Traumatic Floating Total Hip Arthroplasty: A Case Report.

CASE: A 58-year-old woman with medical history of a left total hip arthroplasty performed by the direct anterior (DA) approach 2 years prior presented with left hip pain. She was found to have sustained a transverse Vancouver C periprosthetic femur fracture and an unstable periprosthetic pelvic fracture. CONCLUSIONS: This patient's case represents a previously not reported injury about a total hip arthroplasty-with disruption distal to the femoral implant and proximal to the acetabular implant, with the implant-to-bone interface unaffected. This case may guide future treatment of similar injuries.

No Differences in Clinical, Functional, or Patient-Reported Outcomes Following Trial of Nonoperative Management Before Open Reduction and Internal Fixation of Humeral Shaft Fractures.

OBJECTIVES: To test the hypothesis that primary osteosynthesis of humeral shaft fractures may lead to more favorable clinical, functional, and patient-reported outcomes than fixation following a trial of nonoperative management. DESIGN: Retrospective cohort review. SETTING: Academic level I trauma center. PATIENT SELECTION CRITERIA: Adult patients who presented with humeral shaft fractures and ultimately underwent open reduction and internal fixation (ORIF) from May 2011 to May 2021. Patients who underwent ORIF within 2 weeks of injury were grouped into the primary osteosynthesis cohort, and patients who underwent ORIF >4 weeks from the date of injury were grouped into the trial of nonoperative cohort. OUTCOME MEASURES AND COMPARISONS: Postoperative complications, elbow arc of motion, time to radiographic union, and patient-reported outcomes were investigated and compared between the primary osteosynthesis and trial of nonoperative management cohorts. RESULTS: One hundred twenty-seven patients fit the study criteria, 84 underwent primary osteosynthesis and 43 trialed initial nonoperative treatment. No differences were found in patient demographics between the primary osteosynthesis and trial of nonoperative management cohorts, including age (53 ± 19 vs. 57 ± 18; P = 0.25), sex (39% vs. 44% male, 61% vs. 56% female; P = 0.70), and Body Mass Index (BMI) (30 ± 6 vs. 32 ± 9; P = 0.38). The average time to operative intervention in the primary osteosynthesis group was 4 days (0-14 days) and 105 days (28-332 days) in the trial of nonoperative treatment group ( P < 0.01). No differences were found with regard to intraoperative blood loss, total operative time, time to radiographic union (determined using the Radiographic Union Scores for Humeral scoring system), or overall complication rates, including primary and secondary radial nerve injuries ( P = 0.23 and 0.86, respectively). Patients reported similar patient-reported outcomes measurement information system pain interference ( P = 0.73), depression (D) ( P = 0.99), and physical function ( P = 0.66) scores at their 6-month postsurgical follow-up visits. CONCLUSIONS: Patients who attempted a trial of nonoperative management for humeral shaft fractures before ORIF had similar clinical, functional, and patient-reported outcomes as those who underwent primary osteosynthesis. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Adjunctive dorsal spanning plate fixation for challenging distal radius injuries.

Background: Distal radius fractures with severely osteoporotic bone or articular comminution can provide challenges to fixation with traditional volar locked plating alone. The purpose of this study was to evaluate the clinical, radiographic, and patient reported outcomes of patients undergoing distal radius fixation with volar locked plating and adjunctive dorsal bridge plating. Methods: We retrospectively identified 16 patients with distal radius fractures who underwent our preferred surgical technique for fixation. Patients underwent volar locked plate fixation as well as dorsal bridge fixation at time of surgery. Seven patients were indicated for severe articular comminution with volar rim fragmentation (44%), three patients were revised for nonunion after previous volar locked late fixation (19%), and six patients had severely osteoporotic bone with articular comminution (38%). Two patients (13%) sustained AO/OTA 23-A3 distal radius fracture, two patients (13%) had a 23-B3 fracture, two patients (13%) had a 23-C2 fracture and ten patients (63%) had a 23-C3 fracture. Results: The average patient age was 51.8 years ± 20.6. Patients were followed for an average of 12.2±6.3 months. The dorsal bridge plate was removed at an average of 11.1±2.4 weeks. The average post-operative radial inclination was 18.9±2.4°, radial height 12.4 mm ± 2.6 mm, and volar tilt 7.1±1.9°. There were no cases of deep or superficial infection. After dorsal bridge plate removal, patients demonstrated an average wrist extension of 55.3±9.5°, flexion 54.4±12.8°, radial deviation 15.7±3.2°, 25.2±3.9 degrees of ulnar deviation. Conclusion: Distal radius fractures in the setting of severely osteoporotic bone, salvage procedures, articular comminution, volar rim fractures, and revision surgery present uniquely difficult surgical challenges. Volar locked plating with adjunctive dorsal bridge plating can be used with good short- and long-term results.

Reduction of Posterior Malleolus Fractures With Open Fixation Compared to Percutaneous Treatment.

Background: Operative decision making between approaches to posterior malleolus reduction remains a challenge. The purpose of this study is to compare the quality of reduction between percutaneous and open reduction of posterior malleolus fractures and to identify factors associated with malreduction. Methods: Operatively managed ankle fractures that included posterior malleolus fixation were reviewed. Fracture characteristics were determined on preoperative CT scans. Initial postoperative radiographs were used to measure reduction of the posterior malleolus articular surface and graded as satisfactory (<2 mm step-off) or malreduced (≥2 mm step-off). Final postoperative PROMIS scores and 1-year complications were compared between percutaneous and open cohorts. A multivariate stepwise regression model was used to evaluate predictors for malreduction. Results: A total of 120 patients were included. Open reduction was performed in 91 (75.8%) compared with 29 (24.2%) who underwent percutaneous reduction. Malreduction (≥2-mm articular step-off) occurred in 11.7% of patients. Malreduction rates were significantly higher with percutaneous fixation than open fixation (24.1% vs 7.7%, P = .02). Multiple fragments and those with ≥5 mm of displacement demonstrated higher malreduction rates with percutaneous fixation (P < .05 for both), whereas single fragments and those with <5 mm of displacement experienced similar malreduction rates with percutaneous or open fixation. Initial displacement ≥5 mm (relative risk [RR] = 3.8, 95% CI = 1.2-11.5, P = .02) and percutaneous treatment (RR = 4.1, 95% CI = 1.6-10.5, P < .01) were identified as independent risk factors for malreduction. There were no significant differences in 1-year complication rates or final PROMIS scores between groups. Conclusion: Open reduction of the posterior malleolus may lead to improved fracture reduction compared to percutaneous reduction without significant increase in complications. Open fixation improves reduction among fractures with multiple fragments or ≥5 mm of displacement, whereas fractures with a single fragment or <5 mm of displacement achieve similar reductions regardless of approach. Initial displacement ≥5 mm and percutaneous reduction are independent risk factors for malreduction. Level of evidence: Level III, therapeutic.

Increased Neighborhood Deprivation Is Associated with Prolonged Hospital Stays After Surgical Fixation of Traumatic Pelvic Ring Injuries.

BACKGROUND: The purpose of this study was to understand the role of social determinants of health assessed by the Area Deprivation Index (ADI) on hospital length of stay and discharge destination following surgical fixation of pelvic ring fractures. METHODS: A retrospective chart analysis was performed for all patients who presented to our level-I trauma center with pelvic ring injuries that were treated with surgical fixation. Social determinants of health were determined via use of the ADI, a comprehensive metric of socioeconomic status, education, income, employment, and housing quality. ADI values range from 0 to 100 and are normalized to a U.S. mean of 50, with higher scores representing greater social deprivation. We stratified our cohort into 4 ADI quartiles. Statistical analysis was performed on the bottom (25th percentile and below, least deprived) and top (75th percentile and above, most deprived) ADI quartiles. Significance was set at p < 0.05. RESULTS: There were 134 patients who met the inclusion criteria. Patients in the most deprived group were significantly more likely to have a history of smoking, to self-identify as Black, and to have a lower mean household income (p = 0.001). The most deprived ADI quartile had a significantly longer mean length of stay (and standard deviation) (19.2 ± 19 days) compared with the least deprived ADI quartile (14.7 ± 11 days) (p = 0.04). The least deprived quartile had a significantly higher percentage of patients who were discharged to a resource-intensive skilled nursing facility or inpatient rehabilitation facility compared with those in the most deprived quartile (p = 0.04). Race, insurance, and income were not significant predictors of discharge destination or hospital length of stay. CONCLUSIONS: Patients facing greater social determinants of health had longer hospital stays and were less likely to be discharged to resource-intensive facilities when compared with patients of lesser social deprivation. This may be due to socioeconomic barriers that limit access to such facilities. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

"Social media perceptions of hip fractures: A two-year cross-sectional analysis".

BACKGROUND: The outcomes of hip fracture rely heavily on subjective pain relief, and social media provides a remarkable lens to examine the patient experience. METHODS: A search of public posts on Instagram and Twitter was performed over a 2 -year period, selected through use of the following hashtags: #hipfracture, #hipfracturerecovery, and #hipfracturerepair. A categorical classification system was used for media format (picture or video), perspective, timing, tone, and content. Post-popularity (number of likes) and geographic location were also recorded. RESULTS: Of the Instagram posts analyzed, 50.6% were made by patients. The most common content included in Instagram posts was rehabilitation and or educational posts on hip fracture. Amongst the Twitter posts analyzed, 66% of posts were made by professional organizations. Frequently referenced themes included education, and posts produced by the hospital or surgeon. Of Facebook posts analyzed, 62.8% of posts were produced by businesses. CONCLUSION: Social media analysis is a powerful tool for evaluating characteristics important to patients. Instagram was used more by patients and focused on rehabilitation. Twitter posts were more frequently made by professional organizations and tended to be educational. Lastly, Facebook posts were made primarily by businesses and focused on marketing.

Single Medial vs 2-Incision Approach for Double Hindfoot Arthrodesis: Is There a Difference in Joint Preparation?

BACKGROUND: Double hindfoot arthrodesis is a reliable treatment option in lower extremity deformity and arthritis. Single (medial) and 2-incision techniques have been described. The purpose of this study was to evaluate the extent of cartilage debrided in each approach and to evaluate the competency of the deltoid ligament. METHODS: Eight matched pairs of cadaveric specimens were acquired. One limb from each pair was randomly assigned to the single medial incision and the other to the 2-incision technique. Stress radiographs were obtained prior to dissection to evaluate for valgus tibiotalar tilt. The talonavicular and subtalar articular surfaces were denuded of cartilage and the joints disarticulated. The percentage of cartilage debrided was determined using ImageJ software. Postoperative tibiotalar tilt was measured with a technique and threshold previously described by our group. The intraclass correlation coefficient was calculated to determine inter- and intraobserver reliability. RESULTS: The single medial incision demonstrated significantly less cartilage denuded than the 2-incision technique at the talar head (61.1% ± 20.4% vs 88.1% ± 6.1%, P < .001), and the posterior facets of the talus (53.5% ± 7.6% vs 73.6% ± 7.0%, P < .001) and calcaneus (55.3% ± 16.5% vs 81.0% ± 7.4%, P = .001). Overall, 75% of specimens that underwent a single medial incision approach demonstrated increased valgus tibiotalar tilt postdissection, whereas none that underwent the 2-incision technique developed increased tibiotalar tilt (P < .01). The average tibiotalar tilt among these specimens was 4.6 ± 1.3 degrees (range 2.5-5.7 degrees). For all measurements, the intraclass correlation coefficient was greater than 0.8. CONCLUSION: The posterior facet of the subtalar joint and talar head are at risk of subtotal debridement, as well as increased tibiotalar tilt with the single medial incision technique. Adequate debridement may require greater soft tissue dissection, possibly at the expense of medial ankle stability. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Bladder incarceration within a displaced pelvic ring nonunion.

Pelvic ring injuries can be challenging to manage and may have a range of associated injuries. When bladder injuries occur in combination with pelvic ring fractures, a multidisciplinary approach may be required to plan the best course of treatment. Acute entrapment or injury to the urinary bladder after a pelvic fracture is well reported. Here, we present an interesting case of chronic bladder incarceration within a lateral compression pelvic ring injury nonunion after failed nonoperative management of the initial pelvis fracture. Treatment of the nonunion was complicated by an incidental diagnosis of lymphoma.

Increasing the Educational Value of the Orthopaedic Subinternship: The Design and Implementation of a Fourth-Year Medical Student Curriculum.

INTRODUCTION: Most orthopaedic subinternships function as month-long interviews. These rotations remain relatively unstructured and lack standardization, and their overall educational value has been called into question. The goals of this educational initiative were to create a structured subinternship curriculum for orthopaedic applicants and to shift the focus of the subinternship from a month-long interview to an organized educational experience. METHODS: After review of knowledge and skills expected for early orthopaedic residency under the structure of the Accreditation Council for Graduate Medical Education Milestones, a curriculum dedicated to orthopaedic subinternships was created. Students who completed the curriculum filled out anonymous Likert scale evaluations (rating their comfort/knowledge from 0 to 10 before and after their rotation) and answered open-ended qualitative questions. RESULTS: Forty-six subinterns participated in the program over 3 years. Four weekly learning modules were designed and taught by orthopaedic residents, with faculty oversight of content and structure. Each monthly rotation began with an orthopaedic surgical skills laboratory and concluded with a case-based oral presentation. Weeks two and three covered different milestone-based topics and included didactic and skills development. Data analysis revealed that students reported notable improvement in knowledge and familiarity with each of the topics. The greatest improvements were in tibia intramedullary nailing and applying a tension band to an olecranon fracture. When asked which surgical skills station was the most helpful, 70% chose lag screw insertion and basic plating techniques. All students felt that creating their case presentation was productive. CONCLUSION: This educational initiative resulted in the successful design and implementation of a milestone-based orthopaedic surgery subinternship curriculum. The program was well received by students, contributed to learning and competency, and provided teaching opportunities for residents. The format and content of this subinternship curriculum can easily be adapted to regional and national teaching programs.

Clinical utilization of species-specific immunoassays for identification of Staphylococcus aureus and Streptococcus agalactiae in orthopedic infections.

Staphylococcus aureus and Streptococcus agalactiae (Group B streptococcus, GBS) are common causes of deep musculoskeletal infections (MSKI) and result in significant patient morbidity and cost to the healthcare system. One of the major challenges with MSKI is the lack of faithful diagnostics to correctly identify the primary pathogen, as standard culture-based assays are prone to false positives in the case of polymicrobial infections, and false negatives due to limitations in sample acquisition and antibiotic use before presentation. To improve upon our current diagnostic methods for MSKI, we developed a multiplex immunoassay for antigen-specific IgGs in serum (Luminex), and medium enriched for newly synthesized antibodies (MENSA) for anti-S. aureus and GBS generated from cultured peripheral blood mononuclear cells (PBMCs) of orthopedic infection patients undergoing surgical treatment. Samples were obtained from 110 MSKI patients: 80 diabetic foot ulcer, 21 periprosthetic joint infection, 5 septic arthritis, 2 spine, 1 hand, and 1 fracture-related infection (FRI). Anti-S. aureus and anti-GBS antibody titers were compared to culture results to assess their concordance in identifying the pathogens. Immunoassay, particularly MENSA, showed high diagnostic potential for monomicrobial S. aureus and GBS orthopedic infections (AUC > 0.95). MENSA also demonstrated diagnostic potential for GBS polymicrobial orthopedic infection and for GBS DFU (AUC > 0.83 for both). Serum showed high diagnostic potential for S. aureus PJI (AUC > 0.95). Taken together, these findings support the development of species-specific immunoassays for the identification of causal pathogens in active MSKI, especially in conjunction with standard culture.

The Treatment of Periprosthetic Distal Femoral Fractures After Total Knee Replacement: A Critical Analysis Review.

Periprosthetic distal femoral fracture after total knee arthroplasty carries substantial morbidity and mortality regardless of fixation technique. Surgical treatment is favored in most patients compared with conservative therapy because of high rates of nonunion, malunion, and reoperation after casting or bracing. Internal fixation techniques including retrograde intramedullary nailing and locked plating are favored for surgical treatment in most fractures when bone stock in the distal fragment allows for appropriate fixation. In the setting of deficient distal femoral bone stock or femoral component loosening, revision arthroplasty with distal femoral replacement is the favored technique. Further studies with regard to the use of intramedullary nailing, locked plating, and distal femoral replacement are necessary to refine the indications for each technique and to define the use of combinations of these fixation techniques.

Periprosthetic Intertrochanteric Fracture between Hip Resurfacing and Retrograde Nail.

Periprosthetic femur fractures present a growing worldwide challenge for orthopaedic surgeons. Fractures around a hip resurfacing implant create unique management problems. When considering fixation, there can be limited options for ideal stabilization and some require creative constructs. We present an interesting case of a periprosthetic intertrochanteric femur fracture between a hip resurfacing implant and retrograde intramedullary nail.

A Bioinformatic Approach to Utilize a Patient's Antibody-Secreting Cells against Staphylococcus aureus to Detect Challenging Musculoskeletal Infections.

Noninvasive diagnostics for Staphylococcus aureus musculoskeletal infections (MSKI) remain challenging. Abs from newly activated, pathogen-specific plasmablasts in human blood, which emerge during an ongoing infection, can be used for diagnosing and tracking treatment response in diabetic foot infections. Using multianalyte immunoassays on medium enriched for newly synthesized Abs (MENSA) from Ab-secreting cells, we assessed anti-S. aureus IgG responses in 101 MSKI patients (63 culture-confirmed S. aureus, 38 S. aureus-negative) and 52 healthy controls. MENSA IgG levels were assessed for their ability to identify the presence and type of S. aureus MSKI using machine learning and multivariate receiver operating characteristic curves. Eleven S. aureus-infected patients were presented with prosthetic joint infections, 15 with fracture-related infections, 5 with native joint septic arthritis, 15 with diabetic foot infections, and 17 with suspected orthopedic infections in the soft tissue. Anti-S. aureus MENSA IgG levels in patients with non-S. aureus infections and healthy controls were 4-fold (***p = 0.0002) and 8-fold (****p < 0.0001) lower, respectively, compared with those with culture-confirmed S. aureus infections. Comparison of MENSA IgG responses among S. aureus culture-positive patients revealed Ags predictive of active MSKI (IsdB, SCIN, Gmd) and Ags predictive of MSKI type (IsdB, IsdH, Amd, Hla). When combined, IsdB, IsdH, Gmd, Amd, SCIN, and Hla were highly discriminatory of S. aureus MSKI (area under the ROC curve = 0.89 [95% confidence interval 0.82-0.93, p < 0.01]). Collectively, these results demonstrate the feasibility of a bioinformatic approach to use a patient's active immune proteome against S. aureus to diagnose challenging MSKI.

What Regions of the Distal Clavicle Have the Greatest Bone Mineral Density and Cortical Thickness? A Cadaveric Study.

BACKGROUND: Osteosynthesis of distal clavicle fractures can be challenging because of comminution, poor bone quality, and deforming forces at the fracture site. A better understanding of regional differences in the bone structure of the distal clavicle is critical to refine fracture fixation strategies, but the variations in BMD and cortical thickness throughout the distal clavicle have not been previously described. PURPOSE: /questions (1) Which distal clavicular regions have the greatest BMD? (2) Which distal clavicular regions have the greatest cortical thickness values? METHODS: Ten distal clavicle specimens were dissected from cadaveric shoulders. Eight specimens were female and two were male, with a mean (range) age of 63 years (59 to 67). The specimens were selected to match known epidemiology, as distal clavicular fractures occur more commonly in older patients with osteoporotic bone, and clavicular fractures in older patients are more common in females than males. The clavicles were then imaged using quantitative micro-CT to create 3-D images. The BMD and cortical thickness were calculated for 10 regions of interest in each specimen. These regions were selected to represent locations where distal clavicular fractures commonly occur and locations of likely bony comminution. Findings were compared between different regions using repeated measures ANOVA with Geiser-Greenhouse correction, followed by Bonferroni method multiple comparison testing. Effect size was also calculated to estimate the magnitude of difference between regions. RESULTS: The four most medial regions of the distal clavicle contained the greatest BMD (anterior intertubercle space 887 ± 31 mgHA/cc, posterior intertubercle space 879 ± 26 mgHA/cc, anterior conoid tubercle 900 ± 21 mgHA/cc, posterior conoid tubercle 896 ± 27 mgHA/cc), while the four most lateral regions contained the least BMD (anterior lateral distal clavicle 804 ± 32 mgHA/cc, posterior lateral distal clavicle 800 ± 38 mgHA/cc, anterior medial distal clavicle 815 ± 27 mgHA/cc, posterior medial distal clavicle 795 ± 26 mgHA/cc). All four most medial regions had greater BMD than the four most lateral regions, with p < 0.001 for all comparisons. For the BMD ANOVA, η was determined to be 0.81, representing a large effect size. The four most medial regions of the distal clavicle also had the greatest cortical thickness (anterior intertubercle space 0.7 ± 0.2 mm, posterior intertubercle space 0.7 ± 0.3 mm, anterior conoid tubercle 0.9 ± 0.2 mm, posterior conoid tubercle 0.7 ± 0.2 mm), while the four most lateral regions had the smallest cortical thickness (anterior lateral distal clavicle 0.2 ± 0.1 mm, posterior lateral distal clavicle 0.2 ± 0.1 mm, anterior medial distal clavicle 0.3 ± 0.1 mm, posterior medial distal clavicle 0.2 ± 0.1 mm). All four most medial regions had greater cortical thickness than the four most lateral regions, with p < 0.001 for all comparisons. For the cortical thickness ANOVA, η was determined to be 0.80, representing a large effect size. No differences in BMDs and cortical thicknesses were found between anterior and posterior regions of interest in any given area. CONCLUSIONS: In the distal clavicle, BMD and cortical thickness are greatest in the conoid tubercle and intertubercle space. When compared with clavicular regions lateral to the trapezoid tubercle, the BMD and cortical thickness of the conoid tubercle and intertubercle space were increased, with a large magnitude of difference. CLINICAL RELEVANCE: Distal clavicular fractures are prone to comminution and modern treatment strategies have centered on the use of locking plate technology and/or suspensory fixation between the coracoid and the clavicle. However, screw pullout or cortical button pull through are known complications of locking plate and suspensory fixation, respectively. Therefore, it seems intuitive that implant placement during internal fixation of distal clavicle fractures should take advantage of the best-available bone. Although osteosynthesis was not directly studied, our study suggests that the best screw purchase in the distal clavicle is available in the areas of the conoid tubercle and intertubercle space, as these areas had the best bone quality. Targeting these areas during implant fixation would likely reduce implant failure and strengthen fixation. Future studies should build on our findings to determine if osteosynthesis of distal clavicular fractures with targeted screw purchase or cortical button placement in the conoid tubercle and intertubercle space increase fixation strength and decreases construct failure. Furthermore, our findings provide consideration for novel distal clavicular locking plate designs with modified screw trajectories or refined surgical techniques with suspensory fixation implants to reliably capture these areas of greatest bone quality.

Vitamin D and Metabolic Supplementation in Orthopedic Trauma.

Active assessment and management of hypovitaminosis D among orthopedic patients is low-risk and low-cost while retaining significant potential to improve patient care. Vitamin D has an established role in musculoskeletal development and calcium homeostasis, and vitamin D deficiency is pervasive in orthopedic trauma populations. Clinical guidelines for screening and supplementation for hypovitaminosis D are lacking. Literature on the effects of vitamin K on bone health is limited. Anabolic hormone analogues may have a future role in delayed union or nonunion treatment. Vitamin D deficiency and other endocrine abnormalities should be considered in orthopedic trauma patients presenting with fracture nonunion of uncertain cause.

Reconstruction of the Superior Glenoid Labrum With Biceps Tendon Autograft: A Cadaveric Biomechanical Study.

PURPOSE: To describe 2 superior labral reconstruction techniques using long head of the biceps (LHB) autograft and to investigate the ability of the 2 reconstruction techniques to restore superior restraint to the glenohumeral joint compared with superior labrum-deficient models. METHODS: In this biomechanical study, 10 cadaveric shoulders were cycled on a servohydraulic machine while the force required to cause superior subluxation was recorded. Each specimen was cycled under 4 conditions: intact labrum, SLAP tear, posterior (9- to 12-o'clock position) labral reconstruction using LHB autograft (superior labral reconstruction 1 [SLR1]), and 180° (9- to 3-o'clock position) labral reconstruction using LHB autograft (superior labral reconstruction 2 [SLR2]). RESULTS: The mean peak force required to cause superior subluxation in the intact labrum was 32.75 N versus 19.75 N in the SLAP tear (P = .0120). SLR1 required a mean peak force of 31.23 N versus 44.09 N for SLR2 (P = .0175). SLR1 required 94.96% of the force needed in the intact labrum to cause subluxation, whereas SLR2 required 140.6%. SLR1 and SLR2 required 34.21% higher (P = .0074) and 79.84% higher (P = .0033) forces, respectively, to generate subluxation compared with the SLAP tear state. CONCLUSIONS: Both proposed superior labral reconstruction techniques increased the force needed for humeral head superior migration in the setting of a labral tear. SLR1 (posterior labral reconstruction) closely matched the constraint of an intact labrum, whereas SLR2 (180° labral reconstruction) provided greater superior constraint than an intact labrum. CLINICAL RELEVANCE: The natural history of irreparable rotator cuff tears results in superior glenohumeral escape and eventual arthrosis. The superior glenoid labrum is an important contributor to superior glenohumeral constraint and is often degenerated in this setting. Clinical application of the 2 described superior labral reconstruction techniques may improve glenohumeral superior stability in patients with rotator cuff disease and superior labral deficiency.

Superior Capsular Reconstruction With a Long Head of the Biceps Tendon Autograft: A Cadaveric Study.

BACKGROUND: Several procedures have been proposed to address irreparable rotator cuff (RC) tears with pseudoparalysis. One recently proposed procedure is superior capsular reconstruction (SCR) using a tensor fasciae latae (TFL) autograft. HYPOTHESIS: SCR with a locally available long head of the biceps tendon (LHB) autograft is biomechanically equivalent to SCR using TFL autograft for preventing superior humeral migration and the development of RC arthropathy in patients with irreparable RC tears. STUDY DESIGN: Controlled laboratory study. METHODS: Ten cadaveric shoulders (5 matched pairs) were tested. One shoulder from each pair was randomly assigned to the LHB reconstruction group using our novel technique, while the contralateral side was assigned to the TFL reconstruction group. SCR with a TFL autograft was performed based on previously described techniques. Massive RC tears were created by detachment of the supraspinatus and infraspinatus footprints from the greater tuberosity. The force required to superiorly translate the humerus 1.5 cm was then tested and recorded using a servohydraulic testing machine under 2 conditions: (1) after a massive RC tear and (2) after SCR with either a TFL autograft or an LHB autograft. RESULTS: SCR with an LHB autograft required 393.2% ± 87.9% (P = .029) of the force needed for superior humeral migration in the massive RC tear condition, while SCR with a TFL autograft required 194.0% ± 21.8% (P = .0125). The LHB reconstruction group trended toward a stronger reconstruction when normalized to the torn condition (P = .059). CONCLUSION: SCR with an LHB autograft is a feasible procedure that is shown to be biomechanically equivalent and potentially even stronger than SCR with a TFL autograft in the prevention of superior humeral migration. CLINICAL RELEVANCE: This new technique may help to prevent superior humeral migration and the development of RC arthropathy in patients with irreparable RC tears.

Randomized, Prospective Study of the Order of Preoperative Preparation Solutions for Patients Undergoing Foot and Ankle Orthopedic Surgery.

BACKGROUND: Surgical site infection is routinely cited as the most common complication following orthopedic foot and ankle surgery. Our institution uses 4% chlorhexidine gluconate followed by 70% isopropyl alcohol to reduce skin bacterial loads prior to surgery. These solutions have potential synergistic qualities to prevent a postoperative infection. The purpose of this study was to determine if the order of these solutions has a significant effect on the residual bacterial pathogens load following operative site preparation for foot and ankle surgery, as evidenced by positive culture swabs. METHODS: A total of 95 consecutive patients, undergoing surgery of the foot and ankle with a single surgeon, were prospectively randomized to 1 of 2 operative preparation groups: isopropyl alcohol (IPA) group, whose operative site preparation consisted of a 4% chlorhexidine application followed by alcohol rinse (49 patients), and chlorhexidine gluconate (CHG) group, which had 46 patients undergo operative site preparation using alcohol followed by chlorhexidine. A total of 4 aerobic culture specimens were obtained from the third web space of the operative foot on each patient: (1) prior to operative site preparation, (2) after the prep was completed, (3) after completion of the procedure, and (4) after the incision was closed. Each patient was then followed for 6 months postoperatively to monitor the operative site. Medical comorbidities were also analyzed. RESULTS: The average time for IPA procedures was 52 minutes vs 54 for CHG (ns). There was no difference between groups with respect to diabetes, tobacco use, obesity, race, or immunosuppression. Both groups had 100% bacterial growth from specimens obtained prior to operative site preparation (P > .05). For all postpreparation swabs, 19.0% (28/147) of the IPA cultures were positive compared to 10.9% (15/138) from the CHG group cultures (P = .07). The amount of patients with positive culture results favored the CHG group at each collection point: 6.5% (3/46) versus 25% (12/49) after draping (P = .02); 15% (7/46) versus 33% (16/49) after completion of the surgery (P = .05); and 20% (9/46) versus 35% (17/49) after skin closure (P = .07). One operative site infection was seen in the first 30 days following surgery for each treatment group, each treated with oral antibiotics. No additional skin or wound complications were encountered during the 6-month study follow-up. CONCLUSION: Postoperative infection rates following foot and ankle orthopedic surgery was low. Both chlorhexidine and isopropyl alcohol solutions were effective methods in reducing operative site bacterial colonization when combined. In this study, applying isopropyl alcohol solution followed by the chlorhexidine solution was more effective in reducing positive bacterial cultures taken after operative site preparation. No difference in clinical wound infection rate was seen. LEVEL OF EVIDENCE: Level I, prospective randomized study.

Inadvertent screw stripping during ankle fracture fixation in elderly bone.

Poor screw purchase because of osteoporosis presents difficulties in ankle fracture fixation. The aim of our study was to determine if cortical thickness, unicortical versus bicortical purchase, and bone mineral density are predictors of inadvertent screw stripping and overtightening. Ten paired cadaver ankles (average donor age, 81.7 years; range, 50-97 years) were used for the study. Computed tomography scanning with phantoms of known density was used to determine the bone density along the distal fibula. A standard small-fragment, 7-hole, one-third tubular plate was applied to the lateral surface of the fibula, with 3 proximal bicortical cortical screws and 2 distal unicortical cancellous screws. A posterior plate, in which all 5 screws were cortical and achieved bicortical purchase, was subsequently applied to the same bones and positioned so that the screw holes did not overlap. A torque sensor was used to measure the torque of each screw during insertion (Ti) and then stripping (Ts). The effect of bone density, screw location, cortical thickness, and unicortical versus bicortical purchase on Ti and Ts was checked for significance (P < .05) using a general linearized latent and mixed model. We found that 9% of the screws were inadvertently stripped and 12% were overtightened. Despite 21% of the screws being stripped or being at risk for stripping, we found no significant predictors to warn of impending screw stripping. Additional work is needed to identify clinically useful predictors of screw stripping.