Early Antibiotic Administration Is Associated with a Reduced Infection Risk When Combined with Primary Wound Closure in Patients with Open Tibia Fractures.

BACKGROUND: Early administration of antibiotics and wound coverage have been shown to decrease the deep infection risk in all patients with Type 3 open tibia fractures. However, it is unknown whether early antibiotic administration decreases infection risk in patients with Types 1, 2, and 3A open tibia fractures treated with primary wound closure. QUESTIONS/PURPOSES: (1) Does decreased time to administration of the first dose of antibiotics decrease the deep infection risk in all open tibia fractures with primary wound closure? (2) What patient demographic factors are associated with an increased deep infection risk in Types 1, 2, and 3A open tibia fractures with primary wound closure? METHODS: We identified 361 open tibia fractures over a 5-year period at a Level I regional trauma center that receives direct admissions and transfers from other hospitals which produces large variation in the timing of antibiotic administration. Patients were excluded if they were younger than 18 years, had associated plafond or plateau fractures, associated with compartment syndrome, had a delay of more than 24 hours from injury to the operating room, underwent repeat débridement procedures, had incomplete data, and were treated with negative-pressure dressings or other adjunct wound management strategies that would preclude primary closure. Primary closure was at the descretion of the treating surgeon. We included patients with a minimum follow-up of 6 weeks with assessment at 6 months and 12 months. One hundred forty-three patients with were included in the analysis. Our primary endpoint was deep infection as defined by the CDC criteria. We obtained chronological data, including the time to the first dose of antibiotics and time to surgical débridement from ambulance run sheets, transferring hospital records, and the electronic medical record to answer our first question. We considered demographics, American Society of Anesthesiologists classification, mechanism of injury, smoking status, presence of diabetes, and Injury Severity Score in our analysis of other factors. These were compared using one-way ANOVA, chi-square, or Fisher's exact tests. Binary regression was used to to ascertain whether any factors were associated with postoperative infection. Receiver operator characteristic curves were used to identify threshold values. RESULTS: Increased time to first administration of antibiotics was associated with an increased infection risk in patients who were treated with primary wound closure; the greatest inflection point on that analysis occurred at 150 minutes, when the increased infection risk was greatest (20% [8 of 41] versus 4% [3 of 86]; odds ratio 5.6 [95% CI 1.4 to 22.2]; p = 0.01). After controlling for potential confounding variables like age, diabetes and smoking status, none of the variables we evaluated were associated with an increased risk of deep infection in Type 1, 2, and 3A open tibia fractures in patients treated with primary wound closure. CONCLUSION: Our findings suggest that in open tibia fractures, which receive timely antibiotic administration, primary wound closure is associated with a decreased infection risk. We recognize that more definitive studies need to be performed to confirm these findings and confirm feasibility of early antibiotic administration, especially in the pre-hospital context. LEVEL OF EVIDENCE: Level III, therapeutic study.

Antibiotic cement spacer retention for chronic shoulder infection after minimum 2-year follow-up.

HYPOTHESIS: The treatment of periprosthetic shoulder infections and proximal humerus osteomyelitis is challenging. The outcomes of antibiotic cement spacer retention are poorly defined in the literature. The purpose of this study was to review long-term functional and patient-reported outcomes data of patients with retained antibiotic cement spacers. We predict reasonable functional outcomes and minimal pain. METHODS: We identified 22 patients of the senior author who have been treated with definitive antibiotic spacer placement. All patients were originally offered a 2-stage revision and declined. Twelve patients had a minimum follow-up of 2 years and were included in our cohort. Mean age was 70.7 (range 59-81), 8/12 patients were female, and the average body mass index was 27.8 (range = 17-45). Functional outcome assessments included the Standardized Shoulder Assessment Form, the Quick Disabilities of the Arm, Shoulder, and Hand Score (QuickDASH), and visual analog scale (VAS) along with clinical range of motion examination. RESULTS: The patients were followed up for a mean of 5.6 years. Eight patients had spacer placement for chronic shoulder arthroplasty infections, whereas 4 patients had spacer placement for chronic osteomyelitis of the proximal humerus. No patients were currently being treated with suppressive antibiotics. One patient had negative cultures at the time of antibiotic spacer placement. The most common organisms were Cutibacterium acnes (6), Staphylococcus epidermidis (6), and methicillin-resistant Staphylococcus aureus (4), with 4 patients growing more than 1 species. The average ASES score was 54 (range = 27-73), QuickDASH was 45 (range = 14-89), and VAS score 2.8 (range = 0-8). Average active range of motion was 68° of forward elevation and 35° of external rotation. CONCLUSIONS: Retention of antibiotic cement spacer is a viable option in the treatment algorithm for chronic shoulder infections. Long-term antibiotic cement spacer may be considered for those patients who are unwilling or unable to undergo a 2-stage revision. Patients can expect a reasonable amount of function and little to no pain with an antibiotic cement spacer.

Medial Patellofemoral Ligament Reconstruction With Concomitant Tibial Tubercle Transfer: A Systematic Review of Outcomes and Complications.

PURPOSE: To examine the outcomes and complications of medial patellofemoral ligament (MPFL) reconstruction and concomitant tibial tubercle (TT) transfer. METHODS: A systematic review of published literature on MPFL reconstruction and TT transfer was performed using the following databases: PubMed/Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, and Cochrane. To be included, studies were required to present outcomes and/or complication data for MPFL reconstruction performed in combination with TT transfer. Each study was assessed for quality and level of evidence. RESULTS: Five studies consisting of 92 knees met the inclusion criteria. Between 57% and 77% of the patients were female patients, and the mean age at surgery was 20.6 years (range, 19 to 31 years). The mean follow-up period was 38 months (range, 23 to 53 months). Postoperative outcome measures including the Lysholm score, Kujala score, International Knee Documentation Committee score, Knee Injury and Osteoarthritis Outcome Score, and visual analog scale score were similar to those previously reported for isolated MPFL reconstruction. Reported complication rates were lower than 15% and included wound infection, hardware irritation, and stiffness. Four studies were graded as Level IV evidence, and 1 study was graded as Level II evidence. Only 1 study scored greater than 50% in the quality analysis. CONCLUSIONS: Results from the analyzed studies indicate that MPFL reconstruction combined with TT transfer is a safe and effective procedure, with a low to moderate risk of complications but overall favorable results. TT transfer is most often performed in conjunction with MPFL reconstruction in the setting of malalignment such as an increased TT-to-trochlear groove distance, and although the surgical indications may differ, the outcomes and risk profiles are similar to those of isolated MPFL reconstruction. With the recognition that these patients are difficult to standardize, additional well-designed studies are needed to further investigate the ideal surgical candidates for MPFL reconstruction with concomitant TT transfer. LEVEL OF EVIDENCE: Level IV, systematic review of Level II and IV studies.

Initial Correction Predicts the Need for Secondary Achilles Tendon Procedures in Patients With Idiopathic Clubfoot Treated With Ponseti Casting.

BACKGROUND: The Ponseti method is the most common method to treat idiopathic clubfoot in North America. Despite initial correction, recurrence is common with this method. The factors predictive of recurrence are not well defined in the literature. METHODS: A retrospective chart review was done of procedures performed at our institution from 2005 to 2010 in children undergoing general anesthesia for primary percutaneous Achilles tenotomy for the treatment of idiopathic clubfoot using the Ponseti casting method (101 patients, 148 feet). All patients were followed up for at least 2 years postoperatively (2 to 7.5 y, average 3.5 y). The patients were divided into 2 groups: group N with no repeat procedures on Achilles tendon and group R with a secondary procedure to address the residual equinus deformity. We looked at postoperative equinus correction through the use of postoperative measurements on digital images using a goniometer. The amount of postoperative dorsiflexion at the initial procedure was compared between the 2 groups using the paired t test. The feet were then divided into 3 groups on the basis of the amount of initial correction, and the rates of future surgical procedures were compared among these groups. RESULTS: A total of 101 patients (148 feet) were evaluated. Seventy-two patients (106 feet) did not have any future procedures to address equinus deformity (group N). Twenty-nine patients (42 feet) underwent future procedure (group R) to correct the residual equinus. The N and R groups differed in amount of postoperative dorsiflexion (14.0 vs. 5.1; P<0.01). Patients in whom at least 10 degrees of dorsiflexion was achieved after the initial tenotomy had only a 12% rate of future procedures. Patients with neutral or less than neutral dorsiflexion had 64% chance of future procedures to address the residual equinus. CONCLUSIONS: Residual equinus deformity after Achilles tenotomy in clubfeet treated by the Ponseti method is associated with a high rate of future surgical procedures. Correction of this deformity before bracing could potentially decrease the rate of future surgery. LEVEL OF EVIDENCE: Level III­Retrospective.

Low Superior Pubic Ramus Screw Failure Rate With Combined Anterior and Posterior Pelvic Ring Fixation.

OBJECTIVES: To determine whether fracture pattern, implant size, fixation direction, or the amount of posterior pelvic ring fixation influences superior ramus medullary screw fixation failure. DESIGN: Retrospective cohort review. SETTING: Regional Level 1 trauma center. PATIENTS/PARTICIPANTS: After exclusion criteria, 95 patients with 111 superior ramus fractures with 3 months minimum follow-up were included. INTERVENTION: All patients underwent anterior and posterior pelvic ring fixation. MAIN OUTCOME MEASUREMENTS: Comparison of immediate postoperative radiographs and/or computer tomography scan with the latest postoperative image to calculate interval fracture displacement and implant position. Postoperative fracture displacement or implant position change greater than 1 cm were considered fixation failures. RESULTS: Five screws were defined as failures (4.5%), including 3 retrograde, 3 with bicortical fixation, 4 with a 4.5-mm screw, and 1 with a 7.0-mm screw. Fracture patterns included 2 oblique and 3 comminuted fractures. Based on the Nakatani classification, there were 3 zone II, 1 zone I, and 1 zone III. Failure modes included 3 with cut-out along the screw head and 1 cut-out and 1 cut-through at the screw tip. CONCLUSIONS: Our incidence of superior pubic ramus intramedullary screw fixation failure was 4.5%. Even with anterior and posterior fixation along with precise technique, failures still occur without a common failure predictor. The percutaneous advantages and proven strength provided by an intramedullary implant make it desirable to help reestablish global pelvic ring stability. Biomechanical and clinical studies are needed to further understand intramedullary superior ramus screw fixation. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Are Routine Postoperative Computer Tomography Scans Warranted for All Patients After Operative Fixation of Pelvic Ring Injuries?

OBJECTIVE: To evaluate the efficacy of routine postoperative computed topography (CT) scan after percutaneous fixation of unstable pelvic ring injuries. DESIGN: Retrospective chart review. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: A total of 362 consecutive patients underwent operative fixation of unstable pelvic ring injuries during the study period. INTERVENTION: Postoperative CT scan of the pelvis was obtained in 331 (91%) of the 362 patients treated operatively for unstable pelvic ring injuries. MAIN OUTCOME MEASUREMENTS: Revision surgery based on routine postoperative CT scan. RESULTS: Two patients (0.55%) returned to the operating room on the basis of postoperative CT scans due to malpositioned implants. There were no significant differences of age, sex, body mass index, Injury Severity Score, mechanism of injury, smoking status, or diabetes status between those who did and did not undergo revision surgery. A dysmorphic pelvis was identified in 154 (47%) patients. Both patients undergoing revision surgery were determined to have a dysmorphic pelvis while no patients with normal pelvic anatomy returned to the operating room based on postoperative CT (2/154, 1.3% vs. 0/177, 0%, P = 0.22). CONCLUSIONS: Although there remains a role for postoperative CT scans in the appropriately selected patient, in the hands of experienced orthopaedic traumatologists, patients with adequate intraoperative fluoroscopy and a nondysmorphic pelvis may not require routine postoperative three-dimensional imaging. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Early-Onset Fat Embolism Syndrome: A Case Report.

CASE: We present the case of a 26-year-old otherwise healthy man with an isolated tibial and fibular shaft fracture who developed signs of fat embolism syndrome (FES) within 6 hours of injury and prior to any operative treatment. CONCLUSION: General orthopaedists and traumatologists should be aware that the onset of FES is not always delayed for several days, but can develop within 6 hours of injury. After initiation of appropriate management, including respiratory support, our patient did well. There was union of the fracture, and he was able to return to work at 3 months postinjury.

Femoroacetabular impingement as a complication of acetabular fracture fixation.

CASE: We present the case of a thirteen-year-old female who sustained a posterior wall acetabular fracture dislocation. She underwent urgent closed reduction and subsequent uncomplicated open reduction and internal fixation. Post reduction computed tomography demonstrated a concentrically reduced hip joint with no evidence of femoroacetabular impingement (FAI). She subsequently healed her fracture and returned to running activities; however, one year later presented with aching pain in her thigh. Radiographs demonstrated the development of a large osseous prominence on her anterolateral femoral neck consistent with femoroacetabular impingement. Based on these findings she was evaluated by a hip preservation specialist. She subsequently underwent successful hip arthroscopy for labral repair and femoral osteochondroplasty. She was eventually able to return to running sports with little pain. SUMMARY: We present a case of FAI presenting as a complication of acetabular fracture fixation. This should be discussed with patients presenting with traumatic hip dislocations as a possible complication of surgical fixation or possibly of the injury itself.

Pain and overcorrection in clubfeet treated by Ponseti method.

Long-term outcomes of Ponseti casting have consistently shown improvement over soft-tissue release. The incidence of foot pain and overcorrection in clubfeet treated by Ponseti method has not been reported. We studied the rate of overcorrection and its association with pain in clubfeet treated with Ponseti casting. A retrospective review of clubfoot patients treated with Ponseti method with at least 8 years of follow-up was carried out. Patient charts were reviewed for demographic data, recurrence, type and number of procedures, and patient-reported complaints of foot pain. Pedobarographs were used to document overcorrection. Eighty-one patients comprising 115 clubfeet were included in the study. There were 14 (12.2%) feet with valgus overcorrection and 101 feet that had achieved a normal, plantigrade position. Overall, 50% of patients with overcorrected clubfeet and 32% with corrected, plantigrade clubfeet experienced pain. Overcorrection was found to be predictive of pain complaints (P<0.001). Hence, valgus overcorrection occurs after Ponseti casting, with an incidence of 12%.

Compartment Syndrome in Children.

Compartment syndrome in children can present differently than adults. Increased analgesic need should be considered the first sign of evolving compartment syndrome in children. Children with supracondylar humerus fractures, floating elbow injuries, operatively treated forearm fractures, and tibia fractures are at high risk for developing compartment syndrome. Elbow flexion beyond 90° in supracondylar humerus fractures and closed treatment of forearm fractures in floating elbow injuries are associated with increased risk of compartment syndrome. Prompt diagnosis and treatment with fasciotomy in children result in excellent long-term outcomes.

Fracture at the Modular Junction of a Cementless Revision Hip System: A Case Report.

CASE: Multiple cases of modular femoral component failure involving fatigue at the modular stem junction have been reported following revision total hip arthroplasty. In the present report, we describe what we believe to be the first case of catastrophic failure involving the Biomet Arcos revision system. The failure involved a young patient with an elevated body mass index and proximal bone deficiency. CONCLUSION: The possibility of this failure mechanism must be weighed against the potential advantages of modular cementless stems when planning for complex hip arthroplasty, especially in the young, active patient.