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OBJECTIVES To identify the incidence of distal articular fractures in a series of distal third tibia shaft fractures and to report the utility of both computed tomography (CT) scans and Radiographic Investigation of the Distal Extension of Fractures into the Articular Surface of the Tibia (RIDEFAST) ratios for identification of articular involvement. DESIGN Retrospective cohort. SETTING Level 1 trauma center. PATIENTS Four hundred seventeen patients with distal third tibia shaft fractures were included in the study. INTERVENTION Intramedullary nail or plate fixation. MAIN OUTCOME MEASURES Type of articular fracture, time of diagnosis, and RIDEFAST ratios. RESULTS One hundred one of the 417 distal third fractures (24%) had a fracture of the distal tibia articular surface. Of these 101 fractures, 41 (41%) represented an extension of the primary fracture line and 60 (59%) were separate malleolar fractures. Of the 101 articular fractures, 95 (94%) were identified preoperatively and 6 (6%) were identified intraoperatively. Of the 95 fractures identified preoperatively, 87 (92%) were identified on plain radiographs and 8 (8%) by CT scan. Thirty-five preoperative CT scans were performed on distal third tibia shaft fractures in search of an intra-articular fracture. In 27 patients (77%), no articular fracture was present, representing an overall yield of 23% among CT scans performed to rule out an articular fracture in distal third tibia shaft fractures. RIDEFAST ratios for all 101 distal tibia shaft fractures with articular involvement and 100 fractures with no articular involvement were not significantly different (P > 0.05) using both coronal and sagittal plane measurements. CONCLUSIONS CT scans performed on distal third tibia shaft fractures in search of articular fractures had a low yield (23%). Widespread use of CT scan to diagnose fractures of the distal tibia articular surface in the setting of distal tibia shaft fractures does not seem warranted. No statistically significant differences in RIDEFAST ratios were found between fractures with and without articular involvement, indicating that more work is necessary before RIDEFAST can be used to reliably rule out articular involvement in this setting. LEVEL OF EVIDENCE Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

STUDY DESIGN A retrospective comparative study with radiographic measurements. OBJECTIVE The aim of this study was to investigate incidences and risk factors of screw-related superior facet articular surface violation (FASV) and optimal pedicle screw angles (PSAs) to avoid FASV at L4 and L5 levels in transforaminal lumbar interbody fusion (TLIF) with either open surgery (OS) or minimal invasive (MIS) techniques with 3D C-arm navigation. SUMMARY OF BACKGROUND DATA L4 to S1 are common levels in TLIF. Adjacent segment diseases (ASD) following TLIF is not uncommon. Screw-related FASV at the superior level is one of the potential risk factors for ASD. METHODS In the OS and MIS groups, 111 and 110 screws were included at L4 level, and 114 and 110 screws at L5 level, respectively. Postoperative computed tomography examined screw-related FASV at L3-4 and L4-5 facet levels. The entry point was the location where pedicle screws placed into the facet joints. RESULTS The OS technique and insertion at the L5 level increased the likelihood of FASV 2.56 and 1.81 times, respec-tively. Multivariate logistic regressions analysis determined PSA was a significant factor associated with FASV. Pearson r between PSA and the distance between midline and entry point was 0.905 (P

Patellar fracture morphology varies based on the mechanism of injury. Most fractures are either a result of direct impact or through an indirect eccentric extensor contraction injury. Each fracture pattern requires appropriate preoperative planning and individualization of the fixation method. Displaced fractures affect the extension apparatus, and often require surgical fixation. Surgical treatment is recommended in fractures with any of the following features: articular step-off > 2 mm, > 3 mm of fracture displacement, open fractures, and displaced fractures affecting the extensor mechanism. Meticulous handling of the soft-tissue envelope is of the utmost importance, given the patella's tenuous blood supply and limited soft-tissue envelope. Incongruent articular surface can result in detrimental long-term effects; therefore, surgical treatment is directed toward anatomic reduction and fixation. The evolution of patellar fracture fixation continues to maximize options to balance rigid fixation with low-profile fixation constructs. Improving functional outcomes, minimizing soft-tissue irritation, and limiting postoperative complications are possible by using the therapeutic principles of rigid anatomical fixation and meticulous soft-tissue handling.

BACKGROUND Previous studies analyzing the acetabuli in patients with slipped capital femoral epiphysis (SCFE) have not definitively addressed the relationship between SCFE and acetabular shape. Femoral head overcoverage and acetabular version are thought to contribute to SCFE. The purpose of this study was to determine the acetabular morphology and orientation in hips with SCFE and compare them with normally developing children. METHODS Pelvic computed tomography (CT) images of patients with SCFE were compared with pelvic CTs of patients without orthopedic abnormalities (normal controls). Three-dimensional (3-D) reconstructions were created from each CT examination. Custom software uniformly aligned the pelvis then determined acetabular measures from the reconstructions including acetabular version, acetabular tilt, articular surface area, and acetabular coverage angle measured in a radial manner dividing the acetabulum into octants. RESULTS Two-hundred forty-four hips were included (53 SCFE, 31 unaffected contralateral hips in patients with SCFE, and 160 controls). The acetabular version was similar among SCFE hips, unaffected contralateral hips, and normal controls (P=0.48). Control hips had higher acetabular tilt than SCFE-affected hips (P=0.01) and unaffected contralateral hips (P=0.04). The acetabular surface area was higher in SCFE-affected hips compared with controls (P

An interesting international debate has been developed over the past 10 years (the last decade) surrounding the surgical procedure for recurrent anteroinferior instability and a definitive consensus is lacking on the factors which favor one technique over another, especially when bone loss is present (soft tissue vs. bone block). Glenoid bone loss is commonly observed in the shoulder with anterior instability, and it is difficult to evaluate the shape of the glenoid using plain radiograph, therefore, computed tomography or intraoperative observation is recommended for accurate assessment of glenoid bone loss and Hill-Sachs lesion. When we consider the bony defect of the glenoid as a risk factor for surgical failure, it is crucial to take into consideration the features of a concomitant Hill-Sachs lesion. However, all the previous reports focusing on the size of the Hill-Sachs lesion or on the glenoid bone loss in isolation, overlook the interaction of the 2 lesions through the arc of range of motion and how this may influence instability. The glenoid track is the first model to determine, in a dynamic way, how bone loss on both sides of the joint can lead to instability. The glenoid track is a zone of contact created by the glenoid on the humeral articular surface when the arm is moved along the end-range of motion (abduction and external rotation). The use of the glenoid track concept can potentially help guide surgical decision-making.

Objectives To assess the outcome of the sinus tarsi approach and C-Nail fixation of displaced intra-articular calcaneal fractures (DIACFs). Design Prospective study. Setting University Trauma Department. Patients Sixty-four patients (mean age 44.3 years, 48 men and 16 women) with 75 DIACFs were treated between October 1, 2016 and December 31, 2018. Intervention In all cases, the posterior facet was reduced through the sinus tarsi approach and fixed with one or 2 screws. After reducing all fragments to the articular block, the final fixation was performed percutaneously with C-Nail, locked with 6 screws. Main outcome measurements Patients were assessed for restoration of the Bohler angle, complications, and overall fracture reduction. To assess the functional outcome, we used the Mean American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score and Maryland Foot Score after 12 months. Results The Bohler angle improved from -0.5 degrees preoperatively to 28.6 degrees postoperatively. The articular step-off was reduced from 5.4 mm preoperatively to 0.6 mm postoperatively. The postoperative radiologic calcaneal score was 2.9, on average. Superficial wound edge necrosis was seen in 3 patients (4%) and superficial infection was observed in one (1.3%). After a 1-year follow-up, we recorded a mean American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score of 90.2 and a mean Maryland Foot Score of 91.2. Conclusions After obtaining an anatomic reduction of the articular surface of the posterior facet with lag screws, the C-Nail represented a viable alternative to plate stabilization in the treatment of DIACFs, combining primary stability with low soft tissue complications. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background The optimal treatment of acetabular fractures in the senior cohort is undetermined. Total hip arthroplasty in the setting of an acetabular fracture is increasing in popularity. However, there is concern regarding the fixation of a prosthetic cup in a fractured acetabulum. The purpose of this study is to map the area of stable articular surface and bone corridors available for cup fixation in this fracture cohort. Methods CT scans of acetabular fractures in 131 consecutive geriatric patients older than 65 years from two level 1 academic trauma centers were analyzed. Acetabular fractures were classified using the Letournel classification, the available stable articular surface, and the bone corridors available for fixation. Results Fractures involving the anterior column were the most common fracture type seen. The dome only pattern was the most common stable articular surface pattern. The sciatic corridor was available for fixation in all fracture types, followed by the gluteal pillar corridor. Most fractures had at least two corridors (93%) available for screw fixation. Conclusions The findings of this study may aid in the development and evaluation of fixation strategies for acetabular cups allowing geriatric acetabular fracture patients earlier weight bearing after primary hip arthroplasty.

OBJECTIVES We hypothesized that a constant radiographic relationship exists between the lateral tibial and femoral condyles and that no side-to-side variation exists. METHODS We reviewed anteroposterior x-rays of 217 uninjured adults ages 18-65, Included 109 unilateral and 108 bilateral radiographs with no or minimal osteoarthrosis (Kellgren-Lawrence grades 0-1). The perpendicular distance between the lateral-most margins of the tibial plateau articular surface (A) and the lateral femoral epicondyle (B) and the lateral femoral condyle articular surface (C) was measured in millimeters (mm). Medial and lateral measurements to point (A) were recorded as (-) and (+), respectively. First, the average of measured distances in all unilateral knees and randomly selected either right or left knees from the bilateral group (n = 217) was calculated. Comparison was made between both sexes. Next, A-B and A-C distances were compared between right and left knees in the bilateral group (n = 108) to find any significant difference (2-tailed t test, alpha = 0.05). RESULTS The average A-B distance was 0.60 ± 2.40 mm (-4.82 to +6.49 mm). The mean A-C distance was -3.96 ± 2.07 mm (-8.51 to +3.98 mm). No significant difference was found between A-B and A-C distances between males (0.40 ± 2.62 mm and -3.91 ± 2.05 mm) and females (0.70 ± 2.28 mm and -3.99 ± 2.09 mm). Similarly, no significant difference was found between A-B and A-C distances between right (1.08 ± 2.31 mm and -3.90 ± 1.73 mm) and left knees (0.90 ± 2.38 mm and -4.31 ± 1.7 mm). Concordance coefficient for interobserver and intraobserver reliability showed substantial agreement. CONCLUSION In conclusion, this study provided a "normal" range for the relationship of the proximal lateral tibial plateau relative to the lateral femoral condyle. The lateral femoral epicondyle is generally aligned with the lateral tibial articular margin. The relationship between the lateral tibial plateau, lateral femoral epicondylar surface, and lateral femoral articular surface is constant from side to side. This technique is reproducible in the setting of fracture, and templating off of the contralateral uninjured knee may be beneficial in tibial plateau fracture surgery.

Articular fractures of the elbow require direct reduction and interfragmentary fixation to restore anatomic stability. The fragments are often small, with limited bone stock, hence implants are often placed through the articular surface to gain maximal purchase. Traditional techniques involve the use of countersunk cortical screws or cannulated headless compression screws. We describe a technique in which small locking screws are used independently from a plate as a substitute for headless or other traditional screws. This method of fixation negates the need for countersinking the screw head, or over drilling a guide wire, and enables the use of smaller diameter screws which provide excellent purchase in very small fragments. Independent locking screws can be considered for any fracture that previously would have been amenable to cortical or headless compression screw fixation. Locking screws from several manufacturers have been used with equal success. Screws can be used in a unicortical manner if necessary, as the grip comes from engaging the subchondral bone with the locking thread. This technique has been used on 35 consecutive articular elbow fractures with a minimum 6-month follow-up. All fractures have achieved bony union within this period, and there have been no loss of fixations or requirement for further surgeries to remove prominent metalwork.

Mallet fractures are traditionally treated surgically when greater than one third of the articular surface is involved. We aimed to investigate outcomes in a cohort of 141 patients with Doyle Type IV closed mallet injuries, treated with conservative splint therapy. Pearson chi-squared test was used to investigate the significance of subluxation and articular surface greater than one third. Articular surface was also investigated as a continuous variable using Spearman-rank correlation. Sixty-five patients had involvement of less than one third of the articular surface, and 75 had involvement of one third to two thirds. Subluxation was present in 53. Crawford outcomes were excellent in 54% of patients, good in 37%, and fair in 9%. Percentage of articular surface involvement and presence of subluxation were both independent of outcomes. Our findings support non-surgical treatment of closed mallet injuries in the presence of up to two thirds of articular surface involvement.

OBJECTIVES To evaluate the accuracy of reduction of the acetabular articular surface using an intraoperative computed tomography scanner (O-Arm) and screw navigation compared with a classical open technique. DESIGN Prospective matched cohort study. SETTING Tertiary referral center. PATIENTS/PARTICIPANTS Adult patients with acute acetabular fractures were included in the study. All patients were treated by 2 senior surgeons using intraoperative imaging and screw navigation. MAIN OUTCOME MEASUREMENTS The primary outcome measure was articular reduction. Secondary outcomes were radiation dosage, operative variables [operative time, time for image acquisition, intraoperative bleeding (cell saver), number of surgical plates, and number of screws], and postoperative variables (first postoperative day pain on the visual analog scale, postoperative transfusion, and hemoglobin change). P < 0.05 was considered statistically significant. RESULTS Thirty-five patients were treated in the inclusion period (2016-2017) and were matched to 35 cases in our database (2013-2016). Mean age was 43 years, and the most common fracture type was a both-column fracture (OTA/AO type C). Postoperative image analysis showed that reduction was achieved in 87.1% of the cases in the O-Arm group versus 64.7% in the control group (P < 0.05). Mean gap of the articular fragments was 3.6 mm in the O-Arm group compared with 5.6 mm (P = 0.01) in the control group. There was no significant difference between the 2 groups in regards to all other studied variables except a decrease in intraoperative blood loss and transfusions and an increase in surgical time with the O-Arm group. Finally, the total radiation dose was decreased using the intraoperative O-Arm compared with a routine postoperative computed tomography scan (dose length product in O-Arm: 498 mGy.cm; dose length product in historical group: 715 mGy.cm). CONCLUSIONS Using intraoperative imaging and screw navigation for displaced acetabular fractures allow screw navigation with increasing articular surface reduction accuracy. Operative and anesthesia times were not increased, whereas radiation exposure to the patient was significantly decreased. We recommend the use of intraoperative imaging for the treatment of displaced acetabular fractures. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE To evaluate the effectiveness of an additional rim plate [3.5-mm precontoured locking compression plate (LCP)] for stabilizing the posterolateral fragment in lateral tibial plateau fractures. METHODS Standard lateral locking plates [either a proximal tibial plate (PTP) or a proximal tibial locking plate (PTLP)] were applied to 40 matched pair knees from 20 fresh-frozen cadavers followed by the application of a secondary rim plate [variable angle LCP (VALCP)] posterior laterally. RESULTS The mean ratio of supported articular surface in the PTP group was 0.692, whereas that in the PTLP group was 0.569. This difference was statistically significant (P < 0.001). Additional rim plating with a VALCP could only be performed for 27 of 40 knees; 8 of 20 knees in the PTP group and 5 of 20 knees in the PTLP group could not be fitted with a VALCP due to anatomic limitations. For the total standard plating group alone, the mean ratio of supported articular surface was 0.596, whereas the mean ratio of supported articular surface with additional rim plating was 0.798 (P < 0.001). In contrast, additional rim plating was possible for more knees that received a PTLP than a PTP. Ultimately, there was no significant difference in the ratio of supported articular surface after additional rim plating between the 2 different types of standard plates (P = 0.087). CONCLUSION Our results identified a bare area in the posterolateral corner of the lateral plateau that was unsupported by rafting screws following conventional, 3.5-mm, precontoured LCP plating. Thus, additional rim plating may be useful for treating plateau fractures with a posterolateral fragment.

The purpose of this study was to determine if patient age could accurately identify disrupted articular cartilage overlying an osteochondritis dissecans (OCD) lesion of the femoral condyle in adolescents. This could have important implications for imaging and treatment decisions.All patients from 2001 to 2014 who were arthroscopically treated for a femoral condyle OCD were included in this Institutional Review Board-approved study. Exclusion criteria were trochlear and patellar OCD lesions, idiopathic arthritis, and traumatic osteochondral injuries. Arthroscopy was performed to visualize and probe the articular surface. Arthroscopic and magnetic resonance imaging (MRI) findings were recorded as "intact" or "disrupted" cartilage. Extra-articular drilling was performed when the articular cartilage was intact.There were 119 patients (81 male, 68%) with 139 OCD lesions in 136 knees. The mean age at time of surgery was 13.0 years (range, 7.2 to 19.3 y). At arthroscopy, 115 knees had intact cartilage and 24 had disrupted cartilage. There was a significant difference in age between patients with intact versus disrupted cartilage at arthroscopy (12.5 vs. 15.3 y; P0.0001). Eighty-eight OCD lesions had MRIs preoperatively, showing 69 as intact and 19 (24%) disrupted. MRI reading for cartilage status had 94% sensitivity and 97% specificity. Multivariable regression analysis revealed that age (P0.01) and MRI status (P0.0001) were strong predictors of cartilage status. Sixteen years was the critical age in which both sensitivity was maximized and false positive probability was minimized. Over the age of 17 years, 7 of 7 (100%) had disrupted cartilage. Age alone was 100% sensitive for children below the age of 10, and 96% sensitive below the age of 13.Age was a good predictor of cartilage status in both younger (13 y) and older (≥17 y) patients in this study. For patients in the mid-range group (13 through 16 y), age alone is not an adequate predictor of cartilage status, but adding MRI increased accuracy.Age can be used to stratify patients and thereby influence diagnostic and treatment strategies.Level IV.

Scaphoid fracture is the most common carpal fracture of the upper extremity and a significant proportion of these can eventually progress to nonunion. Excision of pseudoarthrosis and fibrous scar tissue at the nonunion site is regarded as one of the important steps in management of scaphoid nonunions. We describe a technique of internal bone grafting, where curettage of the nonunion site was performed through a drill hole in the scaphoid and bone graft was packed through this same hole before fixation with a headless compression screw. We have been able to achieve a union rate of 86% using this technique. The advantage of the technique is that it does not disturb the external fibrocartilaginous shell that would have formed around the nonunion site, thus leaving the articular surface undisturbed.

Background: The medial patellofemoral ligament varies in attachment of its fibers to the patella and vastus intermedius tendon. Our aim was to identify and describe its anatomic midpoint. To account for the variability of the attachment site, we refer to it as the medial patellofemoral complex. Methods: Using AutoCAD software, we identified the midpoint of the medial patellofemoral complex attachment on photographs of 31 cadaveric knee dissections. The midpoint was referenced relative to the superior articular surface of the patella (P1) and was described in terms of the percentage of the patellar articular length distal to this point. A second point, at the junction of the medial border of the vastus intermedius tendon with the superior articular border of the patella, was identified (P2). The distances of the midpoint to P1 and P2 were calculated and were compared using paired t tests. Results: Twenty-five images had appropriate quality and landmarks for digital analysis. The midpoint of the medial patellofemoral complex was located a mean (and standard deviation) of 2.3% ± 15.8% of the patellar articular length distal to the superior pole and was at or proximal to P1 in 12 knees. In all knees, the midpoint was at or proximal to P2. After exclusion of 2 knees with vastus intermedius tendon attachments only, the medial patellofemoral complex midpoint was closer to P2 (5.3% ± 8.6% of the patellar articular length) than to P1 (9.3% ± 8.5% of the patellar articular length) (p = 0.06). Conclusions: The midpoint of the medial patellofemoral complex was 2.3% of the articular length distal to the superior pole of the patella. Additionally, we describe an anatomic landmark at the junction of the medial border of the vastus intermedius tendon and the articular border of the patella that approximates the midpoint of this complex. Clinical Relevance: Our study shows that the anatomic midpoint of the attachment of the medial patellofemoral complex is proximal to the junction of the medial vastus intermedius tendon and the articular border of the patella, suggesting that graft placement may be more anatomic on the vastus intermedius tendon rather than on the patella.

We proposed a simple posterolateral approach to the articular surface of the trochlea for fresh and late fractures of the humeral lateral condyle. Twenty consecutive cases, 16 fresh and four old fractures, were approached between triceps and anconeus before the age of 15 years. All fractures achieved union in 3 months. Nineteen cases were classified as excellent or good by the Hardacre score after 31.3 months of follow-up. One late fracture with elbow subluxation showed radiographic fragmentation of the capitellum and a fair clinical result. This simple optional approach offers good exposure of intra-articular fracture at the trochlea, especially for late fractures.

Background Adverse local tissue reactions (ALTRs) around hip arthroplasties are an important reason for failure of metal-on-metal (MoM) hip implants. Little is known about capsular dehiscence patterns as ALTRs decompress from the hip into the surrounding tissue planes; these patterns may also influence the onset and severity of patient symptoms.

Background Highly crosslinked ultrahigh-molecular-weight polyethylene (XLPE) has been shown to reduce wear in hip arthroplasty, but the advantages over conventional polyethylene (PE) in total knee arthroplasty (TKA), if any, remain unclear.

A nonunion of the distal tibial metaphysis in close proximity to the articular surface is a challenging clinical problem. Many of the commonly used techniques in a surgeon's treatment armamentarium can be ineffective because of the relative lack of distal bone stock. This study describes a technique of en bloc excision of all infected or nonunited distal tibial bone with an application of a circular external fixator and limb shortening. After treatment with parental antibiotics, when appropriate, and docking of the distal excision site, distraction osteogenesis of the proximal tibia is performed with a second circular frame.

Only four cases of triplane distal radius fracture have been described in the literature. We report the first that has been treated with open reduction and internal fixation. A 15-year-old boy sustained a triplane fracture of the distal radius. After an unsuccessful attempt at closed reduction, open reduction and internal fixation were performed. Six months after injury, the patient is asymptomatic, but radiographs show a partial growth arrest. The goal of treatment is to achieve anatomic reduction of the articular surface. In this case interposed periosteum prevented anatomic reduction, requiring open reduction and internal fixation. Because of the patient's advanced age the partial physeal arrest should advance to complete arrest before length impairment or occurrence of angular deformity.

PURPOSE Exostosis osteochondroma is usually resected with the whole condyle even part of it is not involved. This study was to report the effect of using digital template in the assistant of resection while protecting the uninvolved condyle. METHODS We used computer-aided design technique in the assistant of making preoperative plan of a patient with giant condylar osteochondroma of exogenous type, including determining the boundary between the tumor and the articular surface of condyle, and designing the virtual tumor resection plane, surgical approach, and remove-out path of the tumor. The digital osteotomy template was made by rapid prototyping technique based on the preoperative plan. Postoperative CT scan was performed and merged with the preoperative CT by the Proplan 1.3 system to evaluate the accuracy of surgical resection with the guide of digital template. RESULTS The osteotomy template was attached to the lateral surface of condyle accurately, and the tumor was removed totally by the guide of the template without injuries to adjacent nerves and vessels. Postoperative CT showed that the osteochondroma was removed completely and the unaffected articular surface of condyle was preserved well. The merging of postoperative and preoperative CT by Proplan 1.3 system showed the outcome of the operation matched with the preoperative planning quite well with an error of 0.92 mm. There was no sign of recurrence after 6 months of follow-up. CONCLUSIONS The application of digital template could improve the accuracy of the giant condylar tumor resection and help to preserve the uninvolved condyle. The use of digital template could reduce injuries to the nerves and vessels as well as save time for the operation.

Forty-one patients with intra-articular fracture of the distal radius (AO Type C) were treated with a double joint-bridging external fixator placed radial side of the fracture site and the wrist placed in slight flexion and ulnar deviation equal to the palmar tilt and radial inclination of the uninjured wrist. The patients were evaluated according to the system of Gartland and Werley an average of 43 months (range, 34 to 53 mo) after surgery. There were 14 excellent, 18 good, 7 fair, and 2 poor results. The average flexion was 94% of the normal side, extension 91%, pronation 95%, and supination 84%. The average radial inclination was 22 ± 10 degrees, palmar tilt 8 ± 14 degrees, and maximum articular step or gap was 2 mm. Bridging external fixation with slight wrist flexion and ulnar deviation equal to preinjured palmar tilt and radial inclination provides acceptable clinical and radiologic results.

Intra-articular distal radial fractures with partial bone loss at the wrist were reconstructed using osteochondral grafts in 2 patients who were followed up for at least 18 months. Both patients experienced posttraumatic arthrosis of the wrist joint. The materials of the intra-articular fixation were bioabsorbable plates and screws. Reconstruction of a partially destroyed articular surface using a costal osteochondral graft is reliable and allows filling and resurfacing an articular cartilage void.

Posttraumatic osteoarthritis (PTOA) occurs after traumatic injury to the joint. It is most common following injuries that disrupt the articular surface or lead to joint instability. The reported risk of PTOA following significant joint trauma is as high as 75%; articular fractures can increase the risk more than 20-fold. Despite recent advances in surgical management, the incidence of PTOA following intra-articular fractures has remained relatively unchanged over the last few decades. Pathogenesis of PTOA after intra-articular fracture is likely multifactorial and may be associated with acute cartilage injury as well as chronic joint overload secondary to instability, incongruity, and malalignment. Additional studies are needed to better elucidate how these factors contribute to the development of PTOA and to develop advanced treatment algorithms that consist of both acute biologic interventions targeted to decrease inflammation and cellular death in response to injury and improved surgical methods to restore stability, congruity, and alignment.

Morphological data of talus are important for the design of talar prostheses. The talar morphology of Chinese population has been rarely reported. This study adopted a three-dimensional (3D) measurement approach to provide accurate data for the anatomical morphology of talus in Northeast Chinese population and compared it with that of foreigners. One hundred forty-six healthy subjects form Northeast China underwent computed tomography (CT) arthrography. 3D digital talar model was reconstructed and thirteen morphological parameters were measured through Mimics and Magics software. Length and breadth indexes of total talus, trochlea, medial and lateral malleolus articular surface were mainly selected. Statistical analysis was conducted by independent-samples and paired-samples t test through SPSS software. All the indexes were normally distributed. No significant difference between left and right talus was identified in either males or females (P > .05). Most of the indexes showed significant sexual differences except the radian of lateral malleolus articular surface and the posterior breadth of trochlea (P

Aims: To identify evidence in the literature for management strategies for posterior malleolar ankle fractures To identify current management strategies for posterior malleolar ankle fractures To identify factors which affect patient decisions on management for posterior malleolar ankle fractures To identify factors which affect surgeon decision of management for posterior malleolar ankle fractures Study design: Literature review of previous evidence Local audit assessing current practice in line with BOAST guidelines Patient questionnaire asking what factors impact on their decision to undergo surgical treatment Consultant questionnaire focusing on management decision and factors affecting their decision to operate Patients: In the UK, of the fractures sustained by patients between the ages of 20 and 65 years those involving the ankle are the most common, with an incidence of almost 90 000 per year (Dattani 2008). The anatomical classification system of Danis and Weber (Danis 1949; Weber 1972) subgroups fibular fractures as A (below the syndesmosis), B (at the syndesmosis) or C (above the syndesmosis) depending on the relationship of the fracture to the syndesmosis (Donken 2012). As well as the site of the fracture in relation to the syndesmosis, these injuries can be complicated by the involvement of the medial and posterior malleolars. Indications for surgery are varied with little evidence in the literature such as more than 25% of the articular surface being involved (Wheeless 2016). For non surgical management, a modified casting technique has been developed, close contact casting, which uses minimal padding compared with traditional casting and achieves fracture reduction by distributing contact pressure by close anatomic fit. This has been advocated in the management of posterior malleolar fracture fractures in certain circumstances (Donken 2011). Outcome(s): To add to limited previous evidence about the management of posterior malleolar fractures.

A posterior approach to the elbow utilizing an olecranon osteotomy has been shown to provide excellent visualization of the distal humerus articular surface. However, many bony stabilization and fixation methods for the olecranon osteotomy are usually prominent, frequently symptomatic, and often require a second operation for removal. This paper evaluates the use of an innovative device, the olecranon sled, in fixation of olecranon osteotomies for exposure of intra-articular distal humerus fractures and provides follow-up results. A retrospective review of all patients with intra-articular distal humerus fracture treated through an olecranon osteotomy approach and fixed with an olecranon sled, between September 2008 and December 2011 was conducted. Charts and radiographs were reviewed to determine olecranon union or nonunion, presence of symptomatic hardware, and need for secondary surgery to remove symptomatic olecranon fixation. Fourteen patients were included in the study. Average clinical follow-up was 33.5 weeks (range, 6 to 118 wk). There were no olecranon nonunions. One patient underwent additional surgery for symptomatic hardware removal (7.1%). Two additional procedures were performed; 1 for revision open reduction and internal fixation of distal humerus fracture nonunion (7.1%) and 1 for release of elbow contracture (7.1%). Although follow-up is limited, the use of this device has been associated with excellent rates of olecranon union with a low rate of symptomatic hardware requiring removal.

The interpretation of metal ion concentrations and their role in clinical management of patients with metal-on-metal implants is still controversial.We questioned whether patients undergoing hip resurfacing with no clinical problems could be differentiated from those with clinical (pain, loss of function) and/or radiographic (component malpositioning, migration, bone loss), problems based on metal ion levels, and if there was a threshold metal level that predicted the need for clinical intervention. Furthermore, we asked if patient and implant factors differed between these functional groups.We retrospectively identified 453 unilateral and 139 bilateral patients with ion measurements at minimum followup of 12 months (mean, 4.3 years; range, 1-12.9 years). Patients were designated as well functioning or poorly functioning based on strict criteria. The acceptable upper levels within the well-functioning group were determined from the 75th percentile plus 1.5× interquartile range. The sensitivity and specificity of these levels to predict clinical problems were calculated.Well-functioning group ions were lower than the poorly functioning group ion levels. The acceptable upper levels were: chromium (Cr) 4.6 μg/L, cobalt (Co) 4.0 μg/L unilateral and Cr 7.4 μg/L, Co 5.0 μg/L bilateral. The specificity of these levels in predicting poor function was high (95%) and sensitivity was low (25%). There were more males in the well-functioning group and more females and smaller femoral components in the poorly functioning group.Metal levels higher than these proposed safe upper limits can predict problems with metal-on-metal resurfacings and are important parameters in the management of at-risk patients.Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Background The Articular Surface Replacement™ (ASR™) metal-on-metal hip arthroplasty system (DePuy Orthopaedics, Inc, Warsaw, IN, USA) reportedly has a higher than anticipated early failure rate leading to a voluntary recall. This prompted us to evaluate all ASR™ components implanted at our center.

Fracture-dislocations of the proximal interphalangeal joint encompass a spectrum of injury severity, ranging from injuries that require little intervention to those that require advanced reconstructive surgery for optimal outcome. Three fracture-dislocation patterns are recognized: dorsal, volar, and pilon. Acceptable outcome is dependent on achieving and maintaining a well-aligned and well-reduced joint, re-establishing normal joint kinematics, and restoring motion. Anatomic articular surface reduction is desirable but not absolutely necessary for a good outcome. Treatment depends on both the type of injury and patient-dependent factors. Optimal outcome for a specific injury is predicated on expedient diagnosis and recognition of injury severity, which enables initiation of appropriate management.

Arthroscopic Bankart repair has traditionally been performed entirely within the capsule, but this has led to less favorable outcomes than those after open repair, and glenohumeral joint damage may occur in some instances due to the close proximity of suture knots to the articular surface. We describe a modification of standard arthroscopic Bankart repair using double-loaded suture anchors which positions the knots away from outside the shoulder capsule. These extracapsular sutures not only provide excellent anterior stabilization, but also eliminate contact of foreign material with intra-articular structures.

Summary: Posterior fracture-dislocations of the shoulder are uncommon and challenging lesions. We present the case of a 76-year-old male patient who sustained a locked posterior humeral head fracture-dislocation during a convulsion. Because more than 40% of the articular surface was involved, preserving the head was not possible. We treated the fracture with a cemented humeral surface replacement. The patient demonstrated good shoulder function and no instability on short-term follow-up. Surface replacement may be a valuable treatment option for fracture-dislocations of the shoulder with articular surface involvement.

The surgical management of pilon fractures has evolved over the last several years with treatment shifting from acute definitive fixation to delayed fixation. One of the driving forces behind this change was the high incidence of soft tissue complications in those patients with high-energy pilon fractures (Orthopaedic Trauma Association 43B and 43C) managed with acute stabilization. Meticulous soft tissue handling along with delayed definitive fixation based on the soft tissue envelope has decreased the short-term complications associated with treatment of these injuries. Anterolateral exposure to the distal tibial articular surface allows for adequate visualization of most fracture patterns, novel reduction strategies, and successful implant placements. This exposure is useful in certain Type C pilon fractures, anterior and anterolateral Type B pilon fractures, and some extra-articular distal tibial fractures. The anterolateral exposure is not suitable in fractures with medial comminution, medial crush, impaction at the medial shoulder of the joint, segmental medial malleolar injuries, or varus deformity at the time of injury. The exposure has the advantage of excellent visualization of the articular surface up to the medial shoulder of the plafond while avoiding dissection of the anteromedial tibial surface.

Despite the clinical success of modern metal-on-metal articulations, concerns with wear-related release of metal ions persist. Evidence suggests metal ion release is related to the effective coverage of the head in the metal shell (the cup's functional articular arc). A recent study suggests a reduced functional articular arc is associated with increased ion release and the arc is a function of component design, size, and the abduction angle.The purposes of this study were to (1) measure the functional articular arc in different sizes of currently available one-piece metal shells from several different manufacturers; and (2) compare the functional articular arc of these one-piece metal shells with the 180 masculine arc of conventional hip arthroplasty acetabular components.We calculated the available articular surface arc for 33 one-piece metal cups using measurements of cup depth and internal cup radius.The arc of the articular surface varied among manufacturers and generally decreased with decreasing shell diameter. The mean functional articular arc was 160.5 degrees +/- 3.6 degrees (range, 151.8 degrees -165.8 degrees), which was less than the 180 degrees arc of a conventional acetabular component.Our data show certain cup designs are at higher risk for failure as a result of the decreased articular surface arc. This, along with analysis of abduction angles, supports the recent findings of bearing failure with vertically placed implants. Care must be taken when implanting these shells to ensure they are placed in less abduction to avoid edge loading and the potential for early bearing failure.

Rationale:The calcaneal fracture without broken lateral wall is rare and the open anatomic reduction and internal fixation (ORIF) is necessary when the subtalar joint articular surface is broken and collapsed.Patient concerns:A 45-year-old male was admitted to our department with complaints

Displaced, unstable intra-articular distal radius fractures are usually treated with reduction and fixation to allow early motion and minimize the potential for development of posttraumatic arthritis. The dorsal surgical approach allows direct visualization of the articular surface to ensure an anatomic reduction. Low profile, locked plates have minimized the unacceptable complication rates previously associated with dorsal plates. This study reviews the historical perspective, indications, technique, complications, and rehabilitation for dorsal, locked plate fixation of intra-articular distal radius fractures. The authors report a strategy for simplifying the fixation of these fractures.

The management of the patellar articular surface at the time of primary total knee arthroplasty (TKA) is controversial. We used expected-value decision analysis to determine whether the patella should be resurfaced in TKA, and also whether secondary resurfacing on an unresurfaced patella is worthwhile. Outcome probabilities and utility values were derived from randomized controlled trials only. A decision tree was constructed and fold-back analysis was performed to ascertain the best treatment path. Sensitivity analyses were performed to determine the effect on decision-making of varying outcome probabilities and utilities. Our model showed patellar resurfacing is the best management strategy for the patella at the time of primary TKA. This decision is robust to changes in the specific data: the best path would remain the same as long as the incidence of persistent anterior knee pain (AKP) with resurfacing remains less than 29% (current mean, 12%) or the incidence of AKP after nonresurfacing falls below 12% (current mean, 26%). Delayed (ie, secondary) patellar resurfacing for ongoing patellar pain provides inferior results for the majority of patients.Level II, decision analysis. See the Guidelines for Authors for a complete description of levels of evidence.

There has been a sharp reduction in complications associated with tibial pilon fractures with the introduction of the two-step approach to treatment. However, there has yet to be any real reevaluation of the standard anterior approach used to expose and reduce these fractures. Now, with the ability to obtain computed tomographic (CT) scans after initial reduction, the fracture pattern of the tibia can be seen more clearly, suggesting that perhaps other surgical approaches may be better suited to visualize, reduce, and stabilize these injuries. At our institution, a two-incision approach using standard medial and lateral incisions, when appropriate to the fracture pattern, was found to allow improved visualization of the tibial articular surface and talus, ease of fixation placement with the new plate designs, and a low complication rate regarding soft-tissue issues when compared with published methods.

A reverse total shoulder arthroplasty is a procedure considered for patients whose shoulder problem cannot be effectively managed with a conventional total shoulder replacement. The reverse total shoulder prosthesis is based on a concept introduced by Professor Paul Grammont, in which a convex articular surface is fixed to the glenoid and a concave articular surface is fixed to the proximal part of the humerus1 (Fig. 1). This prosthesis addresses some of the limitations of conventional arthroplasty. To understand the role of the reverse total shoulder arthroplasty, one must first understand the limitations of conventional arthroplasty. A conventional or anatomic shoulder arthroplasty is the replacement of damaged joint surfaces with prosthetic components that approximate the normal joint surfaces and are stabilized by mechanisms similar to those stabilizing a native glenohumeral joint. In performing a conventional arthroplasty, the surgeon is faced with the following limitations. ### Limited Ability to Manage Glenohumeral Translation The normal glenohumeral joint consists of a small, shallow concave glenoid with a compliant rim for articulation with a spherical humeral head. The small articular surface and minimal constraint of the glenoid allow a large range of rotational motion before the humeral neck abuts on the glenoid rim. They also allow small physiologic translations of the humeral head on the glenoid in response to loads that are applied tangential to the glenoid joint surface. Translation also occurs at the extremes of glenohumeral motion, permitting a greater range of motion than would be possible if the humeral head did not translate. While the compliant rim of the normal glenoid enables full surface contact during small humeral translations, this attribute is not replicated by the much less compliant polyethylene joint surface of a conventional shoulder arthroplasty. If the prosthetic glenoid surface conforms exactly to the humeral head (i.e., if each has the same radius of curvature), no translation …

A new technique for ulna shortening is described. It is a modification of the open-wafer procedure that preserves the distal ulna's articular surface. A 4- to 5-mm chondral-cortical bone block is removed at the distal ulna articular-metaphysis junction. Closing the bone gap results in the osteotomy site proximal to the sigmoid notch. The distal ulna chondral-cortical fragment is secured with 1 or 2 headless compression screws, which permit early motion and results in solid healing. Similar to Feldon's previously described open-wafer procedure, this new technique reduces the ulna carpal load by reducing the distal ulna carpal length at the distal radioulnar joint. This new technique eliminates the exposure of the radiocarpal joint to continuous bleeding from the distal ulna's trabecular bone as seen in Feldon's open-wafer procedure and avoids all the inherent problems associated with plating the ulna for a typical distal ulna osteotomy, such as delayed union and painful hardware.

Background: Several studies have documented that the size of the osteonecrotic lesion in the femoral head is an essential parameter in determining prognosis and treatment. There are several methods currently available to measure lesion size, but no general agreement as to which is most useful. In the present study, three different radiographic methods for determining lesion size were evaluated and compared. Methods: Anteroposterior and lateral radiographs of forty-two hips with osteonecrosis were examined. The extent of osteonecrotic involvement of the femoral head was determined through the use of three different methods: the volume of necrosis by quantitative digital image analysis, and the angular measurements described by Kerboul et al. and Koo and Kim. Graphs were constructed to demonstrate these relationships. Results: Volumetric measurement appeared to be the most reliable. There was only a rough correlation with angular measurements. Several sources of error were noted when simple angular measurements of irregular, three-dimensional lesions were used. The Kerboul method routinely overestimated lesion size and designated 81% of the lesions as “large.” The modified Koo and Kim method provided a more even distribution of lesion size and correlated with volumetric measurements in 74% of hips (thirty-one of forty-two hips). Conclusions: Quantitative volumetric measurements appear to be the most reliable method to measure the true size of a three-dimensional osteonecrotic lesion of the femoral head. Volumetric measurement is more accurate than angular measurement and can be performed easily with modern technology. Angular measurements, although somewhat simpler to use than volumetric measurements, may provide only a rough estimate of lesion size, partly due to the considerable differences in outline or location of the necrotic segments. Nevertheless, determination of lesion size must be part of a comprehensive system of staging of this disease, which includes the evaluation of other parameters, such as the extent and degree of articular surface involvement and the status of the hip joint and the acetabulum. Level of Evidence: Diagnostic Level III. See Instructions to Authors on [jbjs.org][1] for a complete description of levels of evidence. [1]: http://jbjs.org

Three methods of measuring pediatric proximal radius fracture radiographs were compared using injury films of 32 patients. Angulation and displacement were independently measured by four physicians. One physician measured the films by each method a second time 2 months later. Values for interrater and intrarater reliability were determined using inter- and intra-class coefficients (ICC). Interrater reliability was poor for methods using the axis of the proximal radial fragment or the proximal radial physis as a reference (ICC = 0.47 and 0.42, respectively). Measurement of the angle between a line parallel to the proximal radius articular surface and the radial shaft had the highest interrater reliability (0.76); measurement of displacement had the lowest interrater reliability (0.09). The intrarater reliability was excellent for all methods (0.93-0.99) and was also highest when the proximal articular surface reference was used. Of described methods, use of the proximal radius articular surface and the radial shaft as references had the highest interrater and intrarater reliability.

Objective Most patients with traumatic spondylolisthesis of the axis are treated nonsurgically. Some patients do not develop symptoms, but others experience strong and persistent neck pain. To clarify the factor that plays a major role in residual neck pain after this fracture, we reviewed nine patients who underwent conservative treatment. Methods Patients were assessed via telephone interviews an average of 62 months after injury and were divided into two groups: those with and those without neck pain. Angulation and anterior translation between the second and third cervical vertebrae were measured on lateral radiograms at the time of injury, removal of brace, and final follow-up. Fracture lines were also investigated by computed tomography. Results At the time of final follow-up, the average angulation was 6.3 degrees and the average translation was 5.3 mm in the neck-pain group and 0.6 degrees and 0.2 mm, respectively, in the no-symptom group. In patients with fracture lines present on the articular surface of the inferior face joints, angulation persisted or increased, even though the fractures were hemilateral. This was compatible with severe neck pain. In contrast, angulation and translation were improved in patients with an intact inferior articular surface of the axis, and pain was not reported. Conclusions Injury on the inferior articular surface of the axis may disturb spontaneous healing of C2-C3 subluxation and cause residual neck pain. It is necessary to assess the presence of injury to the inferior facet bilaterally with plain or computed tomograms.

Anterior tension band fixation constructs are among the mainstay of treatment of patella fractures and lead to reliable results with simple transverse fracture patterns. However, comminuted fractures of the patella require much more extensive articular reconstruction than interdigitating two large fragments to achieve a good result. In this report, we describe a technique for exposure, reduction, and stabilization of patella fractures that allows for direct visual reduction of the articular surface. Subsequent devices are applied directly to the bony surfaces of the patella without soft-tissue interposition, which distinguishes it from traditional approaches. This technique may be used to ensure articular surface congruity in simple transverse fractures and may be particularly useful in comminuted fractures when patellar excision would otherwise be considered.

Abnormal joint kinematics and loads induced after soft tissue injuries are assumed to contribute to long-term degenerative joint disease and osteoarthritis. Controlling abnormal kinematics after repair and reconstruction of these injured structures would seem to be important for limiting wear of the articular cartilage surfaces. In this paper, we propose to expand the paradigm of functional tissue engineering to more fully characterize normal joint function and to establish design parameters for soft tissue repair and reconstruction to ultimately protect joint surfaces after surgery. Structure-function relationships are examined for tissues of increasing complexity, from tendons to menisci. Emphasis is placed on understanding normal in vivo function of tissues by conducting biomechanical experiments in vitro that better mimic in vivo conditions. This process yields nine classes of functional tissue engineering parameters: differential fiber length, in vivo force and displacement, variations in relative attachment site locations, loading from adjacent structures, fiber interactions, types of insertion, regional variations in material properties, nonparallel fiber orientations, and complex loading within the structure. These functional tissue engineering parameters are useful not only for understanding the function of normal tissues but for more effectively designing their repair and replacement. This paper concludes with a discussion of research directions that investigators might take to establish tissue-specific functional tissue engineering parameters for improving joint function and reducing articular surface degradation and osteoarthritis.

Purpose of review Participation in sports improves general health but increases the risk of osteoarthritis. This review analyzes the relationships among increased joint use, joint injuries, and injury-induced joint degeneration that causes posttraumatic osteoarthritis. The purpose is to help people who participate in sports minimize their risk of joint degeneration. Recent findings Participation in sports that cause minimal joint impact and torsional loading by people with normal joints and neuromuscular function may cause osteophyte formation, but it has minimal, if any, effect on the risk of osteoarthritis. In contrast, participation in sports that subject joints to high levels of impact and torsional loading increases the risk of injury-induced joint degeneration. People with abnormal joint anatomy or alignment, previous joint injury or surgery, osteoarthritis, joint instability, articular surface incongruity or dysplasia, disturbances of joint or muscle innervation, or inadequate muscle strength have increased risk of joint damage during participation in athletics. Summary Gaining the benefits of participation in athletics while minimizing the risk of osteoarthritis requires understanding of the relationships between sports participation and joint injury and the relationships between joint injury and joint degeneration. People who wish to participate in sports should have an evaluation of their joint structure and function, muscle strength, and neuromuscular function, and people with a history of joint injury or mild osteoarthritis should select sports that have limited risk of accelerating joint degeneration.

A closed intraarticular fracture is a complex injury that consists of a physical disruption of the subchondral bone and articular surface, and an impaction injury to the articular surface that occurs at the time of the fracture. Few experimental models have been able to incorporate the elements of displaced articular fractures and blunt impaction injury to the articular surface. This work details the initial stages of an attempt to develop such model. Using a model of a dorsal wall fracture of the acetabulum in a goat, we have developed a bench-top method for assessing articular contact stress. Additionally, preliminary in vivo survival data are presented.

The etiology of posttraumatic arthritis is understood poorly but it clearly has a pathomechanical component. Posttraumatic arthritis likely results from irreversible cartilage damage sustained at the time of injury and chronic cartilage overloading resulting from articular incongruity and instability. However, the relative importance of instability and incongruity is unknown. Clinical studies show that the hip, knee, and ankle tolerate incongruity differently. However, all three joints poorly tolerate instability. Basic mechanical studies have shown that static loading of articular surface incongruities have caused relatively modest increases in contact pressure. However, static testing poorly replicates normal viscoelastic properties of cartilage, which may mask important transient stress elevations that occur during motion. Static tests also ignore potential abnormal loads that may accumulate throughout a motion cycle. We review the clinical and basic scientific evidence linking incongruity and instability to posttraumatic arthritis. Preliminary data from a newly developed dynamic ankle testing device are presented. Dynamic testing allows measurement of transient contact loads and loading rates that occur through the entire motion cycle and it opens the door to measure mechanical abnormalities associated with instability.