Case: A 14-year-old boy underwent open reduction and internal fixation (ORIF) of a tibial tubercle avulsion fracture. Seven weeks postoperatively, the patient slipped in the bathroom and was found to have a superior patellar pole periosteal sleeve avulsion injury. Conclusion: We describe a rare case of periosteal sleeve avulsion fracture of the superior patella pole after tibial tubercle avulsion fracture ORIF in an adolescent male patient. The etiology of this injury pattern may be due to altered tensile forces transmitted through the extensor mechanism related to the previous surgery. Orthopaedic surgeons should be aware of this unusual sequela.
To determine the effectiveness of vancomycin powder in preventing infection after plate and screw fixation of tibial plateau fractures considered at low risk of infection.Retrospective cohort study.Single, Level I trauma center.This study included 459 patients with tibial plateau fractures (OTA/AO 41-B/C) who underwent open reduction and internal fixation from 2006 to 2018 and were considered at low risk of infection based on not meeting the "high risk" definition of the VANCO trial.Vancomycin powder administration on wound closure at the time of definitive fixation.Deep surgical site infection with at least 1 gram-positive bacteria culture.Vancomycin powder administration was associated with reduction in gram-positive infection from 4% to 0% (odds ratio, 0.12; 95% confidence interval, 0.04-0.32; P < 0.01). No significant effect was reported in gram-negative only infections, which were observed in 0.3% in the control group, compared with 0.9% in the intervention group (odds ratio, 2.71; 95% confidence interval, 0.11-69; P = 0.54). Methicillin-resistant Staphylococcus aureus was the most common organism isolated in the control group, growing in 9 of 18 infections (50%).Among patients with low-risk tibial plateau fractures, vancomycin powder at the time of definitive fixation showed a reduction in the incidence of gram-positive deep surgical site infection. The observed relative effect was relatively larger than that observed in a previous randomized trial on high-risk fractures. These data might support broadening the indication for use of vancomycin powder to include tibial plateau fractures at low risk of infection.Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
To characterize long-term outcomes of multiligament knee injuries (MLKIs) using patient-reported outcome measures, physical examination, and knee radiographs.Retrospective clinical follow-up.Twenty knees (18 patients) were evaluated at a mean follow-up of 13.1 years (range 11-15 years). The primary outcome measure was the Internal Knee Documentation Committee score. Patients also completed secondary patient-based outcome assessments including Patient-Reported Outcomes Measurement Information System computer adaptive testing, Short Form-36, and Tegner activity score. Sixteen knees (14 patients) also had physical examination and bilateral knee radiographs assessed with the Kellgren-Lawrence score.The mean Internal Knee Documentation Committee score was 56 points, which was significantly lower than the age-matched normative value of 77 ( P = 0.004) and exceeds the minimum clinically important difference of 12 points. Most secondary outcome scores were worse than normative population values. Posttraumatic arthritis was present in 100% of MLKIs that had radiographs. Comparing operative versus nonoperative management, there were no statistical differences in patient demographics, injury characteristics, physical examination, or imaging, but surgical patients had better Short Form-36 Social Functioning (89 vs. 63, P = 0.02) and Tegner scores (4.5 vs. 2.9, P = 0.05).The long-term outcomes of MLKIs are generally poor, and posttraumatic radiographic evidence of arthritis seems to be universal . Operative management of these injuries may improve long-term outcomes. Clinicians should be aware of these results when counseling patients.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Compartment syndrome (CS) is a potentially devastating injury associated with tibial fractures. Few data exist regarding radiographic indicators of CS. We hypothesized that radiographic signs are associated with development of CS.Retrospective review.Level I trauma center.Consecutive series of adult patients with tibial fractures with (n = 56) and without (n = 922) CS.None.AO/OTA fracture classification, Schatzker type, fracture length, fibular fracture, CS diagnosis.The odds of CS increased by 1.67 per 10% increase in the ratio of fracture length to tibial length when considering all fractures. CS was most likely to occur with plateau fractures at 12% (shaft fractures, 3%; pilon fractures, 2%). Schatzker VI fractures were more likely to develop CS than any other Schatzker type. Fibular fracture was predictive of CS with plateau fractures only. Segmental fractures (AO/OTA type 42-C2) were not more likely to develop CS than other shaft fractures.Several objective and easily reproducible radiographic indicators should raise suspicion for CS. CS was more likely in plateau fractures, especially when fracture length was >20% of the tibial length, in the presence of fibular fracture, and classified as Schatzker VI. Conversely, segmental tibial shaft fractures were not more likely than other shaft fractures to develop CS.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
The objective of our investigation was to explore risk factors associated with primary closure of type IIIA tibial fractures resulting in subsequent flap coverage. A retrospective study identified 278 patients with acute type IIIA open tibial fractures who underwent primary closure at a single center during an 8-year period. Treatment factors, including the number of debridements before closure, duration of external fixation, and timing of wound closure, were reported. The primary outcome was complication requiring unplanned operation of the study injury resulting in flap coverage. Fifty-five (20%) patients underwent flap coverage following complication after attempted primary closure. Patients who required a flap experienced a 42% complication rate after delayed flap coverage. The limb salvage rate was 95% for the study population. Three significant complication predictors were identified: 3 or more debridements before closure (odds ratio [OR], 29.8; 95% CI, 5.9-150.1;
Purpose: The proximal humerus is a common location for both primary and metastatic bone tumors. There are numerous reconstruction options after surgical resection. There is no consensus on the ideal method of reconstruction. Methods: A systematic review was performed with a focus on the surgical reconstructive options for lesions involving the proximal humerus. Results: A total of 50 articles and 1227 patients were included for analysis. Reoperation rates were autograft arthrodesis (11%), megaprosthesis (10%), RSA (17%), hemiarthroplasty (26%), and osteoarticular allograft (34%). Mechanical failure rates, including prosthetic loosening, fracture, and dislocation, were highest in allograft-containing constructs (APC, osteoarticular allograft, arthrodesis) followed by arthroplasty (hemiarthroplasty, RSA, megaprosthesis) and lowest for autografts (vascularized fibula, autograft arthrodesis). Infections involving RSA (9%) were higher than hemiarthroplasty (0%) and megaprosthesis (4%). Postoperative function as measured by MSTS score were similar amongst all prosthetic options, ranging from 66% to 74%, and claviculo pro humeri (CPH) was slightly better (83%). Patients were generally limited to active abduction of approximately 45° and no greater than 90°. With resection of the rotator cuff, deltoid muscle or axillary nerve, function and stability were compromised even further. If the rotator cuff was sacrificed but the deltoid and axillary nerve preserved, active forward flexion and abduction were superior with RSA. Discussion: Various reconstruction techniques for the proximal humerus lead to relatively similar functional results. Surgical choice should be tailored to anatomic defect and functional requirements.
