Faculty Bibliography

HYPOTHESIS/OBJECTIVE:Simple transverse or short oblique olecranon fractures without articular comminution are classified as Mayo type-IIA fractures, and are typically treated with a tension band wire construct. Due to the high reoperation rates, frequently because of prominent hardware, all-suture tension band constructs have been introduced. It was the purpose to compare the biomechanical performance of conventional tension band wire fixation with a novel all-suture tension band tape fixation for simple olecranon fractures. METHODS:Mayo type-IIA olecranon fractures were created in 20 cadaveric elbows from 10 donors. One elbow of each donor was randomly assigned to the tension band wire technique (group TBW) or tension band tape (Arthrex, 1.3mm SutureTape) technique (group TBT). Both groups were cyclically loaded with 500N over 500 cycles, after which a uniaxial displacement was performed to evaluate load to failure. Data was analysed for gap formation after cyclic loading, construct stiffness and ultimate load to failure, where failure was defined as fracture gap formation greater than 4.0 mm. RESULTS:There was no significant difference in gap formation after 500 cycles between the TBW (1.8mm ±1.3) and the TBT (1.9mm ±1.1) groups (p=0.854). The TBT showed a tendency towards greater construct stiffness compared with the TBW construct (mean difference: 142N/mm; p=0.053). Ultimate load to failure was not significantly different comparing both groups (TBW: 1138N ±286 vs. TBT: 1126N ±272; p=0.928). In both groups, all repairs failed due to >4.0 mm gap formation at the fracture site and none due to tension band construct breakage. CONCLUSIONS:Our study shows the TBT technique produces equivalent or superior biomechanical performance to the TBW for simple olecranon fractures. The TBT approach reduces the risk of hardware prominence and as a result mitigates against the need for hardware removal. The TBT technique offers a clinically viable alternative to TBW.

CASE:A 23-year-old woman with an Osborne-Cotterill lesion and posterolateral rotatory instability (PLRI) of the elbow was treated with osteochondral allograft transplantation (OCA) and lateral ulnar collateral ligament (LUCL) repair with internal brace. Two years after surgery, she reported resolution of pain and returned to all recreational activities. She reported no mechanical symptoms and no episodes of postoperative instability. CONCLUSION:PLRI can present with an Osborne-Cotterill lesion in addition to LUCL injury. The purpose of this case report was to describe the use of OCA to manage bony defects in the capitellum in addition to LUCL repair for patients with PLRI.

Among professional combat athletes, excessive and repetitive trauma to the carpometacarpal (CMC) joints may cause instability, arthritis, and the development of traumatic carpal boss. If nonoperative management is unsuccessful, CMC joint arthrodesis with iliac crest bone graft and supplemental Kirschner wire fixation is a reliable surgical option that results in pain-free return to full competition. From 2002 to 2015, 15 professional athletes with 17 symptomatic carpal bosses were treated with CMC joint arthrodesis after unsuccessful nonoperative management. The operative technique included decortication of the articular surface of the CMC joints, insertion of iliac cancellous and corticocancellous slot grafts, and secure Kirschner wire fixation. Patient charts and postoperative imaging were retrospectively reviewed. Outcome measures included grip strength, pain relief, fusion rate, return to competition, and complications. Mean age at the time of surgery was 28.2 years (range, 21-39 years). The radiographic fusion rate was 100% and occurred at a mean of 7.5 weeks. Mean return to competition occurred at 6 months. Grip strength at final follow-up increased 32% from preoperative level and was 90% of the grip strength of the contralateral hand. Postoperatively, 2 patients had sagittal band ruptures, and 1 patient had a fifth metacarpal fracture. No revision procedures were performed. All patients undergoing CMC arthrodesis had successful fusion, without the need for revision surgery and with return to full competition. For professional fighters, CMC arthrodesis with iliac crest autograft is a safe and effective surgical method for treating symptomatic traumatic carpal boss. [Orthopedics. 2022;45(1):e17-e22.].

Introduction/UNASSIGNED:Rock climbing is an increasingly popular sport in the United States. Acute and chronic upper extremity injuries related to rock climbing are frequently reported and include flexor pulley ruptures and hamate stress fractures. Deep space hand infections after indoor rock climbing are a sport-related pathology that has yet to be reported. Our purpose is to describe an acute septic carpal tunnel syndrome following rock climbing at an indoor climbing gym in a patient who required urgent irrigation and debridement. Case Report/UNASSIGNED:A 33-year-old Caucasian male presented with an acute septic carpal tunnel syndrome 4 days after rock climbing at an indoor gym. On physical examination, he exhibited numbness over the fingers, significant tenderness to palpation, and pain with passive range of motion. His inflammatory markers were markedly elevated and deep space hand infection was confirmed with computed tomography scans. The patient was taken for urgent exploration, irrigation and debridement, and carpal tunnel release. Conclusion/UNASSIGNED:We theorize that the patient had an abrasion on the finger or palm that created an entryway for a pathogen. We are unaware of another report of a deep space hand infection associated with rock climbing activities. This case report will hopefully spread awareness of this clinical entity to improve evaluation and prevention of hand infections in rock climbers, as well as providing guidelines for appropriate and timely treatment of the condition.

Ankle fractures with a posterior malleolus component are complex injuries. The most commonly used operative methods include indirect reduction via a percutaneous anterior approach and direct reduction via a posterolateral approach. For large posterior malleolus fractures with medial extension, direct reduction via a posteromedial approach is an alternative operative option. The authors hypothesized that fixation of large posterior malleolus fractures via a posteromedial approach results in anatomic reduction and stable plate fixation. From 2008 to 2015, 22 (9.0%) of 244 consecutive operative ankle fractures were identified as posterior malleolus fractures treated using a posteromedial approach. Patient charts were retrospectively reviewed for demographics, operative details, follow-up time, and any postoperative complications. Postoperative radiographs were reviewed to ensure that anatomic reduction and stable fixation was maintained. Sixteen (72.7%) of 22 patients were female, and the average age at the time of surgery was 54.1 years (range, 26-86 years). The average follow-up time was 13.0 months (range, 2.0-41.4 months). Twenty-one (95.5%) of 22 patients healed on a radiographic and clinical basis. There was an 18.2% (4 of 22) postoperative complication rate: 1 patient had a nonunion, 1 patient had cellulitis, 1 patient had osteomyelitis involving the fibula, and 1 patient had symptomatic heterotopic ossification. Open reduction and internal fixation of posterior malleolus fractures via a posteromedial approach achieved anatomic reduction, stable plate fixation, and complete healing in all but 1 patient. This study demonstrates that the posteromedial approach is a reasonable alternative to other more commonly used methods for treating these fractures. [Orthopedics. 2020;43(3):e166-e170.].

Periprosthetic acetabular fractures sustained following acute trauma after total hip arthroplasty are rare and historically have poor outcomes. This article reviews 5 cases and the treatment algorithm used by a single orthopaedic surgeon specializing in acetabular fracture care with a co-surgeon specializing in arthroplasty. Team-based surgical management with arthroplasty- and fracture-trained surgeon(s) is paramount for optimal outcome. The following approach resulted in satisfactory outcomes without need for revision implants. In fracture patterns with columnar involvement, the columns were restored with plates and screws. In fracture patterns with wall involvement, the acetabular component functioned as a template for wall reconstruction with use of a buttress plate. The acetabular component was revised when deemed loose during stress of the component through the surgical approach used for fracture fixation.

INTRODUCTION/BACKGROUND:Isolated greater tuberosity (GT) fractures (AO 11-A1) tend to occur in the younger patient population and are poorly managed by most precontoured proximal humerus locking plates. The goal of this study was to identify and assess an alternative treatment strategy for greater tuberosity fractures. MATERIALS AND METHODS/METHODS:A retrospective review of all cases of isolated greater tuberosity fractures treated with a 2.4/2.7 mesh plate (Synthes) between 2010 and 2015 was conducted. Patient demographics, operative reports, and clinical notes were reviewed. The time to radiographic union was assessed. Clinical outcomes were retrieved from patients at their follow-up visits or via mailed Disabilities of the Arm, Shoulder, Hand (DASH) questionnaires. RESULTS:Ten patients with isolated GT fractures treated with mesh plating were identified with an average age of 47.1 years. The average radiographic follow-up was 7.2 months and the average clinical follow-up was 8.0 months. The mean time to union was 8.5 weeks. Two patients underwent elective hardware removal. The mean DASH at final follow-up was 28.2 (±22.4), while the mean DASH work was 13.6 (±19.1). CONCLUSION/CONCLUSIONS:We have identified a viable alternative treatment option for the surgical management of isolated greater tuberosity fractures using a mesh plate that can be contoured to the patient's anatomy. Surgeons should be aware of this option for select patients.

BACKGROUND:Anterior tibial stress fractures are associated with high rates of delayed union and nonunion, which can be particularly devastating to a professional athlete who requires rapid return to competition. Current surgical treatment strategies include intramedullary nailing, which has satisfactory rates of fracture union but an associated risk of anterior knee pain. Anterior tension band plating is a biomechanically sound alternative treatment for these fractures. HYPOTHESIS/OBJECTIVE:Tension band plating of chronic anterior tibial stress fractures leads to rapid healing and return to physical activity and avoids the anterior knee pain associated with intramedullary nailing. STUDY DESIGN/METHODS:Case series; Level of evidence, 4. METHODS:Between 2001 and 2013, there were 13 chronic anterior tibial stress fractures in 12 professional or collegiate athletes who underwent tension band plating after failing nonoperative management. Patient charts were retrospectively reviewed for demographics, injury history, and surgical details. Radiographs were used to assess time to osseous union. Follow-up notes and phone interviews were used to determine follow-up time, return to training time, and whether the patient was able to return to competition. RESULTS:Cases included 13 stress fractures in 12 patients (9 females, 3 males). Five patients were track-and-field athletes, 4 patients played basketball, 2 patients played volleyball, and 1 was a ballet dancer. Five patients were Division I collegiate athletes and 7 were professional or Olympic athletes. Average age at time of surgery was 23.6 years (range, 20-32 years). Osseous union occurred on average at 9.6 weeks (range, 5.3-16.9 weeks) after surgery. Patients returned to training on average at 11.1 weeks (range, 5.7-20 weeks). Ninety-two percent (12/13) eventually returned to preinjury competition levels. Thirty-eight percent (5/13) underwent removal of hardware for plate prominence. There was no incidence of infection or nonunion. CONCLUSION/CONCLUSIONS:Anterior tension band plating for chronic tibial stress fractures provides a reliable alternative to intramedullary nailing with excellent results. Compression plating avoids the anterior knee pain associated with intramedullary nailing but may result in symptomatic hardware requiring subsequent removal.