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Objective: To identify the patient, injury, and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multicenter retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction., Design: Multicenter retrospective review., Setting: Sixteen trauma centers., Patients: One thousand and 3 consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures., Main Outcome Measures: Fracture-related infection (FRI) in open ankle fractures., Results: The charts of 1003 consecutive patients were reviewed, and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction, and/or implant failure; FRI was associated with higher rates of these complications (P = 0.01)., Conclusions: Several patient, injury, and surgical factors were associated with FRI in the treatment of open ankle fractures., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Summary: One of the most versatile soft-tissue flaps available for elbow coverage that is reliable, quick, and easy to perform, with minimal donor defect and without the sacrifice of a major blood vessel, is the antegrade posterior interosseous artery flap. A large amount of vascularized fascia can be dissected with the flap, and it can be useful in lining the elbow joint or any exposed implant(s). After flap harvest, the donor site is often amenable to primary closure or requires a simple skin graft for closure. This article explains the technique for harvesting an antegrade posterior interosseous artery flap and describes 10 cases in which the flap was used for complex soft-tissue defects of the elbow not amenable to local wound care or skin grafting., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Tourniquet use is common in total knee arthroplasty (TKA), but debate exists regarding its use and effect on patient outcomes. The study purpose was to compare the effect of short tourniquet (ST) time vs long tourniquet (LT) time on pain, opioid consumption, and patient outcomes., Methods: Patients were prospectively randomized to an ST time of 10 min vs LT time. A total of 100 consecutive patients undergoing primary cementless robotic-assisted TKA underwent randomization, with 5 patients unable to complete follow-up, leaving 49 in the ST group and 46 in the LT cohort. Visual analog scale pain scores, morphine equivalent, serum creatine kinase, distance walked, range of motion, length of stay (LOS), surgical time, hemoglobin (Hgb), and Knee Society Scores (KSS) were prospectively collected., Results: Visual analog scale pain was statistically equivalent at 24, 48, and 72 hours and at 2 and 6 weeks postoperatively. Morphine equivalent consumption was 36 vs 44 (P = .03), 48 vs 50 (P = .72), 31 vs 28 (P = .57), and 4.7 vs 5.5 (P = .75) in the LT vs ST cohorts at 24 hours, 48 hours, 2weeks, and 6weeks postoperatively. Change in Hgb postoperative day 1 was 2.7 in both groups (P = .975). Postoperative day 1 creatine kinase-MB was 3.7 and 3.0 (P = .30) in LT and ST cohorts. Six-week postoperative KSS Knee and Function scores were 82.4 and 70.5 in LT group vs 80.8 and 72.3 in ST group (P = .61 and P = .63). Postoperative range of motion, LOS, and surgical time were equivalent., Conclusion: This study demonstrates no significant advantage of ST use in primary TKA with respect to opioid consumption, patient-reported pain, KSS scores, LOS, or postoperative Hgb level., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background  Extra-articular fractures of the distal radius are often treated with a trial of nonoperative management if radiographic parameters are within an acceptable range, especially in the elderly population. Unfortunately, some malunions become symptomatic or become grossly misaligned during nonoperative management which require corrective surgery to restore the normal osseous anatomy and restore function. Description of Technique  We describe correction of a distal radius malunion utilizing a distraction-type volar osteotomy, a volar plate specific distraction device, and a novel resorbable calcium phosphate bone cement (Trabexus) designed to withstand compressive loads. Patients and Methods  Twelve patients with 13 distal radius fractures were included in this study. The average patient age was 60.9 years and average time from injury to corrective osteotomy was 96.3 days. Radiographic measures (radial inclination, volar tilt, and ulnar variance) and clinical assessment (wrist/forearm range of motion and grip strength) were done pre- and postoperatively and compared. Results  The average time from corrective surgical osteotomy to final clinical follow-up was 375.8 days. After surgical intervention, there was a statistically significant improvement in mean volar tilt (-19.8 vs. +0.5 degrees) and mean ulnar variance (+2.8 vs. -0.4 mm). Improvements were also seen in grip strength (1.7 vs. 43.6 lb), wrist flexion (30.5 vs. 48.3 degrees), wrist extension (33.3 vs. 53.8 degrees), forearm pronation (75.0 vs. 88.8 degrees), and forearm supination (53.8 vs. 81.3 degrees). On average, 56.0% of Trabexus bone substitute remained on final clinical radiographs. Conclusion  This simplified technique of distraction corrective osteotomy after distal radius malunion results in improved clinical and radiographic outcomes for patients., Competing Interests: Conflict of Interest L.P.R. reports personal fees from TRIMED, outside the submitted work. All the other authors report no conflict of interest., (Thieme. All rights reserved.)

Background: Median and ulnar nerve lacerations at the wrist are often combined with zone 5 tendon injury. The inability to provide early range of motion leads to increased adhesions. Current therapy protocols recommend the wrist be held in 30° of flexion post operatively to protect the nerve repair. However, if tension and elongation across the nerve repair stay under a critical level in less wrist flexion, postoperative splinting in more extension could allow for better tendon excursion and less adhesions. Methods: Six cadaveric specimens were used. After appropriate dissection, the median and ulnar nerves were transected and repaired with a single 10-0 nylon suture. The wrist was ranged from 30° flexion to 45° extension to see if the repair would fail. Next, an epineural repair was accomplished with 9-0 nylon suture. The percent elongation along the nerve repair was measured at set increments from 30° flexion to 45° extension. Results: In all 6 specimens, median and ulnar nerve repairs with a single 10-0 nylon suture did not fail with wrist range of motion from 30° flexion to 45° extension. Mean percent elongation stayed under critical levels in up to 30° of extension. Conclusions: Both median and ulnar nerve repairs stayed under critical levels of tension and elongation in up to 30° of wrist extension. We believe it is possible to be more aggressive with wrist positioning in wrist level median and ulnar nerve repairs.

Background: To identify the time course for efficacy of corticosteroid injections in the treatment of trigger finger., Methods: A prospective single-center observational study was conducted, consisting of 38 patients with 41 trigger digits that were injected. Enrolled patients completed an initial Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire to determine the severity of their symptoms. Following the injection, patients were contacted at scheduled time points for up to 12 weeks to determine if, and when, objective resolution of symptoms occurred. Patients who received additional treatment, such as a second injection or surgery, and those who did not have objective relief of symptoms by 12 weeks were classified as failed. Upon symptom resolution or injection failure, patients were given a DASH exit questionnaire., Results: 30 of 41 injected trigger digits resolved and 11 failed treatment with a single corticosteroid injection. The latest that any study participant experienced resolution of symptoms was 69 days. At 38 days, the rate of resolution of the study population slowed significantly., Conclusions: Although symptomatic resolution of trigger finger from a single corticosteroid injection can occur early on, a follow-up of 4 weeks (28 days) does not allow enough time for symptom resolution. The earliest a surgeon and patient should consider a secondary treatment is at 38 days. After 69 days without resolution, both surgeon and patient can be confident that further treatment is needed.

Nili-Ravi buffaloes (n=29) that calved normally between August and November and did not develop any clinical reproductive disorder after calving were studied for the incidence of sub-clinical bacterial infection of the uterus and its effects on postpartum reproductive efficiency. The incidence of subclinical uterine infection was 24% (7/29). Involution of the cervix and uterus was slower (P < 0.01) in the infected group than in the normal group (45.6 vs 31.1 days and 46.3 vs 35.8 days), respectively. The mean diameters of cervix and gravid horn on Day 12 post partum and on completion of involution did not differ between buffaloes of the two groups. However, the rate of involution of the cervix and the gravid horn was lower in buffaloes of the infected group (2.2 vs. 2.7 mm/day and 2.6 vs. 3.2 mm/day). The mean interval to first post partum ovulation was similar in buffaloes in the infected (35.5 days) and the normal group (33.8 days). The life span of corpus luteum formed after first ovulation was shorter (11 days) in buffaloes of both groups than that of a normal estrous cycle (15 to 17 days). The incidence of silent ovulation was apparently higher in buffaloes of the infected group (83 vs. 60%) but the difference was not significant. For the first four months after calving, the mean interval to first postpartum estrus was longer in buffaloes of the infected group (73.0 vs. 47.7 days; P < 0.01). Similarly, the average service period was longer in buffaloes of the infected group (91.0 vs. 64.8 days; P < 0.05). The overall pregnancy rate for the first four months after calving did not differ between buffaloes of the two groups. We conclude that subclinical bacterial infection of the postpartum uterus delays the cervical and uterine involution which can, in turn, delay the occurrence of first postpartum estrus and prolong the service period in buffaloes.

Effects of supplemental prepartum feeding and limited suckling on postpartum reproductive performance of milked Nili-Ravi water buffaloes were examined in two 2 x 2 factorial experiments. Prepartum feeding was either moderate (metabolizable energy = 32 Mcal/d) or high (46 Mcal/d) in Experiment 1 and high (46 Mcal/d) or very high (51 Mcal/d) in Experiment 2. Nutritional treatment was initiated about 75 d prior to calving and stopped at parturition. Half of the buffaloes were suckled by their calves twice daily (2 min at each milking) until second estrus. Prepartum feeding did not influence any trait measured in either experiment. Postpartum intervals to uterine involution, resumption of follicular development, first rise in milk progesterone, first palpable corpus luteum, and first estrus were longer for limited-suckled buffaloes than for those that were only milked. Most buffaloes (86%) showed at least one short luteal phase (8 to 13 d) before first estrus. Number of rises of progesterone before first estrus was greater for limited- suckled buffaloes in Experiment 2 but not in Experiment 1. Luteal activity after first estrus (15 to 19 d) and pregnancy rate to insemination at second estrus (average 50%) did not differ with limited suckling. In conclusion, postpartum anestrus of water buffaloes can be shortened by weaning calves at birth, regardless of supplemental feeding prepartum.

Uterine involution and postpartum ovarian activity were studied in 53 Nili-Ravi buffaloes. Mean intervals to uterine involution (26 days), regression of the corpus albicans of pregnancy (22 days), resumption of follicular activity (21 days) and first postpartum estrus (56 days) were not affected by the month of calving or age. Mean interval to formation of first corpus luteum (CL) after calving as indicated by progesterone in plasma (>/= 1.5 ng/ml) was 23.8 +/- 1.7 days, but only 52% of these CL were palpable. The number of CL formed before first postpartum estrus ranged from zero to five per buffalo; mean values based upon progesterone and palpation were 1.6 +/- 1.3 and 0.8 +/- 0.2, respectively. Based upon either progesterone or palpation, length of first postpartum luteal phase (7.9 or 6.6 days) was shorter than the luteal phase immediately preceeding the first estrus (12.1 or 8.9 days). Intervals from regular cyclic ovarian activity was not established until first estrus and intervals from the end of one luteal phase to the onset of the next were as long as three weeks. High concentrations of progesterone (>/= 1.5 ng/ml) on the day of behavioral estrus were seen in 23% of the buffaloes studied.

Two experiments were conducted to measure response to prepartum feeding using 101 Nili-Ravi buffaloes of mixed ages and lactation numbers. Nutritional treatment was initiated approximately 75 d before calving and stopped at parturition. Levels of prepartum feeding were moderate and high in Experiment 1 and high and very high in Experiment 2. Estimated daily intakes of metabolizable energy by buffaloes on moderate, high, and very high intake treatments were 31.9, 45.8, and 50.6 Mcal, respectively. Prepartum feeding affected the BW gain by buffaloes in both experiments. Yields of milk and milk fat for first 75 d were greater for buffaloes on higher prepartum feeding treatments. In Experiment 2, buffaloes suckled for a limited time produced more milk than nonsuckled buffaloes, but the difference was small. Calf birth weight increased with increasing prepartum feeding in both experiments. Gain in BW of buffalo calves from birth to 75 d of age had no relationship with birth weight. In Experiment 2, calf weight gain was influenced by the interaction of dam's prepartum feeding and suckling. In conclusion, improvement in prepartum feeding can be used to increase milk yield and birth weight of Nili-Ravi buffaloes.