CASE:A 77-year-old woman who sustained a distal radius and ulna fracture underwent open reduction internal fixation through a standard flexor carpi radialis (FCR) approach. On dissection, a proximal division of the median nerve was identified, with an aberrant motor branch crossing radial to ulnar deep to FCR and superficial to flexor pollicis longus. CONCLUSION:Although many anatomic variants of the median nerve have been described, the current case demonstrates a particularly important median motor branch variant, imposing a substantial risk of iatrogenic injury during a standard FCR approach.

BACKGROUND Infection remains a serious clinical concern in patients with open fractures, despite timely antibiotic administration and surgical debridement. Soft tissue and periosteal stripping may alter local tissue homeostasis and antibiotic pharmacokinetics in the injured limb. The tissue (interstitial) concentration of intravenously administered antibiotics at an open fracture site has not been characterized using direct sampling techniques. QUESTION/PURPOSE We performed this study to evaluate the concentration and pharmacokinetics of intravenously delivered cefazolin at an open fracture site after surgical debridement. METHODS Twelve patients with an open fracture distal to the knee who presented at a regional Level I trauma center were approached for enrollment in this nonrandomized, observational study. Of the 12 patients, eight adults (one female, seven male) with a median age of 32 years (range 23 to 51 years) were enrolled and underwent successful sample collection for analysis. Three patients had incomplete datasets because of equipment malfunction and one elected not to participate. Seven patients had open tibia fractures, and one patient had an open fibula fracture associated with a closed tibia fracture. There were six Gustilo-Anderson Type II injuries and two Type IIIA injuries. Empiric antibiotics were administered in the prehospital setting or in the emergency department according to institutional protocol. When patients were taken to the operating room, a 2-g intravenous dose of cefazolin was administered. After surgical debridement, fracture stabilization, and wound closure, a microdialysis catheter was placed transdermally into the injury zone (within 5 cm of the fracture site) and a second catheter was placed in the contralateral uninjured (control) limb. Additional doses of cefazolin were administered every 8 hours postoperatively. Baseline and periodic interstitial fluid and whole blood (plasma) samples were collected in the operating room and at prespecified times for 24 hours postoperatively. Free cefazolin in the interstitial fluid and plasma samples were analyzed by ultra-high-performance liquid chromatography using C18 column separation with quadrupole time-of-flight mass spectrometry detection. Data from the second postoperative dose of cefazolin were used to characterize pharmacokinetic parameters through a noncompartmental analysis using time-concentration curves of free cefazolin and assuming first-order elimination. For pharmacodynamic analyses, the modal cefazolin minimum inhibitory concentration (MIC) of Staphylococcus aureus (1 µg/mL) was used. RESULTS With the samples available, no difference was observed in the median free cefazolin exposure over 24 hours (f area under the curve [AUC]0→24hrs) between injured limbs (352 μg∙hr/mL [IQR 284 to 594 μg∙hr/mL]) and uninjured limbs (341 μg∙hr/mL [IQR 263 to 438 μg∙hr/mL]; p = 0.64). The median time to achieve the maximum concentration of free cefazolin (f Tmax) for injured limbs was delayed (2.7 hours [IQR 2.2 to 3.1 hours]) compared with control limbs (1.7 hours [IQR 1.2 to 2.0 hours]; p = 0.046). The time to the maximum concentration for plasma was not different from that of control limbs (p = 0.08). The time the cefazolin concentration was above the modal S. aureus MIC (T > MIC) in the injured and control limbs over 24 hours was 100% (IQR 100% to 100%) and 100% (IQR 97% to 100%), respectively. CONCLUSION These preliminary findings suggest that current prophylactic cefazolin dosing regimens result in successful antibiotic delivery to the traumatized limb in moderately severe open fractures. Although cefazolin delivery to open-fracture wound beds was delayed compared with healthy tissues, the cefazolin concentration was sustained above the European Union Committee Antimicrobial Susceptibility Testing modal MIC for S. aureus, demonstrating a high likelihood of a prophylactic antimicrobial environment at an open fracture site with this empiric antimicrobial regimen. Importantly, patients in this analysis had Gustilo-Anderson Types II and IIIA injuries. Further research with a larger patient cohort is needed to determine whether antibiotic delivery to traumatized soft tissues in patients with higher-grade open fractures (Gustilo-Anderson Types IIIB and IIIC) demonstrates similar pharmacokinetic characteristics. LEVEL OF EVIDENCE Level II, therapeutic study.

BACKGROUND:Osteomyelitis is a condition that disproportionately affects those with sickle cell anemia (SCA). Despite the frequency of osteomyelitis in this population, there are reports of increasing life expectancy and rates of Staphylococcus aureus infections, which contrasts the belief that Salmonella is the most common organism identified. The purpose of this systematic review is to determine the most commonly identified organism and identify whether age is associated with the development of Salmonella osteomyelitis in homozygous sickle cell patients.METHODS:A search of PubMed, EMBASE Cochrane and databases was performed for studies of all levels of evidence pertaining to osteomyelitis in SCA. Reasons for exclusion included non-English language, case reports, literature reviews, isolated septic arthritis without bony involvement and isolated oral-facial bony involvement.RESULTS:The most common pathogen cultured was nontyphoid Salmonella , which occurred in 117 of 192 (60.9%) of cases identified. This was followed by S. aureus 41 of 192 (21.8%) and other enteric bacteria 14 of 192 (7.2%). Subgroup analysis demonstrated differences at the age of initial presentation with Salmonella cohort at 6.8 years and S. aureus cohort at 22.1 years ( P = 0.0001). On geographic analysis, African countries had an older average age of diagnosis at 13.1 years with decreased rates of Salmonella infections and increased rates of infections from other organisms compared with the US, Middle East and Europe.CONCLUSIONS:This systematic review suggests that Salmonella is most commonly identified in patients with SCA (HbSS phenotype) especially those <12 years old presenting with acute osteomyelitis. Sub-Saharan African countries had later ages of diagnosis compared with the US, Middle East and Europe with bacterial profiles that favors a diagnosis of chronic osteomyelitis and missed acute initial presentation. Therefore, age of presentation is likely a surrogate for geographic and socioeconomic factors such as availability of medical screening and treatment.

Objective:To compare the exposure of the coronoid process, anteromedial facet, and anterior band of the medial collateral ligament using the flexor carpi ulnaris (FCU)-splitting approach with the Taylor-Scham approach modified with an ulnar nerve transposition.Methods:Thirty approaches were performed on 15 fresh cadavers using a randomized cross-over design and standardized incision. Access to key anatomic landmarks was assessed, and a calibrated digital image was taken from the surgeon's best perspective of each approach. Images were analyzed using ImageJ (National Institutes of Health) software to calculate the area of osseous exposure.Results:All key anatomic landmarks were visualized using both approaches. The average area of exposure for the Taylor-Scham was 19.5 cm(2) compared with 13.6 cm(2) for the FCU-splitting (P < 0.0001). The distal extent of the FCU-splitting approach is limited by the ulnar nerve and its branches to the humeral head of the FCU.Conclusion:The Taylor-Scham approach provides a more extensile exposure of the anteromedial coronoid and proximal ulna than the FCU-splitting approach while avoiding cross-tensioning of the ulnar nerve.

BACKGROUND:Intramedullary implants are an increasingly common method for fixation of metacarpal fractures. Numerous techniques for instrumentation have been described with varied consideration for the risk of extensor tendon injury. The current cadaveric study evaluates the prevalence and degree of extensor tendon injury and compares percutaneous approaches with different drilling techniques. METHODS:Ninety-six metacarpals (thumbs excluded) from 24 fresh-frozen cadaveric upper extremities were used to compare 2 percutaneous approaches and 2 drilling techniques. This resulted in 4 subgroups available for comparison: oscillate to bone (OB), forward to bone (FB), oscillating through the skin (OS), and forward through the skin (FS). After instrumentation, the extensor tendons were dissected and disruption was characterized. The main outcome measures were tendon "hit rate" and relative extensor tendon defect width. RESULTS:Tendon hit rate was significantly higher in the long finger (LF), that is, 79.2%, compared with other metacarpals: index finger, 20.8%; ring finger, 12.5%; and small finger 25%. The mean relative tendon disruption was significantly less in the OB group (16.05%) compared with the other groups: FB (31.84%), FS (31.50%), and OS (29.85%). CONCLUSION:Retrograde intramedullary screw fixation of metacarpal fractures can be performed using percutaneous approaches without a significant disruption of the extensor mechanism. Instrumentation through a longitudinal stab incision down to the metacarpal head and the use of drill oscillation minimize injury to the extensor tendons. The LF extensor tendon is most at risk with retrograde intramedullary implant placement.

There have been many attempts to use variations in tibial polyethylene design to better recreate normal knee kinematics in the total knee arthroplasty. The goal of this review is to provide an overview of the various types of tibial inserts that exist and review the theoretical mechanics versus what was demonstrated in vivo. Many polyethylene inserts have been attempted to re-create normal knee kinematics, but none have been able to successfully do so. Previously the only two types of inserts were posterior stabilized (PS) and cruciate retaining (CR) polyethylene inserts. Both of these have shown excellent long-term survival but neither has demonstrated native kinematics. Initially, it was thought that retention of the posterior cruciate ligament (PCL) would allow for more native kinematics, but fluoroscopic evidence has shown that the PCL alone cannot accomplish this. Newer inserts try to restore femoral roll back and the screw home mechanism. The bicruciate retaining total knee inserts are having the most “normal” kinematics, suggesting the importance of both the ACL and PCL in knee biomechanics. Modern polyethylene inserts show favorable short-term data with bicruciate retaining inserts having the best kinematics; however, long-term studies are still needed to determine if survivorship and patient outcomes remain favorable.

Introduction: Blood flow restriction therapy (BFRT) is used in scenarios ranging from muscle building in athletic performance to decreasing recovery time in postoperative orthopedic rehabilitation. The efficacy of BFRT for treating diseases has been increasingly researched; however, there has been less literature focused on establishing the safety of this therapy. Materials and Methods: An extensive literature review pertaining to BFRT and any deleterious events related to its usage was completed by searching multiple databases, including PubMed, EMBASE, and Cochrane Library using the terms "blood flow restriction therapy" or "KAATSU." Results: Ten case reports, five case series, two national surveys, two questionnaires, six randomized controlled studies, and one systematic review were included. A total of 1,672 individuals reported an adverse event following BFRT use out of 25,813 individuals. Commonly reported adverse events were numbness, dizziness, subcutaneous hemorrhage, and rhabdomyolysis. There were unique adverse effects of this therapy reported in individuals with comorbid conditions, such as hypertension and thoracic outlet syndrome, which included isolated cases of central retinal vein occlusion and Paget-Schroeder syndrome. Conclusion: Blood flow restriction provides tremendous opportunity with a potential for accelerated exercise rehabilitation and injury prevention. This modality could be used in the military setting to help injured active duty personnel expeditiously return to deployable status. Further prospective randomized controlled trials are warranted to further support BFRT safety; however, from this literature review, it can be concluded that BFRT can be utilized safely in the proper patient population when administered by qualified professionals who have undergone the appropriate training.

CASE There has been a reemergence of anterior cruciate ligament (ACL) repair. We present the unique case of an ACL repair in a service member with a chronic tear. The patient went on to have a successful outcome with return to full activities without symptoms and functional outcomes scores equal to preinjury levels. CONCLUSION This case demonstrates a preserved ACL remnant after an ACL femoral avulsion secondary to scarring to the posterior cruciate ligament. ACL repair can produce excellent outcomes in the right population, and injury chronicity may not necessarily preclude successful repair in the setting of good-quality ACL remnant.

Snake bites are an uncommon injury requiring intervention by hand surgeons. While counteracting the effects of snake venom is the initial and urgent concern following a bite, infection caused by retention of a foreign body can present in a delayed fashion and may lead to increased morbidity. Standard radiographs of the injury should be carefully examined for foreign bodies, noting that retained snake teeth are somewhat radiolucent due to less mineralization as compared to bone and can be difficult to visualize. In our subject, a retained rattlesnake fang was found in association with a septic interphalangeal joint despite appropriate radiographic evaluation and thorough surgical irrigation and debridement upon initial presentation. This case report highlights a potential complication of snake bites, the importance of aggressive management, and the importance of increased suspicion for retained foreign bodies. Augmenting plain radiographs with additional imaging modalities, such as ultrasound, dark-field, and phase-contrast imaging, may aid in the diagnosis of retained foreign bodies after snake bites.

Summary: Managing fractures of the distal radius is a fundamental skill for orthopaedic surgeons. Given the prevalence of these fractures, complications following operative management are well described and frequently encountered. Surgeons should be observant in the acute phase for emergent conditions such as acute carpal tunnel syndrome. Careful radiographic examination intra-operatively can help prevent delayed complications by identifying surgical errors such as hardware malposition or malreduction. Many problems that arise during the treatment of distal radius fractures are the result of technical errors and can be anticipated.

Pyoderma gangrenosum is an immunologic, ulcerative cutaneous condition often associated with systemic disease and frequently precipitated by trauma. It is noninfectious, but the inflammatory assault can resemble a malignant infection such as necrotizing fasciitis. Despite its clinical resemblance to infection, surgical débridement worsens the condition and may remove morphologic clues to the true disease, thus creating a vicious cycle of surgical débridements and disease progression. Furthermore, diagnostic histopathologic and laboratory features are nonspecific, requiring exclusion of other processes. Therefore, appropriate nonsurgical treatment and immunosuppression are commonly delayed, often at a significant cost to the patient. We present a case of pyoderma gangrenosum occurring after outpatient knee arthroscopy that masqueraded as a postsurgical infection. We discuss the diagnostic approach and how a complex reconstruction involving cartilage restoration and soft-tissue coverage was achieved.

Fixation into the ilium has traditionally been performed for scoliosis. The technique has evolved greatly from open highly invasive techniques with elevation of flaps from the pelvis and placement of contoured rods passed between the inner and outer cortices of the ilium, to open techniques involving iliac bolts and transverse connectors.1., 2., 3. Indications have expanded to include stabilization in complex pelvic tumors and for complex trauma.4., 5., 6., 7. Modern techniques involving entirely percutaneous placement of pelvic instrumentation with subfascial passing of rods into lumbar pedicle screws are the most recent evolution of the technique of fixation to the pelvis.5,8 This article reviews current concepts for minimally invasive percutaneous lumbopelvic fixation and presents illustrative examples .

A 12-year-old otherwise healthy boy presented with acute shoulder pain and remote history of trauma. Despite an unimpressive clinical examination, laboratory workup, and initial radiographic evaluation, the patient was ultimately diagnosed with a Brodie abscess of the distal clavicle. Complete resolution was achieved with débridement and tailored antibiotic therapy. These abscesses are rare, often presenting surreptitiously with nonspecific symptoms and without systemic signs of infection. Therefore, maintaining a broad differential and high clinical suspicion is crucial to mitigate the increased morbidity that can result from a delayed diagnosis.

Objective: The purpose of this study was to examine patient outcomes and the risk of recurrence of mucous cysts affecting the distal interphalangeal (DIP) joint in the absence of osteophytectomy using the described flap technique. Methods: A retrospective review of 143 records of patients who were treated for mucous cysts of the DIP joint by a single surgeon. Inclusion criteria included the absence of an osteophytectomy during treatment using the described dorsally based flap technique and a minimum of 12 months of follow-up. Results: A total of 143 mucous cysts affecting the DIP joint of 131 patients with an average age of 65.3 years were included. The average follow-up was 21.9 months (12 to 139). Postoperative DIP joint extension was less in the surgical digit compared with the same digit of the contralateral hand with a significant change from the preoperative motion (1.5° versus 0.3°; P = 0.05). No significant change in the postoperative flexion of the DIP joint was observed compared with that of the contralateral side (−1.4° versus −0.9°; P = 0.57). Recurrence occurred in 2 patients (1.4%). No infections or wound complications were identified. Conclusions: Using the described technique without an osteophytectomy seemed to be an effective treatment of mucous cysts originating from the DIP joint.

Oxidized zirconium was introduced as an alternative bearing surface to decrease polyethylene wear and reduce aseptic mechanical failure of hip and knee arthroplasties. Oxidized zirconium combines the strength of a metal with wear properties of ceramic, proposing increased survivorship of implant components, and possible decreased rate of revision. Despite a harder surface than cobalt-chromium, the substrate of zirconium is a softer metal. Although uncommon, prior reports have described accelerated wear and severe metallosis after femoral head dislocation in oxidized zirconium total hip arthroplasty; however, this has not been described in total knee arthroplasty. We report a case of an oxidized zirconium total knee arthroplasty failure in a patient with knee instability. This is the first report of catastrophic failure of an oxidized zirconium total knee arthroplasty implant.

The complexity of the human extremity, particularly the upper extremity and the hand, allows us to interact with the world. Prosthetists have struggled to recreate the intuitive motor control, light touch sensation, and proprioception of the innate limb in a manner that reflects the complexity of its native form and function. Nevertheless, recent advances in prosthesis technology, surgical innovations, and enhanced rehabilitation appear promising for patients with limb loss who hope to return to their pre-injury level of function. The purpose of this review is to illustrate recent technological advances that are moving us one step closer to the goal of multi-functional, self-identifiable, durable, and intuitive prostheses. Surgical advances such as targeted muscle reinnervation, regenerative peripheral nerve interfaces, agonist-antagonist myoneural interfaces, and targeted sensory reinnervation; development of technology designed to restore sensation, such as implanted sensors and haptic devices; and evolution of osseointegrated (bone-anchored) prostheses show great promise. Augmented and virtual reality platforms have the potential to enhance prosthesis design, pre-prosthetic training, incorporation, and use. Emerging technologies move surgeons, rehabilitation physicians, therapists, and prosthetists closer to the goal of creating highly functional prostheses with elevated sensory and motor control. Collaboration between medical teams, scientists, and industry stakeholders will be required to keep pace with patients who require durable, high-functioning prostheses.

Acute subdural hematoma is a rare but potentially fatal medical condition in athletes. This condition has been reported in both contact and non-contact sports. Patients who survive an acute subdural hematoma typically have lifelong deficits and require extensive rehabilitation. Prompt recognition of this condition and access to a hospital with an available neurosurgeon is critical. To our knowledge, this is the first report of a subdural hematoma in an elite-level rugby player.

Synovial Sarcoma is a soft tissue sarcoma with a propensity to imitate a benign neoplasm. It is most common in males 15-40 years old, typically presents as a slow growing painful mass, and often arises insidiously without alarm to the patient. Three patients with synovial sarcomas who had each undergone an index procedure to treat a small presumedly benign mass that was later identified as synovial sarcoma were reviewed. All three patients required re-excision of the tumor and tumor bed and are currently undergoing routine surveillance. All patients exhibited the classic translocation t(X;18) (p11.2; q11.2) and all were of the monophasic type. All lesions were less than 35 mm in greatest longitudinal dimension on MRI. None have experienced recurrences of synovial sarcoma to date. Healthcare providers should be aware of the synovial sarcoma's propensity to masquerade as a benign disease and the characteristic clinical and radiological findings. We advocate for a low threshold to obtain advanced imaging and consideration of a tissue diagnosis prior to excision. A referral to an orthopedic oncologist should be considered and biopsy should only be performed where the definitive treatment will take place if malignancy is identified.

Introduction The aim of our study was to describe the injury pattern and outcomes of active-duty subjects that underwent humeral external fixation and to determine if the placement of external fixator pins outside of the radial nerve safe zones is correlated with injury to the radial nerve. Materials and methods We examined all US Service members treated with humeral external fixation at our facility from June 2005 through June 2015. The mechanism of injury, injury pattern, location of external fixation application, pre- and postoperative radial nerve function, presence or absence of radial nerve transection from injury or external fixation, anatomic location of pins in relation to the radial nerve safe zone, and final radial nerve outcomes were recorded. We defined the proximal safe zone as 5 cm distal to the acromion to 14.8 cm proximal to the lateral epicondyle, and we defined the distal safe zone as the proximal 70% of the transepicondylar width of the humerus when projected proximally from the lateral epicondyle. Results For our study, 123 patients were identified over our date range, and 16 subjects were included with documentation regarding nerve function/injury characteristics, appropriate radiographs, and active duty status. Around 80% of injuries resulted from a blast mechanism, and 80% of injury patterns included either an intraarticular or open fracture. The radial nerve safe zone was violated in 15 of the 16 subjects (94%). The one subject with a safe construct did not sustain a nerve injury. Complete preoperative documentation on nerve function was only available for half of the subjects. Two of five subjects known to have intact function prior to external fixation had a postoperative neurologic deficit (40%). Of eight subjects with unknown radial nerve function prior to external fixation, seven subjects had full nerve function at the final follow up, and one subject had partial sensory function only. Of the three subjects with impaired preoperative radial nerve function, two made a full recovery, and the third recovered sensory function only. Around 50% of all subjects required medical retirement. Conclusion External fixation of upper extremity injuries in combat is rarely absolutely indicated, often results in the placement of pins outside of the radial nerve safe zone, and is associated with up to a 40% incidence of radial nerve injury.

The flexor carpi radialis brevis is a rare anomalous flexor of the wrist. Surgeons occasionally encounter it intraoperatively during exposure of the volar radius. In 2 patients, this muscle was identified by its longitudinal fibers during the approach to distal radius fractures. This paper describes a surgical technique for adequately exposing a distal radius fracture when the flexor carpi radialis brevis is identified intraoperatively to preserve the innervation and arterial supply of this anomalous wrist flexor.