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To determine the short-term results of surgical treatment with dual posterolateral and posteromedial approaches for fractures of the entire posterior tibial plafond and secondarily to identify common fracture characteristics.Retrospective.Single academic Level 1 trauma center.Thirty-five patients with posterior pilon fractures followed until fracture union (minimum 3 months).Surgical treatment using simultaneous combined posterolateral and posteromedial exposures for fracture reduction and internal fixation.(1) Surgical outcomes including rate of wound complications and accuracy of the articular reduction. (2) Fracture characteristics including the incidence of articular impaction, comminution interfering with reduction, syndesmosis injury, and the type of fibula fracture.The rate of wound problems was low (6%), and 94% of patients had an articular reduction with less than 1 mm of step or gap. There were high rates of articular comminution (83%) and posteromedial articular impaction (63%) and a 17% rate of syndesmosis injury requiring repair.Surgical fixation using simultaneous, combined posterolateral and posteromedial approaches for posterior pilon fractures had a low rate of wound complications and was an effective strategy for obtaining an accurate reduction. The rate of syndesmotic instability requiring fixation was lower than previous work reporting on fixation using a single approach. This may be a useful technique for surgeons who treat these injuries. Careful assessment of the preoperative imaging is required in patients with posterior pilon fractures.Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Background To report mid-term clinical outcomes after radial head arthroplasty for terrible-triad fracture dislocations. Methods Fourteen patients with terrible triad fracture dislocations treated acutely with arthroplasty and minimum 3-year follow-up. Mayo Elbow Performance Scale (MEPS) and QuickDASH scores. Results All patients achieved excellent (58%) or good (42%) results on the MEPS. Average QuickDASH score was 9.1 (range 0-25). Reoperation rate was 28%. Conclusions Acute radial head arthroplasty as a treatment for nonreconstructable radial head fractures in the setting of terrible triad elbow injuries demonstrates good midterm functional outcomes. Level of Evidence Level IV; Retrospective Case Series Study

Achieving durable mechanical stability in geriatric intertrochanteric proximal femur fractures remains a challenge. Concomitant poor bone quality, unstable fracture patterns, and suboptimal reduction are additional risk factors for early mechanical failure. Cement augmentation of the proximal locking screw or blade is one proposed method to augment implant anchorage. The purpose of this review is to describe the biomechanical and clinical evidence for cement augmentation of geriatric intertrochanteric fractures, and to elaborate indications for cement augmentation. The PubMed database was searched for English language studies up to January 2021. Studies that assessed effect of calcium phosphate or methylmethacrylate cement augmentation during open reduction and internal fixation of intertrochanteric fractures were included. Studies with sample size

OBJECTIVE We sought to determine if white-light three-dimensional (3D) body scanning can identify clinically relevant shoulder girdle deformity after displaced diaphyseal clavicle fracture (DCF). METHODS Adult patients with DCF (OTA/AO 15A) were prospectively enrolled. Four subcutaneous osseous landmarks were used to measure shoulder girdle morphology of the injured and uninjured shoulder. Measurements were made both manually with a tape measure and digitally with a white-light 3D scanner. Bilateral radiographs were obtained, and clavicle length was recorded. Quick-Disabilities of the Arm, Shoulder, and Hand surveys were administered at injury and at 6 and 12 weeks. RESULTS Twenty-two patients were included in the study. At the initial visit, all patients had significant differences in deformity measurements between injured and uninjured shoulders as measured by 3D scanning. There was no difference between shoulders measured using manual measurements. At 6 and 12 weeks, shoulder asymmetry was significantly less in patients treated with surgery compared with nonoperative patients as measured by the 3D scanner alone. Clavicle shortening measured on 3D scanning had weak and moderate positive correlations to radiographs (R = 0.27) and manual measurements (R = 0.53), respectively. Patients treated with surgery had significant functional improvements by 6 weeks, and a similar improvement was not seen until 12 weeks in nonsurgical patients. CONCLUSION White-light 3D scanning was able to identify and monitor clinically relevant shoulder girdle deformity after DCF. This tool may become a useful adjunct to clinical examination and radiographic assessment, when determining clinically relevant deformity thresholds. In the future, quantifying and understanding shoulder deformity may inform clinical decision making in these patients. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND The increasing proportion of telemedicine and virtual care in orthopaedic surgery presents an opportunity for upstream delivery of patient facing tools, such as decision aids. Displaced diaphyseal clavicle fractures (DDCFs) are ideal for a targeted intervention because there is no superior treatment, and decisions are often dependent on patient's preference. A decision aid provided before consultation may educate a patient and minimize decisional conflict similarly to inperson consultation with an orthopaedic traumatologist. METHODS Patients with DDCF were enrolled into 2 groups. The usual care group participated in a discussion with a trauma fellowship-trained orthopaedic surgeon. Patients in the intervention group were administered a DDCF decision aid designed with the International Patient Decision Aid Standards. Primary comparisons were made based on a decisional conflict score. Secondary outcomes included treatment choice, pain score, QuickDASH, and opinion toward cosmetic appearance. RESULTS A total of 41 patients were enrolled. Decisional conflict scores were similar and low between the 2 groups: 11.8 (usual care) and 11.4 (decision aid). There were no differences in secondary outcomes between usual care and the decision aid. DISCUSSION Our decision aid for the management of DDCF produces a similarly low decisional conflict score to consultation with an orthopaedic trauma surgeon. This decision aid could be a useful resource for surgeons who infrequently treat this injury or whose practices are shifting toward telemedicine visits. Providing a decision aid before consultation may help incorporate patient's values and preferences into the decision-making process between surgery and nonoperative management. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Excessive fracture site collapse and shortening in intertrochanteric femur fractures alter hip biomechanics and patient outcomes. The purpose of the study was to compare extent of collapse in cephalomedullary nails with blades or lag screws. We hypothesized that there would be no difference in collapse between helical blades and lag screws. Retrospective cohort study. Single U.S. Level I Trauma Center. 171 consecutive patients treated with cephalomedullary nails with either lag screw or blade for AO/OTA 31A1-3 proximal femur fractures and minimum 3-month follow-up. Lag screw or helical blade in a cephalomedullary nail. The primary outcome was fracture site collapse at 3 months. There was a significantly higher proportion of reverse-oblique and transverse intertrochanteric femur fractures (31-A3) in the lag screw group (15/42 vs 25/129). A3 patterns were associated with more collapse. There was significantly less collapse in the blade group (median 4.7 mm, inter-quartile range 2.5–7.8 mm) than the screw group (median 8.4 mmm, inter-quartile range 3.7–11.2 mm, p 0.006). Median collapse was no different between blades and screws when comparing stable and unstable patterns. However, blades were independently associated with 2.5 mm less collapse (95%CI − 4.2, − 0.72 mm, p 0.006) and lower likelihood of excessive collapse (> 10 mm at 3 months, OR 0.3, 95% CI 0.13–0.74, p 0.007), regardless of fracture pattern. Helical blades are independently associated with significantly less collapse than lag screws in intertrochanteric proximal femur fractures, after adjusting for unstable fracture patterns. In fracture patterns at risk for collapse, surgeons can consider use of a helical blade due to its favorable sliding properties compared to screws.

The purpose of the study was to compare treatment outcomes after short or long cephalomedullary nailing for intertrochanteric femur fractures. A systematic review of perioperative outcomes after short or long cephalomedullary nailing for intertrochanteric femur fractures was performed. The following databases were used: using the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed (1980–2019), and MEDLINE (1980–2019). The queries were performed in June 2019. The following search term query was used: “Intramedullary Nail AND Intertrochanteric Fracture OR “Long OR Short Nail AND intertrochanteric Fracture.” Studies were excluded if they were “single-arm” studies (i.e., reporting on either long or short CMN but not both), or did not report at least one of the outcomes being meta-analyzed. Furthermore, cadaveric studies, animal studies, basic science articles, editorial articles, surveys and studies were excluded. Two investigators independently reviewed abstracts from all identified articles. Full-text articles were obtained for review if necessary, to allow further assessment of inclusion and exclusion criteria. Additionally, all references from the included studies were reviewed and reconciled to verify that no relevant articles were missing from the systematic review. Short nails were associated with statistically significantly less estimated blood loss and operative time compared to long nails. There were no significant differences in transfusion rates, implant failures or overall re-operation rates between implant lengths. Similarly, there was no significant difference in peri-implant fracture between implant lengths. Overall, the available clinical evidence supports the use of short cephalomedullary nails for the majority of intertrochanteric femur fractures. Meta-analysis; Level III, therapeutic.

OBJECTIVES The management of geriatric distal femur fractures is controversial, and both primary distal femur replacement (DFR) and surgical fixation (SF) are viable treatment options. The purpose of this study was to compare patient outcomes after these treatment strategies. DATA SOURCES PubMed, Embase, and Cochrane databases were searched for English language articles up to April 24, 2020, identifying 2129 papers. STUDY SELECTION Studies evaluating complications in elderly patients treated for distal femur fractures with either immediate DFR or SF were included. Studies with mean patient age

OBJECTIVES Accurately stratifying patients in the preoperative period according to mortality risk informs treatment considerations and guides adjustments to bundled reimbursements. We developed and compared three machine learning models to determine which best predicts 30-day mortality after hip fracture. METHODS The 2016 to 2017 National Surgical Quality Improvement Program for hip fracture (AO/OTA 31-A-B-C) procedure-targeted data were analyzed. Three models-artificial neural network, naive Bayes, and logistic regression-were trained and tested using independent variables selected via backward variable selection. The data were split into 80% training and 20% test sets. Predictive accuracy between models was evaluated using area under the curve receiver operating characteristics. Odds ratios were determined using multivariate logistic regression with P < 0.05 for significance. RESULTS The study cohort included 19,835 patients (69.3% women). The 30-day mortality rate was 5.3%. In total, 47 independent patient variables were identified to train the testing models. Area under the curve receiver operating characteristics for 30-day mortality was highest for artificial neural network (0.92), followed by the logistic regression (0.87) and naive Bayes models (0.83). DISCUSSION Machine learning is an emerging approach to develop accurate risk calculators that account for the weighted interactions between variables. In this study, we developed and tested a neural network model that was highly accurate for predicting 30-day mortality after hip fracture. This was superior to the naive Bayes and logistic regression models. The role of machine learning models to predict orthopaedic outcomes merits further development and prospective validation but shows strong promise for positively impacting patient care.

Cephalomedullary nails are a commonly used implant for the treatment of many pertrochanteric femur fractures and are available in short and long configurations. There is no consensus on ideal nail length. Relative advantages can be ascribed to short and long intramedullary nails, yet both implant styles share the potentially devastating complication of peri-implant fracture. Determining the clinical sequelae after fractures below nails of different lengths would provide valuable information for surgeons choosing between short or long nails. Thus, the purpose of the study was to compare injury patterns and treatment outcomes following peri-implant fractures below short or long cephalomedullary nails. This was a multicenter retrospective cohort study that identified 33 patients referred for treatment of peri-implant fractures below short and long cephalomedullary nails (n = 19 short, n = 14 long). We compared fracture pattern, treatment strategy, complications, and outcomes between these two groups. Short nails were associated with more diaphyseal fractures (odds ratio [OR] 13.75, CI 2.2–57.9, p 0.002), which were treated more commonly with revision intramedullary nailing (OR, infinity; p 0.01), while long nails were associated with distal metaphyseal fractures (OR 13.75, CI 2.2–57.9, p 0.002), which were treated with plate and screw fixation (p 0.002). After peri-implant fracture, there were no differences in blood loss, operative time, weight bearing status, or complication rates based on the length of the initial nail. In patients treated with revision nailing, there was greater estimated blood loss (EBL, median 300 cc, interquartile range [IQR] 250–1200 vs median 200 cc, IQR 100–300, p 0.03), blood product utilization and complication rates (OR 11.1, CI 1.1–135.7, p 0.03), but a trend toward unrestricted post-operative weight-bearing compared to patients treated with plate and screw constructs. Understanding fracture patterns and patient outcomes after fractures below nails of different lengths will help surgeons make more informed implant choices when treating intertrochanteric hip fractures. Revision to a long nail for the treatment of fractures at the tip of a short nail may be associated with increased patient morbidity.

Study design Retrospective cohort. Summary of background data Heterotopic ossification (HO) about the hip is a debilitating condition that can occur after fixation for acetabular fractures, total hip replacement, or polytrauma with closed head injuries. No classification exists that informs surgical treatment. Purpose To establish a classification system for HO about the hip by reviewing a consecutive series of HO at a single institution. It was hypothesized that HO about the hip could be grouped into a novel classification scheme based upon the location and involved structures of the hip. Methods Retrospective chart review of single center's case log for HO excision from 2004 to 2018 was performed. Inclusion criteria included all patients undergoing excision of heterotopic bone excision about the hip. Demographic data, pre and post hip range of motion, surgical approach for each surgery, index surgery date and interval to excision are reported as well as presence and location of HO and Brooker classification. Results A total of 36 patients (21 men and 15 women) and 40 hips were identified meeting inclusion criteria. The mean age at the time of the index surgery was 47 (range, 16-77 years). Traumatic injury with fracture (35%) included 9 acetabular fractures (22%), 2 long bone fractures (5%) treated with intramedullary devices, one displaced femoral neck fracture (2%), and one pelvic ring injury (2%). Total hip arthroplasty accounted for 32% of patients. Brooker classification was type 4 (35%), 3 (25%), 2 (23%), 1(17%) which translated to 55% anterior, 48% posterior, 3% medial with respect to location. Average improvement in hip flexion and abduction was 22 and 8°, respectively. Conclusion This study identified discrete locations for heterotopic ossification following hip or acetabulum surgery. Both posterior and anterior structures are implicated in the formation of HO, and this investigation presents a novel classification to guide surgical approach for HO excision based upon location.

Intra-articular screw cut-out is a potential complication of intertrochanteric femur fracture fixation with a cephalomedullary nail. Cement augmentation of fixation in the proximal segment offers the prospect of increased stability and fewer complications, but clinical experience with non-resorbable cement is limited. To determine the handling properties and efficacy of this new technique, we performed a retrospective propensity-matched cohort of forty-four geriatric intertrochanteric femur fractures treated with a cephalomedullary nail with (n = 11) or without (n = 33) augmentation with non-resorbable cement injected into the proximal segment. In the patients treated with cement augmentation, at minimum 3-month follow-up, there were no instances of intra-articular cut-out, and no increase in re-operation compared to conventional fixation. Cement augmentation appears to be safe and effective in geriatric intertrochanteric femur fractures to mitigate risk of cut-out.

The optimal management of valgus-impacted femoral neck fractures remains controversial. Internal fixation is associated with significant rates of re-operation, while historical non-operative management strategies consisting of prolonged bed rest also resulted in patient morbidity. Our hypothesis was that screw fixation would have comparable failure rates to non-operative treatment and immediate mobilization for valgus-impacted femoral neck fractures. Retrospective cohort at a single academic Level I trauma center of patients with valgus-impacted femoral neck fractures (AO/OTA 31-B1) treated with percutaneous screw fixation (n = 97) or non-operatively (n = 28). Operative treatment consisted of percutaneous screw fixation. Non-operative treatment consisted of early mobilization. The primary outcome was a salvage operation. Patient demographics were assessed between groups. More non-operatively treated patients were permitted unrestricted weight-bearing (WBAT; p = 0.002). There was no increase in complication rates or mortality, and return to previous ambulatory status was comparable between operatively and non-operatively treated patients. 35.7% (10/28) of non-operatively treated patients underwent a subsequent operation, compared to 15.5% (15/97) of patients with screw fixation (p = 0.03). Only WBAT was independently associated with treatment failure (OR 3.1, 95%CI 1.2–8.3, p =0.02). WBAT was predictive of treatment failure only in the non-operatively treated group (64.3%, 9/14 WBAT vs 8.3%, 1/12 partial, p =0.005). After controlling for weight-bearing restrictions, we found no difference in failure rates between non-operative treatment and screw fixation. Non-operative treatment with partial weight-bearing had low failure rates, comparable complication and mortality rates, and equivalent functional outcomes to operative treatment and is reasonable if a patient would like to avoid surgery and accepts the risk of subsequent arthroplasty. Overall, there were relatively high failure rates in all groups.

This study evaluated the influence of fracture obliquity and locking screw configuration on interfragmentary motion during torsional loading of distal metaphyseal tibial fractures fixed by intramedullary (IM) nailing. The stability of six IM nail locking screw configurations used to fix distal metaphyseal tibial fractures of various obliquities was evaluated. A coronal osteotomy from proximal lateral to distal medial was made in sawbone tibiae at different obliquities from 0° to 60°. After fixation, motion at the fracture was assessed during internal and external rotation tests to 7 Nm under two compressive loading conditions: 20 N and 500 N. With results organized by interlocking configuration, significant differences in interfragmentary rotation between fracture obliquities are observed when the number of interlocking screws is decreased to one distal static and one proximal dynamic during internal rotation. During external rotation testing, significant rotational differences between fracture obliquities are encountered with two distal static screws and one proximal dynamic. No significant differences were seen between different distal interlocking screw orientations (two parallel versus perpendicular distal screws) for all fracture obliquity patterns tested. Fracture obliquity influences rotational stability which can be mitigated by interlocking screw configurations when nailing distal tibia fractures. At least two distal and one proximal interlocking screw in a static mode is recommended to resist torsional loading of distal tibia fractures undergoing intramedullary nailing. The addition of more interlocking screws than this did not significantly alter control of torsional displacement with load.

INTRODUCTION To determine whether drilling energy correlates with bone mineral density (BMD), maximum insertion torque (MIT), maximum screw compression, and pullout strength (POS). METHODS Ten cadaver tibias were used for testing. Unicortical pilot holes were drilled and the drilling energy measured. Drill site bone quality was determined with microcomputed tomography. Drill holes were randomly assigned to POS or MIT testing using 3.5-mm cortical screws engaging only the near cortex. Pearson correlation coefficients were calculated to determine the relationship between drilling energy, BMD, POS, MIT, and maximum screw compression. RESULTS Drilling energy was correlated with BMD (P < 0.001). Compared with BMD, drilling energy had a better correlation with MIT, maximum screw compression, and POS. Maximum screw compression also correlated with MIT (P = 0.012). CONCLUSIONS Drilling energy better correlates with MIT, maximum screw compression, and POS compared with BMD in cadaver cortical bone. Dynamically measuring drilling energy may help inform the orthopaedic surgeon as to the quality of the bone before insertion of implants.

This study examined the outcomes and complications after treatment of unstable distal clavicle fractures with hook or locking plate fixation. A retrospective search was performed of all acute distal clavicle fractures treated with open reduction and internal fixation from 2009 to 2019 at a Level I trauma center. Patients were separated into hook and locking plate fixation groups. Rates of union, complications, and reoperation, were extracted. QuickDASH (Disabilities of Arm, Shoulder, and Hand) scores were determined. Thirty-one patients met the inclusion criteria and were included in the study. Of these, 12 patients were treated with hook plates and 19 were treated with locking plates. All fractures healed without loss of reduction, regardless of implant selection. There were no immediate or long-term complications in either group. 83% of hook plate patients underwent planned implant removal, while 37% of locking plate patients requested implant removal secondary to irritation. QuickDASH scores were comparable and excellent in both groups. Hook and locking plate fixation for Neer type-II and type-V distal clavicle fractures have comparably high rates of union. Hook plates were removed routinely per protocol, while locking plates were removed only if symptomatic and occurred significantly less often.

Purpose The purpose of this study was to evaluate the safety and efficacy of using lower profile 2.4/2.4 mm and 2.0/2.4 mm dual mini-fragment plate constructs for fixation of diaphyseal clavicle fractures. Methods This was a retrospective case series of all displaced diaphyseal clavicle fractures treated with 2.4/2.4 and 2.0/2.4 dual mini-fragment plate constructs at a single level-one trauma center. Postoperative complications and fracture healing rates were recorded. A subset of patients with long-term follow up was used to determine the rate of reoperation for symptomatic implant removal. Results All 36 identified fractures healed without loss of reduction or implant failure. There was one superficial infection and no deep infections or cases of wound dehiscence. Twenty patients from the entire cohort had longer-term follow up available to assess the reoperation rate for symptomatic implant removal. Two patients (10%) underwent symptomatic implant removal, and one patient with retained implants was planning on future removal due to soft-tissue irritation; this combined to a projected reoperation rate of 15% for symptomatic implant removal. Conclusion Dual mini-fragment plating of diaphyseal clavicle fractures, using 2.4/2.4 mm and 2.0/2.4 mm plate combinations, creates a lower profile construct that reliably maintains fracture reduction to healing, and has a low rate of reoperation for symptomatic implant removal.

Objectives To map the proximal ulnar articular margins and ensure safe extraarticular placement of implants. Methods Ten fresh frozen adult elbow cadaver specimens were obtained. Radiopaque wire was applied to the articular margin of the articular facets and the central trochlear ridge of the proximal ulna. Fluoroscopic images were obtained demonstrating the articular facet margins. Radiographic measurements were performed and used to identify relative safe screw zones. Results All specimens demonstrated marked extension of the ulnar and radial facets dorsal to the central trochlear ridge. The dorsal extent of the ulnar facets from the central trochlear ridge averaged 9.7 mm (range, 7.9-13 mm; SD, 1.5 mm) and 6.2 mm (range, 3.4-9.4 mm; SD, 1.9 mm), respectively. The average footprint of the posterior ulnar facet occupied 44% (±4.9%) of the total ulnar height from the dorsal cortex to the trochlear ridge. Conclusions The articular margins of the anterior and posterior facets of the proximal ulna are challenging to identify radiographically. A surgical "at-risk zone" exists within 9.7 mm from the radiographic margin of the central trochlear ridge. Implants placed within this zone have the potential to violate the articular surface.

Background Septic arthritis is an orthopedic emergency requiring immediate surgical intervention. Current diagnostic standard of care is an invasive joint aspiration. Aspirations provide information about the inflammatory cells in the sample within a few hours, but there is often ambiguity about whether the source is infectious (e.g. bacterial) or non-infectious (e.g. gout). Cultures can take days to result, so decisions about surgery are often made with incomplete data. Novel diagnostics are thus needed. The "Sepsis MetaScore" (SMS) is an 11-mRNA host immune blood signature that can distinguish between infectious and non-infectious acute inflammation. It has been validated in multiple cohorts across heterogeneous clinical settings. Aim To study whether the SMS holds diagnostic validity in determining the etiology of acute arthritis. Methods We conducted a blinded, prospective, non-interventional clinical study of the SMS. All patients undergoing work-up for a septic primary joint were enrolled. Patients proceeded through the normal standard-of-care pathway, including joint aspiration and inflammatory labs [white blood cell (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)]. Venous blood was also drawn into PAX gene RNA-stabilizing tubes and mRNAs were measured using Nano String nCounter™. SMS was calculated blinded to clinical results. Results A total of 20 samples were included, of which 11 were infected based on aspiration or intra-operative cultures. The SMS had an area under the ROC curve (AUROC) of 0.87 for separating infectious from non-infectious conditions. For comparison, the AUROCs for ESR = 0.58, CRP = 0.6, and WBC = 0.59. At 100% sensitivity for infection, the specificity of the SMS was 40%, meaning nearly half of non-septic patients could have been ruled out for further intervention. Conclusion In this pilot study, SMS showed a high level of diagnostic accuracy in predicting septic joints compared to other diagnostic biomarkers. This quick blood test could be an important tool for early, accurate identification of acute septic joints and need for emergent surgery, improving clinical care and healthcare spending.

Morbidly obese patients undergoing total knee arthroplasty have worse functional outcomes and implant survival, and increased revision rates compared with nonobese patients. In addition to increased medical comorbidities and difficult exposure, increased stress on the tibial implant and altered kinematics of knee motion contribute to aseptic loosening and medial collapse. Increased implant fixation, including use of a stemmed tibial implant, may be a way to help avoid these complications. While there is limited data on tibial stems in the morbidly obese patients specifically, cemented stemmed tibial implants should be strongly considered in these patients, especially if bone quality is poor. The initial increased cost of a stemmed implant can be justified in this high-risk patient population to minimize the risk of costly revisions related to compromised tibia component fixation.

Objectives To assess the current portfolio of quality measures and candidate quality measures that address orthopaedic trauma surgery. Data sources We systematically reviewed the National Quality Forum, the Agency for Healthcare Research and Quality, and the Quality Payment Program for quality measures relevant to fracture surgery. We also searched MEDLINE/PubMed, Embase/Scopus, and Cochrane libraries. Data extraction Clinical practice guidelines were included as candidate quality measures if their development was in accordance with the Institute of Medicine criteria for development of clinical practice guidelines, were based on consistent clinical evidence including at least one Level I study, and carried the strongest possible recommendation by the developing body. We categorized the measures as structure, process, or outcome domains according to the framework described by Donabedian. Data synthesis From the 3809 articles initially identified and screened, a total of 189 combined quality or candidate quality measures were extracted from our review. With regard to the Donabedian framework, there were a total of 7% (13/189) structure, 52% process (99/189), and 41% (77/189) outcome measures identified. Conclusions As quality measures progressively inform reimbursement in value-based health care models, quality measures evaluating the care of patients sustaining a fracture will become increasingly relevant to orthopaedic trauma surgeons.

CASE Anatomic reduction of acetabular fractures with femoral head protrusion requires lateralization of the medialized femoral head to facilitate reduction and definitive fixation. In this case of a 71-year-old man with an associated both column acetabular fracture with femoral head medialization after a fall from a 10 foot ladder, we present the successful use of a novel reduction technique involving a modified arthroscopic limb positioner to provide adjustable distraction and counteract the deforming force in this injury pattern. CONCLUSION A limb positioner can provide appropriate on-table traction in pelvis and acetabular surgery to neutralize deforming forces and facilitate reduction and fixation.

Objective To determine the accuracy of International Classification of Disease Version 10 (ICD-10) coding for ankle fracture injury patterns. Design Retrospective cohort study Patients 97 adult patients with fractures about the ankle (rotational ankle fracture or distal tibia fracture) from 2016 to 2020, selected by stratified random sampling. Intervention Assignment of an ICD-10 code representative of a rotational ankle fracture, pilon fracture, or unspecified fracture of the lower leg. Outcome measurements Injury radiographs were reviewed by three authors to determine the correct code. Agreement between the correct code and the electronic medical record (EMR) assigned code was determined using kappa's statistic in the aggregate as well as percent agreement, sensitivity, specificity, and positive predictive value (PPV) between individual codes. Results 59 of 97 cases (60.8%) demonstrated discordance between the existing EMR and surgeon-assigned codes. Aggregate agreement between all codes was fair (K = 0.26). Lateral malleolus fracture codes demonstrated the highest PPV (0.91, 95% CI 0.72–0.99), while the lowest PPV was found for “other fractures of the lower leg” (0.05, 95% CI 0.0–0.24) and “other fracture of the fibula” (0.0, 95% CI 0.0–0.15). Generalized “other fracture” codes comprised 45% of EMR codes compared to only 6% of assigned codes (p Conclusion There is substantial discordance between existing EMR and surgeon-assigned ICD-10 codes for ankle fractures. Database research that relies on ICD-10 coding as a surrogate for primary clinical data should be interpreted with caution and institutions should make efforts to increase the accuracy of their coding.

Background: Supination-adduction (SAD) type II ankle fractures can have medial tibial plafond and talar body impaction. Factors associated with the development of posttraumatic arthritis can be intrinsic to the injury pattern or mitigated by the surgeon. We hypothesize that plafond malreducton and talar body impaction is associated with early posttraumatic arthrosis. Methods: A retrospective cohort of skeletally mature patients with SAD ankle fractures at 2 level 1 academic trauma centers who underwent operative fixation were identified. Patients with a minimum of 1-year follow-up were included. The presence of articular impaction identified on CT scan was recorded and the quality of reduction on final intraoperative radiographs was assessed. The primary outcome was radiographic ankle arthrosis (Kellgren-Lawrence 3 or 4), and postoperative complications were documented. Results: A total of 175 SAD ankle fractures were identified during a 10-year period; 79 patients with 1-year follow-up met inclusion criteria. The majority of injuries resulted from a high-energy mechanism. Articular impaction was present in 73% of injuries, and 23% of all patients had radiographic arthrosis (Kellgren-Lawrence 3 or 4) at final follow-up. Articular malreduction, defined by either a gap or step >2 mm, was significantly associated with development of arthrosis. Early treatment failure, infection, and nonunion was rare in this series. Conclusion: Malreduction of articular impaction in SAD ankle fractures is associated with early posttraumatic arthrosis. Recognition and anatomic restoration with stable fixation of articular impaction appears to mitigate risk of posttraumatic arthrosis. Investigations correlating postoperative and long-term radiographic findings to patient-reported outcomes after operative treatment of SAD ankle fractures are warranted. Level of Evidence: Level IV, retrospective case series.

OBJECTIVE To compare complications and functional outcomes of treatment with primary distal femoral replacement (DFR) versus open reduction and internal fixation (ORIF). DATA SOURCES PubMed, Embase, and Cochrane databases were searched for English language studies up to May 19, 2020, identifying 913 studies. STUDY SELECTION Studies that assessed complications of periprosthetic distal femur fractures with primary DFR or ORIF were included. Studies with sample size ≤5, mean age

Introduction: Bridge plating of distal femur fractures with lateral locking plates is susceptible to varus collapse, fixation failure, and nonunion. While medial and lateral dual plating has been described in clinical series, the biomechanical effects of dual plating of distal femur fractures have yet to be clearly defined. The purpose of this study was to compare dual plating to lateral locked bridge plating alone in a cadaveric distal femur gap osteotomy model. Materials and Methods: Gap osteotomies were created in eight matched pairs of cadaveric female distal femurs (average age: 64 yrs (standard deviation ± 4.4 yrs); age range: 57–68 yrs;) to simulate comminuted extraarticular distal femur fractures (AO/OTA 33A). Eight femurs underwent fixation with lateral locked plates alone and were matched with eight femurs treated with dual plating: lateral locked plates with supplemental medial small fragment non-locking fixation. Mechanical testing was performed on an ElectroPuls E10000 materials testing system using a 10 kN/100 Nm biaxial load cell. Specimens were subject to 25,000 cycles of cyclic loading from 100-1000 N at 2 Hz. Results: Two (2/8) specimens in the lateral only group failed catastrophically prior to completion of testing. All dual plated specimens survived the testing regimen. Dual plated specimens demonstrated significantly less coronal plane displacement (median 0.2 degrees, interquartile range [IQR], 0.0–0.5 degrees) compared to 2.0 degrees (IQR 1.9-3.3, p = 0.02) in the lateral plate only group. Dual plated specimens demonstrated greater bending stiffness compared to the lateral plated group (median 29.0 kN/degree, IQR 1.5–68.2 kN/degree vs median 0.50 kN/degree, IQR 0.23–2.28 kN/degree, p = 0.03). Conclusion: Contemporary fixation methods with a distal femur fractures are susceptible to mechanical failure and nonunion with lateral plates alone. Dual plate fixation in a cadaveric model of distal femur fractures underwent significantly less displacement under simulated weight bearing conditions and demonstrated greater stiffness than lateral plating alone. Given the significant clinical failure rates of lateral bridge plating in distal femur fractures, supplemental fixation should be considered, and dual plating of distal femurs augments mechanical stability in a clinically relevant magnitude.

CASE We describe an irreducible anterolateral tibiotalar dislocation with an AO/OTA (Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association) B-type pilon fracture. The injury was initially treated with closed reduction, using a medializing force achieved with an external fixator to unhinge the talar body from the fibula, followed by temporary stabilization. Definitive fixation was performed once the soft tissues had recovered. CONCLUSION This unique irreducible pilon fracture dislocation pattern is important to recognize to prevent iatrogenic complications associated with multiple failed closed reduction attempts. Frame-assisted, percutaneous, or open maneuvers may be required to facilitate a reduction. Staged treatment with temporization in an external fixator may be required.

SUMMARY Pilon fractures are complex injuries to the tibial plafond requiring stable fixation in the setting of effective soft tissue management, particularly in high-energy injuries, open fractures, or in geriatric individuals. Medial column support of the distal tibial metaphysis is often an essential component when applying balanced fixation. However, the biologic implications of multiple surgical approaches in the setting of damaged tissue, devitalized bone, or significant bone loss may contribute to increased complications. Percutaneous intramedullary large fragment screws offer both stability and a soft tissue-friendly approach for stabilizing the medial column. Here, we present our technique and indications for medial column support in pilon fractures using percutaneous large fragment fixation, along with our early clinical experience in a case series of 7 patients. At minimum 6-month follow-up, all patients healed their injuries with maintained alignment and without complications or further reoperation. Medial column support with percutaneous large fragment fixation in pilon fractures is a viable option to provide mechanical stability while effectively managing tenuous soft tissue envelopes.

INTRODUCTION Olecranon fractures are common in the elderly. Articular impaction is encountered occasionally, but the incidence and outcomes after treatment of this injury pattern have not been well characterized. METHODS We evaluated a cohort of geriatric olecranon fractures to determine the incidence of articular impaction and describe a technique for open reduction and internal fixation. RESULTS Of the 63 patients in our series, 31 had associated intraarticular impaction (49.2%). Patients with articular impaction did not have significantly different rates of postoperative complications (11/31, 35.5% versus 10/31, 32.3%; P = 1.00) or revision surgery (10/31, 32.3% versus 8/31, 25.8%; P = 0.780) compared with those without articular impaction. CONCLUSION Articular impaction is a common feature of geriatric olecranon fractures. Surgeons must maintain a high index of suspicion and have a surgical plan in place for managing this component of the injury.

Delayed union or nonunion are relatively rare complications after fracture surgery, but when they do occur, they can result in substantial morbidity for the patient. In many cases, the etiology of impaired fracture healing is uncertain and attempts to determine the molecular basis for delayed union and nonunion formation have been limited. Prospectively isolating skeletal stem cells (SSCs) from fracture tissue samples at the time of surgical intervention represent a feasible methodology to determine a patient's biologic risk for compromised fracture healing. This report details a case in which functional in vitro readouts of SSCs derived from human fracture tissue at time of injury predicted a poor fracture healing outcome. This case suggests that it may be feasible to stratify a patient's fracture healing capacity and predict compromised fracture healing by prospectively isolating and analyzing SSCs during the index fracture surgery. © 2020 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

OBJECTIVES To determine the incidence of iatrogenic peroneal nerve palsy after application of an intraoperative lateral distractor during open reduction and internal fixation of tibial plateau fractures. DESIGN Retrospective review. SETTING Single academic Level I trauma center. PATIENTS One hundred forty-seven patients met criteria and were included in the study. INTERVENTION Patients with unicondylar and bicondylar tibial plateau fractures underwent open reduction and internal fixation and received application of an intraoperative lateral distractor to aid in visualization and reduction of the impacted lateral plateau. MAIN OUTCOME MEASUREMENTS Incidence of iatrogenic peroneal nerve palsy. RESULTS There was a 2.0% incidence of iatrogenic peroneal nerve symptoms (3 of 147 patients), most of which were incomplete sensory deficits. There was no association with staged external fixation, regional anesthesia, or tourniquet use. CONCLUSION Use of an intraoperative lateral distractor is safe and has a low incidence of iatrogenic peroneal nerve palsy if applied carefully. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Platelet-rich plasma (PRP) is a promising treatment for musculoskeletal maladies and clinical data to date have shown that PRP is safe. However, evidence of its efficacy has been mixed and highly variable depending on the specific indication. Additional future high-quality large clinical trials will be critical in shaping our perspective of this treatment option. The heterogeneity of PRP preparations, both presently and historically, leads sweeping recommendations about its utility impossible to make. This heterogeneity has also made interpreting existing literature more complicated.

Background and Objective: Persistent periprosthetic joint infection (PJI) is a devastating complication after Total Knee Arthroplasty (TKA). We hypothesize that our novel treatment algorithm utilizing a customized knee spanning recon nail combined with an antibiotic eluting cement spacer improves ambulation status and prevents recurrent PJI in patients with failed TKA and severe bone loss. Methods: In a retrospective case series, 15 consecutive patients who underwent knee arthrodesis after failed ipsilateral TKA secondary to infection from 2004-2017 with at least 1 year of follow-up were enrolled. The average age of patients at the time surgery was 68 (range 50-81) years with an average follow-up of 3.2 (range 1-6) years. Post-surgical ambulation status and eradication of index infection were analyzed as primary outcomes using McNemar’s test for before-and-after study design with p Results: Cement arthrodesis significantly improved ambulation with 67% (10/15) of patients unable to ambulate before arthrodesis and 93% (14/15) of patients able to ambulate at final follow-up (p=0.004). The complication rate was 20% (3/15). There were no periprosthetic fractures. Amongst patients who presented with active PJI, 91% (10/11) had eradication of their index infection final follow-up (p=0.002). Overall prevention of recurrent index infection was 93% (14/15) (p=0.0001). Conclusion: Cement arthrodesis utilizing a custom knee spanning recon nail combined with an antibiotic eluting spacer improves ambulation status and prevents or treats recurrent infection in the majority of patients who have failed total knee arthroplasty.

The use of percutaneous clamps is often a helpful tool to aid reduction and intramedullary nailing of distal tibial spiral diaphyseal fractures. However, the anterior and posterior neurovascular bundles are at risk without careful clamp placement. We describe our preferred technique of percutaneous clamp reduction for distal spiral tibial fractures with a distal posterolateral fracture spike, with care to protect the adjacent neurovascular structures. We also investigated the relationship between these neurovascular structures and the site of common percutaneous clamp placement. Preoperative computed tomography images of surgically managed patients who sustained this specific common fracture pattern (distal third spiral diaphyseal tibia fracture with a posterolateral fragment) were retrospectively reviewed. On computed tomography, we extrapolated the ideal virtual clamp site on the posterolateral fracture fragment to facilitate reduction. The average distance of this clamp position from the anterior neurovascular bundle was 14 mm (SD = 7.6), with a range of 6-32 mm. The average distance of the clamp site from the posterior neurovascular bundle was 19 mm (SD = 6.1), with a range of 11-30 mm. In 31% of patients, the distal fragment's apex extended anterior to the interosseous membrane, and in 69% of patients, the apex was posterior to the interosseous membrane. We also describe our preferred surgical technique with percutaneous clamping and tibial nailing, which involves sliding the posterolateral tine of the percutaneous clamp along the lateral tibial cortex to prevent neurovascular bundle injury.

Critical-sized bone defects are defined as those that will not heal spontaneously within a patient's lifetime. Current treatment options include vascularized bone grafts, distraction osteogenesis, and the induced membrane technique. The induced membrane technique is an increasingly utilized method with favorable results including high rates of union. Tissue engineering holds promise in the treatment of large bone defects due to advancement of stem cell biology, novel biomaterials, and 3D bioprinting. In this review, we provide an overview of the current operative treatment strategies of critical-sized bone defects as well as the current state of tissue engineering for such defects.

Objectives To compare precontoured (Pc) small fragment plating to dual mini-fragment plating (DmF) for open reduction and internal fixation of diaphyseal clavicle fractures. Design Retrospective cohort. Setting Level 1 trauma center. Patients/participants A total of 133 patients with displaced fractures of the diaphyseal clavicle (OTA/AO 15-B1, -2, and -3) treated with open reduction and internal fixation with a minimum of 1 year follow-up or until radiographic and clinical union. Intervention Two patient cohorts were identified: (1) patients treated with orthogonal DmF plate constructs and (2) patients treated with Pc clavicle-specific plates. Outcome measurements Union rate and implant removal were assessed using standard descriptive statistics. Odds ratios, 95% confidence intervals, and P values (P) were calculated. Results There were 60 DmF and 74 Pc patients. There were no significant differences between groups with respect to age, sex, surgeon, body mass index, or mode of fixation. There was no significant difference in union (98.3% DmF; 100% Pc, P = 0.45) or maintenance of reduction (98.3% DmF; 100% Pc, P = 0.45). A total of 8% of DmF patients had symptomatic implant removal compared with 20% of Pc patients (odds ratio 0.36, confidence interval 0.12-1.05, P = 0.061). Conclusions This retrospective comparative study found no difference in union or maintenance of reduction for diaphyseal clavicle fractures fixed with DmF compared with Pc plating. Patients treated with DmF plates may have lower rates of symptomatic implant removal. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives To determine reoperation rates after treatment of a proximal humerus fracture with cage fixation. Design Retrospective case series. Setting Eleven U.S. hospitals. Patients Fifty-two patients undergoing surgical treatment of proximal humerus fractures. Intervention Open reduction and internal fixation of a proximal humerus fracture with a proximal humerus cage. Main outcome measurements Reoperation rate at 1 year. Results At a minimum follow-up of 1 year, reoperations occurred in 4/52 patients (7.7%). Avascular necrosis (2/41) occurred in 4.9% of patients. Conclusion Standard locked plating remains an imperfect solution for proximal humerus fractures. Proximal humerus cage fixation had low rates of revision surgery at 1 year. Proximal humerus cage fixation may offer reduced rates of complication and reoperation when compared with conventional locked plating for the management of proximal humerus fractures. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

The indications for the use of intramedullary (IM) nails have been extended to include extra-articular distal metaphyseal tibia fractures. We hypothesize that interfragmentary motion during physiologic compressive loading of distal tibia fractures is influenced by fracture obliquity and can be modulated by interlocking screw configuration. Sawbone specimens were osteotomized with frontal plane obliquities ranging from 0° to 60° and then fixed by IM nailing with six interlocking screw configurations. Interfragmentary motion was evaluated during loading in axial compression to 1000 N. Comparisons of interfragmentary motions were made (1) between configurations for the various fracture obliquities and (2) between fracture obliquities for the various screw configurations using a mixed-effects regression model. As the degree of fracture obliquity increased, significantly more interfragmentary displacement was shown in configurations with two distal interlocking screws and one proximal screw set in dynamic mode. Fracture obliquity beyond 30° causes demonstrated instability in configurations with less than two distal locking screws and one proximal locking screw. Optimizing the available screw configurations can minimize fracture site motion and shear in distal tibial fractures with larger fracture obliquities.

Objectives To biomechanically compare plated constructs using nonlocking bone–screw–fasteners with interlocking threads versus locking screws with traditional buttress threads in geriatric female bone. Methods Eleven matched pairs of proximal and distal segments of geriatric female cadaveric tibias were used to create a diaphyseal fracture model. Nonlocking bone–screw–fasteners or locking buttress threaded screws were applied to a locking compression plate on the anterolateral aspect of the tibia placed in bridge mode. Specimens were subjected to incrementally increasing cyclic axial load combined with constant cyclic torsion. Total cycles to failure served as a primary outcome measure, with failure defined as 2 mm of displacement or 10 degrees of rotation. Secondary outcome measures included initial stiffness in compression and torsion determined from preconditioning testing and overall rigidity as determined by maximum peak-to-peak axial and rotational motion at 500 cycle intervals during cyclic testing. Group comparisons were made using paired Student's t-tests. Significance was set at p Results Bone–screw–fastener constructs failed at an average of 40,636 ± 22,151 cycles and locking screw constructs failed at an average of 37,773 ± 8433 cycles, without difference between groups (p = =0.610). Total cycles to failure was higher in the bone–screw–fasteners group for 7 tibiae out of the eleven matched pairs tested. During static and cyclic testing, bone–screw–fastener constructs demonstrated increased initial torsional stiffness (7.6%) and less peak-to-peak displacement and rotation throughout the testing cycle(p Conclusions In female geriatric bone, constructs fixed with bone–screw–fasteners incorporate multiplanar interlocking thread geometry and performed similarly to traditional locked plating. These novel devices may combine the benefits of both nonlocking and locking screws when plating geriatric bone.

Purpose Bone tumors are common in the distal femur and often treated with intralesional curettage. The optimal method of stabilization of large distal femoral defects after curettage remains unclear. The goal of this study is to compare stabilization techniques for large distal femoral defects. Methods Large defects (60 cm3) were milled in the distal lateral metaphysis of 45 adult composite sawbone femurs. The defect was either (1) left untreated or reconstructed with (2) locked plate fixation, (3) calcium phosphate cement packing, or (4) locked plate fixation with calcium phosphate cement packing, or (5) polymethylmethacrylate packing. Each specimen then underwent axial and torsional stiffness testing followed by torsional loading to failure. The data were analyzed using ANOVA with Tukey–Kramer post-hoc analysis. Results The calcium phosphate cement filled defect with a locked plate was the stiffest construct in axial and torsional loading as well as the strongest in torque to failure. However, this difference only reached significance with respect to all other groups in torque to failure testing. The calcium phosphate cement filled defect with a locked plate was significantly stiffer than three of the four other groups in both axial and torsional stiffness testing. Conclusions These results indicate that calcium phosphate cement, with or without the addition of locked plate fixation, may provide improved construct stability under time zero testing conditions. This result warrants further testing under cyclic loading condition and consideration for fixation of large femoral metaphyseal defects in future clincal trails.

The prevalence of chronic osteomyelitis due to trauma and surgical complications does not seem to be diminishing in our society. In many African Nations, with the urbanization and shift to the larger cities that has been occurring, Trauma has been classified as the number one disease problem plaguing such societies. This brings along with it the ensuing infections. With our better understanding of how microbes gain attachment to sites in our body and morph from a planktonic state to the slow growing sessile phase of growth, combined with their formation of a highly structured biofilm colony, we have come to realize that we must resort to other forms of treatment. This means changing our philosophical approach to treatment utilized over the past nearly 70 years involving complete reliance on chemotherapeutic agents with their resultant questionable efficacy in the treatment of chronic osteomyelitis. We report on preliminary early outcome results in the treatment of 127 patients with chronic osteomyelitis treated by a single surgeon in which all patients except those with underlying immunological impairment were treated with in-hospital intravenous antibiotics only. Only 5.5% of the patient population then received intravenous antibiotics following hospital discharge, and with this treatment approach there remained a 98.4% cure rate in the treatment of this chronic infection.

Background: Spontaneous heparin induced thrombocytopenia (HIT) is a medical phenomenon whereby patients develop clinical and laboratory features of HIT without prior exposure to heparin. Aim: We present a patient who underwent bilateral total knee replacement complicated by spontaneous HIT causing bilateral adrenal hemorrhage and deep vein thrombosis. Our patient had no prior history of heparin exposure. We reconcile our patient’s presentation with other case reports of spontaneous HIT in patients who had orthopaedic surgery. Conclusion: Spontaneous HIT is a rare but potentially devastating complication associated with total knee arthroplasty.

Background: Female collegiate athletes with serum relaxin concentrations above 6.0 pg/mL have been shown to have more than 4 times increased risk for anterior cruciate ligament (ACL) tears. However, the intracellular effect of relaxin on ACL cells has not been elucidated. Hypotheses: The hypotheses were that relaxin binding to receptors on female ACL cells will result in (1) an increase in matrix metalloproteinase (MMP) and decrease in tissue inhibitor of metalloproteinase (TIMP) gene expression, (2) a decrease in collagen and alpha smooth muscle actin (αSMA) expression, (3) inhibition of transforming growth factor β1 (TGFβ1)–induced fibrosis, and (4) an increase in cyclic adenosine 3′,5′-monophosphate (cAMP) production and that these changes will not be observed in male ACL cells. Study Design: Controlled laboratory study. Methods: Ligament cells from ACL tissue were isolated from 7 male and 7 female human donors and expanded in vitro. The cells were incubated with escalating concentrations of relaxin-2, as well as with TGFβ1 or 17β-estradiol in certain groups. Cells were then lysed and analyzed for MMP1 (collagenase-1), MMP3 (stromelysin-1), MMP13 (collagenase-3), TIMP1, type I collagen, type III collagen, and/or αSMA mRNA expression using quantitative real-time polymerase chain reaction. Intracellular cAMP levels were assessed via an enzyme-linked immunoassay. Results: ACL cells primed with estrogen and treated with 10 ng/mL and 100 ng/mL relaxin illustrated increased MMP1 expression ( P = .012 and .006, respectively) and MMP3 expression ( P = .005 and .001, respectively). Treatment with 100 ng/mL relaxin decreased αSMA expression ( P = .001). When ACL tissue isolated from female donors with a history of oral contraceptive use was excluded from the analysis, 100 ng/mL of relaxin decreased type I collagen ( P = .005) and type III collagen ( P = .028) expression in cells primed with estrogen. Relaxin exhibited no significant effect on male-derived ACL cells. Conclusion: Relaxin-2 significantly upregulated intracellular processes in human female ACL cells, but no effect was observed in male cells. Relaxin increased MMP (MMP1 and MMP3) and decreased αSMA and type I and III collagen expression, which may act to alter the structural integrity of the ACL tissue over time. Clinical Relevance: Female athletes with higher circulating relaxin levels may be more susceptible to ACL injury.

This review evaluates current clinical literature on the use of platelet-rich plasma (PRP), including leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP), in order to develop evidence-based recommendations for various musculoskeletal indications. Abundant high-quality evidence supports the use of LR-PRP injection for lateral epicondylitis and LP-PRP for osteoarthritis of the knee. Moderate high-quality evidence supports the use of LR-PRP injection for patellar tendinopathy and of PRP injection for plantar fasciitis and donor site pain in patellar tendon graft BTB ACL reconstruction. There is insufficient evidence to routinely recommend PRP for rotator cuff tendinopathy, osteoarthritis of the hip, or high ankle sprains. Current evidence demonstrates a lack of efficacy of PRP for Achilles tendinopathy, muscle injuries, acute fracture or nonunion, surgical augmentation in rotator cuff repair, Achilles tendon repair, and ACL reconstruction. PRP is a promising treatment for some musculoskeletal diseases; however, evidence of its efficacy has been highly variable depending on the specific indication. Additional high-quality clinical trials with longer follow-up will be critical in shaping our perspective of this treatment option.

Objectives: The number of Mesenchymal Stem/Stromal Cells (MSCs) in the human bone marrow (BM) is small compared to other cell types, estimated at 0.01-0.02%. Bone marrow aspirate concentration (BMAC) may be used to increase numbers of MSCs, but the efficacy of BMAC, as well as the composition of MSC subpopulations after processing, is currently unknown. The purpose of this descriptive laboratory study is to assess the enrichment of MSC subpopulations in bone marrow aspirate by two different BMAC devices versus standard BM aspiration from single donors. Methods: 120 mL of BM was aspirated from multiple punctures of the iliac crest in 9 human male donors. Each sample was divided into 3 partitions and processed by 2 different commercially available systems Harvest BMAC or Emcyte PureBMC, and compared to untreated BM aspirate as an internal control. Samples were quantitatively analyzed with multicolor flow cytometry for cellular viability and expression of hematopoietic and MSC subpopulation markers. Colony-forming unit-fibroblasts (CFU-F) assays were performed to estimate the number of functional progenitor cells. Results: Cell viability after processing was over 90% in all groups without significant differences, and hematopoietic cell content was lower in BMAC where, in contrast, non-hematopoietic stem cell subpopulations were significantly enriched. Specifically, BMAC from Harvest BMAC contained more CD45-CD73+CD90+ (11.44 fold vs control, p = 0.01), CD45-CD10+ (3.68 fold vs control, p = 0.01), CD45-CD29+ (1.54 fold vs control, p = 0.03), and CD45-CD119+ (5.52 fold vs control, p = 0.02) cells, whereas Emcyte PureBMC concentrated more CD45-CD73+ cells (13.90 fold vs control, p = 0.04). Both BMAC devices mainly enriched the CD45-CD90+CD271+ MSC subpopulation (Harvest BMAC: 13,011.84 fold vs control, p = 0.001; Emcyte PureBMC: 10,669.11 fold vs control, p = 0.02) compared to other MSC subpopulations. Both BMAC systems significantly increased progenitor colonies (Harvest BMAC: 2692 CFU-F/mL; Emcyte PureBMC: 4336 CFU-F/mL) verses control BM aspiration (183 CFU-F/mL), pConclusion: BMAC devices lead to: 1) enrichment of functional mesenchymal stem cell subpopulations with distinct phenotypes, 2) no increase in hematopoietic stem cell concentration, and 3) no significant loss of cell viability.