Evaluation of Self-Inflicted versus Non-Self-Inflicted Gunshot Wounds and Associated Injuries Involving the Hand and Upper Extremity.

Orthopedic costs associated with gunshot wounds (GSWs) totaled approximately USD 510 million from 2005 to 2014. Previous studies have identified differences in injuries associated with self-inflicted (SI) GSWs; however, there remains a gap in understanding injury patterns. This study aims to expand upon the current literature and shed light on injury patterns and outcomes associated with SI vs. non-self-inflicted (NSI) GSWs. This is a retrospective cohort study of upper extremity GSWs from January 2012 to December 2022. Data were analyzed using the two-sample t-test, Pearson's chi-squared test, and Fisher's exact test. SI GSWs tended to be high-velocity GSWs and occurred more often in distal locations compared to NSI GSWs (p = 0.0014 and p < 0.0001, respectively). SI GSWs were associated with higher Gustilo-Anderson (GA) and Tscherne classifications (p < 0.0001 and p = 0.0048, respectively) and with a greater frequency of neurovascular damage (p = 0.0048). There was no difference in fracture rate or need for operative intervention between the groups. GA and Tscherne classifications were associated with the need for and type of surgery (p < 0.0001), with a higher classification being associated with more intricate operative intervention; however, GSW velocity was not associated with operative need (p = 0.42). Our findings demonstrate that velocity, wound grading systems, and other factors are associated with the manner in which GSWs to the upper extremity are inflicted and may thus have potential for use in the prediction of injury patterns and planning of trauma management and surgical intervention.

Antibiotic Prophylaxis for Grade 3 Open Fractures: A Retrospective Comparison of Ceftriaxone Plus Vancomycin Versus Cefazolin Plus Gentamicin.

Background: Because of the established path of bacterial entry and contamination-associated mechanisms, grade 3 open orthopedic fractures represent a substantial infection risk. The Eastern Association for the Surgery of Trauma (EAST) guidelines recommended covering Staphylococcus aureus and adding aminoglycoside gram-negative coverage. Local institutional guidelines rely on ceftriaxone for gram negative coverage and add methicillin-resistant Staphylococcus aureus coverage with vancomycin. Patients and Methods: The electronic health records of adults admitted for a grade 3 open fracture between January 1, 2016, and October 31, 2021, were retrospectively reviewed. Patients who received cefazolin and gentamicin (CZ+GM) or ceftriaxone and vancomycin (CRO+VA) as prophylaxis were included. We recorded the rate of a composite treatment failure outcome of receipt of antibiotic agents, infection-related hospitalization, or subsequent debridement for injury-site skin and soft tissue infection or osteomyelitis. The presence of acute kidney injury (AKI) was also evaluated. Results: There were 65 patients included in the CZ+GM group and 53 patients in the CRO+VA group. Patients in the CZ+GM group were younger (mean 42.6 compared with 50.6 years; p = 0.02). Otherwise, there were no significant differences between groups' demographics, mechanism and site of injury, timeline of care, or surgical interventions. More patients in the CZ+GM arm met the composite treatment failure outcome, but it was not statistically significant (45% vs. 32%; p = 0.2). There were similar rates of treatment failure at 30 days (21% vs. 26%; p = 0.5) and for only osteomyelitis (8% vs. 9%; p = 1). Conclusions: The trend in numerically lower treatment failure rates in the CRO+VA group across outcomes provides sufficient evidence to continue the current local recommendations. Given our sample size, type 2 error may have occurred, and studies with greater power should analyze this question.

An Immunologic and Biomechanical Comparison of Polyether Ether Ketone-Zeolite and Polyether Ether Ketone Interbody Fusion Devices.

STUDY DESIGN: A laboratory study comparing polyether ether ketone (PEEK)-zeolite and PEEK spinal implants in an ovine model. OBJECTIVE: This study challenges a conventional spinal implant material, PEEK, to PEEK-zeolite using a nonplated cervical ovine model. SUMMARY OF BACKGROUND DATA: Although widely used for spinal implants due to its material properties, PEEK is hydrophobic, resulting in poor osseointegration, and elicits a mild nonspecific foreign body response. Zeolites are negatively charged aluminosilicate materials that are hypothesized to reduce this pro-inflammatory response when used as a compounding material with PEEK. MATERIALS AND METHODS: Fourteen skeletally mature sheep were, each, implanted with one PEEK-zeolite interbody device and one PEEK interbody device. Both devices were packed with autograft and allograft material and randomly assigned to one of 2 cervical disc levels. The study involved 2 survival time points (12 and 26 weeks) and biomechanical, radiographic, and immunologic endpoints. One sheep expired from complications not related to the device or procedure. A biomechanical evaluation was based on measures of segmental flexibility, using 6 degrees of freedom pneumatic spine tester. Radiographic evaluation was performed using microcomputed tomography scans in a blinded manner by 3 physicians. Levels of the pro-inflammatory cytokines, interleukin (IL)-1ß, IL-6, and tumor necrosis factor-alpha at the implant, were quantified using immunohistochemistry. RESULTS: PEEK-zeolite and PEEK exhibited an equivalent range of motion in flexion extension, lateral bending, and axial torsion. A motion was significantly reduced for implanted devices at both time points as compared with native segments. Radiographic assessments of fusion and bone formation were similar for both devices. PEEK-zeolite exhibited lower levels of IL-1ß ( P = 0.0003) and IL-6 ( P = 0.03). CONCLUSION: PEEK-zeolite interbody fusion devices provide initial fixation substantially equivalent to PEEK implants but exhibit a reduced pro-inflammatory response. PEEK-zeolite devices may reduce the chronic inflammation and fibrosis previously observed with PEEK devices.

Conservative Management with Functional Brace Versus Various Surgical Fixation Techniques for Humeral Shaft Fractures: A Network Meta-Analysis.

BACKGROUND: Historically, humeral shaft fractures have been successfully treated with nonoperative management and functional bracing; however, various surgical options are also available. In the present study, we compared the outcomes of nonoperative versus operative interventions for the treatment of extra-articular humeral shaft fractures. METHODS: This study was a network meta-analysis of prospective randomized controlled trials (RCTs) in which functional bracing was compared with surgical techniques (including open reduction and internal fixation [ORIF], minimally invasive plate osteosynthesis [MIPO], and intramedullary nailing in both antegrade [aIMN] and retrograde [rIMN] directions) for the treatment of humeral shaft fractures. The outcomes that were assessed included time to union and the rates of nonunion, malunion, delayed union, secondary surgical intervention, iatrogenic radial nerve palsy, and infection. Mean differences and log odds ratios (ORs) were used to analyze continuous and categorical data, respectively. RESULTS: Twenty-one RCTs evaluating the outcomes for 1,203 patients who had been treated with functional bracing (n = 190), ORIF (n = 479), MIPO (n = 177), aIMN (n = 312), or rIMN (n = 45) were included. Functional bracing yielded significantly higher odds of nonunion and significantly longer time to union than ORIF, MIPO, and aIMN (p < 0.05). Comparison of surgical fixation techniques demonstrated significantly faster time to union with MIPO than with ORIF (p = 0.043). Significantly higher odds of malunion were observed with functional bracing than with ORIF (p = 0.047). Significantly higher odds of delayed union were observed with aIMN than with ORIF (p = 0.036). Significantly higher odds of secondary surgical intervention were observed with functional bracing than with ORIF (p = 0.001), MIPO (p = 0.007), and aIMN (p = 0.004). However, ORIF was associated with significantly higher odds of iatrogenic radial nerve injury and superficial infection than both functional bracing and MIPO (p < 0.05). CONCLUSIONS: Compared with functional bracing, most operative interventions demonstrated lower rates of reoperation. MIPO demonstrated significantly faster time to union while limiting periosteal stripping, whereas ORIF was associated with significantly higher rates of radial nerve palsy. Nonoperative management with functional bracing demonstrated higher nonunion rates than most surgical techniques, often requiring conversion to surgical fixation. LEVEL OF EVIDENCE: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

Return-to-Play Outcomes of Athletes After Operative and Nonoperative Treatment of Lumbar Disc Herniation.

PURPOSE OF REVIEW: Lumbar disc herniation (LDH) is a common injury experienced by athletes and has important clinical considerations for athletes including the timing of return to sport. Lumbar disc herniation may result in loss of individual training and playing time for athletes. Current literature is inconclusive on whether surgical or conservative treatment of LDH is superior in athletes. Our aim was to review the literature to identify return-to-play (RTP) rates and performance outcomes following operative and nonoperative treatment of LDH in the athletic population. RECENT FINDINGS: Athletes have unique measurements of successful treatment for LDH such as time to return to their sport and performance outcomes that are not as applicable as traditional metrics. It is suggested that surgical treatment may provide a quicker return to sport than nonoperative care in athletes. Additionally, conflicting findings have been seen in career length and performance status based on sport, often due to short and tumultuous career patterns. These differences may be seen based on the unique physical demands of each sport, different motivations to prolong sport, or other confounding factors that could not be controlled for or unrelated to LDH. Recent literature on RTP outcomes in athletes treated for LDH show variable results based on sport. Further research is needed to assist physicians and athletes in making the decision to undergo conservative or surgical treatment of LDH in the athletic population.

Complications of surgically treated pelvic ring injuries with associated genitourinary injuries.

OBJECTIVE: Pelvic ring injuries are often associated with vascular and intrapelvic organ injuries including damage to the genitourinary system. The purpose of this study was to examine the relationship between surgically treated pelvic ring injuries and genitourinary injuries. The primary outcome was to determine the rate of post-operative complications including infection, urinary dysfunction, and sexual dysfunction. The secondary outcome was to determine if the time to surgery was associated with post-operative complications. METHODS: Retrospective chart review from September 1, 2015 to December 31, 2019 of patients who sustained a pelvic ring injury which required surgical intervention. All patients with closed triradiate cartilage were included. RESULTS: A total of 115 patients met the inclusion criteria, 12 patients with an associated genitourinary (GU) injury were included in the GU group and 103 without GU injury were placed in the non-GU group. The median (range) age of patients in the GU group was 49.5 years (20, 64) and 48 years (15, 92) in the control group (p = 0.92). Demographic characteristics including age, Injury Severity Score and Elixhauser comorbidity score were similar between groups. Within the GU group, five patients had an injury to their bladder, four to their urethra and three had an injury to their kidney. In the GU group, one patient developed a wound dehiscence and one developed a urinary tract infection with subsequent sepsis (17%), while in the non-GU group, one patient (1%) developed erectile dysfunction (p = 0.028). Regression analysis demonstrated that having concomitant pelvic ring and GU injuries, as well as the number of surgeries were variables associated with post-operative complications, while time to surgery was not. DISCUSSION AND CONCLUSIONS: Pelvic ring injuries with concomitant genitourinary injuries were associated with increased odds of post-operative complications. No differences were noted in complication rates due to the time to surgery between groups.

A biomechanical comparison of superior ramus plating versus intramedullary screw fixation for unstable lateral compression pelvic ring injuries,,.

INTRODUCTION: Management of the anterior component of unstable lateral compression (LC) pelvic ring injuries remains controversial. Common internal fixation options include plating and superior pubic ramus screws. These constructs have been evaluated in anterior-posterior compression (APC) fracture patterns, but no study has compared the two for unstable LC patterns, which is the purpose of this study. METHODS: A rotationally unstable LC pelvic ring injury was modeled in 10 fresh frozen cadaver specimens by creating a complete sacral fracture, disruption of posterior ligaments, and ipsilateral superior and inferior rami osteotomies. All specimens were repaired posteriorly with two fully threaded 7 mm cannulated transiliac-transsacral screws through the S1 and S2 corridors. The superior ramus was repaired with either a 3.5 mm pelvic reconstruction plate (n = 5) or a bicortical 5.5 mm cannulated retrograde superior ramus screw (n = 5). Specimens were loaded axially in single leg support for 1000 cycles at 400 N followed by an additional 3 cycles at 800 N. Displacement and angulation of the superior and inferior rami osteotomies were measured with a three-dimensional (3D) motion tracker. The two fixation methods were then compared with Mann-Whitney U-Tests. RESULTS: Retrograde superior ramus screw fixation had lower average displacement and angulation than plate fixation in all categories, with the motion at the inferior ramus at 800 N of loading showing a statistically significant difference in angulation. CONCLUSION: Although management of the anterior ring in unstable LC injuries remains controversial, indications for fixation are becoming more defined over time. In this study, the 5.5 mm cannulated retrograde superior ramus screw significantly outperformed the 3.5 mm reconstruction plate in angulation of the inferior ramus fracture at 800 N. No other significance was found, however the ramus screw demonstrated lower average displacements and angulations in all categories for both the inferior and superior ramus fractures.

The Presence of Biofilms in Instrumented Spinal Fusions.

Study Design: Prospective observational cohort study. Objective: To determine whether biofilms exist on spinal instrumentation recovered during revision surgery in which microbial cultures were negative. Background: Biofilm bacteria are extremely difficult to detect by conventional culture methods used in the standard hospital setting. Chronic infections in which bacteria form biofilms have been demonstrated to slow healing and prevent bony fusion. These slime encased microbial communities serve to isolate the bacteria from the body's immune responses, while simultaneously providing metabolic resistance to antimicrobial therapy. Methods: Traditional debridement wound cultures were taken from each specimen and sent for microbiological analyses. Bacterial DNA testing was performed using polymerase chain reaction (PCR) electrospray ionization-mass spectrometry (ESI-MS). Based on the PCR/ESI-MS results, specific crossed immune electrophoresis was used to detect the bacterial species within biofilms observed on the removed instrumentation. In addition, fluorescent in situ hybridization (FISH) probes corresponding to the bacterial species identified by PCR/ESI-MS were used with confocal microscopy to visualize and confirm the infecting bacteria. Results: Fifteen patients presented for surgical revision of thoracolumbar spinal implantation: four for clinical suspicion of infection, six for adjacent segment disease (ASD), one with ASD and pseudoarthrosis (PA), three with PA, and one for pain. Infections were confirmed with PCR/ESI-MS for all four patients who presented with clinical infection, and for five of the patients for whom infection was not clinically suspected. Of the presumed non-infected implants, 50% demonstrated the presence of infectious biofilms. Half of the revisions due to pseudoarthrosis were shown to harbour biofilms. The revisions that were performed for pain demonstrated robust biofilms but did not grow bacteria on traditional culture media. Conclusions: Culture is inadequate as a diagnostic modality to detect indolent/subclinical biofilm infections of spinal instrumentation. The PCR/ESI-MS results for bacterial detection were confirmed using species-specific microscopic techniques for both bacterial nucleic acids and antigens. Biofilms may contribute to pseudoarthrosis and back pain in postoperative wounds otherwise considered sterile.

Bacterial Identification and Visualization of Bacterial Biofilms Adjacent to Fracture Sites After Internal Fixation.

Objectives: The primary aims of this study were to determine if any correlation exists in cases of fracture fixation among: (1) bacterial profiles recovered from the instrumentation and adjacent tissues; (2) the type of orthopedic injury; and (3) the clinical outcome-union versus nonunion. A secondary goal was to compare culture and molecular diagnostics for identifying the bacterial species present following fracture fixation. Design: Single-institution, prospective case-control cohort study. Setting: Single level 1 trauma center. Patients: Forty-nine bony nonunion cases undergoing revision internal fixation and 45 healed fracture controls undergoing removal of hardware. Intervention: Bacterial infection was detected by standard microbial culture methods and by a pan-eubacterial domain, molecular diagnostic (MDx) assay. Confirmation of culture and MDx results was achieved with bacterial ribosomal 16S rRNA fluorescence in situ hybridization (FISH) to visualize bacterial biofilms. Main Outcome Measurements: MDx and microbial culture methods results were the primary study outcomes. Results: Ninety-four percent of the nonunion cohort and 93% of the union cohort had bacteria detected by the MDx. Seventy-eight percent of the nonunion cases and 69% of the controls were culture negative, but MDx positive. Although no significant differences in bacterial composition were observed between the cases and controls, differences were observed when cases were divided by comorbidities. Conclusion: The MDx is more sensitive than microbial culture in detecting bacterial presence. The lack of significantly different findings with regard to bacterial profile identified between the cases and controls suggests that host factors and environmental conditions are largely responsible for determining if bony union will occur. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Does operative treatment of geriatric pelvic ring injuries lead to a high risk of one-year mortality?

INTRODUCTION: Non-operative management of pelvic ring injuries in the elderly is associated with a high risk of one-year mortality. The majority of these injuries are the result of a low-energy mechanism, however, due to the multiple medical comorbidities in this patient population the injuries are associated with a high degree of morbidity. The purpose of this study was to determine the one-year mortality risk after operative treatment of pelvic ring injuries in a geriatric patient population and the effect of patient and injury characteristics on the risk of mortality. PATIENTS AND METHODS: We performed a retrospective review of patients over the age of 70 who underwent operative fixation of a pelvic ring injury at two Level 1 trauma centers between January 2016 and June 2019. Medical records were reviewed for patient and injury characteristics including: Charlson Comorbidity Index (CCI), American Society of Anesthesiologists (ASA) physical status score or Injury Severity Score (ISS), hospital and intensive care unit (ICU) length of stay (LOS). The primary outcome of interest was the one-year mortality risk following operative treatment. Secondary outcomes included the effect of patient and injury characteristics on the one-year mortality risk and the hospital LOS. RESULTS: Ninety patients were included with an average age of 79.8  ±  6.5 years. The overall mortality was 8.9% (n = 8) and was significantly associated with the CCI. There was no significant effect related to the ASA physical status score or ISS. The average hospital LOS was 9.2 ± 7.3 days and was associated with the CCI, ASA physical status score, and ISS. DISCUSSION: Non-operative management of pelvic ring injuries in geriatric patients is associated with a high risk of one-year mortality. Our findings suggest operative treatment of these fractures is associated with an acceptable risk of one-year mortality that falls below the commonly reported range for non-operatively managed injuries. Furthermore, the risk of mortality was significantly associated with the patient's pre-injury state as determined by the CCI.

Can preoperative radiographs predict hardware complication or fracture displacement after operative treatment of pelvic ring injuries?

INTRODUCTION: Operative fixation of pelvic ring injuries is associated with a high risk of hardware failure and loss of reduction. The purpose of this study was to determine whether preoperative radiographs can predict failure after operative treatment of pelvic ring injuries and if the method of fixation effects their risk. PATIENTS AND METHODS: We conducted a retrospective cohort study of 143 patients with pelvic ring injuries treated with operative fixation at a level 1 trauma center. Preoperative radiographs were examined for the presence of the following characteristics: bilateral rami fractures, segmental or comminuted rami fractures, contralateral anterior and posterior injuries, complete sacral fracture, and displaced inferior ramus fractures. The method of fixation was classified based on the presence of anterior, posterior, or combined anterior and posterior fixation as well as whether or not posterior fixation was performed at a single or multiple sacral levels. Post-operative radiographs were examined for hardware failure or loss of reduction. RESULTS: Twenty-one patients (14.7%) demonstrated either hardware complication or fracture displacement within 6 months of surgery. Male sex was associated with a decreased risk of hardware complication (OR 0.11 [0.014, 0.86]; p=0.03). Posterior pelvic ring fixation at multiple sacral levels was associated with a decreased risk of fracture displacement (OR 0.21 [0.056, 0.83]; p=0.02). We were unable to demonstrate a significant association between preoperative radiographic characteristics and risk of hardware failure or fracture displacement. CONCLUSION: Our study demonstrates that both gender and the method of posterior fixation are associated with hardware failure or displacement.

Inferior Vena Cava Filter Strut Penetration into the Vertebral Column: A Case of 10-Year Clinical Follow Up.

BACKGROUND: The rate of vena cava (IVC) filter placement has increased over the past decade, especially in the orthopaedic trauma patient population. With the increasing use of IVC filters, radiologists and referring clinicians must be familiar with potential complications. CLINICAL CASE: This case report presents an 18-year-old polytraumatized patient who had an IVC filter placed and required T8-L2 posterior spinal fusion. At 4.5 years of follow-up, a computed tomography (CT) scan for painful spinal hardware incidentally found that the IVC filter had migrated into the L3 vertebral body. The patient eventually underwent removal of her spinal hardware, but the IVC filter migration was managed conservatively with routine surveillance. At 10 years follow-up, the patient continued to remain asymptomatic despite of filter penetration into the vertebral body. CONCLUSION: This case demonstrates, long term follow-up for an asymptomatic patient with IVC migration and vertebral body penetration. This case may suggest that attempt at complex IR filter retrieval is not necessarily warranted in scenarios of strut penetration.

Evaluation of bacterial presence on lead X-ray aprons utilised in the operating room via IBIS and standard culture methods.

BACKGROUND: Despite precautions, surgical procedures carry risk of infection. Radiation-protective lead aprons worn by operating personnel are a potential source of bacterial contamination and have not been fully evaluated. AIM/OBJECTIVE: To evaluate lead aprons as a source of bacterial contamination, identify organisms most commonly found on this source, and devise a method with which to lower the risk of contamination. METHODS: In this basic science study, 20 randomly selected lead X-ray aprons were swabbed at three time points. The experimental treatment was with a hospital-grade disinfectant wipe. The samples were assessed for bacterial growth via traditional plating methods and mass spectrometry. Plates were graded on a scale of 0 to 4+ based on the number of quadrants with growth. Growth on one quadrant or more was considered contaminated. FINDINGS/RESULTS: Bacteria were initially detected via IBIS on a majority of the aprons (32/40), most commonly Staphylococcus epidermidis and Propionibacterium acnes. Virulent organisms cultured were Methicillin-resistant Staphylococcus epidermidis (MRSE), Neisseria, Streptococcus viridans and pseudomonas. MRSE were detected on 5/20 of the samples. Immediately after treatment, the majority of aprons showed less bacterial contamination (0/20 standard culture positive; 13/20 IBIS positive) with some recurrence at the 6-h time point (2/20 standard culture positive, 16/20 IBIS positive). All MRSE detected initially was eradicated. DISCUSSION: Lead X-ray aprons worn in the operating room harbour bacteria. Disinfecting before use may prevent the introduction of virulent organisms to patients. Our proposed method of sanitising with a disinfectant wipe is quick and effective.

Clinical Outcomes After Spine Surgery for Traumatic Injury in the Octogenarian Population.

OBJECTIVE: To review the surgical outcomes of the octogenarian population at a single institution after spinal traumatic injury. METHODS: Patients with both radiographic and clinical evidence of acute traumatic spine injury were reviewed using an institutional trauma survey to determine patient demographics and outcome data in a population of patients aged 80 years and older. RESULTS: Thirty-nine patients aged 80 years and older underwent surgical intervention for acute spinal trauma. There were 25 cases of cervical spine and 14 cases of thoracolumbar spine surgical intervention. Falls were the number one cause of acute spinal injury (31/39, 71%). Major respiratory disorders were the most common postoperative adverse event (12/39, 31%). Five patients experienced superficial wound dehiscence, fascial dehiscence, superficial infection, or delayed wound erosion. Patients were either discharged to home (10.5%), inpatient rehabilitation, (38.5%), skilled nursing facilities (17.9%), or long-term care facilities (17.9%). The postoperative mortality was 10.3%. CONCLUSIONS: Although the octogenarian population has increased risk for postoperative events after acute spinal injuries, surgical intervention may be worthwhile in the elderly population. Although direct surgical complication rates are not higher, medical risks are significantly higher after surgery.

Management of Sacroiliac Joint Pain.

Sacroiliac joint (SIJ)-based pain can be difficult to diagnose definitively through physical examination and conventional radiography. A fluoroscopically guided injection into the SIJ can be both diagnostic and therapeutic. The initial phase of treatment involves nonsurgical modalities such as activity modification, use of a sacroiliac (SI) belt, NSAIDs, and physical therapy. Prolotherapy and radiofrequency ablation may offer a potential benefit as therapeutic modalities, although limited data support their use as a primary treatment modality. Surgical treatment is indicated for patients with a positive response to an SI injection with >75% relief, failure of nonsurgical treatment, and continued or recurrent SIJ pain. Percutaneous SI arthrodesis may be recommended as a first-line surgical treatment because of its improved safety profile compared with open arthrodesis; however, in the case of revision surgery, nonunion, and aberrant anatomy, open arthrodesis should be performed.

Evaluating Postoperative Complications and Outcomes of Orthopedic Fracture Repair in Nonagenarian Patients.

INTRODUCTION: The United States and the world are currently experiencing a tremendous growth in the elderly population. Moreover, individuals surpassing the ages of 80 and 90 are also continuing to increase. As this unique division of society expands, it is critical that the medical community best understands how to assess, diagnose, and treat this population. The purpose of this study was to analyze morbidity, mortality, and overall outcome of patients aged 90 years and older after orthopedic surgical fracture repair. Such knowledge will guide patients and their families in making decisions when surgery is required among nonagenarians. METHODS: The trauma registry of our level I academic medical center was queried to identify potential study participants over the past decade. Two hundred and thirty-three surgical procedures among 227 patients were included and retrospectively assessed. Parameters of specific interest were injury type, mechanism of injury (including high energy vs low energy and height of falls), injury severity score, preoperative comorbidities, postoperative complications, length of hospital stay, discharge destination, and postoperative mortality rate. RESULTS: Overall, 4.3% of the cohort died in the hospital following surgery. Of the patients who survived, 89.7% were discharged to a professionally supervised setting. The nonagenarian population displayed a considerable follow-up rate, as 82.8% of individuals returned for their first postoperative office visit. DISCUSSION: Historically, surgical morbidity and mortality are highly associated with this age group. However, the number of nonagenarians in the United States is increasing, as are these surgical procedures. The epidemiologic and clinical findings of our study support this trend and add further insight into the matter. CONCLUSION: This investigation demonstrates that orthopedic surgery is an appropriate treatment in this population with an acceptable complication rate. Furthermore, nonagenarians have the potential to demonstrate a substantial follow-up rate, but postoperative discharge to a professionally supervised setting may be necessary.

No Difference Between Bracing and No Bracing After Open Reduction and Internal Fixation of Tibial Plateau Fractures.

INTRODUCTION: The use of a postoperative brace may be beneficial after open reduction and internal fixation of tibial plateau fractures. However, bracing has potential drawbacks related to cost, fitting, wound complications, and compliance. We hypothesized that no difference will be found between patients with and without bracing after open reduction and internal fixation of tibial plateau fractures. METHODS: In this prospective, comparative trial, patients were randomized to 6 weeks of bracing or no bracing after open reduction and internal fixation of tibial plateau fractures. Functional, subjective, and radiographic outcomes were recorded. Patients with an open physis, unstable ligamentous injuries, extensor mechanism disruption, and/or <6 months of prospective outcome data were excluded. RESULTS: The 24 patients with bracing (average age, 50 ± 16 years; 14 women and 10 men) were compared with the 25 patients without bracing (average age, 51 ± 12 years [P = 0.74]; 9 women and 16 men). No statistically significant differences were found in most of the functional, subjective, and radiographic outcomes, including fracture characteristics, complications, postoperative range of motion, Medical Outcomes Study 36-Item Short Form scores, and union rates. In the nonbraced group, one patient had late joint collapse with valgus malalignment (>10°). Two wound complications occurred in the braced group and four wound complications occurred in the nonbraced group, but this difference was not statistically significant. DISCUSSION: Improvements in conventional and locking plate technology have allowed more reliable rigid internal fixation of tibial plateau fractures. However, the use of a brace for postoperative rehabilitation after open reduction and internal fixation of tibial plateau fractures continues to be debated. CONCLUSION: Our prospective study showed no statistically significant difference between bracing and no bracing after open reduction and internal fixation of tibial plateau fractures in terms of functional, subjective, and radiographic outcomes. LEVEL OF EVIDENCE: Therapeutic level II.

High Thoracic Disc Herniation Causing Horner Syndrome with the Intraoperative Finding of Conjoined Nerve Root Compression: A Case Report.

CASE: A 29-year-old man presented with right medial arm pain with paresthesia, as well as right-sided ptosis, miosis, and anhidrosis. Magnetic resonance imaging revealed a right paracentral disc herniation at the T1-T2 level. The patient underwent a hemilaminectomy with a medial facetectomy through a posterolateral approach to the T1-T2 disc space, followed by a discectomy. Intraoperative findings were notable for a conjoined nerve root. CONCLUSION: Although high thoracic disc herniation is rare, its diagnosis should be considered when patients present with radicular arm pain and Horner syndrome. A high index of suspicion should be maintained for nerve root anomalies to limit iatrogenic injury and to ensure successful decompression.

Polymerase Chain Reaction-Electrospray-Time-of-Flight Mass Spectrometry Versus Culture for Bacterial Detection in Septic Arthritis and Osteoarthritis.

BACKGROUND: Preliminary studies have identified known bacterial pathogens in the knees of patients with osteoarthritis (OA) before arthroplasty. AIMS: The current study was designed to determine the incidence and types of bacteria present in the synovial fluid of native knee joints from adult patients with diagnoses of septic arthritis and OA. PATIENTS AND METHODS: Patients were enrolled between October 2010 and January 2013. Synovial fluid samples from the affected knee were collected and evaluated with both traditional microbial culture and polymerase chain reaction-electrospray ionization-time-of-flight mass spectrometry (molecular diagnostics [MDx]) to prospectively characterize the microbial content. Patients were grouped by diagnosis into one of two cohorts, those with clinical suspicion of septic arthritis (n = 44) and those undergoing primary arthroplasty of the knee for OA (n = 21). In all cases where discrepant culture and MDx results were obtained, we performed species-specific 16S rRNA fluorescence in situ hybridization (FISH) as a confirmatory test. RESULTS: MDx testing identified bacteria in 50% of the suspected septic arthritis cases and 29% of the arthroplasty cases, whereas culture detected bacteria in only 16% of the former and 0% of the latter group. The overall difference in detection rates for culture and MDx was very highly significant, p-value = 2.384 × 10-7. All of the culture-positive cases were typed as Staphylococcus aureus. Two of the septic arthritis cases were polymicrobial as was one of the OA cases by MDx. FISH testing of the specimens with discordant results supported the MDx findings in 91% (19/21) of the cases, including one case where culture detected S. aureus and MDx detected Streptococcus agalactiae. CONCLUSIONS: MDx were more sensitive than culture, as confirmed by FISH. FISH only identifies bacteria that are embedded or infiltrated within the tissue and is thus not susceptible to contamination. Not all suspected cases of septic arthritis contain bacteria, but a significant percent of patients with OA, and no signs of infection, have FISH-confirmed bacterial biofilms present in the knee.

Traumatic Conus Medullaris Syndrome: A Case Report and Review of the Literature.

CASE: A twenty-six-year-old man was diagnosed with conus medullaris syndrome (CMS) after sustaining a traumatic L1 burst fracture. Surgical decompression and stabilization was performed within ninety-six hours of admission; postoperatively, normal bladder function rapidly returned. CONCLUSION: CMS is difficult to diagnose because of the clinically variable presentation. There is no consensus regarding the natural history of conus medullaris injury or regarding the necessity, approach, or timing for decompression. Higher-level evidence is needed to guide treatment for acute traumatic CMS.