Biomechanical comparison of composite and cadaveric humeri models in experiments on operated humeral shaft fractures.

A study was undertaken to determine how well contacting fracture fragments of composite bone replicated the behavior of fracture fragments in real bone. Ten composite and ten real humeral diaphyses were transected and reconstructed with limited-contact dynamic-compression plates. Two screws were placed on each side of the transection site and a calibrated electronic sensor sheet was placed between the imitated fracture fragments. After insertion of the distal screws, pressure measurements were made during insertion of the first proximal screw in compression mode, during insertion of the second screw in compression mode after loosening the first screw, and finally after retightening the first screw. The process was repeated after bending the plate. The contact area, the net compression force and the average compressive stress were computed and statistically compared. The composite bone and cadaveric bone differed in contact area and compressive stress but not in net compressive force. Plate bending did not produce a significant difference between composite and cadaveric bone. The results indicate that composite bone does not reproduce all the local fracture fragment conditions so that hardware testing in composite bone should proceed carefully. A gap between fracture fragments as is often used in comminuted fracture tests may remain as the most appropriate situation for fracture hardware testing.

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.

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.

Stability, deformity, and fixation of the floating shoulder: a cadaveric biomechanical study.

BACKGROUND: Floating shoulder injuries cause instability and deformity due to disruptions of the scapula, clavicle, and superior shoulder suspensory complex ligaments (SSSC). Resulting deformity of the glenopolar angle (GPA) has not previously been established, nor has the impact on stability and deformity when surgical fixation is performed. This study sought to quantify stability and deformity for multiple injury patterns and the improvement to these parameters provided by clavicle and coracoclavicular (CC) ligament fixation. METHODS: Fourteen cadaveric specimen upper extremities were used, which included the entire upper extremity, scapula, clavicle, and cranial-most ribs. After being mounted upright, a scapular neck fracture was created, followed by either a midshaft clavicle fracture or sectioning of the acromioclavicular and coracoacromial ligaments. Subsequent sectioning of the other structure(s) followed by the CC ligaments was then performed. In all specimens, the clavicle was then plated, followed by a CC ligament repair. At each step, a radiograph in the AP plane of the scapula was taken to measure GPA and displacement of the glenoid fragment using radiopaque markers placed in the scapula. These radiographs were taken both unloaded and with a 100-N applied medializing force. RESULTS: When evaluating deformity related to sectioning, the GPA was reduced when the CC ligaments were sectioned compared to an isolated scapula fracture (P = .022) and compared to a combined scapula and clavicle fracture (P = .037). For stability, displacement with a 100-N force was significantly increased when the CC ligaments were sectioned compared to an isolated scapula fracture (P = .027). In cases of an ipsilateral scapula neck and clavicle fracture with intact ligaments, fixation of the clavicle alone provided a statistically significant improvement in the GPA (P = .002); but not in reduction of displacement (P = .061). In cases of an ipsilateral scapula neck and clavicle fracture with concomitant disruption of the coracoacromial, acromioclavicular, and CC ligaments, the GPA was improved by clavicle fixation (P < .001) and increasingly so by subsequent CC ligament repair (P < .001). Displacement was also improved in these 2 states (P < .001, P = .008, respectively). DISCUSSION: This biomechanical study confirmed the importance of the acromioclavicular, coracoacromial, and CC ligaments in conferring stability in SSSC injuries. Disruption of the CC ligaments created significant deformity of the GPA and instability with a medializing force. Clinical treatment should consider the integrity of these ligaments and their repair in conjunction with clavicle fixation, knowing that this combination should restore a biomechanical state equivalent to an isolated scapula fracture.

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.

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.

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.

Fracture-Associated Microbiome and Persistent Nonunion: Next-Generation Sequencing Reveals New Findings.

INTRODUCTION: Fracture nonunion remains a devastating complication and may occur for several reasons, though the microbial contribution remains poorly estimated. Next-generation sequencing (NGS) techniques, including 16S rRNA gene profiling, are capable of rapid bacterial detection within clinical specimens. Nonunion cases may harbor microbes that escape detection by conventional culture methods that contribute to persistence. Our aim was to investigate the application of NGS pathogen detection to nonunion diagnosis. METHODS: In this prospective multicenter study, samples were collected from 54 patients undergoing open surgical intervention for preexisting long-bone nonunion (n = 37) and control patients undergoing fixation of an acute fracture (n = 17). Intraoperative specimens were sent for dual culture and 16S rRNA gene-based microbial profiling. Patients were followed for evidence of fracture healing, whereas patients not healed at follow-up were considered persistent nonunion. Comparative analyses aimed to determine whether microbial NGS diagnostics could discriminate between nounions that healed during follow-up versus persistent nonunion. RESULTS: Positive NGS detection was significantly correlated with persistent nonunion, positive in 77% more cases than traditional culture. Nonunion cases were observed to have significantly increased diversity and altered bacterial profiles from control cases. DISCUSSION: NGS seems to be a useful adjunct in identification of organisms that may contribute to nonunion. Our findings suggest that the fracture-associated microbiome may be a significant risk factor for persistent nonunion. Ongoing work aims to determine the clinical implications of isolated organisms detected by sequencing and to identify robust microbial predictors of nonunion outcomes. LEVEL OF EVIDENCE: Diagnostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Definitive fixation of open tibia fractures: Does reopening the traumatic wound increase complication rates?

BACKGROUND: It is unknown if surgical approach or use of previous traumatic wounds for open fracture instrumentation has an impact on patient complications or outcomes. This study sought to compare infection and nonunion rates in the staged treatment of open tibia fractures where the traumatic wound was reopened during definitive fixation versus when they were not. METHODS: A retrospective review was performed on all patients at a single institution level 1 trauma center. All patients who had a minimum of 1 year clinical and radiographic outcomes were included. Primary outcome measures were incidence of infection and nonunion. Groups of patients were compared based on surgical approach for definitive fixation. RESULTS: A total of 96 patients were included - 48 patients received definitive treatment and wound closure during initial management of the open fracture (group 1), 22 patients had staged fixation through new incisions (group 2), and 26 patients had their traumatic wound reopened during definitive fixation (group 3). Rates of infection were 10.4%, 31.8% and 11.5% respectively (p = 0.15). Rates of nonunion were 20.8%, 27.3% and 30.8% (p = 1.0). No statistically significant differences in regards to primary outcomes were found between the staged fixation groups. Multiple logistic regression also showed no difference in infection or nonunion when controlling for known risk factors. CONCLUSION: For open tibia fractures that underwent staged fixation, no significant differences in infection or nonunion were observed between procedures that involved reopening the traumatic wound versus procedures performed through new incisions. The presence of a distal tibia periarticular fracture was found to be independently associated with infection risk.

Use of Tantalum Trabecular Metal Cones for Management of Nonunion of the Distal Femur with Segmental Bone Defects: Technique and Case Series.

INTRODUCTION: Segmental bone loss in the distal femur presents a challenge for reconstruction regardless of etiology. Use of tantalum trabecular metal cones with intramedullary fixation and autologous bone graft may be used as a salvage technique in difficult situations where other options have either been exhausted or are unavailable. CASE REPORT: Surgical planning and technique for this approach to reconstruction are described. A retrospective review of five cases with >1 year of follow-up was performed to provide radiographic and clinical outcomes. All five patients had satisfactory outcomes with clinical union and retention of implants at final follow-up (average >4 years). CONCLUSIONS: Use of tantalum metal cones for reconstruction of distal femur nonunion with segmental bone defects can be a successful technique in a complex group of patients.

Does Provisional Minifragment Fixation Prevent Compression With Dynamic Compression Plating? A Biomechanical Analysis.

OBJECTIVES: To compare the compressive force generated by a 3.5-mm compression plate with and without provisional fixation using a 2.0-mm minifragment plate. METHODS: Fourth generation composite large humeral sawbones underwent transection and were divided into 2 groups. The first group underwent fixation with a 3.5-mm compression plate; the second group underwent provisional fixation with a 2.0-mm plate followed by definitive fixation using a 3.5-mm plate. Using a load cell, the compressive force generated was measured after insertion of each of 2 eccentrical placed screws and the total compression recorded. RESULTS: There was no difference in the force generated after each successive compression screw (P = 0.59 and 0.58, respectively). Likewise, there was no significant difference in the total compression generated when the preload was accounted for (P = 0.93). CONCLUSION: Provisional minifragment fixation does not have any adverse effect on the forces generated during compression plating. These findings suggest that provisional minifragment plates do not need to be removed before definitive fixation.

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.

Long-term Functional Outcomes of Nonoperatively Treated Highly Displaced Scapular Body and Neck Fractures.

Historically, extra-articular scapular body fractures were treated nonsurgically, but displaced fractures of the glenoid neck can lead to dysfunction. Controversy exists regarding which extra-articular scapular fractures should be treated surgically; however, nonsurgical management of severely displaced scapular body fractures can result in satisfactory outcomes. Inclusion criteria for this study were medial or lateral displacement greater than 2 cm, angular deformity between fracture fragments greater than 45°, or glenopolar angle less than 22°. Functional outcomes included Disabilities of the Arm, Shoulder and Hand (DASH) score, Short Form-36 (SF-36) score, and American Shoulder and Elbow Surgeons (ASES) shoulder score. Radiographs and computed tomography scans were available for all patients. Range of motion (ROM), strength, other injuries, and complications also were recorded. Twelve patients (10 males, 2 females) with a mean age of 45.6 years (range, 29-57 years) underwent follow-up for a mean of 54.1 months (range, 28.2-74.4 months). At latest follow-up, mean DASH score was 8.9 (range, 0-35), mean SF-36 score was 72.2 (range, 57.3-96.1), and mean ASES score was 85.9 (range, 46.7-100). Mean ROM and strength expressed as a percentage of the contralateral side ranged from 88% to 99% and 70% to 93%, respectively. At longest follow-up, 10 patients reported excellent satisfaction with their treatment. There were no radiographic non-unions. One patient with concomitant clavicle and acromion fractures treated surgically had a postoperative infection requiring operative irrigation and debridement. None of the patients required or sought additional treatment. Nonoperative treatment of highly displaced scapular body fractures resulted in good patient satisfaction, satisfactory long-term functional outcomes, and only minor loss of motion and strength. [Orthopedics. 2020;43(3):e177-e181.].

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.

Cadaveric Study of Bone Tissue Temperature During Pin Site Drilling Using Fluoroptic Thermography.

BACKGROUND: Using fluoroptic thermography, temperature was measured during pin site drilling of intact cortical human cadaver bone with a combination of 1-step drilling, graduated drilling, and 1-step drilling with irrigation of 5.0-mm Schanz pins. MATERIALS AND METHODS: A 1440 revolutions per minute constant force drilling was used on tibial diaphyses while a sensor probe placed 0.5 mm adjacent to the drill hole measured temperature. Four drilling techniques on each of the tibial segments were performed: 3.5-mm drill bit, 5.0-mm Schanz pin, 5.0-mm Schanz pin in a 3.5-mm predrilled entry site, and 5.0-mm Schanz pin using irrigation. RESULTS: One-step drilling using a 5.0-mm Schanz pin without irrigation produced a temperature that exceeded the threshold temperature for heat-induced injury in 5 of the 8 trials. With the other 3 drilling techniques, only 1 in 24 trials produced a temperature that would result in thermal injury. This difference was found to be statistically significant (P = 0.003). The use of irrigation significantly reduced the maximum bone tissue temperature in 1-step drilling of a 5.0-mm Schanz pin (P = 0.02). One-step drilling with a 3.5-mm drill bit achieved maximum temperature significantly faster than graduated drilling and drilling with irrigation using a 5.0-mm Schanz pin (P < 0.01). CONCLUSIONS: One-step drilling with a 5.0-mm Schanz pin into cortical bone can produce temperatures that can lead to heat-induced injury. Irrigation alone can reduce the temperatures sufficiently to avoid damage. Predrilling can increase temperatures significantly, but the extent of any injury should be small.

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.

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.

Presence of bacteria in failed anterior cruciate ligament reconstructions.

BACKGROUND: Novel microbial detection technologies have revealed that chronic bacterial biofilms, which are recalcitrant to antibiotic treatment, are common in failed orthopedic procedures. QUESTIONS: Are bacteria present on failed anterior cruciate ligament (ACL) reconstructions? Is there a difference in the presence or nature of bacteria in failed ACL reconstructions relative to a control set of healthy ACL's? METHODS: We used a case-control study design, where we analyzed the bacterial composition of 10 failed ACL reconstructions and compared it to 10 native ACL's harvested during total knee arthroplasty. The IBIS Universal Biosensor was used to determine the nature of bacteria on ACL specimens, and fluorescent in situ hybridization (FISH) was used to visualize bacteria in a subset of cases. RESULTS: Bacteria are present in failed ACL reconstructions. Bacteria are present in ACL's harvested during total knee arthroplasty, but the nature of the species differs significantly between experimental and control sets. Twelve genera were detected in the experimental set (in both allografts and autografts), and in four samples multiple species were detected. In contrast, the control group was characterized by presence of Propionibacterium acnes. CONCLUSIONS: We demonstrate the presence of bacteria on failed ACLs surgeries, and open the door to investigate whether and how bacteria and the associated immune responses could possibly contribute to graft failure. CLINICAL RELEVANCE: If microbial pathogens can be linked to failed grafts, it could provide: (1) markers for early diagnosis of abnormal healing in ACL surgeries, and (2) targets for early treatment to prevent additional reconstruction surgeries.