Publications by authors named "Geoffrey S Marecek"

39 Publications

Large Individual Bilateral Differences in Tibial Torsion Impact Accurate Contralateral Templating and the Evaluation of Rotational Malalignment.

J Orthop Trauma 2021 Apr 19. Epub 2021 Apr 19.

Keck School of Medicine of USC, Los Angeles, CA, USA Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA, USA Department of Orthopaedics, Cedars-Sinai Medical Center, Los Angeles, CA, USA.

Objective: To determine individual bilateral differences (IBDs) in tibial torsion in a diverse population.

Methods: Computed tomography scans of uninjured bilateral tibiae were used to determine tibial torsion and IBDs in torsion using four measurement methods. Age, sex, and self-identified race/ethnicity were also recorded for each subject. Mean tibial torsion and IBDs in torsion were compared in the overall cohort and when stratified by sex and race/ethnicity. Simple and multiple linear regression models were used to correlate demographic variables with tibial torsion and IBDs in torsion.

Results: 195 patients were evaluated. The mean tibial torsion was 27.5° ± 8.3° (range -3° to 47.5°). The mean IBD in torsion was 5.3° ± 4.0°(range 0 to 23.5°, P < 0.001). 12.3% of patients had IBDs in torsion of ≥10°. In the regression analysis, patients who identified as White had greater average torsion by 4.4° compared to Hispanic/Latinx patients (P = 0.001), whereas age and sex were not significantly associated with absolute torsion. Demographics were not associated with significant differences in IBDs in torsion.

Conclusions: Tibial torsion varies considerably and individual side-to-side differences are common. Race/ethnicity was associated with differences in the magnitude of tibial torsion, but no factors were associated with bilateral differences in torsion. The results of this study may be clinically significant in the context of using the uninjured contralateral limb to help establish rotational alignment during medullary nail stabilization of diaphyseal tibia fractures. Additionally, these findings should be considered in the evaluation of tibia rotational malalignment.

Level Of Evidence: Prognostic Level IV.
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http://dx.doi.org/10.1097/BOT.0000000000002041DOI Listing
April 2021

Treatment of tibial plateau fractures with a novel fenestrated screw system for delivery of bone graft substitute.

Eur J Orthop Surg Traumatol 2021 Jan 24. Epub 2021 Jan 24.

Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.

Purpose: The purpose of this study was to describe the incidence of subsidence in patients with AO/OTA 41 (tibial plateau) fractures which were repaired with a novel fenestrated screw system to used to deliver CaPO4 bone substitute material to fill the subchondral void and support the articular reduction.

Methods: Patients with unicondylar and bicondylar tibial plateau fractures were treated according to the usual technique of two surgeons. After fixation, the Zimmer Biomet N-Force Fixation System®, a fenestrated screw that allows for the injection of bone substitute was placed and used for injection of the proprietary calcium phosphate bone graft substitute into the subchondral void. For all included patients, demographic information, operative data, radiographs, and clinic notes were reviewed. Patients were considered to have articular subsidence if one or more of two observations were made when comparing post-operative to their most recent clinic radiographs: > 2 mm change in the distance between the screw and the lowest point of the tibial plateau, > 2 mm change in the distance between the screw and the most superior aspect of the plate. Data were analyzed to determine if there were any identifiable risk factors for complication, reoperation, or subsidence using logistic regression. Statistical significance was set at p < 0.05.

Results: 34 patients were included with an average follow-up of 32.03 ± 22.52 weeks. There were no overall differences between height relative to the medial plateau or the plate. Two patients (5.9%) had articular subsidence. Six patients (15.2%) underwent reoperation, two (6%) for manipulations under anaesthesia due to arthrofibrosis, and four (12%) due to infections. There were 6 (19%) total infections as 2 were superficial and required solely antibiotics. One patient had early failure.

Conclusion: Use of a novel fenestrated screw system for the delivery of CaPO4 BSM results in articular subsidence and complication rates similar to previously published values and appears to be a viable option for addressing subchondral defects in tibial plateau fractures.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00590-021-02871-yDOI Listing
January 2021

Ballistic trauma patients have decreased early narcotic demand relative to blunt trauma patients: Blunt ballistic injury opioid use.

Injury 2021 May 15;52(5):1234-1238. Epub 2020 Sep 15.

Department of Orthopaedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, United States. Electronic address:

Objectives: Blunt and ballistic injuries are two common injury mechanisms encountered by orthopaedic traumatologists. However the intrinsic nature of these injures may necessitate differences in operative and post-operative care. Given the evolving opioid crisis in the medical community, considerable attention has been given to appropriate management of pain; particularly in orthopaedic patients. We sought to evaluate relative postoperative narcotic use in blunt injuries and ballistic injuries.

Design: Retrospective Cohort Study.

Setting: Academic Level-1 Trauma Center.

Patients: 96 Patients with blunt or ballistic fractures.

Intervention: Inpatient narcotic pain management after orthopaedic fracture management.

Main Outcome Measurements: Morphine equivalent units (MEU).

Results: Patients with blunt injuries had a higher MEU compared to ballistic injuries in the first 24 hours postoperatively (35.0 vs 29.5 MEU, p=0.02). There were no differences in opiate consumption 24-48 hours (34.8 vs 28.0 MEU), 48 hours - 7 days post op (28.4 vs 30.4 MEU) or the 24 hours before discharge (30.0 vs 28.6 MEU). On multivariate analysis, during the 24-48 hours and 24 hours before discharge timepoints total EBL was associated with increased opioid usage. During days 3-7 (p<0.001) and in the final 24 hours prior to discharge (p=0.012), the number of orthopaedic procedures was a predictor of opioid consumption.

Conclusion: Blunt injuries required an increased postoperative narcotic consumption during the first 24 hours of inpatient stay following orthopedic fracture fixation. However, there was no difference at other time points. Immediate post-operative pain regimens may be decreased for patients with ballistic injuries.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.injury.2020.09.005DOI Listing
May 2021

A Survey to Assess Agreement Between Pelvic Surgeons on the Outcome of Examination Under Anesthesia for Lateral Compression Pelvic Fractures.

J Orthop Trauma 2020 09;34(9):e304-e308

Department of Orthopaedics, University of Southern California, Los Angeles, CA.

Objectives: To assess agreement among pelvic surgeons regarding the interpretation of examination under anesthesia (EUA), the methodology by which EUA should be performed, and the definition of a positive examination.

Design: Survey.

Patients/participants: Ten patients who presented to our Level 1 trauma center with a pelvic ring injury were selected as clinical vignettes. Vignettes were distributed to 15 experienced pelvic surgeons.

Intervention: Examination under anesthesia.

Main Outcome Measurements: Agreement regarding pelvic fracture stability (defined as >80% similar responses), need for surgical fixation, definition of an unstable EUA, and method of performing EUA.

Results: There was agreement that a pelvic fracture was stable or unstable in 8 (80%) of 10 cases. There was agreement that fixation was required or not required in 6 (60.0%) of 10 cases. Seven (46.7%) surgeons endorsed performing a full 15-part EUA, whereas the other 8 (53.3%) used an abbreviated or alternative method. Eight (53.3%) surgeons provided a definition of what constitutes a positive EUA, whereas the remaining 7 did not endorse adhering to a strict definition.

Conclusions: Pelvic surgeons generally agree on what constitutes a positive or negative EUA but not necessarily the implications of a positive or negative examination. There is no clear consensus among surgeons regarding the method of performing EUA nor regarding the definition of a positive EUA.

Level Of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001759DOI Listing
September 2020

Standard Versus Low-Dose Computed Tomography for Assessment of Acetabular Fracture Reduction.

J Orthop Trauma 2020 09;34(9):462-468

Department of Orthopaedic Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA.

Objective: First, to assess the impact of varying computed tomography (CT) radiation dose on surgeon assessment of postfixation acetabular fracture reduction and malpositioned implants. Second, to quantify the accuracy of CT assessments compared with the experimentally set displacement in cadaver specimens. We hypothesized that a CT dose would not affect the assessments and that CT assessments would show a high concordance with known displacement.

Methods: We created posterior wall acetabular fractures in 8 fresh-frozen cadaver hips and reduced them with varying combinations of step and gap displacement. The insertion of an intra-articular screw was randomized. Each specimen had a CT with standard (120 kV), intermediate (100 kV), and low-dose (80 kV) protocols, with and without metal artifact reduction postprocessing. Reviewers quantified gap and step displacement, overall reduction, quality of the scan, and identified intra-articular implants.

Results: There were no significant differences between the CT dose protocols for assessment of gap, step, overall displacement, or the presence of intra-articular screws. Reviewers correctly categorized displacement as anatomic (0-1 mm), imperfect (2-3 mm), or poor (>3 mm) in 27.5%-57.5% of specimens. When the anatomic and imperfect categories were condensed into a single category, these scores improved to 52.5%-82.5%. Intra-articular screws were correctly identified in 56.3% of cases. Interobserver reliability was poor or moderate for all items. Reviewers rated the quality of most scans as "sufficient" (60.0%-72.5%); reviewers more frequently rated the low-dose CT as "inferior" (30.0%) and the standard dose CT as "excellent" (25%).

Conclusion: A CT dose did not affect assessment of displacement, intra-articular screw penetration, or subjective rating of scan quality in the setting of a fixed posterior wall fracture.
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http://dx.doi.org/10.1097/BOT.0000000000001778DOI Listing
September 2020

Injury and treatment patterns of ballistic pelvic fractures by anatomic location.

Eur J Orthop Surg Traumatol 2021 Jan 27;31(1):111-119. Epub 2020 Jul 27.

Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Introduction: Pelvic ballistic injuries threaten critical gastrointestinal, vascular, and urinary structures. We report the treatment patterns and injury profiles of ballistic pelvic fractures and the association between location of ballistic fractures of the pelvis and visceral injuries.

Methods: A prospectively collected database at an academic level I trauma center was reviewed for clinical and radiographic data on patients who sustained one or more ballistic fractures of the pelvis. Main outcomes compared included: procedures with orthopedic surgery, emergent surgery, concomitant intrapelvic injuries, and mortality.

Results: Eighty-six patients were included. Eight patients (9.3%) underwent surgical debridement with orthopedic surgery, no ballistic pelvic fractures required surgical stabilization. The anatomical locations of ballistic pelvic fractures included: 10 (14.7%) anterior ring, 13 (19.1%) posterior ring, 27 (39.7%) anterior column, and 18 (20.9%) posterior column. There was a statistically significant association between anterior ring and rectal injury. The association between anterior ring injury and bladder injury approached significance.

Conclusions: This case series included 86 patients with a ballistic fracture of the pelvis, none requiring pelvic ring surgical stabilization. The unpatterned behavior of these injuries demands a high suspicion for visceral injury, with special attention to the rectum and bladder in the setting of anterior ring involvement.

Level Of Evidence: IV.
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http://dx.doi.org/10.1007/s00590-020-02744-wDOI Listing
January 2021

Complications of Methamphetamine Use in Orthopaedic Trauma.

J Orthop Trauma 2020 Oct;34(10):e360-e365

Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, CA.

Objectives: To determine whether methamphetamine (MA) users are at an increased risk for complications compared to matched controls in the setting of orthopaedic trauma.

Design: Retrospective cohort study.

Setting: Academic Level-1 Trauma Center.

Patients: MA users and matched controls.

Intervention: MA use.

Main Outcome Measurements: Infection, Deep Vein Thrombosis (DVT), and nonunion.

Results: Five hundred sixty-seven patients were included in our study (189 MA users, 378 matched controls). On univariate analysis, MA users had a higher incidence of DVT (3.2% vs. 0.5%), but no statistically significant difference in infection or nonunion rates. MA users also had a higher incidence of intensive care unit admission (36.0% vs. 27.8%), leaving the hospital against medical advice (9.0% vs. 2.1%), nonadherence to weightbearing precautions (18.8% vs. 7.3%), and a higher incidence of loss of follow-up (47.1% vs. 30.4%). However, MA users had a lower incidence of surgical treatment for orthopaedic injuries (51.9% vs. 65.9%). When surgical treatment was pursued, more trips to the operating room were required for orthopaedic injuries in the MA group (2.6 vs. 1.5 trips). On multivariate analysis, MA users continued to demonstrate a higher incidence of DVT and a lower incidence of operative management, but more trips to the operating room when surgical management was pursued, a higher admission rate to the intensive care unit, and a greater incidence of loss of follow-up.

Conclusions: MA use is associated with increased inpatient and outpatient complications.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001794DOI Listing
October 2020

Wound Irrigation for Open Fractures.

JBJS Rev 2020 01;8(1):e0061

Department of Orthopedics, Keck Medical Center of USC, Los Angeles, California.

» The optimal regimen for wound irrigation in the setting of an open fracture has been a subject of debate. Basic science evidence as well as results from a recent prospective clinical trial have shed new light on this controversial topic. » While normal saline solution appears to be the optimal irrigation agent, the optimal timing and volume often are determined by the surgeon. Future clinical trials are needed to determine the optimal timing for debridement and irrigation, as well as the ideal volume of irrigant. » Irrigation pressure and the use of pulsatile lavage do not appear to have an effect on outcomes.
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http://dx.doi.org/10.2106/JBJS.RVW.19.00061DOI Listing
January 2020

Effect of bariatric surgery on outcomes in the operative treatment of hip fractures.

Injury 2020 Mar 21;51(3):688-693. Epub 2020 Jan 21.

Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, 1200N. State St. GNH 3900, Los Angeles, CA 90033, United States.

Introduction: Few studies have evaluated the effect of prior bariatric surgery on outcomes following the operative treatment of hip fractures. The purpose of this study is to evaluate these metrics in a population of bariatric surgery patients compared to a control group who were operatively treated for hip fractures.

Materials And Methods: The California Office of Statewide Health Planning & Development (OSHPD) discharge database was accessed to identify patients who sustained a hip fracture between 2000-2014. CPT codes were utilized to identify patients who had a prior history of bariatric surgery within this time period. A control cohort of patients who had undergone previous appendectomy were queried similarly. The study evaluated complication rates and inpatient mortality at 30- and 90-days postoperatively as well as 30- and 90-day readmission rates.

Results: There were 1,327 bariatric and 2,127 control patients identified. Survival rates were significantly lower in bariatric patients compared to controls (87.2% vs. 91.8%, p = 0.048) at 5 years. After controlling for confounders, bariatric patients had higher 30- (OR 1.46, p = 0.005) and 90-day (OR 1.38, p = 0.011) readmission rates. There were no differences in all-cause complication and inpatient mortality rates between groups at 30 or 90 days.

Discussion: Bariatric surgery patients are at increased risk of readmission after hip fracture surgery. Further research is warranted to delineate potential risk factors and mitigate readmission in these patients.

Level Of Evidence: III.
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http://dx.doi.org/10.1016/j.injury.2020.01.022DOI Listing
March 2020

Management of Critical Bone Defects.

Instr Course Lect 2020 ;69:417-432

Bone defects may occur after trauma, infection, or oncologic resection. A critical sized defect is any defect that is unable to spontaneously heal and will require secondary procedure(s) to obtain union. Autologous grafting is widely used, but may be insufficient to obtain union in these situations. Other options include the induced membrane technique, bone transport through distraction osteogenesis, or free vascularized bone transfer. This chapter will review options for obtaining graft, and the aforementioned special techniques for managing these challenging problems.
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February 2020

Characteristics of Marijuana Use Among Orthopedic Patients.

Orthopedics 2020 Mar 16;43(2):108-112. Epub 2019 Dec 16.

Marijuana use among orthopedic patients has not been extensively studied. The purpose of this study was to investigate the prevalence of marijuana use among orthopedic surgery patients. Additionally, the authors sought to better characterize how and why their patients use marijuana. Patients presenting at 3 institutions in 2 states for orthopedic surgery were asked to complete a voluntary survey. In addition to basic demographic information, the survey contained questions regarding the frequency of, methods of, and reasons for marijuana use. Patients who had used marijuana in the past year were categorized as marijuana users. A total of 275 patients completed surveys, of whom 94 (34%) endorsed marijuana use in the past year. A majority of marijuana users (55%) endorsed using marijuana either daily or weekly. Smoking was the most common means of marijuana use (90%), followed by edible products (35%) and vaporizing (24%). Pain management (54%) and recreation (52%) were the most commonly cited reasons for using marijuana. Eighty-six percent of marijuana users indicated that they would stop using marijuana if told by their physician that marijuana use would adversely affect their surgery. Marijuana use is common among orthopedic patients. Many patients believe marijuana is beneficial for managing pain and other medical conditions, although most would be willing to stop using marijuana if told it would negatively impact their surgery. Further study into the effects of marijuana use on musculoskeletal health is warranted because marijuana use may be a risk factor easily modified to improve surgical outcomes. [Orthopedics. 2020; 43(2): 108-112.].
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http://dx.doi.org/10.3928/01477447-20191212-07DOI Listing
March 2020

Effect of Mental Health Conditions on Complications, Revision Rates, and Readmission Rates Following Femoral Shaft, Tibial Shaft, and Pilon Fracture.

J Orthop Trauma 2019 Jun;33(6):e210-e214

Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA.

Objectives: To evaluate the effect of pre-existing mental health (MH) conditions on 90-day complication, 90-day readmission, and all-time revision surgical intervention rates following femoral, tibial, and pilon fractures.

Design: Data were collected using a commercially available database software for which Current Procedural Terminology codes were used to identify patients who underwent surgical treatment of tibial, femoral, or pilon fractures. These patients were then subdivided into those with and without pre-existing MH condition using International Classification of Disease, Ninth Edition codes. Ninety-day postoperative complications, revision surgery, and 90-day readmission rates were then compared between those with and without MH conditions.

Setting: National databases of 70 million combined patients from 2007 to 2015.

Patients/participants: Humana and Medicare insured patients.

Intervention: Surgical treatment of tibial, femoral, and pilon fractures.

Main Outcome Measurements: Ninety-day readmission, 90-day complications, and all-time revision surgical intervention.

Results: The total number of patients for femoral, tibial, and pilon treatment, respectively, included 6207, 6253, and 5940 without MH conditions and 4879, 5247, and 2911 with MH conditions. Femoral, tibial, and pilon readmission rates, revision rates, and complication rates were significantly higher among patients with MH disorders in matched cohorts after controlling for medical comorbidities (P ≤ 0.05 for all).

Conclusions: Comorbid MH conditions are associated with higher postoperative complication, readmission, and revision surgery rates for treated femoral, tibial, and pilon fractures.

Level Of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001438DOI Listing
June 2019

Orthopaedic Injury Profiles in Methamphetamine Users: A Retrospective Observational Study.

J Am Acad Orthop Surg 2020 Jan;28(1):e28-e33

From the Keck School of Medicine of the University of Southern California, Los Angeles, CA.

Introduction: We sought to characterize the prevalence of methamphetamine (MA) abuse and associated orthopaedic injury patterns at our level 1 trauma center.

Methods: We conducted a retrospective review of all orthopaedic consults for the year 2016. Patients were classified as MA users based on urine toxicology results and social history.

Results: The prevalence of MA use was 10.0%. MA users were more likely to present with hand lacerations and other infections (P < 0.05 for all). Regarding the mechanism of injury, MA users were more likely to be involved in automobile versus pedestrian, automobile versus bicycle, ballistic, knife, closed fist, other assault/altercation, and animal bite injuries (P < 0.05 for all).

Discussion: MA use is prevalent at our level 1 trauma center. The prevalence and injury patterns of MA abuse warrant deeper study into the effects of this drug on orthopaedic outcomes.

Level Of Evidence: Level III.
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http://dx.doi.org/10.5435/JAAOS-D-18-00618DOI Listing
January 2020

Gunshot Wounds to the Upper Extremity.

J Am Acad Orthop Surg 2019 Apr;27(7):e301-e310

From the Department of Orthopaedic Surgery, University of Southern California, Keck School of Medicine, Los Angeles, CA.

Upper extremity gunshot wounds result in notable morbidity for the orthopaedic trauma patient. Critical neurovascular structures are particularly at risk. The fractures are often comminuted and may be associated with a variable degree of soft-tissue injury. The literature lacks consensus regarding antibiotic selection and duration, and indications for surgical débridement. Bullets and/or bullet fragments should be removed in cases of plumbism, intra-articular location, nerve impingement, location within a vessel, and location in a subcutaneous position within the hand and/or wrist. Gunshot fractures generally do not follow common fracture patterns seen in blunt injuries, and the complexity of certain gunshot fractures can often be a challenge for the treating orthopaedic surgeon. Common plate and screw constructs may not adequately stabilize these injuries, and innovative fixation techniques may be required. The treatment for bone defects varies by location and severity of injury, and typically requires staged treatment. Nerve injuries after gunshot wounds are common, but spontaneous nerve recovery is expected in most cases.
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http://dx.doi.org/10.5435/JAAOS-D-17-00676DOI Listing
April 2019

Restoring Condylar Width: Radiographic Relationship Between the Lateral Tibial Plateau and Lateral Femoral Condyle in Normal Adult Knees.

J Orthop Trauma 2019 Apr;33(4):180-184

Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA.

Objectives: We hypothesized that a constant radiographic relationship exists between the lateral tibial and femoral condyles and that no side-to-side variation exists.

Methods: We reviewed anteroposterior x-rays of 217 uninjured adults ages 18-65, Included 109 unilateral and 108 bilateral radiographs with no or minimal osteoarthrosis (Kellgren-Lawrence grades 0-1). The perpendicular distance between the lateral-most margins of the tibial plateau articular surface (A) and the lateral femoral epicondyle (B) and the lateral femoral condyle articular surface (C) was measured in millimeters (mm). Medial and lateral measurements to point (A) were recorded as (-) and (+), respectively. First, the average of measured distances in all unilateral knees and randomly selected either right or left knees from the bilateral group (n = 217) was calculated. Comparison was made between both sexes. Next, A-B and A-C distances were compared between right and left knees in the bilateral group (n = 108) to find any significant difference (2-tailed t test, alpha = 0.05).

Results: The average A-B distance was 0.60 ± 2.40 mm (-4.82 to +6.49 mm). The mean A-C distance was -3.96 ± 2.07 mm (-8.51 to +3.98 mm). No significant difference was found between A-B and A-C distances between males (0.40 ± 2.62 mm and -3.91 ± 2.05 mm) and females (0.70 ± 2.28 mm and -3.99 ± 2.09 mm). Similarly, no significant difference was found between A-B and A-C distances between right (1.08 ± 2.31 mm and -3.90 ± 1.73 mm) and left knees (0.90 ± 2.38 mm and -4.31 ± 1.7 mm). Concordance coefficient for interobserver and intraobserver reliability showed substantial agreement.

Conclusion: In conclusion, this study provided a "normal" range for the relationship of the proximal lateral tibial plateau relative to the lateral femoral condyle. The lateral femoral epicondyle is generally aligned with the lateral tibial articular margin. The relationship between the lateral tibial plateau, lateral femoral epicondylar surface, and lateral femoral articular surface is constant from side to side. This technique is reproducible in the setting of fracture, and templating off of the contralateral uninjured knee may be beneficial in tibial plateau fracture surgery.
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http://dx.doi.org/10.1097/BOT.0000000000001412DOI Listing
April 2019

Anterior Pelvic Ring: Introduction to Evaluation and Management.

J Orthop Trauma 2018 Sep;32 Suppl 6:S1-S3

Department of Orthopaedic Surgery, University of California, Irvine, Orange, CA.

The evaluation and management of pelvic ring injuries continues to evolve. Historic treatment was primarily nonsurgical, which yielded to open surgical treatment as the benefits of restoring pelvic anatomy and stability became clear. The development of percutaneous techniques for pelvic ring fixation enabled surgeons to reduce and stabilize certain injuries without the need for large open surgical dissections. Although percutaneous iliosacral screw fixation of sacral fractures and sacroiliac disruptions is the standard for most posterior pelvic ring injuries, the evaluation and treatment of anterior pelvic ring disruptions remains a controversial topic among surgeons who treat these injuries. Universally accepted indications for anterior pelvic ring stabilization do not exist, and there is little comparative data to support one surgical technique over another. In fact, some believe that for many injuries, the anterior ring rarely requires fixation after stable fixation of the posterior pelvic ring. The purpose of this work is to present a brief history on management of the anterior pelvic ring as a component of pelvic ring disruptions and briefly review the anatomy of the anterior pelvic ring. Finally, we will introduce the current techniques available for anterior pelvic reduction/stabilization and present information on evaluation of anterior ring stability as a means of guiding treatment.
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http://dx.doi.org/10.1097/BOT.0000000000001249DOI Listing
September 2018

Use of 3D Printed Models in Resident Education for the Classification of Acetabulum Fractures.

J Surg Educ 2018 Nov;75(6):1679-1684

UC Irvine Department of Orthopaedic Surgery, Division of Orthopaedic Trauma, Irvine, California. Electronic address:

Objective: To determine if three-dimensional (3D) printed models can be used to improve acetabular fracture pattern recognition and be a valuable adjunct in orthopedic resident education.

Design: Fifteen randomized testing stations with each containing plain radiographs (XRs), two-dimensional computed tomography (CT) scans, or 3D model of an acetabular fracture.

Setting: Two orthopedic residency programs based at Level 1 trauma centers.

Participants: Forty-one orthopedic residents, PGY 1-5.

Results: Senior residents were superior to junior residents at correctly identifying the provided acetabular fracture pattern. Overall, use of CT scans or the 3D model improved fracture classification as compared to standard XRs, but there was no significant difference between use of the CT scans and 3D models. Subjective survey results indicated agreement among residents that 3D models were accurate representations of acetabular fractures and that models would be a desired educational modality.

Conclusions: 3D models improved the accuracy of acetabular fracture identification compared to XR. In addition, trainees were able to use 3D models to obtain similar accuracy compared to CT scans despite not having previous exposure to the models. Interobserver agreement improved when comparing CT to 3D, but did not provide greater than a fair agreement indicating that fracture patterns were difficult to accurately classify even with the use of 3D models. Residents' subjective responses indicated a positive experience with the use of 3D models. We conclude that the incorporation of 3D models could be an important adjunct to orthopedic residency education for the evaluation complex fracture patterns, but is not significantly superior to identification with CT scans.
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http://dx.doi.org/10.1016/j.jsurg.2018.04.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6346736PMC
November 2018

Hip dislocations and concurrent injuries in motor vehicle collisions.

Injury 2018 Jul 27;49(7):1297-1301. Epub 2018 Apr 27.

Department of Orthopedic Surgery, Keck School of Medicine of University of Southern California, 1520 San Pablo St, Suite 2000, Los Angeles, CA, 90033, United States. Electronic address:

Introduction: Motor Vehicle Collisions (MVC) can cause high energy hip dislocations associated with serious injury profiles impacting triage. Changes in safety and regulation of restraint devices have likely lowered serious injuries from what was previously reported in the 1990s. This study aims to describe modern-day injury profile of patients with traumatic hip dislocations, with special attention to aortic injury.

Methods: Retrospective review of a prospectively maintained trauma database at an urban level 1 trauma center was conducted. Patients with hip dislocation following MVC between January 2005 and December 2015 were grouped based on seatbelt use and airbag deployment. Patients with unknown restraint use were excluded. Multiple logistic regression was used to identify risk of injury profile between groups.

Results: Of 204 patients with hip dislocation after MVC, nearly 57% were unrestrained. Seatbelt alone was used in 36 (17.7%), airbag deployed in 14 (6.9%), and 38 (18.6%) with both. Gender and number of injuries were similar between groups. The most common concomitant injury was acetabular fracture (53.92%) and the abdominopelvic region was the most injured. Use of a seatbelt with airbag deployment was protective of concomitant pelvic ring injury (OR = 0.22). Airbag deployment was significantly protective of lumbar fracture (OR = 0.15) while increasing the likelihood of radial and ulnar fracture or dislocation (OR = 3.27), acetabular fracture (OR = 5.19), and abdominopelvic injury (OR = 5.07). The no restraint group had one patient (0.80%) with an intimal tear of the thoracic aorta identified on CT chest that was successfully medically managed.

Discussion And Conclusion: Hip dislocations are high energy injuries with severe associated injuries despite upgrades in restraint devices. These patients require careful examination and heightened awareness when evaluating for concomitant injuries.
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http://dx.doi.org/10.1016/j.injury.2018.04.023DOI Listing
July 2018

Operatively Treated Talus Fractures: Complications and Survivorship in a Large Patient Sample.

J Foot Ankle Surg 2018 Jul - Aug;57(4):737-741. Epub 2018 Apr 24.

Assistant Professor of Orthopaedic Surgery, Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.

Talus fractures are relatively uncommon; however, the sequelae of talus fractures can cause significant morbidity. Although avascular necrosis has been a consistently reported complication, the reported rates of subsequent arthrodesis have varied widely. The purpose of the present study was to report the complications in a large patient sample of operatively treated talus fractures and to describe the survivorship of open reduction internal fixation (ORIF) of the talus. Patients undergoing talus ORIF for closed or open fractures from 2007 to 2011 were identified in the United Healthcare System database by International Classification of Diseases, 9th revision, code 825.21 and Current Procedural Terminology codes 28445, 28436, and 28430. Patients with a nonoperative talus fracture or isolated osteochondral defect were excluded, leaving 1527 patients in the final analysis. We also identified patients who had required subsequent subtalar, pantalar, and tibiotalocalcaneal arthrodeses using Current Procedural Terminology codes 28725, 28705, and 28715, respectively. Complications and demographic data were recorded. Of the 1527 patients, 29 (1.9%) had undergone subsequent arthrodesis within 4 years; 64 patients (4.2%) developed wound complications that did not require surgical intervention, 11 patients (0.7%) were readmitted, 204 (13.3%) presented to the emergency department (ED), and 96 (6.3%) underwent operative irrigation and debridement (I&D). The overall complication rate was 19.5%. Patients aged >34 years had a significantly greater rate of ED visits (54.7%, p = .015) and overall complications (56.8%, p < .001). In conclusion, ORIF of talus fractures has good survivorship when considering the failure of initial surgery or the requirement for secondary arthrodesis. Medical complications and hospital readmission were relatively rare; however, ED visits and infection requiring I&D were relatively common after ORIF of talus fractures.
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http://dx.doi.org/10.1053/j.jfas.2017.12.016DOI Listing
December 2018

Risk of Knee Sepsis After Treatment of Open Tibia Fractures: A Multicenter Comparison of Suprapatellar and Infrapatellar Approaches.

J Orthop Trauma 2018 02;32(2):88-92

Department of Orthopaedic Surgery, University of California-Irvine, Orange, CA.

Objectives: The suprapatellar approach for medullary nailing of the tibia is increasing. This requires intra-articular passage of instruments, which theoretically places the knee at risk of postoperative sepsis in the setting of open fracture. We hypothesized that the risk of knee sepsis is similar after suprapatellar or infrapatellar nailing of open tibia fractures.

Design: Retrospective, multicenter.

Setting: Three urban level 1 trauma centers.

Patients: All patients treated with medullary nailing for open diaphyseal tibia fractures (OTA 42) from 2009 to 2015. Patients younger than 18 years of age and with less than 12 weeks of follow-up were excluded. We identified 289 fractures in 282 patients.

Intervention: Suprapatellar (SP) or infrapatellar (IP) medullary nailing of open tibia fractures.

Main Outcome Measurement: Occurrence of ipsilateral knee sepsis, defined as presence of a positive culture from knee aspiration or arthrotomy. Deep infection requiring operative debridement, superficial infection requiring antibiotic therapy alone, and all-cause reoperation were also recorded.

Results: IP nailing was used for 142 fractures. There were 20 infections (14.1%), of which 14 (9.8%) were deep. Fourteen tibias (9.8%) required reoperation for noninfectious reasons for 28 total reoperations (19.7%). SP nailing was used in 147 fractures. There were 24 infections (16.2%), of which 16 (10.8%) were deep. Fourteen additional tibias (9.5%) required reoperation for noninfectious reasons for a total of 30 reoperations (20.4%). There were no differences in the rates of infection, deep infection, or reoperation between groups. There were 2 cases of knee sepsis after SP nailing (1.4%) but zero cases after IP nailing (P = 0.5).

Conclusions: There was no significant difference in the rate of knee sepsis with SP or IP approaches. The risk of knee sepsis after SP nailing of open fractures is low, but present.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000001024DOI Listing
February 2018

Use of a Defined Surgical Approach for the Debridement of Open Tibia Fractures.

J Orthop Trauma 2018 Jan;32(1):e1-e4

Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, CA.

Objectives: To determine whether a defined approach for debridement of open tibia fractures would result in no change in reoperation rate, but reduce the need for flap coverage.

Design: Prospective cohort study.

Setting: Academic Level 1 trauma center.

Patients: A total of 66 patients with 68 open diaphyseal tibia fractures were included. Patients under the age of 18 and with orthopaedic trauma association open fracture classification (OTA-OFC) skin score of 3 were excluded.

Intervention: Debridement of the open fracture through direct extension of the traumatic wound or through a defined surgical interval.

Main Outcome Measurements: Number of operations. Need for soft-tissue transfer.

Results: A total of 47 patients had direct extension of the traumatic wound and 21 patients had a defined surgical approach. The groups had similar proportions of Gustilo-Anderson and OTA-OFC subtypes. The average number of surgeries, including index procedure, per patient was 1.96 in the direct extension group and 1.29 in the defined approach group (P = 0.026). Flap coverage was needed in 9 patients in the direct extension group and no patients in the defined approach group (P = 0.048).

Conclusions: A defined surgical approach to the debridement of open tibia fractures is safe and may reduce the need for flap coverage in select patients.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.1097/BOT.0000000000000998DOI Listing
January 2018

Soft tissue reconstruction and salvage of infected fixation hardware in lower extremity trauma.

Microsurgery 2018 Mar 16;38(3):259-263. Epub 2017 May 16.

Division of Plastic and Reconstructive Surgery, Keck School of Medicine of USC, Los Angeles, California.

Background: Tibial fracture management may be complicated by infection of internal fixation hardware (iIFH) resulting in increased morbidity and amputation rate. When iIFH removal is not possible, salvage of the lower extremity is attempted through debridement, antibiotics, and vascularized soft tissue coverage. This study investigates lower extremity salvage with retention of iIFH.

Methods: Demographics, outcomes, and bacterial speciation in patients with tibial fractures at a level 1 trauma center from 2007 to 2014 were reviewed. The primary outcome was infection suppression, while secondary outcomes included limb salvage, amputation, and osseous union.

Results: Twenty-five patients underwent soft tissue reconstruction for salvage of iIFH. Average age was 41, 19 (76%) were male, average BMI 30.1 kg/m , 10 (40%) patients smoked. Tibial fractures were closed in 8 (32%), Gustilo-Anderson grade I in 1 (4%), II in 8 (32%), IIIb in 5 (20%), and IIIc in 1 (4%). Staphylococcus was most commonly cultured with 11 (44%) demonstrating methicillin-resistance. Soft tissue reconstruction was performed by local flap in 15 (60%) and free flap in 10 (40%). At an average of 16.1 months, 19 (76%) hardware salvage patients demonstrated clinical suppression of infection, 11 of 19 (57.9%) patients had bony union, and 24 (96%) maintained a salvaged limb. One patient was amputated for recurrent infection.

Conclusions: Following complex, infected tibial fractures, salvage of the lower extremity may be attempted even when iIFH cannot be removed. Thorough debridement, antibiotics, and vascularized soft tissue may suppress infection long enough to facilitate osseous union and subsequent removal of iIFH.
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http://dx.doi.org/10.1002/micr.30176DOI Listing
March 2018

Selective versus nonselective embolization versus no embolization in pelvic trauma: A multicenter retrospective cohort study.

J Trauma Acute Care Surg 2017 09;83(3):361-367

From the Department of Surgery, Louisiana State University Health Science Center, New Orleans, Louisiana; Department of Surgery, University of Southern California (S.A., E.B., G.S.M.), Los Angeles, California; and Department of Surgery, University of Texas Southwestern (F.Z., H.A.P.), Dallas, Texas.

Background: Traumatic hemorrhage from pelvic fractures is a significant challenge, and angioembolization has become standard. Optimal treatment is undefined in two clinical scenarios. The first is in the presence of a negative angiogram. Can arterial embolization treat venous bleeding by decreasing the arterial pressure head? If the angiogram is positive, is nonselective embolization (NSE) or selective embolization (SE) better? The purpose of this study is to determine if embolization after a negative angiogram aids in hemorrhage control and when the angiogram is positive, which level of embolization is superior?

Methods: A multicenter retrospective review was conducted including blunt trauma patients with pelvic fractures who underwent angiography. Demographic and clinical data were compiled on all subjects. NSE refers to an intervention at the level of the internal iliac artery and SE is defined as any distal intervention. Theoretical complications of pelvic embolization are those thought to arise from decreased pelvic blood flow and will be referred to as embolization-related complications. Thromboembolic complications included deep vein thrombosis or pulmonary embolism.

Results: One hundred ninety-four patients met inclusion criteria. Of the 67 patients with a negative angiogram, 26 (38.8%) were embolized. In those patients requiring transfusion, the units given in the first 24 hours were decreased in the embolization group (7.5 vs. 4.0, p = 0.054). Embolization-related complications occurred more frequently in those not embolized (11.4% vs. 6.0%, p = 0.414).One hundred forty-five patients were embolized, 99 (68.3%) NSE and 46 (31.7%) SE. There were no significant differences in mortality or transfusion requirements. There was no difference in the rate of embolization-related complications (4.1% vs. 2.1%, p = 0.352). There was a significantly increased rate of thromboembolic complications in the NSE group (12.1% vs. 0, p = 0.010).

Conclusion: Embolization in the face of a negative angiogram may aid in hemorrhage control for those patients being actively transfused. If embolized, then selective occlusion of more distal vessels rather than of the main internal iliac artery should be performed.

Level Of Evidence: Therapeutic, level IV.
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http://dx.doi.org/10.1097/TA.0000000000001554DOI Listing
September 2017

Femoral Head Fractures.

JBJS Rev 2015 Nov;3(11)

1Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine, 1520 San Pablo, Suite 2000, Los Angeles, CA 90033 2Department of Orthopaedic Surgery, University of California, Irvine, 101 The City Drive South, Pavilion III, Building 29A, Orange, CA 92868 3University of Texas-Health Sciences Center at Houston, 6431 Fannin Street, Houston, TX 77030.

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http://dx.doi.org/10.2106/JBJS.RVW.N.00098DOI Listing
November 2015

Treatment of Acute Jones Fractures Without Weightbearing Restriction.

J Foot Ankle Surg 2016 Sep-Oct;55(5):961-4. Epub 2016 Jun 11.

Associate Professor, Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL.

Jones fractures are reportedly prone to nonunion and generally treated with a period of non-weightbearing or operative treatment. Extended non-weightbearing can have adverse effects, and operative treatment poses various risks. We report the clinical results of patients treated without weightbearing restriction. All patients treated for metatarsal fractures by a single surgeon from January 1, 2000 to December 31, 2009 were identified through the clinical billing records by International Classification of Diseases, ninth revision, code. Through a radiographic and medical record review, 27 consecutive patients with acute Jones fractures treated without weightbearing restriction were identified. The demographic information and clinical and radiographic results were recorded. Of the 27 patients, 24 (89%) had achieved clinical union at a mean of 8.0 ± 2.6 weeks. Complete radiographic union was noted in 13 (48%) patients, and 13 (48%) others had made significant progress toward radiographic union but had not yet reached it. Two (8.3%) patients were lost to follow-up. One patient (4%) developed nonunion. Patients with acute Jones fractures can be treated without weightbearing restriction. This protocol results in rapid clinical union and a low rate of nonunion.
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http://dx.doi.org/10.1053/j.jfas.2016.04.013DOI Listing
July 2017

Surgeon preferences regarding antibiotic prophylaxis for ballistic fractures.

Arch Orthop Trauma Surg 2016 Jun 4;136(6):751-4. Epub 2016 Apr 4.

Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Background: Scant evidence exists to support antibiotic use for low velocity ballistic fractures (LVBF). We therefore sought to define current practice patterns. We hypothesized that most surgeons prescribe antibiotics for LVBF, prescribing is not driven by institutional protocols, and that decisions are based on protocols utilized for blunt trauma.

Materials And Methods: A web-based questionnaire was emailed to the membership of the Orthopaedic Trauma Association (OTA). The questionnaire included demographic information and questions about LVBF treatment practices. Two hundred and twenty surgeons responded. One hundred and fifty-four (70 %) respondents worked at a Level-1 trauma center, 176 (80 %) had received fellowship education in orthopaedic trauma and 104 (47 %) treated at least 10 ballistic fractures annually. Responses were analyzed with SAS 9.3 for Windows (SAS Institute Inc, Cary, NC).

Results: One hundred eighty-six respondents (86 %) routinely provide antibiotics for LVBF. Those who did not were more apt to do so for intra-articular fractures (8/16, 50 %) and pelvic fractures with visceral injury (10/16, 63 %). Most surgeons (167, 76 %) do not believe the Gustilo-Anderson classification applies to ballistic fractures, and (20/29, 70 %) do not base their antibiotic choice on the classification system. Few institutions (58, 26 %) have protocols guiding antibiotic use for LVBF.

Conclusions: Routine antibiotic use for LVBF is common; however, practice is not dictated by institutional protocol. Although antibiotic use generally follows current blunt trauma guidelines, surgeons do not base their treatment decisions the Gustilo-Anderson classification. Given the high rate of antibiotic use for LVBF, further study should focus on providing evidence-based treatment guidelines.
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http://dx.doi.org/10.1007/s00402-016-2450-8DOI Listing
June 2016

Antibiotic related acute kidney injury in patients treated for open fractures.

Injury 2016 Mar 23;47(3):653-7. Epub 2016 Jan 23.

Department of Orthopaedic Surgery, USC, Los Angeles, CA, United States.

Objective: Antibiotic administration during the treatment of open fractures has been shown to reduce infection rates and is considered a critical step in the management of these injuries. The purpose of this study was to determine if aminoglycoside administration during the treatment of open fractures leads to acute kidney injury.

Methods: Patient records at a level I trauma centre were reviewed for adult patients who presented in 2014 with open fractures were screened for inclusion. Patients were excluded with fractures of the phalanges, metatarsals, and metacarpals, with isolated traumatic arthrotomies, or pre-existing renal dysfunction. Charts were reviewed for patient age, gender, race, past medical history, medication history, injury severity score, intravenous dye studies and fracture type. Patients were divided into those given cefazolin (Group A) and cefazolin with gentamicin (Group B). Laboratory values were used to determine which patients developed kidney dysfunction as measured using the RIFLE criteria. Wilcoxon-Mann-Whitney test and Chi-square were used to compare interval and categorical variables, respectively. Significance was set at P<0.05.

Results: One-hundred and fifty-nine patients met inclusion criteria. Forty-one (25%) patients were given cefazolin alone and 113 (68%) patients were given cefazolin with gentamicin. Ten (18%) patients with Gustilo-Anderson type III fractures were given cefazolin alone and 67 (67%) patients with types I or II fractures were given a cefazolin with gentamicin. Baseline characteristics and risk factors for renal dysfunction did not vary between groups. Two (4.8%) patients in Group A and 5 (4%) patients in Group B developed acute kidney injury (P=0.599).

Conclusions: Gentamicin use during the treatment of open fractures does not lead to increased rates of renal dysfunction when used in patients with normal baseline renal function.
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http://dx.doi.org/10.1016/j.injury.2016.01.018DOI Listing
March 2016

The effect of axillary hair on surgical antisepsis around the shoulder.

J Shoulder Elbow Surg 2015 May 3;24(5):804-8. Epub 2014 Dec 3.

Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Background: Infection after shoulder surgery can have devastating consequences. Recent literature has implicated Propionibacterium acnes as a causative agent for postoperative shoulder infections. Axillary hair removal has been suggested as a method for infection prevention, although data quantifying its effect on the bacterial load around the shoulder are lacking.

Methods: We clipped one randomly selected axilla in 85 healthy male volunteers with commercially available surgical clippers. Aerobic and anaerobic culture specimens were taken from the clipped and unclipped axillae. Each shoulder was then prepared with 2% chlorhexidine gluconate and 70% isopropyl alcohol. Repeated culture specimens were then taken from both axillae. Cultures were held for 14 days and recorded with a semiquantitative system (0-4 points). Results were compared by the Wilcoxon signed rank test.

Results: There was no difference in the burden of P. acnes between the clipped and unclipped axillae before or after surgical preparation (P = .109, P = .344, respectively). There was a significantly greater bacterial burden in the clipped shoulder compared with the unclipped shoulder before preparation (P < .001) but not after preparation (P = .285). There was a significant reduction in total bacterial load and P. acnes load for both axillae after surgical preparation (P < .001 for all).

Conclusions: Removal of axillary hair has no effect on the burden of P. acnes in the axilla. Clipped axillae had a higher total bacterial burden. A 2% chlorhexidine gluconate surgical preparation is effective at removal of all bacteria and specifically P. acnes from the axilla.
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http://dx.doi.org/10.1016/j.jse.2014.10.007DOI Listing
May 2015

Percutaneous manipulation of intra-articular debris after fracture-dislocation of the femoral head or acetabulum.

Orthopedics 2014 Sep;37(9):603-6

Traumatic fracture-dislocation of the hip usually warrants prompt management by closed manipulative reduction. In some patients, debris malpositioned between the femoral head and the acetabular dome obstructs a completely concentric reduction of the injured hip. To avoid damage to the articular surfaces, the debris between them should be removed in a timely fashion. Techniques for removal include open approaches with or without fracture fixation or hip arthroscopy. Fracture fixation and hip arthroscopy have associated risks and potential complications, may require special equipment, and may not be familiar to all surgeons. The authors present a simple fluoroscopically guided technique for the percutaneous removal of intra-articular debris between the femoral head and the acetabular dome after traumatic femoral head or acetabular fracture-dislocation.
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http://dx.doi.org/10.3928/01477447-20140825-04DOI Listing
September 2014