Schatzker IV tibial plateau fractures: are they always unicondylar?

Objective: The objectives of this study were to describe the incidence and morphology of medial tibial plateau fractures that extend into the lateral articular surface and to describe trends in their management. Design: Retrospective. Setting: Level I Urban Trauma Center. Patients: Seventy consecutive patients sustaining OTA/AO 41 B1 and B3 fractures. Intervention: Open reduction internal fixation of medial tibial plateau fractures. Main Outcome Measurements: Incidence of medial tibial plateau fractures that extend into the lateral articular surface. Secondary outcomes include localization of lateral articular surface depression, neurovascular injury, and trends in surgical management. Results: Seventy patients were included with 9 fractures (12.9%) isolated to the medial condyle (MC) and 61 fractures (87.1%) extending to the lateral condyle (LC). Compartment syndrome was present in 2 patients (2.9%), peroneal nerve palsy in 2 (2.9%), and arterial injury in 1 (1.4%). Initial external fixation was used more frequently in the LC group compared with the MC group (P = 0.028). Of the 61 fractures in the LC group, 49 (80.3%) included lateral articular surface depression which localized to the posteromedial quadrant of the lateral articular surface in 36 of 49 fractures (73.5%). Lateral articular surface depression depth ≥10.6 mm was associated with the use of dual incisions (P < 0.001). Conclusions: Schatzker IV fractures frequently extend to the lateral condyle and often present with depression of the posteromedial lateral articular surface. Fractures with lateral articular surface depression depth ≥10.6 mm were more likely to undergo fixation with dual incisions. Level of Evidence: Therapeutic level IV.

Isolated Lateral Plating for Bicondylar Tibial Plateau Fractures: Factors Influencing Decision Making.

Lateral plating alone has been postulated as an alternative for fixation of bicondylar tibial plateau fractures in attempts to limit morbidity associated with dual plating. Characterization of fracture patterns that may facilitate lateral plating alone for bicondylar tibial plateau fractures is not well established. The authors analyzed radiographic and clinical outcomes of isolated lateral plating in patients with at least 6 months of follow-up. Of 56 patients identified, 37 (66%) had 41 AO Foundation (AO)/Orthopaedic Trauma Association (OTA) C1/C2 fractures with 19 (34%) presenting with 41 C3 fractures. Mean posteromedial articular fracture angle (PMAFA) was 69.9 degrees, with an average of 1.3 medial articular fragments. Only 16 patients (28%) had a PMAFA under 45 degrees. There were no cases of nonunion, and five patients (8.9%) developed wound infection during follow-up. Four patients (7.1%) experienced malreduction over three degrees, and eight patients (14.3%) experienced change in alignment over the follow-up duration, indicating some risk of inadequate fixation with this technique. (Journal of Surgical Orthopaedic Advances 33(2):088-092, 2024).

Efficacy and Accuracy of Diagnosing Septic Arthritis: How Effective are Current Methods for Timely Diagnosis of Septic Arthritis?

The diagnosis of septic arthritis requires a reliance on ancillary tests, including synovial fluid white blood cell count (jWBC), percentage of polymorphonuclear leukocytes (%PMN), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). This study evaluated these tests to determine their diagnostic utility in suspected septic arthritis. A retrospective chart review was performed on patients admitted to an urban hospital who underwent arthrocentesis. The authors evaluated the jWBC, %PMN, ESR, and CRP with receiver operating characteristic (ROC) curve analyses. Two hundred sixty-five patients met inclusion criteria. Sixty-three had a culture-positive aspirate. ROC curve analysis resulted in an area under the curve (AUC) of 0.80 for jWBC with cutoff point of 22,563 cells/mm3 and an AUC of 0.71 for %PMN with cutoff point of 90.5%. CRP and ESR had AUC values of 0.62 and 0.61, respectively. The culture-positive cohort had higher elevations in all assessed diagnostic tests. However, AUC data for ESR and CRP showed little diagnostic utility. Additionally, sensitivities and specificities of jWBC and %PMN were too low. Associated cutoff points would result in excessive unnecessary operative intervention. Further studies should incorporate synovial fluid biomarkers into the workup of a suspected septic joint. (Journal of Surgical Orthopaedic Advances 33(2):108-111, 2024).

Unique Case of Accelerated Bone Growth Precipitating a One-Stage Masquelet: A Case Report.

Introduction: The masquelet technique is a two-stage procedure used by orthopedic surgeons to treat large segmental bone defects secondary to infection, trauma, and tumor resection. This technique characteristically requires the placement of a temporary cement spacer and subsequent bone grafting for complete reconstruction. We describe a unique case of segmental bone loss reconstruction in which a patient successfully achieved fracture union after the first step of the masquelet technique without bone grafting. Case Report: This is a case of a 21-year-old male who presented with an open femur fracture with 10 cm of segmental bone loss after a motorcycle collision. An antibiotic cement spacer was inserted according to the first stage of the masquelet technique. Due to considerable callus formation around the spacer, normal alignment, and pain-free ambulation at follow-up, further surgical intervention was not pursued, and the poly-methyl-methacrylate spacer was left in place. The fracture healed without infection, and the patient remained weight-bearing without pain. Conclusion: This case identifies a unique instance of successful fracture union of a 10 cm segmental bone defect despite the completion of only the first step in the masquelet procedure. While the masquelet technique is believed to be a mandatory two-step procedure, this unique case of rapid bone growth and fracture union warrants further research on the possibilities of masquelet-induced regeneration without bone grafting.

Cost-effectiveness analysis of the Geriatric Fracture Center (GFC) concept: a prospective multicentre cohort study.

INTRODUCTION: Geriatric Fracture Centers (GFCs) are dedicated treatment units where care is tailored towards elderly patients who have suffered fragility fractures. The primary objective of this economic analysis was to determine the cost-utility of GFCs compared with usual care centres. METHODS: The primary analysis was a cost-utility analysis that measured the cost per incremental quality-adjusted life-year gained from treatment of hip fracture in GFCs compared with treatment in usual care centres from the societal perspective over a 1-year time horizon. The secondary analysis was a cost-utility analysis from a societal perspective over a lifetime time horizon. We evaluated these outcomes using a cost-utility analysis using data from a large multicentre prospective cohort study comparing GFCs versus usual care centres that took place in Austria, Spain, the USA, the Netherlands, Thailand and Singapore. RESULTS: GFCs may be cost-effective in the long term, while providing a more comprehensive care plan. Patients in usual care centre group were slightly older and had fewer comorbidities. For the 1-year analysis, the costs per patient were slightly lower in the GFC group (-$646.42), while the quality-adjusted life-years were higher in the usual care centre group (+0.034). The incremental cost-effectiveness ratio was $18 863.34 (US$/quality-adjusted life-year). The lifetime horizon analysis found that the costs per patient were lower in the GFC group (-$7210.35), while the quality-adjusted life-years were higher in the usual care centre group (+0.02). The incremental cost-effectiveness ratio was $320 678.77 (US$/quality-adjusted life-year). CONCLUSIONS: This analysis found that GFCs were associated with lower costs compared with usual care centres. The cost-savings were greater when the lifetime time horizon was considered. This comprehensive cost-effectiveness analysis, using data from an international prospective cohort study, found that GFC may be cost-effective in the long term, while providing a more comprehensive care plan. A greater number of major adverse events were reported at GFC, nevertheless a lower mortality rate associated with these adverse events at GFC. Due to the minor utility benefits, which may be a result of greater adverse event detection within the GFC group and much greater costs of usual care centres, the GFC may be cost-effective due to the large cost-savings it demonstrated over the lifetime time horizon, while potentially identifying and treating adverse events more effectively. These findings suggest that the GFC may be a cost-effective option over the lifetime of a geriatric patient with hip fracture, although future research is needed to further validate these findings. LEVEL OF EVIDENCE: Economic, level 2. TRIAL REGISTRATION NUMBER: NCT02297581.

A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution.

Background: Retrograde intramedullary nailing of the femur is a popular treatment option for femoral shaft fractures. However, this requires accessing the intramedullary canal through the knee, posing a risk of intra-articular infection. The purpose of this study was to examine the rate of intra-articular infection of the knee after retrograde nailing of femoral shaft fractures. Methods: All patients who underwent retrograde intramedullary nailing for femoral shaft fractures between June 2004 and December 2017 at a level 1 trauma center were reviewed. Six months of follow-up or documented fracture union was required. Records were reviewed for documentation of septic arthritis of the ipsilateral knee during the follow-up period. Results: A total of 294 fractures, including 217 closed and 77 open injuries, were included. Eighteen had an associated ipsilateral traumatic arthrotomy; 188 cases had an associated ipsilateral lower extremity fracture. No cases of septic arthritis were identified. Conclusion: There were no cases of septic arthritis in 294 fractures treated with retrograde intramedullary nailing. Retrograde nailing appears safe for risk of postoperative septic arthritis of the knee even in the face of open fractures and traumatic wounds.

Extraskeletal Myxoid Chondrosarcoma Identified in a Traumatic Fracture of the Toe: A Case Report.

Introduction: Extraskeletal myxoid chondrosarcoma (EMC) is a rare soft-tissue sarcoma that typically presents in the proximal lower extremity and limb-girdle. It can be easily misdiagnosed, especially when located in atypical locations like the foot. Case Report: We present the case of an 80-year-old Caucasian female with a left 3rd toe pain and swelling that was initially misdiagnosed as a traumatic fracture on radiographs but later determined to be an indolent EMC based on histology. She was successfully treated with amputation of the toe. Conclusion: EMC should be considered in the differential of osseous and soft-tissue abnormalities on radiographic imaging of the extremities. As reported in the literature, it can present in atypical locations with minimal symptoms and successful treatments include resection. Future cases presenting similarly should be evaluated for EMC and, if present, reported along with their applied treatment protocols to allow for further assessment of current therapeutic guidelines.

Infection of Baker's Cyst without Bacteremia, Sepsis, or Extraneous Source: A Case Report.

Introduction: Baker's cysts are benign fluid-filled cysts that commonly form around knee joints which typically resolve spontaneously. Infection of baker's cysts is uncommon, but most often associated with septic arthritis or bacteremia. We describe a unique case of an infected Baker's cyst that presented without bacteremia, septic knee, or external source of infection. This is a rare manifestation that has not been described in the current literature. Case Report: This is a case of a 46 year-old woman who developed an infected Baker's cyst without bacteremia or septic arthritis. She initially presented with the right knee pain, swelling, and limited range of motion. Blood work and synovial fluid aspiration of her right knee showed no source of infection. The patient subsequently developed erythema and tenderness over her right knee. This prompted MRI imaging that demonstrated a complex Baker's cyst. The patient later developed a fever, tachycardia, and worsening anion-gap metabolic-acidosis. Aspiration of the fluid collection was performed and revealed purulent fluid which grew pansensitive Methicillin-Sensitive Staphylococcus aureus, blood and knee aspiration cultures remained negative. The patient was treated with antibiotics and debridement procedures and her symptoms/infection resolved. Conclusion: Given that isolated infections of Baker's cysts are rare, the localized aspect of this infection makes this case quite unique. Development of an infected Baker's cyst after negative aspiration cultures, combined with the presence of systemic symptoms including fever, without evidence of systemic spread, has not been seen before in the literature to our knowledge. The unique presentation of this case is important for future analysis of Baker's cysts as it introduces the possibility of localized cyst infections as a possible diagnosis for physicians to consider.

Biomechanical analysis of dual versus lateral locked plating in elderly bicondylar tibial plateau fractures: Does medial comminution matter?

OBJECTIVE: To assess dual plating versus lateral locked plate fixation of bicondylar tibial plateau fractures in an elderly cadaveric model with and without medial bone loss PARTICIPANTS: 10 pairs of elderly (range 78-93 years of age) fresh frozen tibias. INTERVENTION: Bicondylar tibial plateau fractures were created reproducing AO/OTA 41 C1 (without medial bone loss) and C2 fractures (with medial bone loss). Cadavers were randomized to 4 different groups. Groups 1 and 2 were 41 C1 fractures and fixated with either dual or lateral plating, respectively. Groups 3 and 4 were fixated in a similar fashion with medial metaphyseal bone loss (41 C2 fracture) with dual plating Group 3 and lateral plating group 4. Lateral plating consisted of a 3.5 mm 5-hole lateral plate (ALPS, ZimmerBiomet) with 6 bicortical locking screws proximally and two diaphyseal screws. Dual plating groups underwent lateral plating and additional 3.5 mm 5-hole posteromedial 1/3 tubular plate (ZimmerBiomet) placed at the apex of the fracture with two shaft screws and one unicortical screw proximally. Specimens were tested in a Mechanical Testing System (MTS) machine loading both condyles. OUTCOME MEASUREMENTS: Specimens were loaded to 300 N and coronal alignment obtained. Specimens were then cycled from 100 N to 700 N for 5000 cycles at 2 Hz. Average axial displacement, maximal displacement, average force and coronal alignment after 5000 cycles were recorded. Lastly, force to failure was recorded at 100 N/sec. RESULTS: Mean axial displacement was 4.21 mm ranging from 3.12 mm in group 1 to 5.92 mm in group 4 (P = 0.51). Failure force averaged 3340 N ranging from 4342 N in group 1 to 2433 N in group 4 (P = 0.36). Maximal displacement ranged from 3.69 mm in group 1 to 7.37 mm in group 4 (P = 0.21). Change in coronal alignment ranged from 0.98° in group 1 to 1.97° in group 4 (P = 0.45). No statistically significant difference was noted between all four groups for all data points. CONCLUSION: The results of this study demonstrate that a lateral locked plate may offer an alternative means of fixation in AO/OTA 41 C1 and C2 fractures.

Geriatric fracture centre vs usual care after proximal femur fracture in older patients: what are the benefits? Results of a large international prospective multicentre study.

OBJECTIVE: The aim of this study was to determine the effect of treatment in geriatric fracture centres (GFC) on the incidence of major adverse events (MAEs) in patients with hip fractures compared with usual care centres (UCC). Secondary objectives included hospital-workflow and mobility-related outcomes. DESIGN: Cohort study recruiting patients between June 2015 and January 2017. Follow-up was 1 year. SETTING: International (six countries, three continents) multicentre study. PARTICIPANTS: 281 patients aged ≥70 with operatively treated proximal femur fractures. INTERVENTIONS: Treatment in UCCs (n=139) or GFCs (n=142), that is, interdisciplinary treatment including regular geriatric consultation and daily physiotherapy. OUTCOME MEASURES: Primary outcome was occurrence of prespecified MAEs, including delirium. Secondary outcomes included any other adverse events, time to surgery, time in acute ward, 1-year mortality, mobility, and quality of life. RESULTS: Patients treated in GFCs (n=142) had a mean age of 81.9 (SD, 6.6) years versus 83.9 (SD 6.9) years in patients (n=139) treated in UCCs (p=0.013) and a higher mean Charlson Comorbidity Index of 2.0 (SD, 2.1) versus 1.2 (SD, 1.5) in UCCs (p=0.001). More patients in GFCs (28.2%) experienced an MAE during the first year after surgery compared with UCCs (7.9%) with an OR of 4.56 (95% CI 2.23 to 9.34, p<0.001). Analysing individual MAEs, this was significant for pneumonia (GFC: 9.2%; UCC: 2.9%; OR, 3.40 (95% CI 1.08 to 10.70), p=0.027) and delirium (GFC: 11.3%; UCC: 2.2%, OR, 5.76 (95% CI 1.64 to 20.23), p=0.002). CONCLUSIONS: Contrary to our study hypothesis, the rate of MAEs was higher in GFCs than in UCCs. Delirium was revealed as a main contributor. Most likely, this was based on improved detection rather than a truly elevated incidence, which we interpret as positive effect of geriatric comanagement. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov: NCT02297581.

Permanent reduction plate and intramedullary nailing of open tibia fractures: Do we need to take them out?

INTRODUCTION: Provisional reduction plating has been advocated as a reduction aid for tibial shaft fractures. Concerns regarding soft tissue stripping, infection, wound complications and nonunion have been postulated. Recent studies investigating reduction plating present patient cohorts where plates are removed or left to the discretion of the surgeon. This study aims to identify a cohort of open tibial shaft fractures treated with intramedullary nailing aided by permanent reduction plating. Our hypothesis is that permanent reduction plating in conjunction with intramedullary nailing of open tibia fractures does not increase risk of nonunion, infection or time to fracture union compared to intramedullary nailing alone. METHODS: An IRB approved retrospective study was performed using trauma registry data from January 2014 to June 2018 at a Level 1 trauma center. Open AO/OTA 41A/42 A-C/43A tibial shaft fractures treated with intramedullary nail alone (IM) or intramedullary nail and permanent reduction plates (PP) were included in patients over 18 years of age with at least six month follow up or until fracture union. Patient demographics, fracture characteristics, mechanism of injury, medical comorbidities, and length of follow up were recorded along with time to union, incidence of nonunion and treatment for documented or suspected infections. RESULTS: During the study period, 389 patients underwent tibial intramedullary nailing with 162 identified as open fractures. 91 patients met inclusion criteria with 39 in the PP group and 52 in IM group. Statistical analysis revealed no difference between the two groups except more AO/OTA 42A fractures were noted in the IM group. Average follow up was 8.0 and 10.2 months for PP and IM respectively. Nonunion occurred in 2 PP group patients and 7 in the IM group (p = 0.29). Time to union was 5.5 months for PP group and 6.1 months for IM group (p = 0.39) with 4 infections in the PP group and 10 infections in IM group (p = 0.38). CONCLUSION: Despite the small sample size, this study suggests that permanent reduction plating, in the setting of open tibia fractures, does not delay time to fracture union or increase risk of nonunion or infection.

Accuracy of Posterior Wall Acetabular Fracture Lag Screw Placement: Correlation Between Intraoperative Fluoroscopy and Postoperative Computer Tomography.

OBJECTIVE: Compare intraoperative "on end" fluoroscopy lag screw position to postoperative computer tomography. DESIGN: Retrospective review. CLINICAL SETTING: Level 1 trauma center. PATIENTS: One hundred sixteen patients sustaining operative acetabular fractures with posterior wall components. INTERVENTION: Posterior wall lag screws placed using "on end" fluoroscopic imaging. MAIN OUTCOME MEASUREMENTS: The primary outcome was determining correlation between lag screw position, in relation to the acetabular articular margin, using intraoperative fluoroscopy and postoperative computer tomography. Analysis was performed based on location around the acetabulum, including posterior (P), superoposterior (SP), and superior (S) regions, and screws 0-5, 5-10, and >10 mm from the joint. RESULTS: Two hundred forty-four lag screws were identified as follows: 51.6% in the P group, 25.4% in SP, and 23.0% in the S group with excellent correlation noted in all groups. For screws pooled based on fluoroscopic distance from the joint, 28.3% were 0-5 mm, 52.9% 5.01-10 mm, and 18.4% >10 mm. Correlation coefficients were 0.60 for 0-5 mm and 0.68 for both groups >5 mm. Subdividing screws based on anatomic region and fluoroscopic location found increasing correlation as screws moved further from the joint in the P region. In the SP group, excellent correlation was noted for screws 0-5 mm with decreasing correlation further from the joint. Within the S group, correlation for screws 0-5 mm did not reach significance, but good correlation was noted for screws >5 mm. Overall incidence of intraarticular screws was 1.2%. CONCLUSIONS: Intraoperative axial fluoroscopy for posterior wall lag screw placement correlates closely with postoperative computer tomography allowing for reliable posterior wall lag screw placement in all regions around the acetabulum. Care should be taken while placing lag screws within 5 mm of the articular surface, particularly within the posterior region.

Autonomic regulation of voltage-gated cardiac ion channels.

Altering voltage-gated ion channel currents, by changing channel number or voltage-dependent kinetics, regulates the propagation of action potentials along the plasma membrane of individual cells and from one cell to its neighbors. Functional increases in the number of cardiac sodium channels (Na(V)1.5) at the myocardial sarcolemma are accomplished by the regulation of caveolae by beta adrenergically stimulated G-proteins. We demonstrate that Na(V)1.5, Ca(V)1.2a, and K(V)1.5 channels specifically localize to isolated caveolar membranes, and to punctate regions of the sarcolemma labeled with caveolin-3. In addition, we show that Na(V)1.5, Ca(V)1.2a, and K(V)1.5 channel antibodies label the same subpopulation of isolated caveolae. Plasma membrane sheet assays demonstrate that Na(V)1.5, Ca(V)1.2a, and K(V)1.5 cluster with caveolin-3. This may have interesting implications for the way in which adrenergic pathways alter the cardiac action potential morphology and the velocity of the excitatory wave.