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Introduction: Distal tibia shaft fractures have a high association with posterior malleolar fractures (PMFs); hence, a preoperative ankle CT scan is commonly obtained. The purpose of this study was to determine whether a CT scan for distal third tibia shaft fractures is associated with differences in recognition of a posterior malleolus fracture (PMF), treatment of an identified PMF, outcomes, and postoperative complications., Methods: We retrospectively reviewed cases of adult patients with distal third tibia shaft fractures treated with an intramedullary nail between 2018 and 2020. Patients were divided into 2 groups based on whether they received a preoperative ankle CT scan. Outcomes included surgical time, the rate of missed PMFs or postoperative PMF displacement, the treatment of the PMFs, postoperative weight-bearing restrictions, Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS Global-10) scores, and unplanned revision surgeries., Results: 124 patients (age 45 ± 18 years; 39.5% female) with distal third tibia shaft fractures treated with intramedullary nailing and with minimum 6 months of follow-up were reviewed. 26 patients received preoperative CT scans, and 98 patients did not have CT scans. The rate of detected PMF was 69.2% (N = 18) in patients with CT and 55.1% (N = 54) in patients without CT (P = 0.19). No significant differences were observed in all outcomes between the 2 groups (P > 0.05). 3 PMFs not visible on radiographs were identified on CT, and they did not require fixation and did not displace. PMFs that were greater than one-third of the joint surface were more likely to have a preoperative CT (P < 0.01)., Discussion: Preoperative CT scans for distal third tibia shaft fractures may be useful in characterizing large PMFs; however, this knowledge does not translate into shorter surgical time, increased fixation rates, decreased unplanned revision surgery, or improved patient-reported outcomes. Discovery of PMFs did not always lead to fixation, and PMFs without fixation did not become further displaced., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Case: A 96-year-old woman with no baseline renal dysfunction presented with a distal femoral shaft fracture after a ground-level fall. Treatment was with a retrograde intramedullary nail and included placement of topical antibiotics. Postoperatively, she developed acute kidney injury and was found to have supratherapeutic antibiotic levels., Conclusion: This case report demonstrates the risk of clinically relevant systemic absorption along with associated downstream end organ damage with the use of topical antibiotics in certain circumstances. We present this case as an illustration of a rare hazard associated with topical antibiotic use., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSCC/B860)., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Objectives: To report the progression of radiographic healing after intramedullary nailing of tibial shaft fractures using the Radiographic Union Score for Tibial fractures (RUST) and determine the ideal timing of early postoperative radiographs., Design: Retrospective case series., Setting: Urban academic Level 1 trauma center., Patients/participants: Three hundred three patients with acute tibial shaft fractures underwent intramedullary nailing between 2006 and 2013, met inclusion criteria, and had at least 3 months of radiographic follow-up., Intervention: Baseline demographic, injury, and surgical data were recorded for each patient. Each set of postoperative radiographs were scored using RUST and evaluated for implant failure., Main Outcome Measurements: Postoperative time distribution for each RUST score, RUST score distribution for 4 common follow-up time points, and the presence and timing of implant failure., Results: The fifth percentile and median times, respectively, for reaching "any radiographic healing" (RUST = 5) was 4.0 weeks and 8.4 weeks, "radiographically healed" (RUST = 9) was 12.1 and 20.9 weeks, and "healed and remodeled" (RUST = 12) was 23.5 weeks and 47.7 weeks. At 6 weeks, 84% of radiographs were scored as RUST ≤ 6 (2 or fewer cortices with callus). No implant failure occurred within the first 8 weeks after surgery, and the indication for all 7 reoperations within this period was apparent on physical examination or immediate postoperative radiographs., Conclusions: The median time to radiographic union (RUST = 9) after tibial nailing was approximately 20 weeks, and little radiographic healing occurred within the first 8 weeks after surgery. Routine radiographs in this period may offer little additional information in the absence of clinical concerns such as new trauma, malalignment, or infection., Level of Evidence: Diagnostic Level IV. 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.)

Background: Anterior native hip dislocation remains poorly studied due to the rarity of the injury. The aim of this study was to describe injury characteristics of anterior hip dislocation, detail its initial treatment, and determine the intermediate term outcomes including the rate of conversion to total hip arthroplasty (THA)., Methods: A cross-sectional study was performed at a single urban academic Level 1 trauma center for patients who sustained traumatic anterior hip dislocations from 2010-2017. Baseline demographic, injury, and treatment data were recorded. Patients were contacted to inquire about subsequent surgery and complete functional outcome questionnaires. Available post-operative radiographs were also reviewed., Results: Thirty-two anterior hip dislocations met inclusion criteria and were included in the study. 69% of dislocations were obturator dislocations and 31% iliac dislocations. Only 22% were simple dislocations with the remainder having an associated femoral head fracture and/or acetabular fracture. Iliac dislocations were more likely to be associated with acetabular fractures and require surgical treatment while obturator dislocations were more likely to be simple dislocations or have femoral head fractures. Excluding two patients treated with acute THA at the time of injury, follow-up information was available for 16 patients at a minimum of eighteen months from the time of injury. Only one required subsequent conversion to THA. For the remaining fifteen patients, modified Harris hip scores (mHHS) averaged 82.6, PROMIS global physical health averaged 51.9, and PROMIS global mental health averaged 48.3 with mean follow-up of 4.2 years. mHHS was significantly higher for obturator dislocations and a negative association was seen with age., Conclusions: Obturator dislocations occurred twice as frequently as iliac dislocations. Associated acetabular or femoral head fractures are common. Conversion to THA was low, occurring in only 1 of 16 patients not treated with acute arthroplasty. Obturator dislocations and age less than 45 years old at the time of injury were associated with better functional outcome at intermediate term follow-up., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Treatment of anterior pelvic ring injuries involves both acute stabilization during the initial resuscitation and definitive fixation. Definitive management has evolved substantially over the past 40 years with improved patient mobilization and long-term outcomes. Although its use has recently declined, external fixation remains a favorable option in certain situations. Symphyseal plating is the preferred technique for stabilization of symphyseal diastasis because of superior stability and low morbidity. Ramus screws can be effective for simple ramus fractures but require a careful technique because of the proximity of neurovascular structures. The subcutaneous internal fixator provides a good option for obese patients in whom external fixation would be poorly tolerated. Regardless of fixation strategy, posterior ring reduction and stabilization is crucial.

Introduction: The purpose of this study was to assess the association of outcomes from posterior medial meniscus root repairs with patient age, sex, and body mass index (BMI)., Methods: Patients who underwent arthroscopic posterior medial meniscus root repair completed the Knee Injury and Osteoarthritis Outcome Score (KOOS) and reported subsequent surgeries. The association of patient factors with subsequent surgery and clinical osteoarthritis (OA) based on the KOOS score was evaluated., Results: Minimum 2-year follow-up was available on 22/25 patients (88%). Two patients (9.1%) had subsequent surgeries, and 10 (45.5%) met the KOOS criteria for OA. A BMI over 35 kg/m was associated with repeat surgery (25% versus 0%; P = 0.049) and clinical OA (75% versus 28.6%; P = 0.035)., Conclusion: Although arthroscopic repair of posterior medial root tears has good clinical outcomes and a low rate of subsequent surgery, an elevated BMI level is associated with worse clinical outcomes and a higher rate of subsequent surgery.

Background: The opioid epidemic in the United States has placed increased pressure on physicians to engage in responsible opioid prescribing practices. However, surgeons currently have little information to guide their postoperative prescription decision-making. The purpose of this study was to assess opioid consumption after knee arthroscopy and identify preoperative factors that may predict higher opioid usage., Methods: A prospective observational study of 221 patients was conducted in patients undergoing outpatient knee arthroscopy for meniscal repair, partial meniscectomy, debridement, chondroplasty, or loose body removal. Participants recorded their daily opioid consumption in a postoperative pain diary. Total opioid consumption was calculated from counts of remaining pills at the 2-week and 6-week postoperative office visits. Variables, including age, sex, body mass index, smoking status, alcohol consumption, preoperative pain severity and duration, preoperative opioid usage, Patient-Reported Outcomes Measurement Information System (PROMIS) scores, and the Connor-Davidson Resilience Scale, were evaluated for an association with opioid consumption., Results: Total opioid consumption ranged from 0 to 188 pills, with a median of 7 pills (hydrocodone 5-mg equivalents). Forty-six percent of patients took ≤5 pills, 59% took ≤10 pills, and 81% took ≤20 pills. Fifty-six percent of patients had discontinued opioid usage by the third postoperative day. Eighty-eight percent of patients had surplus opioid medication at the time of the final follow-up. Patients undergoing meniscal repair, smokers, and those taking preoperative opioids were significantly more likely to take ≥20 pills (p < 0.05)., Conclusions: The median number of pills taken after knee arthroscopy is 7, with the majority of patients consuming ≤20 pills. Meniscal repair, smoking, and preoperative opioid usage were associated with higher postoperative opioid consumption., Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Symptomatic osteochondral lesions of the patellofemoral joint are clinically challenging to manage because of the limited healing potential of articular cartilage; the complex morphology of the patellofemoral joint; the heterogeneity of the articular surface between patients; and high stresses across the joint, which can be altered by malalignment, tilt, or maltracking. Indications for surgery include traumatic lesions, osteochondritis dissecans, and high-grade chondromalacia in association with persistent pain despite a course of nonsurgical management. Various techniques have been described for managing symptomatic osteochondral lesions of the patellofemoral joint, including microfracture, osteochondral autograft transplantation, and biologic cell transplantation, including autologous chondrocyte implantation. Salvage techniques (eg, fresh allograft) may provide satisfactory outcomes after a failed attempt at surgical management. Irrespective of the surgical technique used, outcomes are generally worse in the patellofemoral compartment than in the tibiofemoral joint. The concomitant management of associated pathology, including patellar malalignment, is recommended because it has been shown to improve the success of cartilage restoration procedures.

Background: Patellar tendon ruptures commonly are repaired using transosseous patellar drill tunnels with modified-Krackow sutures in the patellar tendon. This simple suture technique has been associated with failure rates and poor clinical outcomes in a modest proportion of patients. Failure of this repair technique can result from gap formation during loading or a single catastrophic event. Several augmentation techniques have been described to improve the integrity of the repair, but standardized biomechanical evaluation of repair strength among different techniques is lacking., Questions/purposes: The purpose of this study was to describe a novel figure-of-eight suture technique to augment traditional fixation and evaluate its biomechanical performance. We hypothesized that the augmentation technique would (1) reduce gap formation during cyclic loading and (2) increase the maximum load to failure., Methods: Ten pairs (two male, eight female) of fresh-frozen cadaveric knees free of overt disorders or patellar tendon damage were used (average donor age, 76 years; range, 65-87 years). For each pair, one specimen underwent the standard transosseous tunnel suture repair with a modified-Krackow suture technique and the second underwent the standard repair with our experimental augmentation method. Nine pairs were suitable for testing. Each specimen underwent cyclic loading while continuously measuring gap formation across the repair. At the completion of cyclic loading, load to failure testing was performed., Results: A difference in gap formation and mean load to failure was seen in favor of the augmentation technique. At 250 cycles, a 68% increase in gap formation was seen for the control group (control: 5.96 ± 0.86 mm [95% CI, 5.30-6.62 mm]; augmentation: 3.55 ± 0.56 mm [95% CI, 3.12-3.98 mm]; p = 0.02). The mean load to failure was 13% greater in the augmentation group (control: 899.57 ± 96.94 N [95% CI, 825.06-974.09 N]; augmentation: 1030.70 ± 122.41 N [95% CI, 936.61-1124.79 N]; p = 0.01)., Conclusions: This biomechanical study showed improved performance of a novel augmentation technique compared with the standard repair, in terms of reduced gap formation during cyclic loading and increased maximum load to failure., Clinical Relevance: Decreased gap formation and higher load to failure may improve healing potential and minimize failure risk. This study shows a potential biomechanical advantage of the augmentation technique, providing support for future clinical investigations comparing this technique with other repair methods that are in common use such as transosseous suture repair.

Background: The outcomes of corticosteroid injection for trigger finger are well documented only with short-term follow-up. The purpose of this investigation was to determine the long-term effectiveness of a single injection and to examine predictors of success up to ten years after injection., Methods: This case series analyzed 366 first-time corticosteroid injections in flexor tendon sheaths from January 2000 to December 2007 with a minimum follow-up duration of five years. Two hundred and forty patients (66%) were female, 161 patients (44%) had multiple trigger fingers, and eighty-eight patients (24%) had diabetes at the time of injection. The primary outcome of treatment failure was defined as subsequent injection or surgical trigger finger release of the affected digit. Medical records were reviewed, and any patients without documented failure or a return office visit in 2012 to 2013 were contacted by telephone regarding symptom recurrence and the need for additional treatment. Kaplan-Meier analyses with log-rank test and Cox regression analysis assessed the effect of baseline patient and disease characteristics on injection success., Results: Forty-five percent of patients demonstrated long-term treatment success after a single injection. In the final regression model, the interaction of sex and the number of trigger fingers was the single predictor of treatment success. Exploring this association revealed a ten-year success rate of 56% for female patients presenting for the first time with a trigger finger compared with 35% in male patients presenting for the first time with a trigger finger, 39% in female patients with multiple trigger fingers, and 37% in male patients with multiple trigger fingers. Eighty-four percent of treatment failures occurred within the first two years following injection. Patient age, symptom type, and undifferentiated diabetes status were not predictive of treatment success., Conclusions: Female patients presenting with their first trigger finger have the highest rate of long-term treatment success after a single corticosteroid injection. Patients who continue to experience symptom relief two years after injection are likely to maintain long-term success., (Copyright © 2014 by The Journal of Bone and Joint Surgery, Incorporated.)

Purpose: To use the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement checklist to critically evaluate the change in quality of observational trial reporting in the Journal of Hand Surgery American between 2005 and 2011., Methods: A cross-sectional analysis of observational studies published in the Journal of Hand Surgery American was designed to sample 2 6-month periods of publication (March 2005 to August 2005 and June 2011 to November 2011). Fifty-one items were extracted from the STROBE statement for evaluation. Overall STROBE compliance rates for articles and specific checklist items were determined. Final compliance percentages from each period were compared by Student t-testing. Changes in item compliance over time were quantified., Results: Overall compliance with the STROBE statement was 38% (range, 10%-54%) in 2005 and 58% (range, 39%-85%) for 2011 manuscripts representing a significant improvement. Seventy-five percent or greater of articles (2005/2011) provided the explicit reporting of background (100%/97%), follow-up time (85%/94%), overall interpretation of data (100%/94%), and results of similar studies (95%/89%). Twenty-five percent or less of articles provided the study design in the abstract (10%/20%), a clear description of the study's setting (10%/23%), the handling of missing data (0%/6%), the potential directions of bias (5%/11%), and the use of a power analysis (0%/17%). Eighty-six percent (44/51) of items were more frequently satisfied in 2011 articles than in 2005 publications. Absolute increases in compliance rates of 40% or greater were noted in 10 items (20%) with no worsening in compliance for an individual item over 6%., Conclusions: The overall quality of the reporting of observational trials in the Journal of Hand Surgery American improved from 2005 to 2011. Current observational trials in hand surgery could still benefit from increased reporting of methodological details including the use of power analyses, the handling of missing data, and consideration of potential bias., Level of Evidence: Diagnostic III., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Diverse members of the Paramyxovirus family of negative-strand RNA viruses effectively suppress host innate immune responses through the actions of their V proteins. The V protein mediates interference with the interferon regulatory RNA helicase MDA5 to avoid cellular antiviral responses. Analysis of the interaction interface revealed the MDA5 helicase C domain as necessary and sufficient for association with V proteins from human parainfluenza virus type 2, parainfluenza virus type 5, measles virus, mumps virus, Hendra virus, and Nipah virus. The identified approximately 130-residue region is highly homologous between MDA5 and the related antiviral helicase LGP2, but not RIG-I. Results indicate that the paramyxovirus V proteins can also associate with LGP2. The V protein interaction was found to disrupt ATP hydrolysis mediated by both MDA5 and LGP2. These findings provide a potential mechanistic basis for V protein-mediated helicase interference and identify LGP2 as a second cellular RNA helicase targeted by paramyxovirus V proteins.