The duration of antibiotic therapy for fracture related infection does not affect recurrence but leads to increased adverse effects: a comparison among 6, 12 and 24 weeks of treatment.

PURPOSE: The optimal duration of antibiotic therapy for fracture-related infection (FRI) has not been well defined. Our aim was to assess the recurrence rate of infection in patients who underwent six, 12, or 24 weeks of antibiotic therapy following surgical treatment for FRI one year after antibiotic discontinuation. Additionally, complications were monitored. METHODS: Patients with FRI underwent surgical treatment, and antibiotic therapy was initiated. The patients were divided into groups at the 6th and 12th weeks of antibiotic therapy. The primary endpoint was the recurrence of deep or superficial infection at 90 days and one year after the end of antimicrobial therapy. RESULTS: There was no difference in the recurrence of infection 90 days or one year after stopping antibiotic therapy among patients treated for six, 12, or 24 weeks (p = 0.98 and p = 0.19, respectively). The overall recurrence rate of infection 90 days after stopping antibiotic therapy was 4.9% (8/163), and one year after discontinuation of antibiotic therapy was 9.8% (16/163). There was a statistically significant difference in the incidence of adverse effects among the three groups (chi-square; p = 0.01). Adverse effects were more common in the group treated for 24 weeks than in the groups treated for 6 weeks (z score, p = 0.017) or 12 weeks (z score, p = 0.005). CONCLUSION: Antibiotic therapy longer than 6 weeks did not reduce the recurrence of FRI after one year of follow-up. Additionally, antibiotic treatment for 24 weeks increases adverse events such as skin reactions and acute renal failure.

Chondrotoxic effects of tranexamic acid and povidone-iodine on the articular cartilage of rabbits.

PURPOSE: To evaluate the chondrotoxic effects of intra-articular use of TXA 20 mg/kg and/or 0.35% PVPI on knee joint cartilage in an experimental model of rabbits. METHODS: Forty-four male New Zealand adult rabbits were randomly assigned to four groups (control, tranexamic acid (TXA), povidone-iodine (PVPI), and PVPI + TXA). The knee joint cartilage was accessed through an arthrotomy and exposed to physiological saline SF 0.9% (control group), TXA, PVPI, and PVPI followed by TXA. Sixty days after surgical procedure, the animals were sacrificed and osteochondral specimens of the distal femur were obtained. Histological sections of cartilage from this area were stained with hematoxylin/eosin and toluidine blue. The following cartilage parameters were evaluated by the Mankin histological/histochemical grading system: structure, cellularity, glycosaminoglycan content in the extracellular matrix, and integrity of the tidemark. RESULTS: The isolated use of PVPI causes statistically significant changes in cartilage cellularity (p-value = 0.005) and decrease glycosaminoglycan content (p = 0.001), whereas the isolated use of TXA decreased significantly the glycosaminoglycan content (p = 0.031). The sequential use of PVPI + TXA causes more pronounced alterations in the structure (p = 0.039) and cellularity (p = 0.002) and decreased content of glycosaminoglycans (p < 0.001) all with statistical significance. CONCLUSION: Data suggest that intra-articular use of tranexamic acid 20 mg/kg and intraoperative lavage with 0.35% povidone-iodine solution for three min are toxic to the articular cartilage of the knee in an experimental in vivo study in rabbits.

Expanding the indications for calcaneal plates beyond foot fractures: a technical trick and case series.

Although non-locking calcaneal plates are designed to treat calcaneal fractures, they present some interesting characteristics that justify using them beyond their current application in fractures of the foot. Calcaneal plates are malleable, have an increased footprint area for fracture containment or buttressing, and present several hole options for screw placement in different trajectories, thereby providing proper fixation even in comminuted fracture patterns. The aim of this study is to describe the unconventional use of calcaneal plates in the orthopaedic trauma scenario.

Three-dimensional computed tomography evaluation of anterior cruciate ligament footprint for anatomic single-bundle reconstruction.

PURPOSE: Femoral and tibial footprint coordinates have been well studied in double-bundle anterior cruciate ligament (ACL) reconstruction. However, in a single-bundle reconstruction approach, the central coordinate of femoral and tibial footprints have not been determined. The purpose of this study was to describe the central point locations of the ACL footprints visualized by three-dimensional computed tomography (3D CT) images and analysed by the quadrant method. METHODS: Eight cadaveric knees were dissected, and the central points of ACL femoral and tibial footprints were marked and analysed using 3D CT images. RESULTS: In the present study, the means (and standard deviation) of ACL femoral footprint dimensions were in the ventral-dorsal plane and in the cranial-caudal plane 9.4 ± 0.8 and 15.6 ± 0.9 mm, respectively. In the tibial side, the means of ACL footprint dimensions were in the anterior-posterior and in the medial-lateral 18.5 ± 1.9 and 15.5 ± 1.0 mm, respectively. In the tomographic analyses, the means of femoral central location coordinates in the ventral-dorsal (y) and in the cranial-caudal (x) axes were 35.3 ± 4.5 and 30.0 ± 1.6 %, respectively. The means of tibial central location coordinates were in the anterior-posterior (y) and in the medial-lateral (x) axes, respectively: 40.5 ± 5.3 and 50.2 ± 1.3 %, respectively. CONCLUSIONS: These computed tomographic coordinates might help future studies as a reference on ACL single-bundle anatomic reconstruction, with respect to the management of ACL revision surgery or in symptomatic patients after ACL reconstruction. Improvements in three-dimensional image acquisition could facilitate its intraoperative applicability in the coming years.

Lesser metatarsal phalangeal joint arthroscopy: anatomic description and comparative dissection.

PURPOSE: The aim of this article is to describe the normal arthroscopic anatomy of the lesser metatarsophalangeal (MTP) joints and compare it with that seen in open dissection in cadaveric models. METHODS: We performed arthroscopic examination of 18 MTP joints of 6 normal fresh frozen feet. The second, third, and fourth MTP joints were studied because of the higher incidence of pathologic conditions found in these joints. During arthroscopy, each anatomic structure identified was named and marked with different colored sutures using straight suture needles. After the arthroscopic procedure of identification and marking, each MTP joint was dissected, and all the anatomic structures were grossly identified. With these data, the correlation between the arthroscopic and the direct visualization of a normal MTP joint was established. RESULTS: Considering the joint regions, we found that the examination accuracy of the medial gutter was 91%, whereas the central joint accuracy reached 100% and the accuracy of the lateral gutter was 98%. The overall arthroscopic accuracy for the lesser MTP joints was 96%. CONCLUSIONS: There is a high level of anatomic accuracy at the lesser MTP joint with arthroscopy. CLINICAL RELEVANCE: The high overall level of anatomic accuracy of lesser MTP joint arthroscopy (96%) allows us to consider this resource as a valuable tool in the diagnosis and treatment of these joints, expanding the spectrum of indications using this method.

Minimally invasive percutaneous plate osteosynthesis for ankle fractures: a prospective observational cohort study.

BACKGROUND: The gold standard for the surgical management of ankle fractures is through open reduction and internal fixation. The rate of wound problems has been reported to be as high as 18%, especially in patients with poor vascular supply or in diabetics. Minimally invasive percutaneous plate osteosynthesis (MIPPO) has been described as a potential solution for these patients. PATIENTS AND METHODS: This is a prospective observational cohort study. From October 2009 to February 2010, and following ethical approval of our research, adult patients admitted at our level I trauma center with a closed lateral malleolar displaced unstable fracture (Lauge-Hansen supination-external rotation) with or without a medial-sided injury and patients with an undisplaced fracture associated with medial clear space opening on external rotation stress radiographs were recruited and managed using MIPPO technique. All patients were followed up for a minimum of 12 months post-surgery (12-20 with a mean of 16.5 months). Trauma mechanism, comorbidities, classifications, trauma-surgery interval, image intensifier duration, surgery duration, complications, and function American Orthopaedic Foot and Ankle Society (AOFAS) were analyzed. RESULTS: Thirty-two patients were recruited of which 20 fulfilled the inclusion criteria (16 females, 4 males) and were available for follow-up. Ten fractures (50%) were classified as 44-B1, 7 fractures (35%) as 44-B2, and 3 fractures (15%) as 44-B3 according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification (100% were supination-external rotation injuries). At 8 weeks post-surgery, all fractures had healed. The duration of surgery ranged between 15 and 73 min (average 32.8) from skin incision to closure. There were 2 complications (1 malunion and 1 skin necrosis requiring implant removal). At 12-month follow-up, AOFAS average was 88.3 (72-100 standard deviation of 6.8 points). CONCLUSION: MIPPO technique proved to be a viable option for lateral malleolar fracture treatment with a low complication rate and high functional outcome at 1 year. It is particularly useful in patients with a high risk of wound complication.

Biomechanics of internal fixation in Hoffa fractures - A comparison of four different constructs.

OBJECTIVE: Compare the biomechanical effectiveness of four different bone-implant constructs in preventing fracture displacement under axial loading. METHODS: Twenty artificial femora had a standardized coronally oriented fracture of the lateral femoral condyle, representing a Hoffa fracture classified as a Letenneur type I. Four different fixation constructs were applied to the synthetic bones for biomechanical testing. The constructs consisted of a posterolateral (PL) buttressing locking plate in conjunction with two cannulated lag screws inserted from posterior to anterior (PA) - Group 1; Two cannulated screws inserted from anterior to posterior (AP) without plating- Group 2; A posterolateral (PL) buttressing locking plate in isolation - Group 3; and a combination of two lag screws from anterior to posterior (AP) in addition to a horizontal one-third tubular locking plate - Group 4. An axial load was applied to the fracture site with a constant displacement speed of 20 mm/min, and the test was interrupted when a secondary displacement was detected determining a fixation failure. We recorded the maximum applied force and the maximum fracture displacement values. RESULTS: Group 1 demonstrated the highest overall bone-implant axial stiffness with the lowest secondary displacement under loading. Groups 3 and 4 showed equivalent mechanical behavior. Group 2 presented the lowest mechanical stiffness to axial loading. The combination of the one-third tubular locking plate with anterior-to-posterior lag screws (Group 4) resulted in 302 % increase in fixation stiffness when compared to anterior-to-posterior lag screws only (Group 2). CONCLUSIONS: This study confirms the mechanical superiority of having a plate applied parallel to the main fracture plane in the setting of coronally oriented femoral condyle fractures. The addition of a horizontal plate, perpendicular to the main fracture plane, significantly increased the resistance to shearing forces at the fracture site when compared to constructs adopting just cannulated screws. LEVEL OF EVIDENCE: Biomechanical study.

Off-Label Use of Buttress Calcaneal Plate in Medial Distal Femoral Fracture to Augment Internal Fixation.

Background: High-energy traumatic fractures represent a challenge for orthopaedic surgeons because there are a great variety of morphologic patterns and associated injuries1. Although the incidence is higher in developing countries, these fractures pose a major financial burden all over the world because of their considerable hospital length of stay, time away from work, rate of failure to return to work, complications, and cost of treatment2-4. Since the fracture patterns are so variable, some cases may have a lack of available specific osteosynthesis implants, despite recent advancements in implant engineering5. However, experienced surgeons are capable of using their knowledge and creativity to treat challenging lesions with use of preexisting plates while following the principles of fracture fixation and without compromising outcomes. In 2012, Hohman et al. described for the first time the use of a calcaneal plate to treat distal femoral fractures6. In 2020, Pires et al. further expanded the indications for use of a calcaneal plate5. This technical trick is widely utilized in our trauma center, especially in comminuted fractures around the knee. The present video article provides a stepwise description of the off-label use of a calcaneal plate in a medial distal femoral fracture. Description: The key principles of this procedure involve following common fundamentals during open reduction and internal fixation, approaching the fracture, preserving soft-tissue attachments of the comminution, and reducing the main fragments. Afterwards, the off-label use of a calcaneal plate adds the special feature of being able to contain fracture fragments with plate contouring. If necessary and if osseous morphology allows, bone grafting through the plate may also be performed. Alternatives: Multiple fixation implants can be utilized in medial distal femoral fractures. Surgeon-contoured plates (i.e., locking compression plates or low-contact dynamic compression plates), multiple mini-fragment plates, cortical screws alone, cannulated cancellous screws alone, or proximal humeral plates are among the alternatives5-9. However, the lack of specific implants for fixation of fractures involving the medial femoral condyle is notable, even in developed countries10. Rationale: The small-fragment calcaneal plate is a widely available and cheaper implant compared with locking compression plates, which is especially important in developing countries. Additionally, this plate has a lower profile, covers a greater surface area, and allows multiple screws in different planes and directions. The use of this plate represents a great technical trick for surgeons to contain comminution. Expected Outcomes: Patient education regarding fracture severity is mandatory, and it is important to highlight that there is no current gold standard to treat these fractures because of the wide variability of morphological patterns. To our knowledge, all studies reporting the use of a calcaneal plate to treat these fractures have shown promising results, including good functional outcomes and 100% fracture healing with no cases of nonunion, infection, or implant failure5,6,10-14. In the largest case series to date, Shekar et al. performed an interventional prospective study of 30 patients undergoing calcaneal plating for distal femoral unicondylar fractures14. They reported a mean range of motion of 108° ± 28.27° at 6 months, with excellent or satisfactory results in 80% of patients as measured with use of the Neer scoring system14. Important Tips: Preserve the blood supply by performing minimal soft-tissue dissection.Do not detach comminuted fragments from the soft tissues, which will help fracture reduction.Reduce the main fragments anatomically and fix as necessary.Contain the comminution using the spanning property and large covering area of the calcaneal plate.Perform bone grafting through the plate as necessary.

Full Recovery from O'Donoghue's Triad with Autologous Bone Marrow Aspirate Matrix: A Case Report.

O'Donoghue's triad is an extremely debilitating condition. Although there are many conventional treatments available, there is still no consensus regarding the most effective rehabilitation protocol for a full recovery. Surgical interventions have become an ordinary consideration, but problems may still persist even after the surgical procedure. Orthobiologics, however, have gained considerable popularity in regenerative medicine. Notable autologous alternatives, such as bone marrow aspirate (BMA), are often utilized in clinical settings. To our knowledge, the administration of BMA products for the management of O'Donoghue's triad has not been thoroughly investigated in the literature. In this case report we describe a full recovery from O'Donoghue's triad with BMA matrix in a patient who was recalcitrant to surgical intervention due to fear of complications. Our patient received three BMA matrix injections with four-week intervals, exhibiting significant recovery according to pain scores, functional assessment outcomes, and magnetic resonance imaging (MRI) results. The patient returned to normal activities with no complaints and MRI evidence at follow-up showed significant signs of structural restoration of the musculoskeletal tissues. Here, we demonstrate that autologous BMA products are a feasible alternative for the accelerated recovery of musculoskeletal tissue injury with safety and efficacy.

Stromal Vascular Fraction for Knee Osteoarthritis - An Update.

Orthobiologics never cease to cause popularity within the medical science field, distinctly in regenerative medicine. Recently, adipose tissue has been an object of interest for many researchers and medical experts due to the fact that it represents a novel and potential cell source for tissue engineering and regenerative medicine purposes. Stromal vascular fraction (SVF), for instance, which is an adipose tissue-derivative, has generated optimistic results in many scenarios. Its biological potential can be harnessed and administered into injured tissues, particularly areas in which standard healing is disrupted. This is a typical feature of osteoarthritis (OA), a common degenerative joint disease which is outlined by persistent inflammation and destruction of surrounding tissues. SVF is known to carry a large amount of stem and progenitor cells, which are able to perform self-renewal, differentiation, and proliferation. Furthermore, they also secrete several cytokines and several growth factors, effectively sustaining immune modulatory effects and halting the escalated pro-inflammatory status of OA. Although SVF has shown interesting results throughout the medical community, additional research is still highly desirable in order to further elucidate its potential regarding musculoskeletal disorders, especially OA.

Intra-operative four-stranded hamstring tendon graft diameter evaluation.

PURPOSE: To evaluate whether clinical factors enable prediction of the diameter of hamstring tendons harvested for anterior cruciate ligament (ACL) reconstruction. METHODS: Eighty patients were submitted for reconstruction of the ACL with hamstring tendons in a quadruple manner. During surgery the diameter of the graft was measured. The variables analyzed were: age, gender, weight, height, operated side, dominant side, leg length, thigh length, thigh diameter, body mass index (BMI), and sports activity. The data was collected pre-operatively and correlated with the diameter of the graft. RESULTS: The diameter of the graft was strongly related to gender, height, leg length, thigh length, weight, and thigh diameter. Women presented significantly smaller graft diameter than men; as well as weight, height, leg length, and thigh length. Men with height equal to or greater than 1.80 m showed average graft diameter greater than the total group, and greater percentage of 9 mm grafts. CONCLUSION: The diameter of the hamstring graft is significantly associated to weight, height, leg length, thigh length, thigh diameter, and gender. The variable that had most influence was height, followed by gender and leg length. The variables BMI, age, sports activity, and dominant side did not present correlation. Tendon diameter was larger in men than in women. Men with a height equal to or greater than 1.80 m had a higher prevalence of 9 mm grafts and had a larger average tendon diameter. LEVEL OF EVIDENCE: Prospective cross sectional collection of data, Level IV.

Platelet-rich plasma vs bone marrow aspirate concentrate: An overview of mechanisms of action and orthobiologic synergistic effects.

The use of orthobiologics as a novel therapy for the treatment of numerous musculoskeletal disorders has increased considerably over the past decade. Currently, there are multiple alternatives available as suitable treatments; however, the use of autologous blood-derived products such as platelet-rich plasma (PRP), bone marrow aspirate (BMA) and BMA concentrate (BMAC), specifically, is expanding. Although many investigations attempted to demonstrate the effectiveness of these therapies, even with positive results, the literature lacks standardized protocols and overall accuracy in study designs, which leads to variance and difficulty in reproducibility of protocols. The efficacy of PRP for the treatment of cartilage, bone and muscle tissues is well known. Although BMAC has generated optimistic results for the same purposes, its applicability in clinical trials is still relatively recent when compared to PRP. Both products demonstrate the potential to set forth reparative processes, each in their own distinct mechanism. The combination of these biological products has been previously proposed, yet little is known about their synergism. Evidence indicates that growth factor, cytokine, and chemokine profiles seen in both PRP and BMAC vary but are likely to work synergistically to enhance musculoskeletal healing. BMAC products seem to work well without PRP; however, the addition of PRP to BMAC has been shown to act as a rich and natural source of culture medium for stem cells located either peripherally or in the bone marrow itself. Nevertheless, additional variables associated with the use of BMAC and PRP in orthopedics must be further evaluated in order to consolidate the efficacy of this therapeutic strategy.

Firearm-Related Fractures: Epidemiology and Infection Rate.

Objective To investigate the incidence of infection in patients with gunshot-related fractures, and to correlate this finding with the occurrence of surgical debridement in the emergency room. Methods A retrospective, observational, descriptive study that included all cases of fractures caused by firearms between January 2010 and December 2014; 245 fractures in 223 patients were included. Results There was surgical-site infection in 8.5% of the fractures, and the mean number of debridements required to control the infectious process was of 1.273 ± 0.608. A correlation was identified between the surgical treatment chosen and the affected body segment ( p < 0.001). The surgical treatment in the emergency room had a correlation with the occurrence of infection ( p < 0.001; Chi-squared test). Conclusion Patients with gunshot injuries treated non-operatively presented less severe and stable lesions; thus, the incidence of complications in this group was found to be lower. On the other hand, those patients with complex lesions underwent debridement and external fixation. Therefore, a greater number of infectious complications in patients submitted to external fixation was found, as expected.

Radioulnar joint reconstruction: a novel surgical technique and biomechanical assessment for chronic instability.

PURPOSE: This study aims to describe and biomechanically evaluate a novel technique using a strip of the flexor carpi ulnaris tendon for distal radioulnar joint reconstruction. METHODS: Surgical technique was thoroughly detailed, and a cadaveric biomechanical test was conducted to evaluate sagittal plane stability. Pronosupination range of motion was measured before and after the procedure. Dorsal and volar translation resistances were checked in three situations: with the uninjured triangular fibrocartilage complex, after its complete resection and after the surgical procedure. RESULTS: For distal radioulnar joint translation, higher values were found both in dorsal and volar translation in situations with an injured triangular fibrocartilage complex, with means equal to 25.4 mm (SD: 9.4 mm) and 26.1 mm (SD: 8.0 mm), respectively. For intact triangular fibrocartilage complex, both dorsal and volar translations averages were 3.4 mm (SD: 0.9 mm) and 4.5 mm (SD: 1.8 mm), respectively. Finally, when evaluating dorsal and volar translations after surgical reconstruction, means were 6.3 mm (SD: 1.3 mm) and 6.8 mm (SD: 0.9 mm), respectively. Regarding supination and pronation range of motion, which ranged from 57.9 to 63.4o, there were no differences in mean and median measures, when the cadavers with intact and reconstructed triangular fibrocartilage complex were compared (p > 0.05). CONCLUSION: Promising mechanical evaluations encourage us to hypothesize that the technique effectively reconstructs the dorsal and volar radioulnar ligaments, preserving pronosupination and maintaining the physiological characteristics of the wrist joint. Clinical comparative studies are still necessary to fully validate this procedure. LEVEL OF EVIDENCE: Therapeutic - Level V.

Anatomical femoral tunnel positioning in the medial patellofemoral ligament reconstruction: is the free-hand technique accurate?

BACKGROUND: During medial patellofemoral ligament (MPFL) reconstruction, achieving anatomical positioning of the femoral and patellar origins is important for restoration of patellofemoral biomechanics. Although visual and manual detection can also be used to determine the femoral point of the MPFL, minimal research exists regarding accuracy of this method. Our aim was to evaluate the accuracy of free-hand method in determining the femoral point of the MPFL during surgery. METHODS: A prospective analysis was completed with 19 patients (20 knees), age ranging 15 to 39 years, in whom, three orthopedic surgeons with experience in knee procedures performed surgical reconstruction of the MPFL. MPFL femoral origin was accessed in a free-hand technique and a strict lateral view of the knee was then obtained. If the selected point was not considered appropriate, a better position was identified following the criteria set forth by Schottle. RESULTS: In a mean clinical follow-up of 2.3±1.3 years, anatomical point was achieved using the free-hand palpation method in seven knees (28.5%). Among the thirteen knees for whom the anatomical point was not attained without fluoroscopy, the mean error pattern found was 27.5%±8.6% for proximal (P-D axis) and 24%±6.3% for anterior in the posterior-anterior axis. The average error (difference between the marked point and the anatomical point) was 20.6%±5.9% (P=0.98) for the distal-proximal axis and 15.9%±6.1% (P=0.77) for the posterior-anterior axis. CONCLUSIONS: The anatomical palpation technique showed low accuracy, even when performed by experienced surgeons. The most common error pattern observed was proximal and anterior.

Displaced osteochondral fracture of the posterolateral tibial plateau associated with an acute anterior cruciate ligament injury.

An osteochondral fracture of the posterolateral tibial plateau associated with an anterior cruciate ligament (ACL) injury in a 24-year-old boy is reported. Anterior cruciate ligament rupture is accompanied by bone contusions resulting from the impact of the posterolateral tibial plateau on the anterior part of the lateral femoral condyle. The osteochondral fracture of the posterolateral tibial plateau matched the site where the bone bruise is observed.

Clinical outcomes of arthroscopic repair of acetabular labral tears.

PURPOSE: To evaluate the primary clinical outcomes of arthroscopic labral repair. METHODS: All patients who underwent arthroscopic repair of the acetabular labrum performed by a senior surgeon between October 2010 and December 2013 were invited to participate in this prospective study. Patients included were those who had a preoperative diagnosis of labral tears, a lateral centre edge greater than 25° and a labral tear believed to be suturable during the intraoperative evaluation. Patients with Tönnis grade 2 or grade 3 hip osteoarthritis and those who had undergone a previous hip surgery were excluded. All patients were evaluated using the modified Harris Hip Score (mHHS) during the final appointment before surgery, 4 months after surgery and at the final evaluation. Interviews were conducted by the senior surgeon. RESULTS: Eighty-four patients (90 hips) underwent arthroscopic repair. The mean age was 44.2 years and the mean follow-up period was 43.0 months (minimum of 25 months and maximum of 59 months). The mean mHHS was 80.4 preoperatively, 95.0 at 4 months postoperatively and 96.6 at final evaluation. A statistically significant difference existed among these scores (p<0.001). CONCLUSION: Arthroscopic labral repair was associated with a clinically significant improvement in mHHS after short-term (4 months) and medium-term (43 months) follow-up. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Complications and outcomes of the transfibular approach for posterolateral fractures of the tibial plateau.

OBJECTIVE: Evaluate complication rates and functional outcomes of fibular neck osteotomy for posterolateral tibial plateau fractures. DESIGN: Retrospective case series. SETTING: University hospital. PATIENTS: From January 2013 to October 2014, 11 patients underwent transfibular approach for posterolateral fractures of the tibial plateau and were enrolled in the study. All patients who underwent transfibular approach were invited the return to the hospital for another clinical and imaging evaluation. INTERVENTION: Transfibular approach (fibular neck osteotomy) with open reduction and internal fixation for posterolateral fractures of the tibial plateau. MAIN OUTCOME MEASUREMENTS: Complications exclusively related to the transfibular approach: peroneal nerve palsy; knee instability; loss of reduction; nonunion and malunion of fibular osteotomy; and functional outcomes related to knee function. RESULTS: Two patients failed to follow-up and were excluded from the study. Of the 9 patients included in the study, no patients demonstrated evidence of a peroneal nerve palsy. One patient presented loss of fracture reduction and fixation of the fibular neck osteotomy, requiring revision screw fixation. There were no malunions of the fibular osteotomy. None of the patients demonstrated clinically detectable posterolateral instability of the knee following surgery. American Knee Society Score was good in 7 patients (77.8%), fair in 1 (11.1%), and poor in 1 (11.1%). American Knee Society Score/Function showed 80 points average (60-100, S.D:11). CONCLUSION: The transfibular approach for posterolateral fractures is safe and useful for visualizing posterolateral articular injury. The surgeon must gently protect the peroneal nerve during the entire procedure and fix the osteotomy with long screws to prevent loss of reduction. LEVEL OF EVIDENCE: Therapeutic level IV.

Pelvic Rotation in Femoroacetabular Impingement Is Decreased Compared to Other Symptomatic Hip Conditions.

Study Design Cross-sectional, case-control design. Background Pelvic movement has been considered a possible discriminating parameter associated with femoroacetabular impingement (FAI) symptom onset. Decreased pelvic rotation has been found during squatting in people with FAI when compared to people with healthy hips. However, it is possible that changes in pelvic movement may occur in other hip conditions because of pain and may not be specific to FAI. Objectives To compare sagittal pelvic rotation during hip flexion and in sitting between people with FAI and people with other symptomatic hip conditions. Methods Thirty people with symptomatic FAI, 30 people with other symptomatic hip conditions, and 20 people with healthy hips participated in the study. Sagittal pelvic rotation was calculated based on measures of pelvic alignment in standing, hip flexion to 45° and 90°, and sitting. Results There were significant differences in sagittal pelvic rotation among the 3 groups in all conditions (P<.05). Post hoc analyses revealed that participants in the symptomatic FAI group had less pelvic rotation during hip flexion to 45° and 90° compared to participants in the other symptomatic hip conditions group and the hip-healthy group (mean difference, 1.2°-1.9°). In sitting, participants in the other symptomatic hip conditions group had less posterior pelvic rotation compared to those in the hip-healthy group (mean difference, 3.9°). Conclusion People with symptomatic FAI have less posterior pelvic rotation during hip flexion when compared to people with other symptomatic hip conditions and those with healthy hips. Level of Evidence Diagnosis, level 4. J Orthop Sports Phys Ther 2016;46(11):957-964. Epub 29 Sep 2016. doi:10.2519/jospt.2016.6713.