The Influence of Component Design and Positioning on Soft-Tissue Tensioning and Complications in Reverse Total Shoulder Arthroplasty: A Review.

¼ Reverse total shoulder arthroplasty was designed to function in the rotator cuff deficient shoulder by adjusting the glenohumeral center of rotation (COR) to maximize deltoid function.¼ Adjustments in the COR ultimately lead to changes in resting tension of the deltoid and remaining rotator cuff, which can affect implant stability and risk of stress fracture.¼ Soft-tissue balance and complication profiles can be affected by humeral component (version, neck shaft angle, and inlay vs. onlay) and glenoid component (sagittal placement, version, inclination, and lateralization) design and application.¼ A good understanding of the effects on soft-tissue balance and complication profile is critical for surgeons to best provide optimal patient outcomes.

The Effect of High-Normal Preoperative International Normalized Ratios on Outcomes and Complications After Anterior Cervical Spine Surgery.

Hematoma after anterior cervical spine surgery can result in neurologic and airway compromise. Current guidelines recommend an international normalized ratio (INR) <1.5 before elective spine surgery because of increased complications. The risk associated with an INR of 1.25 is not well studied. The purpose of this study was to determine the risk of complications associated with a preoperative INR >1.25 and ≤1.5 in patients undergoing elective anterior cervical spine surgery. The American College of Surgeons National Surgical Quality Improvement Program database was queried. Patients undergoing elective anterior cervical spine surgery from 2012 to 2016 who had an INR recorded within 24 hours of surgery were included. Outcomes of interest included postoperative hematoma requiring surgery, 30-day mortality, and 30-day readmissions and reoperations. A total of 2949 patients were included. The incidence of a postoperative hematoma that required surgical management was 0.2%, 0.6%, and 4.5% in the INR≤1, 11.25 and ≤1.5 before elective anterior cervical spine surgery is associated with significantly higher rates of postoperative hematoma formation as well as 30-day readmission and reoperation; there was a trend toward significance in mortality rate. [Orthopedics. 2024;47(1):e26-e32.].

Maintenance of an Intraoperative External Fixator Is Associated With Decreased Postoperative Stiffness After Definitive Management of High-Energy Tibial Plateau Fractures.

Introduction Postoperative stiffness is a common complication after high-energy tibial plateau fractures. Investigation into reported surgical techniques for the prevention of postoperative stiffness is limited. The purpose of this study was to compare the rates of postoperative stiffness after second-stage definitive surgery for high-energy tibial plateau fractures between groups of patients who had the external fixator prepped into the surgical field and those who did not. Methods Two hundred forty-four patients met the inclusion criteria between the two academic Level I trauma centers, representing the retrospective observational cohort. Patients were separated based on prepping of the external fixator into the surgical field during second-stage definitive open reduction and internal fixation. One hundred sixty-two patients were in the prepped group and 82 were in the non-prepped group. Post-operative stiffness was determined by the need to return to the operating room for subsequent procedures. Results At the final follow-up (mean = 14.6 months), patients in the non-prepped group had an increased rate of stiffness post-operatively (18.3% non-prepped versus 6.8% prepped; p = 0.006). No other investigated variables were associated with increased post-operative stiffness, including the number of days spent in the fixator and operative time. The relative risk for post-operative stiffness associated with complete fixator removal was 2.54 (95% CI 1.26-4.41; p = 0.008 on binary logistic regression; absolute risk reduction 11.5%). Conclusion At the final follow-up, maintenance of an intraoperative external fixator as a reduction aid was associated with a clinically significant decrease in post-operative stiffness after definitive management of high-energy tibial plateau fractures, when compared with complete removal prior to prepping.

Radiographic parameters associated with fracture-related infection in high energy bicondylar tibial plateau fractures managed with two-stage treatment: Identifying the bad actors.

INTRODUCTION: High energy tibial plateau fractures are fraught with complications, particularly fracture-related infection (FRI). Previous studies have evaluated patient demographics, fracture classification, and injury characteristics as risk factors for FRI in patients with these injuries. This study evaluated the relationship between radiographic parameters (fracture length relative to femoral condyle width (FLF ratio), initial femoral displacement (FD ratio), and tibial widening (TW ratio)) and fracture-related infection following internal fixation in high energy bicondylar tibial plateau fractures. METHODS: 225 patients treated for bicondylar tibial plateau fractures at two level I trauma centers were retrospectively reviewed. Patient characteristics, fracture classification, and radiographic measurements were analyzed to determine association with FRI. RESULTS: The rate of FRI was 13.8%. Increased fracture length, FLF ratio, FD ratio, TW ratio, and fibula fracture were each associated with FRI on regression analysis, independent of clinical variables. Cutoff values were identified for each parameter and patients were risk stratified based on these radiographic parameters. High-risk patients had a 2.68- and 12.36-times risk of FRI compared to medium and low-risk patients, respectively. DISCUSSION: This study is the first to examine the relationship between radiographic parameters and FRI in high energy bicondylar tibial plateau fractures. Fracture length, FLF ratio, FD ratio, TW ratio, and fibula fracture were identified as radiographic parameters associated with FRI. More importantly, risk stratifying patients based on these parameters accurately identified patients at increased risk of FRI. Not all bicondylar tibial plateau fractures are created equal and radiographic parameters can be utilized to help identify the bad actors.

Perioperative allogenic blood transfusions are associated with increased fracture related infection rates, but not nonunion in operatively treated distal femur fractures.

INTRODUCTION: Distal femur fractures are common injuries that remain difficult for orthopedic surgeons to treat. High complication rates, including nonunion rates as high as 24% and infection rates of 8%, can lead to increased morbidity for these patients. Allogenic blood transfusions have previously been identified as risk factors for infection in total joint arthroplasty and spinal fusion surgeries. No studies have explored the relationship between blood transfusions and fracture related infection (FRI) or nonunion in distal femur fractures. METHODS: 418 patients with operatively treated distal femur fractures at two level I trauma centers were retrospectively reviewed. Patient demographics were collected including age, gender, BMI, medical comorbidities, and smoking. Injury and treatment information was also collected including open fracture, polytrauma status, implant, perioperative transfusions, FRI, and nonunion. Patients with less than three months of follow up were excluded. RESULTS: 366 patients were included in final analysis. One hundred thirty-nine (38%) patients received a perioperative blood transfusion. Forty-seven (13%) nonunions and 30 (8%) FRI were identified. Allogenic blood transfusion was not associated with nonunion (13% vs 12%, P = 0.87), but was associated with FRI (15% vs 4%, P<0.001). Binary logistic regression analysis identified a dose dependent relationship between number of perioperative blood transfusions and FRI: total transfusion ≥2 U PRBC RR= 3.47(1.29, 8.10, P = 0.02), ≥3 RR= 6.99 (3.01, 12.40, P<0.001), and ≥4 RR= 8.94 (4.03, 14.42, P<0.001). DISCUSSION: In patients undergoing operative treatment of distal femur fractures, perioperative blood transfusions are associated with increased risk of fracture related infection, but not the development of a nonunion. This risk association increases in a dose-dependent relationship with increasing total blood transfusions received.

Patients With Anterior Cruciate Ligament Rupture and Ipsilateral Segond Fractures Have High Rates of Concurrent Knee Pathology.

Purpose: The purpose of this study was to determine the rates of concomitant knee pathology in patients with ACL injuries and Segond fractures. Methods: A retrospective study is undertaken with patients identified via query of CPT codes for ACL reconstruction from 2014 to 2020. All patients with preoperative radiographs were reviewed for the presence of Segond fractures. Operative reports were analyzed for the presence of concurrent pathology, including meniscus, cartilage, and other ligamentous injuries at the time of arthroscopic ACL reconstruction. Results: A total of 1,058 patients were included in the study. Segond fractures were identified in 50 (4.7%) patients. Ipsilateral concomitant knee pathology was identified in 84% of Segond patients. Thirty-eight (76%) patients had meniscal pathology with a total 49 meniscal injuries, of which 43 were treated operatively. Multiligamentous injuries were present in 16 patients (32%), with 8 patients undergoing further ligament repair/reconstruction at the time of surgery. Chondral injuries were identified in 13 patients (26%). Conclusions: A high prevalence of concomitant meniscal, chondral, and ligamentous injuries was found in patients with Segond fractures. These additional injuries may require further operative management and may place patients at increased risk for future instability or degenerative changes. Patients with Segond fractures should be counseled preoperatively on the nature of their injuries and risk of associated pathologies. Level of Evidence: Level IV, prognostic case series.

Operative Traction Technique for an Intertrochanteric Femur Fracture in a Patient with Transfemoral Amputation: A Case Report.

CASE: A 53-year-old woman with a history of transfemoral amputation presented to the emergency department with an ipsilateral intertrochanteric femur fracture. Standard fracture tables that use a boot to pull traction are not helpful in these cases, which makes achieving adequate traction for reduction difficult. CONCLUSION: We describe a unique technique to manipulate an amputated extremity using 2 Schanz pins attached to a weight through a traction rope. This practical technique provided adequate skeletal traction for reduction and internal fixation in our case and can be performed on a standard radiolucent table without the need for special table attachments.

Patients With Simple Posterior Hip Dislocations Have Higher Rates of Hip Dysplasia and Borderline Dysplasia.

OBJECTIVES: To determine if patients suffering simple, posterior hip dislocations are more likely to display dysplastic characteristics of their acetabulum as compared with those suffering fracture dislocations. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Eighty-six patients suffering posterior, native hip dislocations over a 5-year period. MAIN OUTCOME MEASUREMENT: The primary outcome was measurement of the lateral center edge angle (LCEA), acetabular index (AI), acetabular version, and femoro-epiphyseal acetabular roof (FEAR) index. RESULTS: Eighteen patients (20.9%) sustained simple dislocations, whereas 68 patients (79.1%) suffered fracture dislocations. Patients with simple dislocations had decreased LCEA (25.7 vs. 34.3; P < 0.001), increased AI (7.4 vs. 5.8; P = 0.019), and decreased acetabular anteversion (14.02 vs. 18.45; P = 0.011). Additionally, patients with simple dislocations had higher rates of dysplasia and borderline dysplasia (61.1% vs. 7.3%; P < 0.001). Patients with fracture dislocations had higher rates of concomitant injuries (60.9% vs. 29.4%; P = 0.039) and higher injury severity scores (8.1 vs. 12.3; P = 0.022). CONCLUSION: Patients who sustain simple hip dislocations are more likely to have undercoverage of the femoral head by the acetabulum as compared with patients suffering fracture dislocations. In addition, the simple dislocation group had a lower ISS and fewer concomitant injuries, which likely relates to a lower energy required for dislocation in the setting of lesser bony constraint. Surgeons treating these complicated injuries should consider measurements of LCE and AI when counseling patients on treatment strategies. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of outcomes and operative course between septic and aseptic nonunion in long bones.

PURPOSE: The treatment of nonunion of long bones is difficult particularly in the presence of infection, which often involves staged surgical management. There is limited literature to compare the post operative course and outcomes of patients treated for septic versus aseptic nonunion. Thus, the purpose of this study was to determine if a difference exists between the number of surgical procedures, time to union, and rate of successful union for these two groups. METHODS: A retrospective cohort study was performed at a single tertiary care center. Patients suffering nonunion of the humerus, tibia and femur were included. Patient demographic data and characteristics of the post operative course were collected to include number and reason for repeat operations, antibiotic course, time to union, and development of a successful union. RESULTS: About 28 of 122 patients had septic nonunion. After diagnosis of nonunion, the septic group averaged 3.9 surgeries compared to 1.5 in the aseptic group (p < 0.001). There was no difference in the rate of successful union (79.8% versus 85.7%; p = 0.220), though the septic group took 129 days longer on average for successful union. (376 versus 247; p = 0.018). CONCLUSION: Septic nonunion of long bones is associated with the need for significantly more operations as well as time to union, though union rates remain similar. The identification of infection is critical for both the appropriate treatment as well as counseling patients on the expected post operative course.

External fixator pin placement during initial management of tibial plateau fractures: are there parameters to minimize pin-plate overlap?

PURPOSE: External fixator pin site overlap with definitive fixation implants (pin-plate overlap) has been identified as a risk factor for surgical site infection in tibial plateau fractures. Despite this, pin-plate overlap occurs in 24-38% of patients. This study sought to identify radiographic characteristics associated with pin-plate overlap to help minimize occurrences. METHODS: 283 patients at two Level I trauma centers were retrospectively reviewed. Radiographic measurements were recorded including fracture length, distance from fracture to proximal tibial pin site, and pin site distance-to-fracture (PSF) ratio. RESULTS: 70 (24.7%) cases of pin-plate overlap were identified. Pin-plate overlap was associated with increased fracture length (81.5 ± 32.1 mm vs 56.9 ± 26.1 mm, p < 0.001) and decreased distance from fracture to proximal tibial pin site (84.5 ± 37.1 mm vs 126.9 ± 35.8 mm). Pins placed greater than 100 mm and 150 mm from the fracture eliminated 36/70 (51%) and 67/70 (96%) pin-plate overlaps, respectively. Pins placed with a PSF ratio greater than 1.5 and 2.0 eliminated 47/70 (67%), and 57/70 (81%) of pin-plate overlaps, respectively. CONCLUSIONS: Longer fractures, pins closer to the fracture, and decreased PSF ratio were associated with overlap. Placing proximal tibial pins more than 100 mm from the fracture eliminated most pin-plate overlaps.

Do number and location of plates impact infection rates after definitive fixation of high energy tibial plateau fractures?

PURPOSE: Surgical trauma may confer additional infectious risk after operative fixation for high energy tibial plateau fractures. This study aims to determine the impact of plate number and location on infection rates after these injuries. METHODS: This retrospective cohort study completed at two level one trauma centers included patients who underwent staged fixation for a tibial plateau fracture between 2015 and 2019. Plate number and location (lateral, medial, posteromedial, and anterior quadrants) used in the definitive fixation construct were collected from post-operative radiographs. Deep infection rate was primary the outcome. RESULTS: A total of 244 patients met inclusion criteria. The overall infection rate was 13.9% (34/244). Infection rates increased with each additional quadrant utilized (8.0% one quadrant, 13.0% two quadrants, 27.3% three quadrants, 100% four quadrants; p < 0.001), independent of plate number, fracture severity, operative time, number of incisions, external fixator pin and plate construct overlap, and days in the external fixator on multivariate analysis. CONCLUSIONS: Infection risk increases with each quadrant utilized in the fixation of high energy tibial plateau fractures. Providers should attempt to limit the dissection of soft tissue for hardware placement in the fixation of these injuries to limit infection risk. LEVEL OF EVIDENCE: Level III, retrospective therapeutic study.

Assessment of Intraoperative Rotational Alignment of Closed Locked Intramedullary Nailing for Humerus Fractures.

Intramedullary nailing of humerus fractures has evolved over the past half century and has grown in popularity especially for the polytraumatized patient. The importance of restoring appropriate rotational alignment is equivalent to that of restoring sagittal and coronal alignment to decrease the risk of shoulder degenerative changes and limit range of motion discrepancy from the contralateral limb. This technique is designed to introduce an intraoperative fluoroscopic method to obtain adequate rotational alignment of humeral shaft fractures treated with closed antegrade humeral locked nailing.

Utilization Trends, Patient-Demographics, and Comparison of Medical Complications of Sliding Hip Screw or Intramedullary Nail for Intertrochanteric Fractures: A Nationwide Analysis from 2005 to 2014 of the Medicare Population.

Background: Studies demonstrate an increase incidence of intertrochanteric fractures within the United States. Matched studies evaluating intertrochanteric fractures managed with either sliding hip screw (SHS) or intramedullary nail (IMN) within the Medicare population are limited. The purpose of this study was to investigate: 1) annual utilization trends; 2) patient demographics; and 3) complications including mortality. Methods: A retrospective query using a nationwide database was performed. Patients undergoing SHS or IMN for intertrochanteric fractures were identified. The query yielded a total of 37,929 patients utilizing SHS (n = 11,665) or IMN (n = 26,264). Patients were matched 1:1 based on comorbidities. Primary outcomes included: utilization trends, patient demographics, 90-day complications, and 90-day readmission rates. Linear regression analyses were used to compare utilization trends. Pearson's c2 analyses were used to compare patient-demographics, medical complications, and 90-day readmission rates. A p-value less than 0.05 was considered statistically significant. Results: Linear regression analysis demonstrated a statistically significant decrease in utilization of SHS for IT fractures (p<0.0001); whereas utilization for IMN stayed consistent (p=0.36). IMN had significantly higher prevalence of comorbidities compared to SHS, notably, hyperlipidemia (70.6 vs. 62.6%; p<0.0001). Based on 1:1 match, IMN patients had significantly higher rates of 90-day medical complications, such as respiratory failure (11.0 vs. 8.1%; p<0.0001) and VTE (4.2 vs. 3.2%; p<0.001; however, there was not a statistical difference in postoperative infection (1.4 vs. 1.5%, p=0.06). There was no statistical difference in 90-day mortality between IMN and SHS cohorts (0.19 vs .13%, p = 0.249). Conclusion: This analysis demonstrates a difference in utilization of SHS and IMN for patients with IT fractures. Patients with IMN had significantly higher prevalence of comorbid conditions and incidence of 90-day postoperative complications compared to SHS patients. The study can be utilized by orthopaedic surgeons to potentially anticipate healthcare utilization depending on implant selection. Level of Evidence: III.

Pyoderma Gangrenosum Affecting the Dorsal Hand: A Case Report.

Pyoderma gangrenosum is an uncommon neutrophilic dermatosis characterized by an ulcerative lesion with a violaceous border. Most frequently, these lesions present in the lower extremity and are associated with underlying immune-mediated comorbidities. Infrequently, these lesions may present in the upper extremity, which presents difficult challenges for upper extremity surgeons as the lesions are frequently misdiagnosed as an infectious process. This often leads to inappropriate surgical debridement and antibiotic administration. Local trauma to the lesion can lead to a process of pathergy and worsening of the lesion. Here, we report on a case of cutaneous pyoderma gangrenosum affecting the dorsal hand, originally misidentified as an atypical infection with subsequent unsuccessful surgical debridement. After involvement of a multidisciplinary team, appropriate diagnosis was made, and treatment with local immunosuppressive agents achieved resolution of the lesion.

Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients.

BACKGROUND: Tibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds. METHODS: A retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure. RESULTS: Of the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39). CONCLUSION: Data from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation.

Two-Tiered Resection of Cam Lesions in Hip Femoroacetabular Impingement: Optimizing Femoral Head Sphericity.

Hip arthroscopy is one of the most rapidly growing fields in orthopaedic surgery. One of the most frequent pathologies treated with hip arthroscopy remains femoroacetabular impingement, which is addressed by labral repair and femoral osteoplasty. The most commonly cited reason for failure of arthroscopic treatment of femoroacetabular impingement is under-resection of the cam lesion. Surgeons frequently use evaluations of preoperative images, intraoperative fluoroscopy, and dynamic range of motion to ensure adequate resection. In this article, we describe a reproducible and standardized technique to assist in appropriate resection. This is achieved by a 2-tiered resection technique: Tier 1 aims to set the depth of resection and restore the head-neck offset. Tier 2 then matches the depth of the resection set by tier 1 and allows for retention of appropriate transition of the proximal convexity to the distal concavity seen in more ideally shaped femoral heads. With this technique, we offer a tool to avoid under-resection in the area of maximal conflict while simultaneously minimizing the risk of proximal over-resection and thus compromising the fluid seal dynamics of the joint in deeper flexion angles.

Ipsilateral ACL injured patients with Segond fractures demonstrate increased posterior tibial slope.

BACKGROUND: The anterolateral complex has been demonstrated to assist with rotational stability and prevention of anterior tibial translation during the pivot shift. In this study the Segond fracture is used as a surrogate for an anterolateral complex injury to determine if there is an association between Segond fracture and increased posterior tibial slope. METHODS: Patients' charts and radiographs were analyzed retrospectively for the presence of Segond fractures on injury radiographs. These patients, the Segond cohort, were then age and gender matched to a control cohort. Demographic as well MRI measurements of medial and lateral posterior tibial slope and lateral-to-medial slope asymmetry were collected for each cohort. Secondary outcome of anterior cruciate ligament reconstruction failure data was also collected. RESULTS: The Segond group demonstrated a statistically significantly greater lateral posterior tibial slope (8.42° versus 6.55°, P = 0.003) as well as medial posterior tibial slope (6.57° versus 5.34° degrees, P = 0.045). There was no significant differences between lateral-to-medial asymmetry (2.18°versus 1.83°, P = 0.246). CONCLUSION: Patients with Segond fractures at the time of anterior cruciate ligament injury have increased medial and lateral posterior tibial slope. This may relate to increased rotational and translational instability associated with anterolateral complex injuries. Surgeons treating these patient may use this information to counsel their patients on the risks of associated pathology at the time of arthroscopy such as lateral meniscal posterior root tears.

No Difference Between Anchorless and Traditional Suture Anchors in Arthroscopic Bankart Repair: A Clinical Comparison.

Background Shoulder instability and recurrent dislocations are common problems encountered by orthopedic surgeons and are frequently associated with a Bankart lesion. These are classically treated with either open or arthroscopic repair utilizing traditional suture anchors, though anchorless fixation techniques have recently been developed as an alternate fixation method that reduces native bone loss and has comparable pull-out strength. Methods A retrospective review was performed at a single institution for patients who underwent Bankart repair from January 2008 through February 2014. American Shoulder and Elbow Surgeons (ASES) questionnaires were mailed to 35 patients with anchorless fixation and 35 age-, gender-, and surgeon-matched patients with traditional suture anchors. Statistical analysis was performed comparing re-dislocation, additional surgery, and ASES scores with statistical significance set at p < 0.05. Results Eleven patients in the anchorless implant group and 15 patients in the anchor group completed the questionnaire. The mean follow-up was 4.1 years in the anchorless group and 5.6 years in the anchor group (p=0.04). The number of implants was 4.82 in the anchorless group and 3.87 in the anchor group (p = 0.04). No difference was found in re-dislocation rates (p = 0.80) or additional surgery on the affected shoulder (p = 0.75). ASES scores were found to have no statistical difference (89.89 for the anchorless group versus 85.37 for the anchor group; p = 0.78). Conclusion In patients undergoing arthroscopic Bankart lesion repair with traditional anchors compared to anchorless fixation, there appears to be no difference in shoulder re-dislocation rates, recurrent ipsilateral shoulder surgery, or ASES scores.

Are Infection Rates Increased After Sterilization of the External Fixator During Staged Internal Fixation of High-Energy Tibial Plateau Fractures?

OBJECTIVES: To compare infection rates after second-stage definitive surgery for high-energy tibial plateau fractures between groups of patients who had the external fixator prepped into the surgical field and those who did not. DESIGN: Retrospective cohort study. SETTING: Two academic Level 1 trauma centers. PATIENTS/PARTICIPANTS: Two hundred forty-four patients met inclusion and exclusion criteria between the 2 institutions. INTERVENTION: Prepping of the external fixator into the surgical field during second-stage definitive open reduction and internal fixation. 162 patients were in the prepped group, and 82 patients were in the nonprepped group. MAIN OUTCOME MEASUREMENTS: The primary outcome was the rate of deep infection after definitive fixation. Secondary outcome was operative time. RESULTS: There were no significant differences in infection rates between prepped (11.7%) and nonprepped (18.3%) groups ( P = 0.162). Patients in the prepped groups had significantly decreased operative time (168.2 minutes vs. 221.9 minutes, P < 0.001) even after controlling for confounders in regression analysis. CONCLUSIONS: There is no increased risk of infection associated with prepping and maintenance of the external fixator during definitive internal fixation for high-energy tibial plateau fractures. These data suggest that this practice may lead to shorter operative times as well. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Occult Chondral Injury Sustained After a Primary Patellar Dislocation.

Background and objective Primary patellar dislocations can concomitantly involve osteochondral injuries for which prompt recognition is paramount for joint preservation. These injuries can be missed on radiographs, necessitating MRI examinations. In this study, we aimed to identify patient parameters that correlate with occult osteochondral injuries. Methods Patients were retrospectively identified between 2015 and 2020 through a chart review. The inclusion criteria were as follows: patients diagnosed with a primary patellar dislocation with three radiographic views and an MRI of the injured knee. Demographic and radiographic data were evaluated. Results A total of 61 patients met the inclusion criteria. There were no statistically significant demographic differences between patients with osteochondral injuries and those without (p>0.05). Seven knees (88%) with an osteochondral lesion and 20 (38%) without had an effusion (p=0.02). There was no association in terms of ligamentous laxity (p=0.49), Caton-Deschamps index (CDI) (p=0.68), sulcus angle (SA) (p=0.68), congruence angle (CA) (p=0.56), and lateral patellofemoral angle (LPFA) (p=0.25) between patients with and without an occult osteochondral injury. Conclusion Among the parameter examined, the presence of an effusion was the only one that correlated with the presence of occult osteochondral injury in our cohort.