Fixation of Olecranon Fractures Using a Hybrid Intramedullary Screw and Tension Band Construct.

Introduction: Olecranon fractures are common injuries that require surgical intervention for optimal outcomes. Various fixation methods have been described in the literature, including the use of intramedullary proximal ulna screws in combination with tension band augmentation. Limited research has compared this hybrid technique to other established methods of fixation. This study compared complication and reoperation rates between multiple groups. Methods: A retrospective review was conducted on patients with olecranon fractures who underwent internal fixation at a level 1 trauma center between January 1st, 2013, and April 22nd, 2023. Data was collected using CPT codes, and patients were categorized into five groups based on the method of fixation received: no implant, tension band only, locking olecranon plate, intramedullary screw and tension band hybrid, and others. Variables such as patient demographics, Mayo fracture classification, open vs. closed injury, implant type, reoperation rates, and postoperative complications were recorded. Results: A total of 217 patients were included in the study. No difference was found with implant choice and reoperation rate (p = 0.461). There was a significant difference found with reoperation and fracture type (p = 0.027) and open fracture (p = 0.002). Conclusion: The primary findings of this study indicate no significant difference in implant choice and reoperation rates among the various fixation methods used for olecranon fractures. These findings suggest that the hybrid fixation technique, utilizing intramedullary proximal ulna screws in combination with tension band augmentation, is a viable and comparable treatment option when evaluated against other well-documented methods of fixation. This study also reiterates that severity of initial injury is often the most important factor related to poorer outcomes. Further discussion and analysis of the data will provide a comprehensive understanding of implications and recommendations for olecranon fracture fixation.

Subtrochanteric fracture after femoral neck system of femoral neck fractures: a report of four cases.

BACKGROUND: The femoral neck system (FNS) is commonly used for internal fixation of femoral neck fractures and has shown promising results. However, we have observed cases of peri-implant subtrochanteric femur fractures associated with the use of FNS at our institution. This case series aims to investigate four cases of peri-implant subtrochanteric fractures in patients treated with the FNS implant for femoral neck fractures. CASE PRESENTATION: We reviewed 35 patients who underwent treatment with FNS for femoral neck fractures between January 2017 and December 2021 at our level 1 trauma institution. Among these patients, four cases of peri-implant subtrochanteric femur fractures were identified. In contrast, no such fractures occurred in patients treated with cannulated screws or dynamic hip screws (DHS). Interestingly, all four cases of peri-implant fractures were seen in patients with incomplete nondisplaced femoral neck fractures. Only one case involved an identifiable technical error. CONCLUSIONS: This case series sheds light on peri-implant subtrochanteric femur fractures as a previously unreported complication associated with the use of FNS for femoral neck fractures. These fractures were observed exclusively in patients with incomplete nondisplaced fractures who received FNS fixation. No similar complications were observed in patients treated with other types of fixation. This finding suggests the need for caution and further investigation when considering FNS as a treatment option for this specific fracture pattern. The identification of peri-implant subtrochanteric femur fractures as a potential complication of FNS usage in incomplete nondisplaced femoral neck fractures raises important considerations for clinical decision-making and patient management in orthopedic trauma.

Effects of powdered rifampin and vancomycin solutions on biofilm production of staphylococcus aureus on orthopedic implants.

PURPOSE: Hardware infections in orthopedic surgery, specifically those involving biofilm producing bacteria, are troublesome and are highly resistant to systemic antibiotics. The purpose of this study was to demonstrate the power of rifampin and vancomycin solutions in inhibiting as well as eliminating in vitro on staphylococcus aureus (S. aureus) biofilm in vitro on stainless-steel implants. METHODS: A suspension of either S. aureus or a S. aureus containing a plasmid that cods for the green fluorescence protein containing fluorescent protein plasmid was applied to 1 × 1cm sterile stainless steel orthopedic plating material (coupon). Biofilm development was confirmed by; the quantitative assay (colony forming unit [CFU/coupon]) and visualized using confocal laser scanning microscopy. With this established method of biofilm development, we determined the minimum biofilm inhibitory concentration (MBIC) and the minimum biofilm eradication concertation (MBEC) of Rifampicin and Vancomycin. To determine the MBIC, stainless steel plates were subjected to different concentrations of antibiotic solution and inoculated with overnight cultures of S. aureus. After 24 h of incubation at 37 °C, the biofilms on the untreated and antibiotic-treated coupons were quantified. To determine the MBEC, partial S. aureus biofilms were developed on the coupons and then treated with the different concentrations of each antibiotic for 24 h. The number of bacteria within the control untreated as well as treated coupons was determined. RESULTS: Both rifampin and vancomycin solutions inhibited biofilm production of S. aureus on stainless steel mediums; the MBIC for rifampin and vancomycin were 80 ng/mL and 1 µg/mL respectively. The MBEC for Rifampicin was similar to the MBIC. However, the MBEC for Vancomycin was 6 mg/ml. CONCLUSIONS: When applied to orthopedic stainless steel hardware in vitro, solutions of rifampin and vancomycin powder separately or in combination can completely prevent and eliminate biofilm produced by S. aureus. LEVEL OF EVIDENCE: II.

A retrospective analysis of the aspiration of fracture blisters.

INTRODUCTION: Fracture blisters are frequently encountered in orthopaedic trauma. Fracture blisters are associated with increased infection rates and wound breakdown. This study was performed to determine whether fluid aspirate from blisters is sterile or colonized. MATERIALS AND METHODS: This is a retrospective review of a prospectively gathered cohort of patients. Patients with fracture blisters were recruited from a U.S. level I trauma center between 2011 and 2017. The blisters were aspirated under sterile conditions. Fluid was analyzed for gram stain and quantitative culture. Medical history obtained included blister location, presence of blood in blister, injury mechanism, gender, diabetes status and tobacco use. The demographic and behavioral descriptors were compared across positive aspirate or infection status using chi-square and Fisher's exact tests. RESULTS: We enrolled 64 patients in the study, seven of which had colonized aspirates (10.9%). None of the potential risk factors were significantly associated. Tobacco use trended towards significance for a positive aspirate (p = 0.09), but not for infection (p = 0.61). We followed patients for an average of 4.6 months. Four patients went on to have surgical site infections and none of them had positive aspirates. CONCLUSION: Fracture blisters cannot be assumed to be sterile with more than 10% of our sample being colonized. Blister rupture during surgery or prepping for surgery could represent a contamination of the sterile field. No risk factors were significantly associated with colonization in our sample. However, colonized aspirates may not predispose patients to increased infection rates.

Periprosthetic Fracture through a Unicortical Tracking Pin Site after Computer Navigated Total Knee Replacement.

A rare complication from computer-navigated total knee arthroplasty is a fracture through the insertion site of a tracking pin. These pins are inserted across the femoral and tibial shafts either bicortically, transcortically, or unicortically and have a reported fracture incidence of 1.38%, with all published cases occurring after bicortical pin placement. In this case, a 60-year-old female suffered a femoral shaft fracture through a unicortically inserted computer navigation tracking pin 6 weeks after total knee arthroplasty. Her fracture was successfully fixated with an intramedullary nail with retention of the knee prosthesis. This case is important as it records the risk for a postoperative fracture through a unicortically inserted computer navigation pin.

Intrawound Vancomycin Powder Reduces Bacterial Load in Contaminated Open Fracture Model.

OBJECTIVES: To compare the effectiveness of both vancomycin powder and antibiotic bead placement to irrigation and debridement alone in prevention of infection in a contaminated open fracture model in rats. METHODS: In a previously described model of contaminated open fractures, 45 rats had simulated open fractures created, stabilized, and contaminated with Staphylococcus aureus. They were then treated 6 hours later with 3 interventions: irrigation and debridement alone (control group) or in combination with placement of polymethyl methacrylate beads containing vancomycin and tobramycin powders (antibiotic bead group) or placement of 10 mg of intrawound vancomycin powder (powder group). Rats were allowed to recover and then killed 14 days later for harvest of femurs and plates. Femurs and plates were both incubated overnight, and bacterial colonies were counted in each group for comparison. RESULTS: Quantitative counts of bacteria in bone showed significantly reduced growth in both bead and powder groups when compared with control group (P < 0.0001). Quantitative counts of bacteria in plates showed significantly reduced growth in both bead and powder groups when compared with control group (P < 0.0003; 0.029). No significant differences were seen in bacterial growth between bead and powder groups for either bones (P = 0.13) or plates (P = 0.065). CONCLUSIONS: When compared with irrigation and debridement alone, placement of intrawound vancomycin powder significantly decreased bacterial load in a contaminated open fracture model in rats similar to placing antibiotic beads. This may provide an additional adjuvant treatment that does not require a secondary surgery for bead removal.

Bosworth Dislocation without Associated Fracture.

One of the rarest ankle injuries is the Bosworth fracture-dislocation, whereby the distal fibula fractures and is lodged behind the tibia and is often unable to be reduced in a closed fashion. Even more rarely, a Bosworth dislocation without any accompanying fractures may occur. In this case, a 19-year-old male presented with a Bosworth dislocation, with the ipsilateral tibia having previously undergone intramedullary nailing. After closed reduction was attempted, open reduction and fixation was performed, directly reducing the fibula and fixing the unstable syndesmosis with 2 quadricortical screws. Bosworth injuries are rare, yet severe, and should be treated in a timely manner. We were able to provide good reduction and fixation without requiring removal of the intramedullary nail, and we support the use of 2 quadricortical screws as a valid treatment option for the fixation of Bosworth dislocations.

Do local antibiotics reduce periprosthetic joint infections? A retrospective review of 744 cases.

Periprosthetic joint infections (PJI) are uncommon but not rare and have significant morbidity and financial implications. Local antibiotics have been used successfully in other areas of orthopedics to reduce postoperative infections, but this method has not been proven in total joint arthroplasty (TJA). Beginning January 1, 2014, our primary investigators began using surgical site lavage with providone-iodine solution and administering 2 g of vancomcyin powder in the surgical wound prior to capsule closure for all primary and revision total hip and knee arthroplasties. We performed a retrospective chart review of patients two years prior to this date and two years after to compare occurrence of PJI. The groups were broken down into patients who received local antibiotics versus those who did not. The groups were further broken down by type of surgery performed; primary or revision total hip or knee arthroplasty. Administration of local antibiotics was preventative for PJI only in the primary total knee arthroplasty group (aOR = 0.28, 0.09-0.89). Administration of local antibiotics trended towards a preventative effect for PJI in the other groups but was not statistically significant. Patients receiving local antibiotics had similar blood urea nitrogen and creatinine levels postoperatively compared to the no antibiotics group indicating minimal systemic effects of local vancomycin powder. While the use of local antibiotics may prevent PJI, more data is required especially in the revision arthroplasty groups.

The Utility of the Tip-Apex Distance in Predicting Axial Migration and Cutout With the Trochanteric Fixation Nail System Helical Blade.

OBJECTIVES: To determine whether a tip-apex distance (TAD) <20 mm is associated with a higher rate of axial migration and perforation with the Trochanteric Fixation Nail (TFN) System helical blade implant. DESIGN: Retrospective. SETTING: Level I Trauma Center. PARTICIPANTS: Four hundred forty-three patients surgically treated for proximal femur fractures were identified through a query of Current Procedural Terminology code 27245 from January 2009 to February 2013. A total of 258 patients treated with the TFN helical blade system were included in the study. MAIN OUTCOME MEASURED: The association of axial migration and perforation with the measured TAD. RESULTS: The overall rate of mechanical complications was 10.1%. The average TAD was 20.4 mm. Axial perforation occurred in 8 patients (3.4%). Axial migration up to subchondral bone without perforation occurred in 3 patients (1.1%). Only 1 fracture failed in varus (0.38%). There was a significant difference in the rates of combined axial migration and perforation with a TAD <20 mm (P = 0.03). Logistic regression model demonstrated increased odds for combined axial cutout and migration with TAD less than 20 (odds ratio = 1.15, P = 0.01). CONCLUSIONS: A TAD <20 mm was associated with an increased frequency of axial migration and cutout with the TFN helical blade. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Tangential Bicortical Locked Fixation Improves Stability in Vancouver B1 Periprosthetic Femur Fractures: A Biomechanical Study.

OBJECTIVES: The biomechanical difficulty in fixation of a Vancouver B1 periprosthetic fracture is purchase of the proximal femoral segment in the presence of the hip stem. Several newer technologies provide the ability to place bicortical locking screws tangential to the hip stem with much longer lengths of screw purchase compared with unicortical screws. This biomechanical study compares the stability of 2 of these newer constructs to previous methods. METHODS: Thirty composite synthetic femurs were prepared with cemented hip stems. The distal femur segment was osteotomized, and plates were fixed proximally with either (1) cerclage cables, (2) locked unicortical screws, (3) a composite of locked screws and cables, or tangentially directed bicortical locking screws using either (4) a stainless steel locking compression plate system with a Locking Attachment Plate (Synthes) or (5) a titanium alloy Non-Contact Bridging system (Zimmer). Specimens were tested to failure in either axial or torsional quasistatic loading modes (n = 3) after 20 moderate load preconditioning cycles. Stiffness, maximum force, and failure mechanism were determined. RESULTS: Bicortical constructs resisted higher (by an average of at least 27%) maximum forces than the other 3 constructs in torsional loading (P < 0.05). Cables constructs exhibited lower maximum force than all other constructs, in both axial and torsional loading. The bicortical titanium construct was stiffer than the bicortical stainless steel construct in axial loading. CONCLUSIONS: Proximal fixation stability is likely improved with the use of bicortical locking screws as compared with traditional unicortical screws and cable techniques. In this study with a limited sample size, we found the addition of cerclage cables to unicortical screws may not offer much improvement in biomechanical stability of unstable B1 fractures.

Intrawound vancomycin powder reduces surgical site infections in posterior cervical fusion.

STUDY DESIGN: Retrospective comparative study using prospectively collected data. OBJECTIVE: To compare the rate of infection with and without the use of vancomycin powder application during posterior cervical instrumentation. SUMMARY OF BACKGROUND DATA: Surgical site infections (SSI) are a significant source of morbidity in multilevel posterior-instrumented fusions for cervical spondylotic myelopathy (CSM). Local delivery of antibiotics has been associated with decreased rates of SSI in posterior-instrumented fusions, but no study has addressed the effects of these measures on a population composed of exclusively multilevel posterior cervical instrumentation performed with decompression for CSM. METHODS: All patients undergoing multilevel posterior decompression and instrumentation for CSM by a single surgeon from 2003-2011 were included. Post hoc analysis of prospectively collected data was analyzed comparing consecutive patients treated without the use of vancomycin powder with those treated after the initiation of vancomycin powder prophylaxis. Intervention cohort and controls were examined for differences in SSI rate, body mass index, neurological status, comorbidities, and complications. RESULTS: A total of 112 patients were included in the study. Intervention (n = 40) and control (n = 72) groups were statistically similar with regard to age, body mass index, comorbidities, estimated blood loss, and operative time. Univariate analysis showed a significant decrease in infection rate in the intervention group (0%) compared with the control group (15%) in this high-risk population (P = 0.007; power = 81%). No adverse events were noted in the intervention group associated with the use of vancomycin powder. CONCLUSION: The local application of vancomycin was associated with a significant reduction in the risk of SSI in multilevel posterior cervical-instrumented fusions for CSM. This study supports the growing body of evidence that vancomycin powder placed in the wound can reduce the incidence of postoperative wound infections, and is the first that addresses this specific population. LEVEL OF EVIDENCE: 2.

A validation study comparing two self-reported upper extremity symptom surveys with clinical examinations for upper extremity musculoskeletal disorders.

OBJECTIVE: Evaluate the validity of two self-report symptoms surveys with two disorder classification protocols. PARTICIPANTS: 100 graduate students at a private school in the Southwest United States. METHODS: Study participants completed two self-report upper extremity musculoskeletal symptoms surveys: a nine item 10 cm Visual Analogue Scale (VAS) and a nine item Likert categorical scale anchored from "None" to "Very severe". Clinical examinations were administered using two musculoskeletal disorder classification protocols. RESULTS: For the nine body regions, concordance between the two self-report symptoms scales ranged from 0.49-0.75. Overall there was greater than 80% agreement for the two disorder classification protocols. Using either symptom survey with either disorder classification protocol provided high sensitivities and specificities (Youden's J ≥ 0.70). Three of possible six symptom survey/classification protocol pairings provided high sensitivities and specificities across all disorder groups. CONCLUSION: In this graduate student sample, none of the self-report symptom survey-classification protocol pairings was demonstratively more useful than any other pairing for studies of musculoskeletal disorders among computer users.

Implantation of allogenic synovial stem cells promotes meniscal regeneration in a rabbit meniscal defect model.

BACKGROUND: Indications for surgical meniscal repair are limited, and failure rates remain high. Thus, new ways to augment repair and stimulate meniscal regeneration are needed. Mesenchymal stem cells are multipotent cells present in mature individuals and accessible from peripheral connective tissue sites, including synovium. The purpose of this study was to quantitatively evaluate the effect of implantation of synovial tissue-derived mesenchymal stem cells on meniscal regeneration in a rabbit model of partial meniscectomy. METHODS: Synovial mesenchymal stem cells were harvested from the knee of one New Zealand White rabbit, expanded in culture, and labeled with a fluorescent marker. A reproducible 1.5-mm cylindrical defect was created in the avascular portion of the anterior horn of the medial meniscus bilaterally in fifteen additional rabbits. Allogenic synovial mesenchymal stem cells suspended in phosphate-buffered saline solution were implanted into the right knees, and phosphate-buffered saline solution alone was placed in the left knees. Meniscal regeneration was evaluated histologically at four, twelve, and twenty-four weeks for (1) quantity and (2) quality (with use of an established three-component scoring system). A similar procedure was performed in four additional rabbits with use of green fluorescent protein-positive synovial mesenchymal stem cells for the purpose of tracking progeny following implantation. RESULTS: The quantity of regenerated tissue in the group that had implantation of synovial mesenchymal stem cells was greater at all end points, reaching significance at four and twelve weeks (p < 0.05). Tissue quality scores were also superior in knees treated with mesenchymal stem cells compared with controls at all end points, achieving significance at twelve and twenty-four weeks (3.8 versus 2.8 at four weeks [p = 0.29], 5.7 versus 1.7 at twelve weeks [p = 0.008], and 6.0 versus 3.9 at twenty-four weeks [p = 0.021]). Implanted cells adhered to meniscal defects and were observed in the regenerated tissue, where they differentiated into type-I and II collagen-expressing cells, at up to twenty-four weeks. CONCLUSIONS: Synovial mesenchymal stem cells adhere to sites of meniscal injury, differentiate into cells resembling meniscal fibrochondrocytes, and enhance both quality and quantity of meniscal regeneration.

Upper extremity pain and computer use among engineering graduate students: a replication study.

BACKGROUND: Recent literature identified upper extremity musculoskeletal symptoms at a prevalence of >40% in college populations. The study objectives were to determine weekly computer use and the prevalence of upper extremity musculoskeletal symptoms in a graduate student population, and make comparisons with previous graduate and undergraduate cohorts. METHODS: One hundred sixty-six graduate students completed a survey on computing and musculoskeletal health. Associations between individual factors and symptom status, functional limitations, academic impact, medication use, and health services utilization were determined. Logistic regression analyses evaluated the association between symptom status and computing. Cross-study comparisons were made. RESULTS: More symptomatic participants experienced functional limitations than asymptomatic participants (74% vs. 32%, P < 0.001) and reported medication use for computing pain (34% vs. 10%, P < 0.01). More participants who experienced symptoms within an hour of computing used health services compared to those who experienced symptoms after an hour of computer use (60% vs. 12%, P < 0.01). Years of computer use (OR = 1.59, 95% CI 1.05-2.40) and number of years in school where weekly computer use was more than 10 hr (OR = 1.56, 95% CI 1.04-2.35) were associated with pain within an hour of computing. Cross-study comparisons found college populations more similar than different. CONCLUSION: The overall findings reinforced previous literature documenting the prevalence of upper extremity musculoskeletal symptoms in college populations, suggesting an important population for participating in public health interventions designed to support healthy computing practices and identify risk factors important to evaluate in future cohort studies. Am. J. Ind. Med. 52:113-123, 2009. (c) 2008 Wiley-Liss, Inc.