Biomechanical comparison of fixation stability using a Lisfranc plate versus transarticular screws.

BACKGROUND: To obtain adequate fixation in treating Lisfranc soft tissue injuries, the joint is commonly stabilized using multiple transarticular screws; however iatrogenic injury is a concern. Alternatively, two parallel, longitudinally placed plates, can be used to stabilize the 1st and 2nd tarsometatarsal joints; however this may not provide adequate stability along the Lisfranc ligament. Several biomechanical studies have compared earlier methods of fixation using plates to the standard transarticular screw fixation method, highlighting the potential issue of transverse stability using plates. A novel dorsal plate is introduced, intended to provide transverse and longitudinal stability, without injury to the articular cartilage. METHODS: A biomechanical cadaver model was developed to compare the fixation stability of a novel Lisfranc plate to that of traditional fixation, using transarticular screws. Thirteen pairs of cadaveric specimens were tested intact, after a simulated Lisfranc injury, and then following implant fixation, using one method of fixation randomly assigned, on either side of each pair. Optical motion tracking was used to measure the motion between each of the following four bones: 1st metatarsal, 2nd metatarsal, 1st cuneiform, and 2nd cuneiform. Testing included both cyclic abduction loading and cyclic axial loading. RESULTS: Both the Lisfranc plate and screw fixation method provided stability such that the average 3D motions across the Lisfranc joint (between 2nd metatarsal and 1st cuneiform), were between 0.2 and 0.4mm under cyclic abduction loading, and between 0.4 and 0.5mm under cyclic axial loading. Comparing the stability of fixation between the Lisfranc plate and the screws, the differences in motion were all 0.3mm or lower, with no clinically significant differences (p>0.16). CONCLUSIONS: Diastasis at the Lisfranc joint following fixation with a novel plate or transarticular screw fixation were comparable. Therefore, the Lisfranc plate may provide adequate support without risk of iatrogenic injury to the articular cartilage.

Low-Cost Intra-Articular Distraction Technique Using Kirschner Wires and a Toothed Lamina Spreader.

We describe a low-cost (instrument cost) technique for joint distraction using 2 Kirschner wires and a toothed lamina spreader in lieu of a Hintermann distractor. The described technique allows for temporary intra-articular distraction and visualization and preservation of the articular surface with extra-articular instrumentation. The technique can also allow for closed reduction and percutaneous treatment in cases of soft tissue compromise. Additionally, the technique uses common orthopedic surgical instruments, leading to a minimal learning curve for novice surgeons. We have found this distraction technique to be most effective for intra-articular preparation of hindfoot and midfoot arthrodeses and for navicular fracture reduction.

Traumatic anterior instability of the pediatric shoulder: a comparison of arthroscopic and open bankart repairs.

BACKGROUND: Arthroscopic and open Bankart repairs have proven efficacy in adults with recurrent anterior shoulder instability. Although studies have included children in their analysis, none have previously compared functional outcomes or redislocation rates between these 2 methodologies for anteroinferior glenoid labrum repair in this young population. We hypothesize that open and arthroscopic Bankart repair in children will have similar functional outcomes and redislocation rates, but differing results from adults treated in a similar manner. METHODS: A retrospective chart review was performed on all Bankart repairs performed between 2006 and 2010 at a tertiary care children's hospital. A shift in treatment modalities occurred in 2008 creating 2 cohorts, open and arthroscopic. Brachial plexus injury, congenital soft-tissue disorder, or incomplete charts were excluded. Demographics, age at surgery, follow-up length, and sport were recorded. Telephone interviews were then performed obtaining the most current QuickDASH (Disability Arm, Shoulder, or Hand), WOSI (Western Ontario Shoulder Instability Index), SF-12 (Short Form 12), SANE (Single Assessment Numeric Evaluation), and verbal pain scores; as well as, inquiring about recurrent dislocation and further surgery. RESULTS: Ninety-nine children (16.9±1.5 y) were included (28 open, 71 arthroscopic). There were no differences in preoperative demographics. Fifty-one patients completed the questionnaires (11 open, 40 arthroscopic). No significant differences in the outcomes scores were seen between the 2 groups. Of the 99 patients, 21 (21%) had redislocation or secondary surgery; there was no significant difference in failure rate between groups (4 open, 17 arthroscopic). A plotted survival curve demonstrated that the adolescent shoulder undergoing Bankart repair for recurrent traumatic anterior instability has a 2-year survival of 86% and a 5-year survival of only 49%, regardless of technique. CONCLUSIONS: In adolescents, there is no significant difference in functional outcomes or redislocation rates between open and arthroscopic Bankart repair, yet both demonstrate a very high risk of failure in this young, athletic population which contrasts the results in the historic adult population. LEVEL OF EVIDENCE: Level III-retrospective comparative study.

Body posture and backpack loading: an upright magnetic resonance imaging study of the adult lumbar spine.

PURPOSE: Axial loading of the spine while supine, simulating upright posture, decreases intervertebral disc (IVD) height and lumbar length and increases lumbar lordosis. The purpose of this study is to measure the adult lumbar spine's response to upright posture and a backpack load using upright magnetic resonance imaging (MRI). We hypothesize that higher spinal loads, while upright and with a backpack, will compress lumbar length and IVD height as well as decrease lumbar lordosis. METHODS: Six volunteers (45 ± 6 years) underwent 0.6 T MRI scans of the lumbar spine while supine, upright, and upright with a 10 % body weight (BW) backpack. Main outcomes were IVD height, lumbar spinal length (distance between anterior-superior corners of L1 and S1), and lumbar lordosis (Cobb angle between the superior endplates of L1 and S1). RESULTS: The 10 % BW load significantly compressed the L4-L5 and L5-S1 IVDs relative to supine (p < 0.05). The upright and upright plus 10 % BW backpack conditions significantly compressed the anterior height of L5-S1 relative to supine (p < 0.05), but did not significantly change the lumbar length or lumbar lordosis. CONCLUSIONS: The L4-L5 and L5-S1 IVDs compress, particularly anteriorly, when transitioning from supine to upright position with a 10 % BW backpack. This study is the first radiographic analysis to describe the adult lumbar spine wearing common backpack loads. The novel upright MRI protocol described allows for functional, in vivo, loaded measurements of the spine that enables the study of spinal biomechanics and therapeutic interventions.

Limited Health Literacy Among Patients With Orthopedic Injuries: A Cross-sectional Survey of Patients Who Underwent Orthopedic Trauma Surgery in a County Hospital Setting.

BACKGROUND: Patients with limited health literacy have difficulty understanding their injuries and postoperative treatment, which can negatively affect their outcomes. MATERIALS AND METHODS: This cross-sectional questionnaire-based study of 103 adult patients sought to quantify patients' health literacy at a single county hospital's orthopedic trauma clinic and to examine their ability to understand injuries and treatment plans. Demographics, Newest Vital Sign (NVS) health literacy assessment, and knowledge scores were used to assess patients' comprehension of their injuries and treatment plan. Patients were grouped by NVS score (NVS <4: limited health literacy). Fisher's exact tests and t tests were used to compare demographic and comprehension scores. Multivariate logistic regression analysis was used to examine the association among low health literacy, sociodemographic variables, and knowledge scores. RESULTS: Of the 103 patients, 75% were determined to have limited health literacy. Patients younger than 30 years were more likely to have adequate literacy (50% vs 23%, P=.01). Patients who spoke Spanish as their primary language were 8.77 times more likely to have limited health literacy with respect to sociodemographic factors (odds ratio, 8.77; 95% CI, 1.03-76.92; P=.04). Low health literacy was 3.52 and 4.14 times more likely to predict discordance in answers to specific bone fractures and the narcotics prescribed (P=.04 and P=.02, respectively). CONCLUSION: Spanish-speaking patients have demonstrated limited health literacy and difficulty understanding their injuries and postoperative treatment plans compared with English-speaking patients. Patients with low health literacy are more likely to be unsure regarding which bone they fractured or their prescribed opiates. [Orthopedics. 2024;47(4):249-255.].

Risk Factors of Failure in 228 Periprosthetic Distal Femur Fractures: A Multicenter Study.

OBJECTIVES: To identify risk factors of reoperation to promote union or to address deep surgical-site infection (DSSI) in periprosthetic distal femur fractures treated with lateral distal femoral locking plates (LDFLPs). DESIGN: Multicenter retrospective cohort study. SETTING: Ten level-I trauma centers. PATIENT SELECTION CRITERIA: Patients with Orthopaedic Trauma Association/Association of Osteosynthesis (OTA/AO) 33A or 33C periprosthetic distal femur fractures who underwent surgical fixation between January 2012 and December 2019 exclusively using LDFLPs were eligible for inclusion. Patients with pathologic fractures or with follow-up less than 3 months without an outcome event (unplanned reoperation to promote union or for deep surgical infection) before this time point were excluded. Fracture fixation constructs used medial plates, intramedullary nails, or hybrid fixation constructs were excluded from analysis. OUTCOME MEASURES AND COMPARISONS: To examine the influence of patient demographics, injury characteristics, and features of the fracture fixation construct on the occurrence of unplanned reoperation to promote union or to address a DSSI. RESULTS: There was an 8.3% rate (19/228) of unplanned reoperation to promote union. Predictive factors for the need for reoperation to promote union included increasing body mass index (odds ratio [OR] = 1.09; 95% confidence interval [CI]: 1.02-1.16; P = 0.01), increasing number of screws in the distal fracture segment (OR = 1.73; 95% CI: 1.06-2.95; P = 0.03), and decreasing proportion of proximal segment screws that are locking (OR = 0.17; 95% CI: 0.03-0.70; P = 0.02) There was a 4.8% rate (11/228) of reoperation to address DSSI. There were no statistically significant predictive factors identified as risk factors of the need for reoperation to address DSSI ( P > 0.05). CONCLUSIONS: 8.3% of periprosthetic distal femur fractures treated at 10 centers with LDFLPs underwent unplanned reoperation to promote union. Increasing patient body mass index and increasing number of screws in the distal fracture segment were found to be predictive factors, whereas increased locking screws in the proximal segment were found to be protective. 4.8% of patients in this cohort underwent reoperation to address DSSI. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Timing of radiographic healing for distal femur fractures treated with intramedullary nails.

OBJECTIVES: This study aimed to profile modified Radiographic Union Scale for Tibia (mRUST) scores over time in distal femur fractures treated with intramedullary nails and identify predictors of radiographic union timing and delayed progression. METHODS: Design: Multicenter retrospective cohort study. SETTING: Ten Level I Trauma Centers. PATIENT SELECTION CRITERIA: The inclusion criteria were patients with distal femur fractures (OTA/AO 33A and 33C) treated with intramedullary nails, with a minimum follow-up of one year or until radiographic union or reoperation. The exclusion criteria were fractures treated with combination nail-plate constructs, pathologic fractures, and patients under 18 years old.Outcome Measures and Comparisons: The primary outcome was the mRUST score at 3, 6, and 12 months post-operatively. Receiver operating characteristic (ROC) curve analysis identified the optimal 3-month mRUST score predicting reoperation. Multivariable models were used to identify predictors of radiographic union timing and delayed progression. RESULTS: The study included 155 fractures in 152 patients, with a mean patient age of 51 and a mean follow-up of 17 months. A 3-month mRUST score of ≤8 predicted reoperation with a PPV of 25%, and a NPV of 99%. The timing of radiographic union was associated with tobacco use (1.2 months later; p = 0.04), open fracture (1.4 months later; p = 0.04), and the use of topical antibiotics (2.1 months longer; 95% CI: 0.33 - 3.84; p = 0.02), however topical antibiotics was at high risk of being confounded by injury severity. Delayed progression to fracture healing, wherein the most rapid radiographic healing occurs more than 3 months post-operatively, was predicted by chronic kidney disease (p < 0.01). CONCLUSIONS: A 3-month mRUST score >8 suggests a very high likelihood of avoiding reoperation for nonunion.Tobacco use and open fractures were associated with a longer time to radiographic union. Chronic kidney disease is associated with a delayed radiographic progression, suggesting a need for adjusted expectations and management strategies in these patients. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Technical Factors Contributing to Nonunion in Supracondylar Distal Femur Fractures Treated With Lateral Locked Plating: A Risk-Stratified Analysis.

OBJECTIVE: To identify technical factors associated with nonunion after operative treatment with lateral locked plating. DESIGN: Retrospective cohort study. SETTING: Ten Level I trauma centers. PATIENT SELECTION CRITERIA: Adult patients with supracondylar distal femur fractures (OTA/AO type 33A or C) treated with lateral locked plating from 2010 through 2019. OUTCOME MEASURES AND COMPARISONS: Surgery for nonunion stratified by risk for nonunion. RESULTS: The cohort included 615 patients with supracondylar distal femur fractures. The median patient age was 61 years old (interquartile range: 46 -72years) and 375 (61%) were female. Observed were nonunion rates of 2% in a low risk of nonunion group (n = 129), 4% in a medium-risk group (n = 333), and 14% in a high-risk group (n = 153). Varus malreduction with an anatomic lateral distal femoral angle greater than 84 degrees, was associated with double the odds of nonunion compared to those without such varus [odds ratio, 2.1; 95% confidence interval (CI), 1.1-4.2; P = 0.03]. Malreduction by medial translation of the articular block increased the odds of nonunion, with 30% increased odds per 4 mm of medial translation (95% CI, 1.0-1.6; P = 0.03). Working length increased the odds of nonunion in the medium risk group, with an 18% increase in nonunion per 10-mm increase in working length (95% CI, 1.0-1.4; P = 0.01). Increased proximal screw density was protective against nonunion (odds ratio, 0.71; 95% CI, 0.53-0.92; P = 0.02) but yielded lower mRUST scores with each 0.1 increase in screw density associated with a 0.4-point lower mRUST (95% CI, -0.55 to -0.15; P < 0.001). Lateral plate length and type of plate material were not associated with nonunion. ( P > 0.05). CONCLUSIONS: Malreduction is a surgeon-controlled variable associated with nonunion after lateral locked plating of supracondylar distal femur fractures. Longer working lengths were associated with nonunion, suggesting that bridge plating may be less likely to succeed for longer fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nail Plate Combination Fixation Versus Lateral Locked Plating for Distal Femur Fractures: A Multicenter Experience.

OBJECTIVES: To (1) report on clinical, radiographic, and functional outcomes after nail-plate fixation (NPF) of distal femur fractures and (2) compare outcomes after NPF with a propensity matched cohort of fractures treated with single precontoured lateral locking plates. DESIGN: Multicenter retrospective cohort study. SETTING: Ten Level 1 trauma centers. PATIENTS/PARTICIPANTS: Patients with OTA/AO 33A or 33C fractures. INTERVENTION: Fixation with (1) retrograde intramedullary nail combined with lateral locking plate (n = 33) or (2) single precontoured lateral locking plate alone (n = 867). MAIN OUTCOME MEASUREMENTS: The main outcomes of interest were all-cause unplanned reoperation and presence of varus collapse at final follow-up. RESULTS: One nail-plate patient underwent unplanned reoperation excluding infection and 2 underwent reoperation for infection at an average of 57 weeks after surgery. No nail-plate patients required unplanned reoperation to promote union and none exhibited varus collapse. More than 90% were ambulatory with no or minimal pain at final follow-up. In comparison, 7 of the 30 matched lateral locked plating patients underwent all-cause unplanned reoperation excluding infection (23% vs. 3%, P = 0.023), and an additional 3 lateral locked plating patients were found to have varus collapse on final radiographs (10% vs. 0%, P = 0.069). CONCLUSIONS: Despite a high proportion of high-energy, open, and comminuted fractures, no NPF patients underwent unplanned reoperation to promote union or demonstrated varus collapse. Propensity score matched analysis revealed significantly lower rates of nonunion for NPF compared with lateral locked plating alone. Larger studies are needed to identify which distal femur fracture patients would most benefit from NPF. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of Deep Infection After Distal Femur Fracture: A Multicenter Study.

OBJECTIVES: To identify potentially modifiable risk factors for deep surgical site infection after distal femur fracture. DESIGN: Multicenter retrospective cohort study. SETTING: Ten Level-I trauma centers. PATIENTS/PARTICIPANTS: Patients with OTA/AO 33A or C distal femur fractures (n = 1107). INTERVENTION: Surgical fixation of distal femur fracture. MAIN OUTCOME MEASUREMENT: The outcome of interest was deep surgical site infection. RESULTS: There was a 7% rate (79/1107) of deep surgical site infection. In the multivariate analysis, predictive factors included alcohol abuse [odds ratio (OR) = 2.36; 95% confidence interval (CI), 1.17-4.46; P = 0.01], intra-articular injury (OR = 1.73; 95% CI, 1.01-3.00; P = 0.05), vascular injury (OR = 3.90; 95% CI, 1.63-8.61; P < 0.01), the use of topical antibiotics (OR = 0.50; 95% CI, 0.25-0.92; P = 0.03), and the duration of the surgery (OR = 1.15 per hour; 95% CI, 1.01-1.30; P = 0.04). There was a nonsignificant trend toward an association between infection and type III open fracture (OR = 1.73; 95% CI, 0.94-3.13; P = 0.07) and lateral approach (OR = 1.60; 95% CI, 0.95-2.69; P = 0.07). The most frequently cultured organisms were methicillin-resistant Staphylococcus aureus (22%), methicillin-sensitive Staphylococcus aureus (20%), and Enterobacter cloacae (11%). CONCLUSIONS: Seven percent of distal femur fractures developed deep surgical site infections. Alcohol abuse, intra-articular fracture, vascular injury, and increased surgical duration were risk factors, while the use of topical antibiotics was protective. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Risk Factors for Reoperation to Promote Union in 1111 Distal Femur Fractures.

OBJECTIVES: To identify modifiable and nonmodifiable risk factors for reoperation to promote union after distal femur fracture. DESIGN: Multicenter retrospective cohort study. SETTING: Ten Level-I trauma centers. PATIENTS/PARTICIPANTS: Patients with OTA/AO 33A or C distal femur fractures (n = 1111). INTERVENTION: Surgical fixation of distal femur fracture. Fixation constructs were classified as lateral plate, dual plate, nail, or nail plate combination. MAIN OUTCOME MEASUREMENTS: The outcome of interest was unplanned reoperation to promote union. RESULTS: There was an 11% (121/1111) rate of unplanned reoperation to promote union. In the multivariate analysis, predictive factors included body mass index [odds ratio (OR) = 1.18; 95% confidence interval (CI), 1.06-1.32; P < 0.01], intra-articular fracture (OR = 1.57; 95% CI, 1.01-2.45; P = 0.04), type III open injury (OR = 2.29; 95% CI, 1.41-3.72; P < 0.01), the presence of medial comminution (OR = 1.85; 95% CI, 1.14-3.06; P = 0.01), and medial translation on postoperative radiographs (OR = 1.23 per one 10th of condylar width; 95% CI, 1.01-1.48; P = 0.03). Construct type was not significantly predictive. CONCLUSIONS: Eleven percent of distal femur fractures underwent unplanned reoperation to promote union. Body mass index, intra-articular fracture, type III open injury, medial comminution, and medial translation on postoperative radiographs were predictive factors. Construct type was not associated with unplanned reoperation; however, this conclusion was limited by small numbers in the dual plate and nail plate groups. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Tranexamic acid use decreases transfusion rate in children with cerebral palsy undergoing proximal femoral varus derotational osteotomy.

ABSTRACT: Previous studies demonstrated the safety of tranexamic acid (TXA) use in cerebral palsy (CP) patients undergoing proximal femoral varus derotational osteotomy (VDRO), but were underpowered to determine if TXA alters transfusion rates or estimated blood loss (EBL). The purpose of this study was to investigate if intraoperative TXA administration alters transfusion rates or EBL in patients with CP undergoing VDRO surgery.We conducted a retrospective review of 390 patients with CP who underwent VDRO surgery between January 2004 and August 2019 at a single institution. Patients without sufficient clinical data and patients with preexisting bleeding or coagulation disorders were excluded. Patients were divided into 2 groups: those who received intraoperative TXA and those who did not.Out of 390 patients (mean age 9.4 ±â€Š3.8 years), 80 received intravenous TXA (TXA group) and 310 did not (No-TXA group). There was no difference in mean weight at surgery (P = .25), Gross Motor Function Classification System level (P = .99), American Society of Anesthesiologist classification (P = .50), preoperative feeding status (P = .16), operative time (P = .91), or number of procedures performed (P = .12) between the groups. The overall transfusion rate was lower in the TXA group (13.8%; 11/80) than the No-TXA group (25.2%; 78/310) (P = .04), as was the postoperative transfusion rate (7.5%; 6/80 in the TXA group vs 18.4%; 57/310 in the No-TXA group) (P = .02). The intraoperative transfusion rate was similar for the 2 groups (TXA: 7.5%; 6/80 vs No-TXA: 10.3%; 32/310; P = .53). The EBL was slightly lower in the TXA group, although this was not significant (TXA: 142.9 ±â€Š113.1 mL vs No-TXA: 177.4 ±â€Š169.1 mL; P = .09). The standard deviation for EBL was greater in the No-TXA group due to more high EBL outliers. The percentage of blood loss based on weight was similar between the groups (TXA: 9.2% vs No-TXA: 10.1%; P = .40). The number needed to treat (NNT) with TXA to avoid one peri-operative blood transfusion in this series was 9.The use of intraoperative TXA in patients with CP undergoing VDRO surgery lowers overall and postoperative transfusion rates.Level of evidence: III, Retrospective Comparative Study.

Distal Humerus Traction Radiographs: Is the Interobserver and Intraobserver Reliability Comparable With Computed Tomography?

OBJECTIVES: To compare the interobserver and intraobserver reliability of traction radiographs with 2-dimensional computed tomography (2D CT) in distal humerus fracture classification and characterization. DESIGN: Randomized controlled radiographic review of retrospectively collected data. SETTING: Academic Level 1 trauma center. PATIENTS/PARTICIPANTS: Skeletally mature patients with intra-articular distal humerus fractures with both traction radiographs and CT scans were reviewed by 11 orthopaedists from different subspecialties and training levels. INTERVENTION: The intervention involved traction radiographs and 2D CT. MAIN OUTCOME MEASUREMENTS: The main outcome measurements included interobserver and intraobserver reliability of fracture classification by the OTA/AO and Jupiter-Mehne and determination of key fracture characteristics. RESULTS: For the OTA/AO and Jupiter-Mehne classifications, we found a moderate intraobserver agreement with both 2D CT and traction radiographs (κ = 0.70-0.75). When compared with traction radiographs, 2D CT improved the interobserver reliability of the OTA/AO classification from fair to moderate (κ = 0.3 to κ = 0.42) and the identification of a coronal fracture from slight to fair (κ = 0.2 to κ = 0.34), which was more pronounced in a subgroup analysis of less-experienced surgeons. When compared with 2D CT, traction radiographs improved the intraobserver reliability of detecting stable affected articular fragments from fair to substantial (κ = 0.4 to κ = 0.67). CONCLUSIONS: Traction radiographs provide similar diagnostic characteristics as 2D CT in distal humerus fractures. For less-experienced surgeons, 2D CT may improve the identification of coronal fracture lines and articular comminution.

Correlating Arthroscopic and Radiographic Findings of Deep Deltoid Ligament Injuries in Rotational Ankle Fractures.

BACKGROUND: The deep deltoid ligament (DDL) is a key stabilizer to the medial ankle and ankle mortise and can be disrupted in ligamentous supination external rotation type IV (LSER4) ankle fractures. The purpose of this study was to define the medial clear space (MCS) measurement on injury mortise radiographs that corresponds with complete DDL injury. METHODS: A retrospective record review at a level 1 hospital was performed identifying patients with LSER4 ankle fractures who underwent arthroscopy and open reduction internal fixation. Chart reviews provided arthroscopic images and operative reports. Complete DDL injury was defined as arthroscopic visualization of the posterior tibial tendon (PTT). Inability to completely visualize the PTT was defined as a partial DDL injury. MCS was measured on injury mortise radiographs. Eighteen subjects met inclusion criteria. RESULTS: Twelve subjects had complete and 6 subjects had partial DDL injury based on arthroscopic findings. Patients with complete DDL injury and those with partial DDL injury had injury radiograph MCS ranging from 5.5 to 29.9 mm and 4.0 to 5.0 mm, respectively. All patients with MCS ≥5.5 mm on injury radiographs had complete DDL injury and all patients with MCS ≤5.0 mm on injury radiographs had partial DDL injury. CONCLUSION: Complete DDL injury was found on injury ankle mortise radiographs as MCS widening of ≥5.5 mm, which correlated with arthroscopic visualization of the PTT. Using this cutoff, surgeons can surmise the presence of a complete deltoid ligament injury, allowing for improved preoperative planning. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Functional Outcomes of Patella Fractures Treated With Anterior Plate Osteosynthesis at One Year.

OBJECTIVES: To evaluate the functional outcomes of patients with displaced patellar fractures treated with anterior plate constructs. DESIGN: Prospective cohort and retrospective clinical and radiographic assessment. SETTING: Level I Trauma Center. PATIENTS/PARTICIPANTS: Between 2014 and 2018, 18 patients who underwent operative intervention for an isolated, displaced patella fracture (OTA/AO 34C1-3) with a minimum of 1-year follow-up agreed to participate in the study. The mean follow-up was 19.5 ± 6.0 months. INTERVENTION: Patients were treated with 2.4 or 2.7-mm plates and supplemental screws or cerclage wires. MAIN OUTCOME MEASUREMENTS: Patients were evaluated with the Short Form-36 Survey and the Knee Injury and Osteoarthritis Outcome Scores and asked about symptomatic implants. The range of motion was assessed by goniometer. RESULTS: The cohort had no wound complications, infections, nonunion, loss of reduction, or implant failure. Active knee flexion was 131 ± 7 degrees. Five patients (28%) endorsed implant irritation. Only one patient (5.5%) underwent implant removal, which consisted of transverse screw removal alone. Twelve of the 14 patients (86%), who were previously employed, returned to work at 10 ± 7 weeks. All Knee Injury and Osteoarthritis Outcome Scores subscale scores and the Short Form-36 Survey scores for physical functioning, limitations due to physical health, limitations due to mental health, and social functioning were significantly lower than reference population norms (P < 0.05). CONCLUSIONS: Anterior plating provides reliable fixation for displaced patellar fractures and results in a low incidence of implant irritation. However, patients who had anterior fixation for displaced patella fractures continue to exhibit functional deficits at 1-year postoperatively. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

External Fixator-Assisted Reduction of Distal Femur Fractures: A Technical Trick.

SUMMARY: Restoration of anatomical alignment while preserving the soft-tissue envelope around the fracture site remains a challenge during distal femur fracture fixation. Although the lateral distal femoral locking plate allows surgeons to achieve adequate bony stability, their application has been associated with malalignment leading to inferior outcomes. We propose a biologically friendly, percutaneous technique that sequentially reduces and aligns distal femur fractures with an anterior external fixator before definitive fixation with a lateral distal femoral locking plate.

Current illicit drug use profile of orthopaedic trauma patients and its effect on hospital length of stay.

INTRODUCTION: The purpose of this study was to investigate the prevalence of illicit drug use among patients admitted with traumatic orthopaedic injuries and to determine its effect on hospital length of stay (LOS). We hypothesized that patients with pre-injury drug use would have a longer hospital LOS compared to those who do not use drugs. METHODS: We conducted a retrospective cohort study at our level 1 urban trauma center of patients admitted with traumatic orthopaedic injuries between 2013 and 2015 with urine toxicology screening. We collected demographic and hospital LOS data from chart review. RESULTS: Of 611 patients, over half (55%) had a positive drug screen: marijuana (41%), amphetamine (19%), cocaine (7%), and/or PCP (2%). The highest incidence of drug use was in males under 19 years of age (81%). Patients with any drug use had a longer hospital LOS compared to those who did not use drugs (8.3 vs. 6.3 days; p = 0.03). Patients who used amphetamines had a longer hospital LOS than those patients who did not (9.5 vs. 6.9 days; p = 0.01). CONCLUSION: Compared to the orthopaedic trauma population two decades ago, the current population using illicit drugs is younger (<30 years) with an increased preference for amphetamine and marijuana and a decreased preference for cocaine. Pre-injury drug use was associated with a longer hospital LOS in patients with a traumatic orthopaedic injury. Knowledge of the current trends in illicit drug use amongst orthopaedic trauma patients could facilitate medical decision-making regarding clinical care and optimizing resource utilization in this complex population of individuals.

A Medial Malleolar "Fleck Sign" May Predict Ankle Instability in Ligamentous Supination External Rotation Ankle Fractures.

BACKGROUND: Ankle joint stability dictates treatment in ligamentous supination external rotation ankle injuries (LSERAI). Investigation of the medial structures that support the ankle mortise is critical, and a small avulsion fracture, or "fleck", of the medial malleolus is occasionally encountered. This study aimed to assess the utility of this medial malleolus fleck sign (MMFS) in diagnosing instability requiring surgery in LSERAI. METHODS: This retrospective observational study examined 166 LSERAI at a single level I trauma center. A standardized diagnostic and treatment protocol for ankle fractures was followed. LSERAI at presentation were reported as having a normal, dynamically wide, or statically wide medial clear space. Patient demographics, MMFS characteristics, and the use of operative management were recorded. RESULTS: MMFS incidence in the cohort was 16 (10%) of 166 and was present in 25% of patients with unstable LSERAI. Fifteen (94%) of 16 patients with a MMFS were deemed to have an unstable LSERAI (P < .005). MMFS had a 25% sensitivity and 99% specificity in diagnosing an unstable LSERAI. For the subgroup of patients without a statically wide medial clear space, MMFS had a 50% sensitivity and 99% specificity in determining instability. CONCLUSION: A MMFS may be indicative of an unstable LSERAI. With previous MRI studies demonstrating complete deltoid disruption in unstable LSERAI, we deduce the MMFS may be associated with extensive deltoid incompetence. The MMFS may help to diagnose a complete deltoid injury in LSERAI with a normal medial clear space, which could influence treatment and reduce patient morbidity, radiation exposure, and healthcare costs. LEVELS OF EVIDENCE: Level III: Retrospective Cohort Study.

Case Series Using a Novel Implant and Accelerated Rehabilitation for Patients Undergoing an Isolated Talonavicular Arthrodesis.

UNLABELLED: Talonavicular (TN) arthrodeses for TN arthritis have a high rate of nonunions for an essential hindfoot joint. In this case series, 12 patients underwent an isolated TN arthrodesis using a novel implant (IO FiX) by a single surgeon with a minimum 1-year follow-up (30.1 ± 14.7 months; mean ± SD). All patients (62 ± 12 years) underwent an aggressive rehabilitation protocol given the strength and compression of the implant. There were no nonunions, nor were there any patients lost to follow-up. Time to radiographic union was 9.6 ± 1.4 weeks. The Visual Analog Scale pain level decreased from 7.3 ± 0.9 preoperatively to 2.1 ± 0.7 postoperatively (P < .001). The Short-Form-12 physical component improved from 27.9 ± 4.2 preoperatively to 42.2 ± 3.5 postoperatively (P < 0.001), while the Short-Form-12 mental component did not change from 50.8 ± 6.9 preoperatively to 54.4 ± 3.8 postoperatively (P > .05). Use of the novel fixation device for TN arthrodesis by a single surgeon with an accelerated rehabilitation protocol significantly decreased patients' pain and improved their physical functional outcomes (P < .001). The IO FiX implant can potentially improve TN arthrodesis fusion rates and surgical outcomes. LEVELS OF EVIDENCE: Therapeutic, Level IV: Case series.

Altered disc compression in children with idiopathic low back pain: an upright magnetic resonance imaging backpack study.

STUDY DESIGN: This study is a repeated measures design to measure the lumbar spine's response to common backpack loads in children with idiopathic low back pain (ILBP) using upright magnetic resonance imaging (MRI). OBJECTIVE: The purpose of this study is to analyze the lumbar spine's response to backpack loads with upright MRI in children with ILBP to compare their results with previously published normal child data under the same conditions. We hypothesize that typical backpack loads will have a different effect on the lumbar spine of normal children and children with ILBP. SUMMARY OF BACKGROUND DATA: Research in normal children shows that backpack loads compress the lumbar intervertebral discs (IVDs), increase lumbar coronal deformity, and increase pain. METHODS: Fifteen pediatric and adolescent patients with ILBP were selected. Patients were excluded if a spinal deformity, an underlying pathology, or known injury was identified. A 0.6-T upright MRI scanner imaged the subjects while in supine and standing positions wearing 0-kg, 4-kg, and 8-kg backpacks. IVD height, lumbar lordosis, lumbar coronal deformity, and pain score were recorded after each condition and compared using analysis of variances. We compared the above-mentioned variables between ILBP and normal subjects using generalized least squares models. RESULTS: The cohort's mean age was 13 ± 3 years. The 4-kg and 8-kg backpacks only compressed the L5-S1 IVD relative to upright with no load. Subjects experienced increasing pain with increasing load. Load had no effect on lumbar lordosis or lumbar coronal deformity. Compared with normal children, children with ILBP experience significantly less disc compression at T12-L1 to L4-L5, less lumbar lordosis, and more pain with increasing load. CONCLUSION: In children with ILBP, increasing backpack load compresses only the L5-S1 IVD. Compared with normal children, children with ILBP experience less lumbar IVD compression, less lumbar lordosis, and more pain due to increasing load suggesting altered mechanisms for load tolerance in children with ILBP. LEVEL OF EVIDENCE: 3.