Publications by authors named "Vivek Chadayammuri"

29 Publications

  • Page 1 of 1

Effectiveness of topical adjuvants in reducing biofilm formation on orthopedic implants: an in vitro analysis.

J Shoulder Elbow Surg 2021 Jan 30. Epub 2021 Jan 30.

Department of Orthopedic Surgery, UConn Health, Farmington, CT, USA.

Background And Hypothesis: The treatment of periprosthetic joint infection is complicated by the presence of residual biofilm, which resists eradication owing to bacterial adherence to orthopedic implants. The purpose of this study was to compare Bactisure (Zimmer Biomet, Warsaw, IN, USA), povidone-iodine (Betadine), and chlorhexidine gluconate solution (Irrisept; Irrimax, Gainesville, FL, USA) in reducing biofilm formation of Staphylococcus aureus, Staphylococcus epidermidis, and Cutibacterium acnes inoculated on cobalt-chrome, titanium, and stainless steel disks, representing metals commonly used for shoulder arthroplasty. The hypothesis was that there would be no significant difference in biofilm reduction among the 3 topical adjuvants.

Methods: Strains of S aureus (ATCC 35556), S epidermidis (ATCC 35984), and C acnes (LMG 16711) were grown on cobalt-chrome, titanium, and stainless steel disks. For each strain, the disks were divided into 4 groups: (1) control, (2) povidone-iodine (Betadine), (3) chlorhexidine gluconate (Irrisept), and (4) Bactisure. Bacteria were grown on 5% sheep blood agar plates. Biofilm eradication was quantified using adenosine triphosphate bioluminescence and compared with controls 48 and 72 hours after implementation of the topical adjuvant.

Results: At 72 hours after implementation of the topical adjuvant, a statistically significant reduction in colony-forming units was observed for all topical adjuvants across all tested metals, as compared with their respective control. With respect to the topical adjuvants themselves, Bactisure more consistently demonstrated the most significant reduction in colony-forming units across all bacteria when the tested medium was adjusted for, with the exception of S aureus, which showed similar results to Betadine at 72 hours.

Conclusion: By use of commonly encountered topical adjuvants on S aureus-, S epidermidis-, and C acnes-inoculated disks of various implant metals, a significant reduction in biofilm production was observed. Bactisure, a recent Food and Drug Administration-approved topical adjuvant, demonstrated the overall greatest efficacy of the agents studied.
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http://dx.doi.org/10.1016/j.jse.2020.12.009DOI Listing
January 2021

High prevalence of a deep lateral femoral notch sign in patients with anterior cruciate ligament (ACL) and concomitant posterior root tears of the lateral meniscus.

Knee Surg Sports Traumatol Arthrosc 2021 Apr 21;29(4):1018-1024. Epub 2020 May 21.

Department of Orthopaedic Sports Medicine, Technical University of Munich, Ismaninger Str. 22, 81675, Munich, Germany.

Purpose: To determine the prevalence of a deep lateral femoral notch sign (LFNS) in magnetic resonance imaging (MRI) in patients with anterior cruciate ligament (ACL) and concomitant posterior root tears of the lateral meniscus (PLRT).

Methods: A retrospective chart review was conducted to identify all patients undergoing ACL reconstruction between 2016 and 2018. Based on the arthroscopic appearance of the lateral meniscus, patients were assorted to one of three groups: isolated ACL tear (ACL-Group), ACL tear with concomitant lateral meniscus tear not involving the posterolateral root (Meniscus-Group), and ACL tear with concomitant PLRT (PLRT-Group). Incidence and depth of a LFNS on preoperative MRI was compared between the three cohorts.

Results: 115 patients (mean age: 29.5 ± 11.3 years) were included in the study, with 58 patients (50.4%) assorted to the ACL-Group, 24 patients (20.9%) to the Meniscus-Group, and 33 patients (28.7%) to the PLRT-Group. The prevalence of a LFNS was significantly higher in the PLRT-Group (39.4%), when compared to the ACL- (5.2%) or Meniscus-Groups (25.0%; p < 0.001, respectively). Additionally, logistic regression analysis demonstrated that patients with PLRT were 5.3 times more likely to have a LFNS as compared to those without a lateral root tear (p < 0.001).

Conclusion: In patients with ACL tears, the presence of a LFNS on preoperative MRI may be predictive for a PLRT. As the LFNS occurs in almost 40% of the patients with combined ACL tears and PLRT, the LFNS may be a useful secondary diagnostic finding in early MRI diagnostic. Identifying PLRT on MRI is clinically relevant, as it prevents misdiagnosis and facilitates surgical decision-making, thus avoiding subsequent delayed treatment.

Level Of Evidence: Level IV.
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http://dx.doi.org/10.1007/s00167-020-06071-9DOI Listing
April 2021

Size of Initial Bone Bruise Predicts Future Lateral Chondral Degeneration in ACL Injuries: A Radiographic Analysis.

Orthop J Sports Med 2020 May 6;8(5):2325967120916834. Epub 2020 May 6.

Department of Orthopaedic Surgery, University of Connecticut Health Center, Farmington, Connecticut, USA.

Background: Bone marrow contusions are common after an acute anterior cruciate ligament (ACL) injury. It is unknown whether the severity of this initial bruise can predict the potential of developing chondral changes even after ACL reconstructive surgery (ACLR).

Purpose: To investigate whether the initial bone bruise area could be predictive of progressive chondral defects.

Study Design: Cohort study; Level of evidence, 3.

Methods: A retrospective chart review was performed to capture patients with an acute ACL injury with pre- and post-ACLR magnetic resonance imaging (MRI) between January 2000 and December 2017. Lesion areas were measured on initial MRI, and chondral wear was graded on final imaging by use of the modified Outerbridge classification. An ordinal model was created to determine whether the initial area was a significant predictor for future chondral degeneration.

Results: A total of 40 patients with a mean age of 34.5 ± 12.6 years were included for analysis. All patients underwent ACLR at a mean 139 ± 64 days from initial injury. A lateral tibial and femoral bone bruise was most commonly present in patients (77.5% and 62.5%, respectively). A medial femoral bone bruise was found in only 12.5% (5/40) of patients. The initial contusion area significantly correlated with increasing chondral wear over time in the tibia and lateral femoral condyle ( < .001). Patients with a bone bruise encompassing 100% of the lateral femoral compartment on MRI had a 74% chance of having grade 3 or 4 chondral changes at 5 years ( = .001). Absence of a bone bruise on initial MRI was the greatest predictor of no cartilage wear at 5 years in all compartments ( < .001). The presence of a concomitant lateral meniscal injury increased the risk of developing type 3 or 4 chondral wear in the lateral tibial plateau ( = .012) but did not pose increased risk of femoral wear ( = .23).

Conclusion: A significant relationship between area of initial bone bruise at the time of injury and progressive posttraumatic chondral disease was found in the tibial and lateral femoral compartments.
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http://dx.doi.org/10.1177/2325967120916834DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7222279PMC
May 2020

Increased Prevalence of Femoroacetabular Impingement in Patients With Proximal Hamstring Tendon Injuries.

Arthroscopy 2019 05 12;35(5):1396-1402. Epub 2019 Apr 12.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado, U.S.A.. Electronic address:

Purpose: To determine the prevalence of clinically diagnosed femoroacetabular impingement (FAI) in a consecutive series of patients presenting with proximal hamstring tendon injury and to correlate this with pelvic anatomic factors.

Methods: The prevalence of clinically symptomatic cam-, pincer-, and mixed-type and overall FAI was calculated among a consecutive series of patients presenting to a hip preservation clinic with a confirmed clinical and radiographic diagnosis of proximal hamstring tendon injury between 2012 and 2017. The presence of a cam lesion was determined by an alpha angle > 50° on radiographs and computed tomography radial sequences of the head-neck junction and a femoral head-neck offset ratio < 0.18. Clinical diagnoses of osseous impingement were determined according to accepted pathomorphologic signs and measurements. A diagnosis of FAI was confirmed by imaging findings of acetabular overcoverage for pincer-type FAI and the presence of an anterior or lateral cam lesion for cam-type FAI.

Results: Overall, 120 hips in 97 patients (mean age, 45 years) were included in this study. A clinical diagnosis of FAI was noted in 70.8% of hips (pincer-type 9.2%, cam-type 40.8%, mixed-type 20.8%), an approximate 2- to 7-fold increased prevalence in comparison with the general population from prior studies.

Conclusions: The prevalence of FAI is high in patients with symptomatic proximal hamstring tendon pathology. Because FAI results in restriction of hip range of motion and altered pelvic tilt, future studies are warranted to investigate whether the presence of FAI acts as a predisposing factor for injury to the hamstring muscle complex.

Level Of Evidence: Level IV, case series.
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http://dx.doi.org/10.1016/j.arthro.2018.11.037DOI Listing
May 2019

Simultaneous Bilateral Hip Arthroscopy in Adolescent Athletes With Symptomatic Femoroacetabular Impingement.

J Pediatr Orthop 2019 Apr;39(4):193-197

Department of Orthopedics, University of Colorado School of Medicine.

Background: Femoroacetabular impingement represents a common cause of hip pain in adolescents. The purpose of the present study was to evaluate the safety and efficacy of simultaneous bilateral hip arthroscopy for bilateral symptomatic femoroacetabular impingement in adolescent athletes.

Methods: Clinical data were collected in a prospective database on patients who underwent unilateral or simultaneous bilateral hip arthroscopy and included complications, reoperation rate, and return to play time. Differences in International Hip Outcome Tool (iHOT)-12 scores according to hip side and postoperative follow-up time (preoperative, 1.5, 3, 6, 12, and 24 mo) were evaluated using a 2×6 repeated-measures analysis of variance with post hoc repeated-measures 1-way analysis of variance and Bonferroni-corrected paired t tests.

Results: In total, 24 patients (36 hips) were studied, of whom 12 underwent simultaneous bilateral hip arthroscopy (24 hips) and a case-matched control group of 12 patients underwent unilateral hip arthroscopy. There were 5 males in each group (41.7%). Average age was 15.7 and 16.5 years in the bilateral and unilateral groups, respectively. No patients were lost to follow-up. In the bilateral group, a significant increase in mean iHOT-12 score was observed between 1.5- and 3-month follow-up (61.8 vs. 82.8, respectively; P=0.003), and 6-, 12-, and 24-month follow-up (91.4, 95.1, and 96.6, respectively, P=0.004). At all follow-up times, there were no significant differences in mean iHOT-12 scores or other outcome measures between bilateral and unilateral cohorts. Time to return to preinjury level of activity was similar between the bilateral and unilateral groups (4.7 vs. 4.9 mo, respectively; P=0.40). One transient lateral femoral cutaneous nerve palsy occurred in each group, though no other complications were documented. No patients required revision surgery by latest follow-up.

Conclusions: Bilateral simultaneous hip arthroscopy is safe and reproducible in adolescent athletes, achieving equivalent outcomes, and similar rehabilitation time when compared with unilateral surgery.

Level Of Evidence: Level II-therapeutic study.
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http://dx.doi.org/10.1097/BPO.0000000000000987DOI Listing
April 2019

A multicenter, double-blind, randomized controlled trial comparing magnetic resonance imaging evaluation of repaired versus unrepaired interportal capsulotomy in patients undergoing hip arthroscopy for femoroacetabular impingement.

J Hip Preserv Surg 2018 Dec 26;5(4):349-356. Epub 2018 Nov 26.

Department of Orthopedics, University of Colorado School of Medicine, Aurora, CO, USA.

The purpose of this study was to evaluate the magnetic resonance imaging (MRI) appearance of the hip capsule in patients with femoroacetabular impingement (FAI) undergoing hip arthroscopy with capsular repair versus non-repair. A multicenter clinical trial was performed with 31 patients (49 hips) undergoing hip arthroscopy for treatment of FAI. A small- to moderate-sized interportal capsulotomy was performed. Each hip was randomized to capsular repair versus non-repair of the interportal capsulotomy. MRI was performed at 6 and 24 weeks postoperatively and was analyzed by two musculoskeletal radiologists. Patients and the radiologists were blinded to the treatment applied. Capsular defect size and capsule thickness were recorded on each scan. Mean patient age was 31.4 years. Capsular repair was performed in 23 (46.9%) hips. Mean capsulotomy length was 35 mm at Center X and 23 mm at Center Y. At 6 weeks postoperatively, a healed hip capsule (with no apparent capsulotomy defect) was observed in 10 (43.4%) hips that underwent capsular repair and 4 (15.4%) hips that did not undergo capsular repair ( = 0.13). At 24 weeks postoperatively, 25/30 hips (83.3%) achieved complete closure of the capsulotomy defect, with no significant difference between treatment groups. Repair of an interportal capsulotomy following hip arthroscopy for FAI results in a non-significantly higher percentage of healed hip capsules at 6 weeks postoperatively compared with leaving the capsule unrepaired, though the difference normalizes by 24-week follow-up. Repair of a small- to moderate-sized interportal capsulotomy does not provide a radiographic advantage following hip arthroscopy for FAI.
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http://dx.doi.org/10.1093/jhps/hny045DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6328748PMC
December 2018

Standardizing the Prearthritic Hip Joint Space Width: An Analysis of 994 Hips.

Arthroscopy 2018 07 2;34(7):2114-2120. Epub 2018 May 2.

Department of Orthopedics, University of Colorado School of Medicine, University of Colorado, Aurora, Colorado, U.S.A.. Electronic address:

Purpose: The purposes of this study were (1) to define a normal prearthritic hip joint space width (JSW) in symptomatic and asymptomatic patients with various degrees of acetabular coverage based on the lateral center edge angle (LCEA) and (2) to determine predictors of JSW using patient-specific variables.

Methods: In a consecutive series of patients presenting to a hip preservation clinic between July 2012 and April 2016, a standard weight-bearing anteroposterior pelvic view was obtained. JSW was defined as the distance between the bony contour of the acetabular rim and femoral head in 2 locations (lateral and medial weight-bearing zone). Hips with severe anatomic deformity, a Tönnis grade >0, or a lateral or medial JSW <2.5 mm were excluded. A linear mixed model analysis was performed in order to determine which variables (age, sex, side, height, weight, symptomatic/asymptomatic, LCEA, and clinical diagnosis) were significantly related to JSW.

Results: A total of 994 hips were included. LCEA was found to be a significant predictor of both the lateral and medial JSW, with a decreased JSW associated with increasing degrees of acetabular bony coverage (P < .02). A mean 0.9 mm (20%) difference in medial JSW was found between patients with frank dysplasia (LCEA <20°) compared with those with pincer-type FAI (LCEA ≥40°). There was no difference between symptomatic and asymptomatic hips, either for lateral (asymptomatic: 4.51 ± 0.83 mm; symptomatic: 4.52 ± 0.85 mm; P = .58) or medial JSW (asymptomatic: 4.02 ± 0.96 mm; symptomatic: 3.97 ± 0.84 mm; P = .49).

Conclusions: The LCEA is a significant predictor of hip JSW, with the mean JSW decreasing with increasing degrees of acetabular bony coverage. Joint space is not a major factor in symptomatology in adults with prearthritic hip pain.

Level Of Evidence: Level III, retrospective comparative study.
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http://dx.doi.org/10.1016/j.arthro.2018.02.036DOI Listing
July 2018

Split-Depressed Lateral Tibial Plateau Fractures: A Comparison of Augmented Percutaneous Screws Versus Augmented Plate and Screw Construct in a Cadaveric Model.

J Orthop Trauma 2018 07;32(7):e270-e275

Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, CO.

Objectives: To compare the strength of fixation of percutaneous screw versus plate/screw fixation in a paired cadaver model of OTA 41-B3 (Schatzker type II) split-depression fractures of the lateral tibial plateau.

Methods: Six matched pairs of cadaveric knees were acquired. An OTA 41-B3 (Schatzker type II) split-depression fracture was created in all specimens using a standardized method. One specimen from each matched pair of knees was fixed with percutaneous screws, and the other was fixed with a plate/screw construct. All specimens underwent augmentation of the central metaphyseal defect with calcium phosphate. Mean residual displacement (depression) was measured on thin-slice high-resolution computed tomography using a standardized methodology following 3 experimental conditions: (1) after they were fixed, before loading; (2) unloaded cycling (simulating postoperative range of motion exercises); and (3) loaded cycling (simulating postoperative weight-bearing). Load to failure was also compared.

Results: After adjustment for baseline measurements, there was no significant difference in mean residual depression of the lateral tibial plateau between treatments groups after unloaded or loaded cyclic testing. Mean residual depression was less than 1 mm in both the treatment groups. Load to failure was statistically equivalent between treatment groups.

Conclusions: In our cadaveric study, in combination with calcium phosphate augmentation for both methods, percutaneous screw fixation conferred comparable strength of fixation compared with plate/screw constructs for treatment of OTA 41-B3 (Schatzker type II) tibial plateau fractures.
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http://dx.doi.org/10.1097/BOT.0000000000001177DOI Listing
July 2018

Arthroscopic knotless rotator cuff repair: Factors associated with construct selection and recent trends from a manual review of 1617 cases.

J Orthop 2018 Mar 31;15(1):216-221. Epub 2018 Jan 31.

Hofstra Northwell School of Medicine Department of Orthopaedic Surgery, United States.

Purpose: Our aim was to identify predictors of construct selection and recent trends for arthroscopic knotless rotator cuff repair (RCR).

Methods: A manual review of 1617 operative reports was performed.

Results: A medium-sized tear had a threefold increase in odds of single row (SR) knotless repair (OR, 6.91; p = 0.009) versus SR knotted (OR, 3.05; p = 0.003). Generalist orthopaedic surgeons were 79% less likely to perform SR knotless repairs versus sports medicine trained specialists (p < 0.001).

Conclusion: There was a significant increase from 2009 to 2016 in SR knotless and double row medial row knotless constructs contrasting the declining use of the SR knotted technique.
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http://dx.doi.org/10.1016/j.jor.2018.01.037DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5896168PMC
March 2018

Femoral Version Abnormalities Significantly Outweigh Effect of Cam Impingement on Hip Internal Rotation.

J Bone Joint Surg Am 2018 Feb;100(3):205-210

Department of Orthopedics, University of Colorado School of Medicine, Aurora, Colorado.

Background: The purpose of this study was to investigate the effects of femoral version, cam-type femoroacetabular impingement (FAI), and the combination of the 2 on the passive hip range of motion (ROM).

Methods: We prospectively analyzed a consecutive cohort of 220 patients (440 hips) who presented with unilateral or bilateral hip pain. The passive hip ROM was measured bilaterally with the patient in prone, supine, and lateral positions. Femoral version was measured and the presence of cam-type deformity was determined on preoperative computed tomography (CT) scans. Diagnostic findings of cam-type FAI included an alpha angle of >50° on CT radial sequences of the head-neck junction and a femoral head-neck offset ratio of <0.18 on both radiographs and CT.

Results: Multivariate linear regression analysis confirmed that femoral version, as compared with the presence of a cam lesion, was a stronger independent predictor of internal rotation ROM. Conversely, the presence of a cam lesion resulted in a significant decrease in the passive hip flexion ROM (p < 0.001) with no additional effects due to the degree of femoral version. The passive hip internal rotation ROM in neutral flexion/extension and with the hip in 90° of flexion were maximized in patients with femoral anteversion and decreased significantly with each incremental decrease in femoral version (p < 0.001).

Conclusions: Abnormalities in femoral version significantly outweigh the effect of cam-type impingement on the passive hip internal rotation ROM. In contrast, the presence of a cam lesion significantly decreases the hip flexion ROM, irrespective of the degree of femoral version. These findings help to inform surgical decision-making for patients with cam-type FAI or femoral version abnormalities.

Clinical Relevance: It is common clinical practice to ascribe loss of hip internal rotation to the presence of a cam lesion and to assume that arthroscopic femoral osteoplasty will substantially improve internal rotation postoperatively. Our study shows that the cam lesion is more intimately tied to hip flexion than to hip internal rotation. This result directly impacts the clinical assessment of a patient presenting with radiographic findings of FAI.
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http://dx.doi.org/10.2106/JBJS.17.00376DOI Listing
February 2018

MRI Evaluation of Repaired Versus Unrepaired Interportal Capsulotomy in Simultaneous Bilateral Hip Arthroscopy: A Double-Blind, Randomized Controlled Trial.

J Bone Joint Surg Am 2018 Jan;100(2):91-98

Departments of Radiology (C.D.S.) and Orthopaedics (O.M.-D.), University of Colorado School of Medicine, Aurora, Colorado.

Background: Techniques used in hip arthroscopy continue to evolve, and controversy surrounds the need for capsular repair following this surgical intervention. The purpose of this study was to evaluate the magnetic resonance imaging (MRI) appearance of the hip capsule in patients with femoroacetabular impingement (FAI) who underwent simultaneous bilateral hip arthroscopy through an interportal capsulotomy with each hip randomized to undergo capsular repair or not undergo such a repair.

Methods: This double-blind, randomized controlled trial included 15 patients (30 hips), with a mean age of 29.2 years, who underwent simultaneous bilateral hip arthroscopy utilizing a small (<3-cm) interportal capsulotomy for the treatment of FAI. The first hip treated in each patient was intraoperatively randomized to undergo capsular repair or no capsular repair. The contralateral hip then received the opposite treatment. MRI was performed at 6 and 24 weeks postoperatively, and the scans were analyzed by 2 musculoskeletal radiologists. The patients and the radiologists were blinded to the treatment performed on each hip. Capsular dimensions were measured at the level of the healing capsulotomy site and, for hips with a persistent defect, at locations both proximal and distal to the defect. These values were then analyzed at both time points to assess the rate and extent of capsular healing.

Results: At 6 weeks postoperatively, a continuous hip capsule (with no apparent capsulotomy defect) was observed in 8 hips treated with capsular repair and 3 hips without such a repair. Of the 19 hips with a discontinuous capsule at 6 weeks, 17 were available for follow-up at 24 weeks postoperatively; all 17 demonstrated progression to healing, with a contiguous appearance without defects and no difference in capsular dimensions between treatment cohorts.

Conclusions: Arthroscopic repair of a small interportal hip capsulotomy site yields an insignificant increase in the percentage of continuous hip capsules seen on MRI at 6 weeks postoperatively compared with no repair. Repaired and unrepaired capsulotomy sites progressed to healing with a contiguous appearance on MRI by 24 weeks postoperatively.

Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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http://dx.doi.org/10.2106/JBJS.17.00365DOI Listing
January 2018

Age and dressing type as independent predictors of post-operative infection in patients with acute compartment syndrome of the lower leg.

Int Orthop 2017 12 20;41(12):2591-2596. Epub 2017 Jul 20.

Department of Orthopaedic Surgery, Denver Health Medical Center, 777 Bannock Street, Denver, CO, 80204, USA.

Purpose: The purpose of this study was to determine independent factors, including timing of fasciotomy, that confer an increased risk of post-operative surgical site infection (SSI) in patients presenting with acute compartment syndrome (ACS) of the lower extremity.

Methods: A retrospective analysis was performed on a consecutive cohort of 53 adult patients requiring fasciotomy for lower-extremity fractures complicated by ACS presenting to a single Level I trauma center over a seven-year study period. The primary outcome measure was the incidence of SSI (as defined by the CDC) occurring within 12 months of fasciotomy. Explanatory variables including site of ACS, time of injury, time of fasciotomy, operative findings, and requirement for additional soft tissue coverage procedures were recorded for all patients. Multivariate regression was used to determine independent predictors of post-operative SSI.

Results: post-operative SSI was detected in 16 (30.2%) patients. Compared to infection-free patients, patients with post-operative SSI had a significantly higher median age (52.0 vs. 37.0 years, p = 0.010), frequency of intra-operative myonecrosis at time of fasciotomy (31.2% vs. 5.4%, p = 0.021), and requirement for negative-pressure wound therapy [NPWT] (93.7% vs. 45.9%, p = 0.002). Multivariate logistic regression analysis confirmed that requirement for NPWT (odds ratio [OR], 17.10; 95% confidence interval [CI], 1.78-164.0; p = 0.014) and increasing age (OR, 1.07; 95% CI, 1.01-1.14; p = 0.037) were independent predictors of post-operative SSI. Timing of fasciotomy following injury was not independently related to the risk of SSI.

Conclusions: ACS occurs on a spectrum of disease severity that evolves variably over time. Increasing age of the patient and requirement for NPWT following fasciotomy are independent predictors of post-operative SSI following emergent fasciotomy for ACS. Further studies are required to inform optimal treatment strategies in such patients.

Level Of Evidence: Therapeutic, Level III.
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http://dx.doi.org/10.1007/s00264-017-3576-1DOI Listing
December 2017

Locking screw-plate interface stability in carbon-fibre reinforced polyetheretherketone proximal humerus plates.

Int Orthop 2017 09 13;41(9):1735-1739. Epub 2017 Jul 13.

University of Colorado School of Medicine, Aurora, CO, USA.

Purpose: Carbon-fibre reinforced polyetheretherketone (CFR-PEEK) plates have recently been introduced for proximal humerus fracture treatment. The purpose of this study was to compare the locking screw-plate interface stability in CFR-PEEK versus stainless steel (SS) proximal humerus plates.

Methods: Locking screw mechanical stability was evaluated independently in proximal and shaft plate holes. Stiffness and load to failure were tested for three conditions: (1) on-axis locking screw insertion in CFR-PEEK versus SS plates, (2) on-axis locking screw insertion, removal, and reinsertion in CFR-PEEK plates, and (3) 10-degree off-axis locking screw insertion in CFR-PEEK plates. Cantilever bending at a rate of 1 mm/minute was produced by an Instron machine and load-displacement data recorded.

Results: Shaft locking screw load to failure was significantly greater in CFR-PEEK plates compared to SS plates (746.4 ± 89.7 N versus 596.5 ± 32.6 N, p < 0.001). The stiffness and load to failure of shaft locking screws was significantly decreased when inserted 10 degrees off-axis compared to on-axis in CFR-PEEK plates (p < 0.001). Stiffness and load to failure did not vary significantly following screw reinsertion in CFR-PEEK plates.

Conclusion: The mechanical stability of locking screws in CFR-PEEK plates is comparable or superior to locking screws in SS plates.
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http://dx.doi.org/10.1007/s00264-017-3562-7DOI Listing
September 2017

Diagnostic accuracy of various modalities relative to open bone biopsy for detection of long bone posttraumatic osteomyelitis.

Eur J Orthop Surg Traumatol 2017 Oct 25;27(7):871-875. Epub 2017 May 25.

Department of Orthopaedics, Denver Health Medical Center, School of Medicine, University of Colorado, 777 Bannock Street, Denver, CO, 80204, USA.

Background: Long bone posttraumatic osteomyelitis (PTOM) is a relatively common complication following surgical fixation of open fractures. There is a lacking consensus on ideal strategies for diagnostic evaluation of long bone PTOM. While open bone biopsy and culture is considered the 'gold diagnostic standard,' its cost and invasiveness are often prohibitive and have prompted the search for alternate diagnostic methods.

Objective: To evaluate the sensitivity and specificity of various diagnostic modalities relative to open bone biopsy and culture for the detection of long bone PTOM.

Design: Retrospective cohort study; Level of Evidence, III.

Setting: Urban Level I trauma center and safety-net institution.

Patients/participants: A consecutive cohort of 159 adult patients presenting with long bone PTOM at our Level I trauma center between January 1, 2004, and December 31, 2013, were retrospectively identified. All included patients fulfilled diagnostic criteria for PTOM (as defined by the Center for Disease Control and Prevention) that involved a long bone (femur, fibula, tibia, humerus, radius, and ulna). Patients with diabetic foot infection, septic arthritis, osteomyelitis of the spine/pelvis/hand, or insufficient medical records were excluded.

Main Outcome Measurements: Sensitivity and specificity of deep wound culture, soft tissue histopathologic examination, and elevated levels of acute phase reactants [C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and leukocyte count (WBC)] were determined using findings of open bone biopsy and culture as a reference standard.

Results: The most common pathogen isolated on open bone culture was staphylococci, contributing to 89 (57%) of 159 cases of long bone PTOM (p < 0.001). Relative to open bone biopsy and culture as the gold diagnostic standard, soft tissue histopathology demonstrated a sensitivity of 69.8% [95% confidence interval (CI) 53.7-82.3%] and specificity of 38.9% (95% CI 18.3-63.9%) for the detection of long bone PTOM. Deep wound culture exhibited a lower sensitivity of 66.0% (95% CI 56.1-74.8%) and specificity of 28.1% (95% CI 12.9-49.5%), a difference that was statistically significant (p = 0.021). Among inflammatory markers, elevated levels of CRP and ESR were equally sensitive for the detection of PTOM compared to open bone biopsy and culture, while WBC was significantly less sensitive (sensitivity 33.2%; 95% CI 25.3-43.7; p < 0.001).

Conclusion: Soft tissue histopathologic examination and deep wound culture are relatively poor substitutes for the diagnosis of long bone PTOM compared to open bone biopsy and culture. The accurate identification of causative pathogens underlying long bone PTOM is critical for diagnosis and choice of antibiotic treatment. Future studies investigating the use of higher-resolution diagnostic methods are merited.
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http://dx.doi.org/10.1007/s00590-017-1976-yDOI Listing
October 2017

Factors associated with adverse postoperative outcomes in patients with long bone post-traumatic osteomyelitis.

Eur J Orthop Surg Traumatol 2017 Oct 28;27(7):877-882. Epub 2017 Apr 28.

Department of Orthopaedics, Denver Health Medical Center, School of Medicine, University of Colorado, 777 Bannock Street, Denver, CO, 80204, USA.

Aims: To evaluate short-term clinical and functional outcomes following operative treatment of long bone post-traumatic osteomyelitis (PTOM).

Methods: We retrospectively analyzed a consecutive cohort of 142 adult patients undergoing operative treatment of long bone PTOM at our Level I trauma center over a 10-year study period. In addition to subjective patient evaluations, surveyed postoperative outcomes included incidence of residual infection, fracture malunion or nonunion, and requirement for limb amputation. All included patients had a minimum follow-up of 12 months postoperatively.

Results: Patients suffering an adverse postoperative outcome tended to have a higher incidence of polymicrobial infection (25.4 vs. 11.4%, p = 0.042) and requirement for skin grafting (58.1 vs. 37.9%, p = 0.024) and free-flap procedures (43.6 vs. 19.5%, p = 0.003) compared to those achieving complete healing. Sequential administration of parenteral and oral antibiotic therapies was associated with a reduced incidence of adverse postoperative outcome (p = 0.047).

Discussion: Patients with long bone PTOM and extensive soft tissue defects often fail to develop complete remission of their symptoms by 12 months postoperatively. Sequential administration of parenteral and oral antibiotics may help to limit infection recurrence. Further research is required to inform optimal treatment strategy.
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http://dx.doi.org/10.1007/s00590-017-1962-4DOI Listing
October 2017

Lateral acetabular coverage as a predictor of femoroacetabular cartilage thickness.

J Hip Preserv Surg 2016 Oct 10;3(4):262-269. Epub 2016 Nov 10.

Department of Orthopaedics, Division of Sports Medicine and Hip Preservation, University of Colorado School of Medicine, Aurora, CO 80045, USA.

To investigate the correlation between femoroacetabular cartilage thickness and lateral acetabular coverage in patients undergoing hip arthroscopy for a variety of indications. Articular cartilage at the hip is hypothesized to undergo adaptive change secondary to unique patterns of pathomechanical loading which results in a direct relationship between acetabular coverage and femoroacetabular cartilage thickness. A cohort of 252 patients presenting to our dedicated hip preservation service between June 2013 and June 2015 were retrospectively analysed. Preoperative radiographs and MRI studies were obtained for all symptomatic hips and classified according to radiographic lateral center edge angle (LCEA) as follows: normal acetabular coverage (25-40°), acetabular overcoverage (≥40°), borderline dysplasia (20-24.9°) and frank dysplasia (<20°). Femoroacetabular cartilage thickness was measured on a preoperative MRI-scan at the fovea, middle sourcil, and lateral sourcil. In all groups, cartilage thickness was maximized at the lateral sourcil relative to the middle sourcil or fovea ( < 0.001). Furthermore, articular cartilage thickness was significantly increased when comparing one group to successive groups with diminished lateral acetabular coverage. Indeed, multivariate analyses confirmed LCEA to be the strongest determinant of femoroacetabular cartilage thickness compared with age, gender, body-mass index or presence of cam/pincer lesions. Patients with borderline and frank dysplasia exhibit increased values of femoroacetabular cartilage thickness in the weight-bearing zone, potentially indicating a compensatory reaction to the lack of bony coverage. Articular cartilage thickness may serve as an instability marker and inform clinical decision-making for patients with borderline dysplasia.
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http://dx.doi.org/10.1093/jhps/hnw034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5883176PMC
October 2016

Effect of General Anesthesia on Preoperative Hip Range of Motion in Patients Undergoing Hip Arthroscopy.

Orthopedics 2016 Nov 18;39(6):e1165-e1169. Epub 2016 Aug 18.

The purpose of this study was to investigate the effect of general anesthesia on preoperative passive hip range of motion (ROM) in patients undergoing hip arthroscopy for various indications. A total of 260 consecutive patients undergoing hip arthroscopy were included in this study. Passive hip ROM was evaluated bilaterally in the clinic and subsequently under general anesthesia immediately preoperatively. Demographic variables, including age, height, weight, and clinical diagnosis, were recorded for all patients. Hips with pincer-type femoroacetabular impingement (FAI) and hips with acetabular dysplasia showed a mean increase of 4° and 6°, respectively, in hip external rotation at 90° of hip flexion (ER-90) with induction of anesthesia (P=.018 and P=.021, respectively). In contrast, a statistically significant reduction in hip abduction (2°) and hip flexion (4°) was observed following induction of anesthesia in healthy contralateral hips of patients presenting with unilateral hip pathology (P=.01 and P<.001, respectively). Hip ROM does not change to a clinically significant extent with induction of general anesthesia. Small increases in external rotation in patients with FAI or acetabular dysplasia are within the standard error for ROM measurements. [Orthopedics. 2016; 39(6):e1165-e1169.].
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http://dx.doi.org/10.3928/01477447-20160811-03DOI Listing
November 2016

All-Arthroscopic Ligamentum Teres Reconstruction With Graft Fixation at the Femoral Head-Neck Junction.

Arthrosc Tech 2016 Feb 15;5(1):e143-7. Epub 2016 Feb 15.

Hip Preservation Center, Sports Medicine, Orthopedics Department, University of Colorado, Aurora, Colorado, U.S.A.

Ligamentum teres (LT) tears are increasingly being recognized as a source of pain and dysfunction in the hip. Although debridement for partial tears of the LT has long been established as the standard of care with good pain relief, reconstruction has been successfully performed in select patients to address concerns of persistent symptomatic instability. The current technique for femoral tunnel preparation carries the added morbidity of open dissection in the peritrochanteric space, an unnecessarily long tunnel with excessive bone removal, and a need for a very long graft due to distal fixation at the lateral femoral cortex. To address these shortcomings, we present a technique for arthroscopic femoral tunnel drilling at the level of the head-neck junction, allowing for an all-arthroscopic LT reconstruction.
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http://dx.doi.org/10.1016/j.eats.2015.10.020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4886042PMC
February 2016

Delayed Anterior Cruciate Ligament Reconstruction in Young Patients With Previous Anterior Tibial Spine Fractures.

Am J Sports Med 2016 Aug 6;44(8):2047-56. Epub 2016 May 6.

Department of Orthopaedic Surgery, University of Colorado Hospital, Aurora, Colorado, USA Department of Orthopedic Surgery, Children's Hospital of Colorado, Aurora, Colorado, USA.

Background: Avulsion fractures of the anterior tibial spine in young athletes are injuries similar to anterior cruciate ligament (ACL) injuries in adults. Sparse data exist on the association between anterior tibial spine fractures (ATSFs) and later ligamentous laxity or injuries leading to ACL reconstruction.

Purpose: To better delineate the incidence of delayed instability or ACL ruptures requiring delayed ACL reconstruction in young patients with prior fractures of the tibial eminence.

Study Design: Case series; Level of evidence, 4.

Methods: We identified 101 patients between January 1993 and January 2012 who sustained an ATSF and who met inclusion criteria for this study. All patients had been followed for at least 2 years after the initial injury and were included for analysis after completion of a questionnaire via direct contact, mail, and/or telephone. If patients underwent further surgical intervention and/or underwent later ACL reconstruction, clinical records and operative reports pertaining to these secondary interventions were obtained and reviewed. Differences between categorical variables were assessed using the Fisher exact test. The association between time to revision ACL surgery and fracture type was assessed by Kaplan-Meier plots. The association between need for revision ACL surgery and age, sex, and mechanism of surgery was assessed using logistic regression.

Results: Nineteen percent of all patients evaluated underwent delayed ACL reconstruction after a previous tibial spine fracture on the ipsilateral side. While there were a higher proportion of ACL reconstructions in type II fractures, there was not a statistically significant difference in the number of patients within each fracture group who went on to undergo later surgery (P = .29). Further, there was not a significant association between fracture type, sex, or mechanism of injury as it related to the progression to later ACL reconstruction. However, there was a significant association between age at the time of injury and progression to later ACL reconstruction (P = .02). For every year increase in age at the time of injury, the odds of going on to undergo delayed ACL reconstruction were greater by a factor of 1.3 (95% CI, 1.1-1.6).

Conclusion: Although an ATSF is a relatively rare injury, our cohort of patients suggests that a subset of young patients with all types of tibial spine fractures will require later ACL reconstruction. There is a need to counsel patients that a delayed ACL rupture is a potential risk after an ATSF, especially as children approach skeletal maturity. Further patient follow-up and prospective studies are required.
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http://dx.doi.org/10.1177/0363546516644597DOI Listing
August 2016

Arthroscopic Bone Grafting of Deep Acetabular Cysts Using a Curved Delivery Device.

Arthrosc Tech 2016 Feb 1;5(1):e113-9. Epub 2016 Feb 1.

Hip Preservation Center, Sports Medicine, Orthopedics Department, University of Colorado, Aurora, Colorado, U.S.A.

Acetabular intraosseous cysts are frequently encountered in patients with dysplasia or femoroacetabular impingement. Small cysts are typically addressed by removing the cyst lining and stimulating healing via microfracture or abrasion chondroplasty. In contrast, larger cysts involving 1-3 cm(3) frequently require additional fortification with bone graft material to facilitate osseous ingrowth and cyst healing. Previous arthroscopic reports have described the use of rim trimming to access the extra-articular side of the cyst, with subsequent use of straight metal cannulas for delivery of bone graft material. The downsides of this technique include the requirement for rim trimming, which may be ill advised in patients with normal coverage or dysplasia, as well as the creation of a second breach in the cyst wall, precluding pressurization of the bone graft material. We describe an arthroscopic technique using a curved delivery device allowing for deeper penetration into the cyst cavity through the articular side and greater delivery of bone graft material.
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http://dx.doi.org/10.1016/j.eats.2015.10.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4811202PMC
February 2016

Measurement of lateral acetabular coverage: a comparison between CT and plain radiography.

J Hip Preserv Surg 2015 Dec 22;2(4):392-400. Epub 2015 Oct 22.

2. Department of Orthopaedic Surgery, Division of Sports Medicine and Hip Preservation.

Unlabelled: We prospectively evaluated the degree of absolute agreement between measurements of lateral center-edge angle (LCEA) on plain radiography (XR) and computed tomography (CT) in a consecutive cohort of 205 patients (410 hips) undergoing hip arthroscopy. Preoperative measurements of the LCEA were performed bilaterally utilizing standardized anteroposterior radiographs and coronal reformatted CT scans. Demographic variables including age, gender, height, weight, BMI and clinical diagnosis were recorded for all patients. Overall, measured values of the LCEA were 2.1° larger on CT compared with XR (32.9° versus 30.8°, P < 0.001). Subgroup analysis revealed the highest mean difference in hips with acetabular dysplasia and concomitant cam-type femoroacetabular impingement (FAI) [mean difference (CT-XR) 5.5°, 95% confidence interval (CI) 3.7°-7.3°, P = 0.011], followed by hips with isolated acetabular dysplasia (mean difference [CT-XR] 4.9°, 95% CI 2.7°-7.0°, P < 0.001). In contrast, 119 (29.0%) of the hips demonstrated larger measurements of the LCEA on 25 XR relative to CT. Of these hips, 20 (16.8%) had pincer-FAI and 25 had cam-FAI (21.0%), representing a significantly higher proportion compared with all other clinical subgroups (P = 0.045 and 0.036, respectively). Our study demonstrates measured values of the LCEA are consistently inflated on CT relative to XR for a wide variety of hip pathologies, highlighting the need for standardization and validation of CT-based measurements to improve the quality of clinical decision making.

Level Of Evidence: Diagnostic Level II.
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http://dx.doi.org/10.1093/jhps/hnv063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4732381PMC
December 2015

Lateral Acetabular Coverage Predicts the Size of the Hip Labrum.

Am J Sports Med 2016 Jun 17;44(6):1582-9. Epub 2016 Mar 17.

Division of Sports Medicine and Hip Preservation, Department of Orthopaedics, University of Colorado School of Medicine, Aurora, Colorado, USA

Background: Bony morphological abnormalities of the hip joint are often accompanied by adaptive soft tissue changes. These adaptive changes, if better understood and characterized, may serve to inform clinical decision making.

Purpose: To investigate the correlation between the size of the hip labrum and lateral acetabular coverage in patients at our hip preservation clinic.

Study Design: Cross-sectional study; Level of evidence, 3.

Methods: A cohort of 236 patients seen at a dedicated hip preservation service between June 2013 and June 2015 were retrospectively analyzed. Patients were grouped according to the degree of acetabular coverage, as measured by the lateral center-edge angle (LCEA): normal acetabular coverage (25°-39.9°), acetabular overcoverage (≥40°), borderline dysplasia (20°-24.9°), and frank dysplasia (<20°). Preoperative magnetic resonance imaging was utilized to measure the length of the labrum at 3 locations: laterally, anteriorly, and anteroinferiorly.

Results: Frankly dysplastic and borderline dysplastic hips exhibited larger values of labral length at all locations when compared with hips with normal acetabular coverage (P < .001) or acetabular overcoverage (P < .001). Interestingly, mean labral length values in frank dysplasia were statistically similar to corresponding measurements in borderline dysplasia. In hips with frank dysplasia, borderline dysplasia, or normal acetabular coverage, labral length was consistently greatest at the lateral labrum and correspondingly lowest at the anteroinferior labrum (P < .001). In hips with acetabular overcoverage, labral length did not vary significantly between the lateral, anterior, and anteroinferior locations. Multivariate analyses confirmed LCEA to be the strongest predictor of labral length, irrespective of measurement location.

Conclusion: Patients with borderline dysplasia and frank dysplasia exhibited increased values of labral length in the weightbearing zone, potentially indicating a compensatory reaction to the lack of bony coverage. Labral length may serve as an instability marker and inform clinical decision making for patients with borderline dysplasia.
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http://dx.doi.org/10.1177/0363546516634058DOI Listing
June 2016

Passive Hip Range of Motion Predicts Femoral Torsion and Acetabular Version.

J Bone Joint Surg Am 2016 Jan;98(2):127-34

Division of Sports Medicine and Hip Preservation (T.G., C.P.-G., and O.M.-D.), Department of Orthopaedics, University of Colorado School of Medicine (V.C.), Aurora, Colorado

Background: Orientation abnormalities of the acetabulum and femur have been implicated in early-onset coxarthrosis. The purpose of this study was to identify clinical examination findings predictive of such hip morphologies.

Methods: A consecutive cohort of 221 patients (442 hips) undergoing hip arthroscopy was included. Demographic characteristics including age, diagnosis, sex, height, weight, body mass index (BMI), and physical activity level were recorded. Passive range of motion was measured for all hips. Preoperative computed tomography scans were utilized to measure femoral torsion and central acetabular version, and a combined femoral torsion-acetabular version (COTAV) index was defined as their sum.

Results: The study cohort comprised 221 patients (sixty-four males, 157 females) with a mean age of 32.5 years and mean BMI of 24.2 kg/m(2). Overall, hips with femoral antetorsion and acetabular anteversion exhibited the greatest internal rotation range of motion at a neutral hip position (mean, 44.2°), whereas hips with femoral retrotorsion and acetabular retroversion demonstrated the lowest corresponding value (20.1°; p < 0.001). Femoral torsion was significantly associated with female sex (p < 0.001), BMI (p < 0.001), and presence of pathology corresponding to cam-type femoroacetabular impingement (FAI) (p = 0.044). Central acetabular version was significantly associated with age (p = 0.021), female sex (p < 0.001), and absence of mixed-type FAI pathology (p = 0.025). Increasing age and internal rotation range of motion at a neutral hip position were the most significant predictors of an increased COTAV index.

Conclusions: This study confirmed that passive hip range of motion significantly predicts combined femoral torsion and central acetabular version. Accurate clinical assessment of the COTAV index may inform surgical decision-making in hip preservation surgery.
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http://dx.doi.org/10.2106/JBJS.O.00334DOI Listing
January 2016

Reconstruction of Long Bone Infections Using the Induced Membrane Technique: Tips and Tricks.

J Orthop Trauma 2016 Jun;30(6):e188-93

*Department of Orthopaedics, Denver Health Medical Center, University of Colorado, School of Medicine, Denver, CO; †Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI; and ‡Service de chirurgie orthope[Combining Acute Accent]dique, traumatologique, ho[Combining Circumflex Accent]pital Saint-Antoine, Paris, France.

Unlabelled: The management of posttraumatic long bone osteomyelitis remains a challenging clinical problem. A systematic approach is necessary, beginning with eradication of the infected bone and soft tissue. There are a number of options for reconstruction of the remaining bone defect, including the induced membrane technique developed by Masquelet. We describe our technique for the 2-stage treatment of long bone osteomyelitis. The first stage involves a radical debridement, stabilization of the bone with either external fixation or an antibiotic-coated intramedullary nail, and placement of a polymethylmethacrylate spacer. The second stage includes excision of the spacer and placement of autologous bone graft. Various resection methods, fixation strategies, antibiotic additives, and types of bone grafts or substitutes can be used. The purpose of our technical article is to share our personal experience and describe several nuances that are critical for the success of this treatment strategy.

Level Of Evidence: Therapeutic 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.0000000000000500DOI Listing
June 2016

Does the OTA Open Fracture Classification Predict the Need for Limb Amputation? A Retrospective Observational Cohort Study on 512 Patients.

J Orthop Trauma 2016 Apr;30(4):194-8

*Department of Orthopaedics, Denver Health Medical Center, School of Medicine, University of Colorado, Denver, CO; and †Department of Orthopaedic Surgery, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, Republic of Korea.

Background: Few studies have examined the utility of the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) compared to the traditional Gustilo-Anderson classification for prediction of treatment outcomes in patients with open fractures. QUESTIONS/OBJECTIVES:: (1) How do the Gustilo-Anderson classification and OTA-OFC systems compare in accuracy of predicting limb amputation, infection, and need for soft tissue coverage? (2) Is there an OTA-OFC summative threshold score that may guide the discussion and decision-making with regard to limb salvage or amputation?

Design: Retrospective observational cohort study; Level IV evidence.

Setting: Level I trauma center and urban safety-net institution.

Patients/participants: Consecutive adult patients with open long bone fractures who underwent operative treatment between January 1, 2007 and December 31, 2012.

Main Outcome And Measurements: Postoperative complications of infection, early limb amputation, and requirement for soft-tissue procedures.

Results: The study cohort comprised 512 patients with mean age 49.6 ± 14.9 years. Nineteen patients (3.7%) underwent amputation. The Gustilo-Anderson classification demonstrated no correlations with any of the primary outcome measures, while OTA-OFC summative scores significantly varied between all outcome comparison groups. The skin injury component of the OTA-OFC was an independent predictor of limb amputation (OR, 5.44; 95% CI, 2.37-12.47), and an OTA-OFC summative score of ≥10 best correlated with need for amputation (P < 0.001). Sensitivity and specificity of the reported model were 79% and 94%, respectively.

Conclusions: Our results should be interpreted with caution due to the retrospective nature of our study. Based on our data, the OTA-OFC is superior to the Gustilo-Anderson classification system for prediction of postoperative complications and treatment outcomes in patients with open long bone fractures. A summative threshold score of 10 seems to identify increased odds of successful limb salvage.
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http://dx.doi.org/10.1097/BOT.0000000000000479DOI Listing
April 2016

Percutaneous Ultrasound-Guided Hydrodissection of a Symptomatic Sural Neuroma.

Orthopedics 2015 Nov;38(11):e1046-50

Symptomatic neuromas of the sural nerve are a rare but significant cause of pain and debilitation in athletes. Presentation is usually in the form of chronic pain and dysesthesias or paresthesias of the lateral foot and ankle. Treatment traditionally ranges from conservative measures, such as removing all external compressive forces, to administration of nonsteroidal anti-inflammatory drugs, vitamin B6, tricyclic antidepressants, antiepileptics, or topical anesthetics. This article reports a case of sural nerve entrapment in a 34-year-old male triathlete with a history of recurrent training-induced right-sided gastrocnemius strains. The patient presented with numbness in the right lateral foot and ankle that had persisted for 3 months, after he was treated unsuccessfully with extensive nonoperative measures, including anti-inflammatory drugs, activity modification, and a dedicated physical therapy program of stretching and strengthening. Orthopedic assessment showed worsening pain with forced passive dorsiflexion and manual pressure applied over the distal aspect of the gastrocnemius. Plain radiographs showed normal findings, but in-office ultrasound imaging showed evidence of sural nerve entrapment with edema and neuromatous scar formation in the absence of gastrocnemius or soleus pathology. Percutaneous ultrasound-guided hydrodissection of the sural nerve at the area of symptomatic neuroma and neural edema was performed the same day. The patient had complete relief of symptoms and full return to the preinjury level of participation in competitive sports. This case report shows that hydrodissection, when performed by an experienced physician, can be an effective, minimally invasive technique for neurolysis in the setting of sural nerve entrapment, resulting in improvement in clinical symptoms.
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http://dx.doi.org/10.3928/01477447-20151020-15DOI Listing
November 2015

Innovative strategies for the management of long bone infection: a review of the Masquelet technique.

Patient Saf Surg 2015 14;9:32. Epub 2015 Oct 14.

Department of Orthopaedic Surgery, Denver Health Medical Center, University of Colorado, School of Medicine, 777 Bannock Street, Denver, CO 80204 USA.

Post-traumatic long bone osteomyelitis (PTOM) is a relatively frequent occurrence in patients with severe open fractures and requires treatment to prevent limb-threatening complications. The Masquelet technique represents a length-independent, two-staged reconstruction that involves the induction of a periosteal membrane and use of an antibiotic-impregnated cement spacer for the treatment of segmental bone loss that result from bone infection. In this review, we summarize recent developments regarding the diagnosis and treatment of long bone PTOM, with a special emphasis on the use of the Masquelet technique for reconstruction of wide diaphyseal defects.
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http://dx.doi.org/10.1186/s13037-015-0079-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4604613PMC
October 2015

Transarticular plating for acute posterior sternoclavicular joint dislocations: a valid treatment option?

Int Orthop 2016 Jul 11;40(7):1503-8. Epub 2015 Aug 11.

Department of Orthopaedics, Denver Health Medical Centre, University of Colorado, School of Medicine, 777 Bannock Street, Denver, CO, 80204, USA.

Background: Restoration of the sternoclavicular joint after posterior dislocation is important for upper limb function. The proximity of neuro-vascular mediastinal structures makes open reduction and internal fixation (ORIF) a high-risk procedure. The ideal treatment strategy is still debated. Our aim is to review the treatment of acute posterior sternoclavicular joint dislocation with a locking compression plate.

Materials And Methods: We present our experience of transarticular plating using a locking compression plate for the treatment of three consecutive patients with posterior sternoclavicular dislocation (SCD). Our primary outcome measure was objective functional outcome using DASH (disability of the arm, shoulder and hand) and PROMIS (patient-reported outcomes measurement information system) questionnaires. All patients had a minimum follow-up of six months, and serial radiographs were reviewed to evaluate maintenance of reduction.

Results: All three patients presented a posterior SCD with instability refractory to closed reduction. In all three patients, we opted for surgical management using open reduction and fixation with a locking compression plate and allowed early mobilization at two weeks postoperatively. No complications were encountered during follow-up. Good functional outcomes were evidenced by DASH scores of 7.5, 20 and 30, and PROMIS scores were 53.8, 53.8 and 38.1 in each patient, respectively.

Conclusion: Our experience of transarticular plating using a locking compression plate for posterior SCD is positive, as it allows early mobilization and resulted in good functional outcomes.
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http://dx.doi.org/10.1007/s00264-015-2952-yDOI Listing
July 2016

An observational case series of HIV-positive patients treated with open reduction internal fixation for a closed lower extremity fracture.

Eur J Orthop Surg Traumatol 2015 Jul 4;25(5):815-9. Epub 2015 Feb 4.

Department of Orthopaedics, Denver Health Medical Center, School of Medicine, University of Colorado, 777 Bannock Street, Denver, CO, 80204, USA.

Objectives: The purpose of this study was to investigate the influence of immune deficiency status of HIV-positive patients on postoperative complication such as surgical site infection and nonunions.

Design: Retrospective observational cohort study: Level III.

Setting: Level I trauma center.

Patients/participants: Consecutive adult HIV-positive patients with closed fractures who underwent operative treatment between January 1, 2001 and December 31, 2012.

Main Outcome And Measurements: postoperative complication including infection and fracture nonunion.

Results: A total of 42 HIV-positive patients with closed fractures who underwent surgical fracture fixation were identified during the 12-year study time window. Of these, 18 patients were excluded due to incomplete medical records (n = 16) or open fractures (n = 2). The remaining 24 patients with closed fracture treated surgically (19 males and 5 females; mean age 45.1 ± 10.5 years; age range 20-67 years) were included in the study. Within a 6-month period from the time of injury, 16 patients had a CD4+ cell count >200 and five patients had a CD4+ cell count <200 (CD4+ cell count was not available in three patients). Twenty-two patients (91.6 %) were on antiretroviral therapy at the time of injury. Only one patient, with associated end-stage renal failure and diabetes mellitus, developed a postoperative infection (4.2 %). All patients achieved fracture union within 180 days postoperatively, without the need for surgical revisions.

Conclusions: Our study suggests that HIV infection does not seem to correlate with a higher risk for the development of postoperative complication related to surgical site infection and fracture nonunions after operative fixation of closed fractures.
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http://dx.doi.org/10.1007/s00590-015-1595-4DOI Listing
July 2015