10.8 days for the outpatient group (p<0.0001). The overall complication rate was over twice as high in the outpatient group (27 versus 12%, p=0.04) and the serious complication rate was 6.5 times higher when patients were managed as outpatients (9% versus 1%, p=0.09). With the numbers available, there were no significant differences in the quality of reduction obtained at surgery. CONCLUSION: This study suggests that this inpatient soft tissue management protocol of calcaneal fractures is a feasible treatment option when a patient is kept in the hospital that offers a reduction in postoperative wound complications while enabling surgery 4 days earlier on average.

Ultrasound Evaluation of Radial Nerve Palsy Associated with Humeral Shaft Fractures to Guide Operative Versus Non-Operative Treatment.

OBJECTIVE: To determine the effectiveness of diagnostic ultrasound (US) at evaluating the condition of the radial nerve in the setting of humeral shaft fractures. MATERIALS AND METHODS: An observational study was performed of 18 patients with radial nerve palsy associated with humeral shaft fractures who underwent US examination to assess the condition of the radial nerve. RESULTS: Six patients with humeral shaft fractures treated nonoperatively in a functional brace had US findings consistent with contusion or stretch radial nerve injury. Twelve patients ultimately underwent surgery either because US showed an entrapped or lacerated radial nerve, or for other operative indications. There was a 92% concordance (11/12 patients) between US and intraoperative findings with regards to the condition and location of the radial nerve, with the remaining case being complicated by delayed surgical treatment secondary to patient factors. CONCLUSION: Our study demonstrates that US is an effective diagnostic tool in evaluating radial nerve injuries in the setting of humeral shaft fractures and can aid in clinical decision making by differentiating between patients with nerve laceration or entrapment who may benefit from surgery from those with neurapraxia managed nonoperatively.

"Jelly VAC" for Negative-Pressure Therapy for Complex Wound Closure: A Report of Two Cases.

CASE: A 35-year-old man sustained an open calcaneal fracture with bone loss, and a 57-year-old woman sustained an avulsion of the entirety of the plantar skin. Both patients were treated with multiple debridements and soft-tissue coverage. "Jelly-VAC" (vacuum-assisted closure) therapy was used after each debridement and during the soft-tissue coverage. CONCLUSION: Jelly-VAC therapy is a promising alternative that allows negative-pressure therapy with the use of ultrasound jelly to prevent air leakage into the wound. We propose using this technique in areas where obtaining a seal is difficult, where VAC therapy is contraindicated because of adhesive dressings (i.e., with damaged or poor-quality skin), or when long-term VAC therapy is needed to prevent wound maceration or there is a need for "VAC holidays."

Prothrombin Complex Concentrates: An Alternative to Fresh Frozen Plasma.

Insufficiency fractures are a common cause of morbidity among geriatric patients worldwide. Improved outcomes are known to result from decreased delay to definitive operative fixation and mobilization. Use of warfarin is an important potential cause of delay. The ideal mode of warfarin reversal is currently unknown. Prothrombin complex concentrates (PCCs) offer rapid correction with small infusion volume, both of which are important for elderly patients with multiple comorbidities. The authors present 2 cases of insufficiency fractures occurring in geriatric patients receiving warfarin therapy reversed with a 3-factor PCC. Both patients were independent, community ambulators without significant functional disability and returned to their prior level of functioning. There were no significant bleeding or venous thromboembolic complications. To the authors' knowledge, no previous reports have described the use of PCC in geriatric patients with fractures. Nonetheless, its potential is well documented in emergency and trauma surgery literature. The use of PCC could potentially allow surgeons and hospitals to avoid complications related to immobility and the associated costs of treatment, extended hospital stay, and readmission. The authors' limited experience suggests 3-factor PCC preparations may provide adequate correction to allow expeditious surgical treatment. [Orthopedics. 2017; 40(2):e367-e369.].

Management of postoperative complications: general approach.

The goal of postoperative management is to promote early mobility and avoid postoperative complications, recognizing the potentially devastating impact of complications on elderly patients with hip fracture. The recommended approach involves early mobilization; freedom from tethers (indwelling urinary catheters and other devices); effective pain control; treating malnutrition; preventing pressure ulcers; reducing risk for pulmonary, urinary, and wound infections; and managing cognition. This carefully structured and patient-centered management provides older, vulnerable patients their best chance of returning to their previous level of functioning as quickly and safety as possible.

Biomechanical evaluation of suture-augmented locking plate fixation for proximal third fractures of the olecranon.

OBJECTIVES: To describe a method of suture augmentation of locking plate fixation (PF) of proximal olecranon fractures and to evaluate the biomechanical effectiveness of the suture augmentation using a human cadaveric model. METHODS: Six matched pairs of cadaveric elbows were used. Proximal one-third fractures of the olecranon were simulated via a transverse osteotomy. Identical locking PF was performed on each elbow using olecranon locking plates. One elbow of each pair was assigned to suture augmentation of the construct. The choice of left/right specimen for augmentation was performed in an alternating fashion. Augmentation was performed using a no. 2 ultra-high-molecular weight polyethylene-braided suture attaching the triceps to the plate via a modified Krackow stitch. The elbows were mounted into a custom jig and linearly loaded to failure using a hydraulic testing machine. Load to and modes of failure were recorded for each sample. The data were analyzed using the Wilcoxon signed-rank test for nonparametric distributions. RESULTS: Suture augmentation improved the single load-to-failure strength in all pairs. One pair was excluded due to failure of the triceps attachment to the test machine. A median 398 N (P = 0.04 range, 197-633 N) or a median 48% (range, 30%-130%) improvement in strength was seen. The most common mode of failure was loss of fixation of the proximal olecranon fragment. CONCLUSIONS: Suture augmentation can significantly increase the single load-to-failure strength of locking PF for proximal olecranon fractures.

Functional outcomes for surgically treated 3- and 4-part proximal humerus fractures.

Surgical treatment of 3- and 4-part proximal humeral fractures remains challenging. This study retrospectively evaluated functional outcomes of locked plate fixation vs hemi-arthroplasty in 57 patients with 3- and 4-part proximal humerus fractures from 2003 to 2005 with a mean follow-up time of 35 months (range, 15.7-52.7 months). Mean patient age was 56.9 years (range, 29-81.7 years) for the open reduction and internal fixation group (n=42) and 66.4 years (range, 38.1-90 years) for hemiarthroplasty group (n=15). All 57 patients completed the American Shoulder and Elbow Surgeons score, the Simple Shoulder Test, the Euroqol EQ-5D, [corrected] and the visual analog pain scale. Range of motion, the Constant Score, and the UCLA Shoulder score were used to evaluate a subset of 33 patients. Forty-one patients in the open reduction and internal fixation group achieved union, and 1 had symptomatic avascular necrosis requiring subsequent hemiarthroplasty. Two patients had implant removal for impingement symptoms. In the hemiarthroplasty group, there was 1 revision for a loose prosthesis. The American Shoulder and Elbow Surgeons score (P=.023), Simple Shoulder Test (P=.012), patient satisfaction (P=.034), Constant Score (P=.008), Kelsh Adjusted Constant Score (P=.015), UCLA Shoulder score (P=.01), and range of motion (forward flexion, P=.002; abduction, P=.001) were significantly better in the open reduction and internal fixation group than the hemiarthroplasty group. No significant differences between the groups existed in terms of SF-12 (physical, P=.118; mental, P=.134), Euroqol EQ-5D [corrected] (P=.169), or visual analog pain scale scores (P=.135), but all trended toward better with open reduction and internal fixation.