Orthopedics

Taniguchi, A., Alejandro, S.F., Kane, J.M., Daoud, Y., Tanaka, Y., Ford, S.E. and Brodsky, J.W. (2021). “Association of Cavovarus Foot Alignment With Peroneal Tendon Tears.” Foot Ankle Int: 1071100721990348.

Full text of this article.

BACKGROUND: Although it is a widely accepted clinical principle that cavovarus deformity predisposes to peroneal tendon problems, there are limited data to support that assumption. This study tested the hypothesis that cavovarus is associated with peroneal tendon tears and evaluated which radiographic measures correlated with that association. METHODS: A retrospective comparison of radiographic measures of cavovarus in 234 consecutive patients operatively treated for chronically symptomatic peroneal tendon tears was compared to a matched control group. Measures included calcaneal pitch, anteroposterior (AP) talometatarsal and talocalcaneal angles, and talonavicular coverage angle. A novel coordinate system analyzed midfoot and hindfoot components of cavovarus. Analysis of variance was used to compare cohorts, and a Tukey-Kramer test used to analyze 3 subgroups of brevis and longus tears, and concomitant tears. RESULTS: The distribution of tears was 73% peroneus brevis, 8% longus, and 19% both tendons. Compared with controls, the study group, and subgroups, had multiple measures of increased cavovarus, including greater calcaneal pitch (P = .0001), decreased AP talo-first metatarsal angle (P = .0001), and increased talonavicular coverage angle (P = .0001). Elevated medial longitudinal arch, and rotational changes in the radiographic profiles of the hindfoot were found with the coordinate system described by Yokokura. CONCLUSION: This study found a statistically significant association of increased cavovarus deformity with peroneal tendon tears, compared to controls. It documented the relative incidence of tears of peroneus brevis, peroneus longus, and concomitant tears in a large surgical series. It demonstrated which simple radiographic angles and complex coordinate measurements of cavovarus deformity were significantly associated with peroneal tendon tears. LEVEL OF EVIDENCE: Level III, retrospective comparative cohort study.

O’Toole, R.V., Joshi, M., Carlini, A.R., Murray, C.K., Allen, L.E., Huang, Y., Scharfstein, D.O., O’Hara, N.N., Gary, J.L., Bosse, M.J., Castillo, R.C., Bishop, J.A., Weaver, M.J., Firoozabadi, R., Hsu, J.R., Karunakar, M.A., Seymour, R.B., Sims, S.H., Churchill, C., Brennan, M.L., Gonzales, G., Reilly, R.M., Zura, R.D., Howes, C.R., Mir, H.R., Wagstrom, E.A., Westberg, J., Gaski, G.E., Kempton, L.B., Natoli, R.M., Sorkin, A.T., Virkus, W.W., Hill, L.C., Hymes, R.A., Holzman, M., Malekzadeh, A.S., Schulman, J.E., Ramsey, L., Cuff, J.A.N., Haaser, S., Osgood, G.M., Shafiq, B., Laljani, V., Lee, O.C., Krause, P.C., Rowe, C.J., Hilliard, C.L., Morandi, M.M., Mullins, A., Achor, T.S., Choo, A.M., Munz, J.W., Boutte, S.J., Vallier, H.A., Breslin, M.A., Frisch, H.M., Kaufman, A.M., Large, T.M., LeCroy, C.M., Riggsbee, C., Smith, C.S., Crickard, C.V., Phieffer, L.S., Sheridan, E., Jones, C.B., Sietsema, D.L., Reid, J.S., Ringenbach, K., Hayda, R., Evans, A.R., Crisco, M.J., Rivera, J.C., Osborn, P.M., Kimmel, J., Stawicki, S.P., Nwachuku, C.O., Wojda, T.R., Rehman, S., Donnelly, J.M., Caroom, C., Jenkins, M.D., Boulton, C.L., Costales, T.G., LeBrun, C.T., Manson, T.T., Mascarenhas, D.C., Nascone, J.W., Pollak, A.N., Sciadini, M.F., Slobogean, G.P., Berger, P.Z., Connelly, D.W., Degani, Y., Howe, A.L., Marinos, D.P., Montalvo, R.N., Reahl, G.B., Schoonover, C.D., Schroder, L.K., Vang, S., Bergin, P.F., Graves, M.L., Russell, G.V., Spitler, C.A., Hydrick, J.M., Teague, D., Ertl, W., Hickerson, L.E., Moloney, G.B., Weinlein, J.C., Zelle, B.A., Agarwal, A., Karia, R.A., Sathy, A.K., Au, B., Maroto, M., Sanders, D., Higgins, T.F., Haller, J.M., Rothberg, D.L., Weiss, D.B., Yarboro, S.R., McVey, E.D., Lester-Ballard, V., Goodspeed, D., Lang, G.J., Whiting, P.S., Siy, A.B., Obremskey, W.T., Jahangir, A.A., Attum, B., Burgos, E.J., Molina, C.S., Rodriguez-Buitrago, A., Gajari, V., Trochez, K.M., Halvorson, J.J., Miller, A.N., Goodman, J.B., Holden, M.B., McAndrew, C.M., Gardner, M.J., Ricci, W.M., Spraggs-Hughes, A., Collins, S.C., Taylor, T.J. and Zadnik, M. (2021). “Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial.” JAMA Surg 156(5): e207259.

Full text of this article.

IMPORTANCE: Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. OBJECTIVE: To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. DESIGN, SETTING, AND PARTICIPANTS: This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. INTERVENTIONS: A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. MAIN OUTCOMES AND MEASURES: The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. RESULTS: The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. CONCLUSIONS AND RELEVANCE: Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02227446.

Wood, D.S., Watson, S.L., Eckel, T.M., Peters, P.C., Jr., Kitziger, K.J. and Gladnick, B.P. (2021). “Decreased costs with maintained patient satisfaction after total joint arthroplasty in a physician-owned hospital.” J Orthop 24: 212-215.

Full text of this article.

OBJECTIVE: Comparing total joint arthroplasty (TJA) costs and patient-reported outcomes between a physician-owned hospital (POH) and a non-POH. METHODS: Costs for each 90-day TJA episode at both facilities were determined, and patients were asked to complete a patient satisfaction questionnaire. RESULTS: Average TJA episode cost was $19,039 at the POH, compared to $21,302 at the non-POH, a difference of $2,263 (p = 0.03), largely driven by decreased skilled nursing facility utilization in the POH group. There were no differences between groups for patient satisfaction. CONCLUSION: TJA can be performed at reduced cost with comparable patient satisfaction at POHs, compared to non-POH facilities.

Verhey, J.T., Verhey, E., Holland, D., Baker, J.C. and Long, J.R. (2021). “Ulnar shaft stress fractures in fast-pitch softball pitchers: a case series and proposed mechanism of injury.” Skeletal Radiol 50(4): 835-840.

Full text of this article.

BACKGROUND: Stress fractures of the upper extremities in athletes are important injuries for radiologists to appreciate despite being far less common than stress fractures of the lower extremities. Among upper extremity stress fractures, those involving the olecranon have been well described in overhead pitching athletes. Isolated stress fractures of the ulnar shaft however are less commonly reported in the literature and considered to be rare. We have observed a correlation between young patients with ulnar shaft stress fractures and the activity of fast-pitch softball pitching. CASE REPORTS: In this series, we present the imaging findings in four cases of ulnar shaft stress fractures in softball pitchers who presented with insidious onset forearm pain. Furthermore, a review of the literature focusing on softball pitching mechanics is provided to offer a potential underlying mechanism for the occurrence and location of these injuries. CONCLUSION: An awareness of the imaging appearance of ulnar shaft stress fractures along with an understanding of its proposed mechanism will facilitate accurate and timely imaging diagnosis of this injury by the radiologist.

O’Toole, R.V., Joshi, M., Carlini, A.R., Murray, C.K., Allen, L.E., Huang, Y., Scharfstein, D.O., O’Hara, N.N., Gary, J.L., Bosse, M.J., Castillo, R.C., Bishop, J.A., Weaver, M.J., Firoozabadi, R., Hsu, J.R., Karunakar, M.A., Seymour, R.B., Sims, S.H., Churchill, C., Brennan, M.L., Gonzales, G., Reilly, R.M., Zura, R.D., Howes, C.R., Mir, H.R., Wagstrom, E.A., Westberg, J., Gaski, G.E., Kempton, L.B., Natoli, R.M., Sorkin, A.T., Virkus, W.W., Hill, L.C., Hymes, R.A., Holzman, M., Malekzadeh, A.S., Schulman, J.E., Ramsey, L., Cuff, J.A.N., Haaser, S., Osgood, G.M., Shafiq, B., Laljani, V., Lee, O.C., Krause, P.C., Rowe, C.J., Hilliard, C.L., Morandi, M.M., Mullins, A., Achor, T.S., Choo, A.M., Munz, J.W., Boutte, S.J., Vallier, H.A., Breslin, M.A., Frisch, H.M., Kaufman, A.M., Large, T.M., LeCroy, C.M., Riggsbee, C., Smith, C.S., Crickard, C.V., Phieffer, L.S., Sheridan, E., Jones, C.B., Sietsema, D.L., Reid, J.S., Ringenbach, K., Hayda, R., Evans, A.R., Crisco, M.J., Rivera, J.C., Osborn, P.M., Kimmel, J., Stawicki, S.P., Nwachuku, C.O., Wojda, T.R., Rehman, S., Donnelly, J.M., Caroom, C., Jenkins, M.D., Boulton, C.L., Costales, T.G., LeBrun, C.T., Manson, T.T., Mascarenhas, D.C., Nascone, J.W., Pollak, A.N., Sciadini, M.F., Slobogean, G.P., Berger, P.Z., Connelly, D.W., Degani, Y., Howe, A.L., Marinos, D.P., Montalvo, R.N., Reahl, G.B., Schoonover, C.D., Schroder, L.K., Vang, S., Bergin, P.F., Graves, M.L., Russell, G.V., Spitler, C.A., Hydrick, J.M., Teague, D., Ertl, W., Hickerson, L.E., Moloney, G.B., Weinlein, J.C., Zelle, B.A., Agarwal, A., Karia, R.A., Sathy, A.K., Au, B., Maroto, M., Sanders, D., Higgins, T.F., Haller, J.M., Rothberg, D.L., Weiss, D.B., Yarboro, S.R., McVey, E.D., Lester-Ballard, V., Goodspeed, D., Lang, G.J., Whiting, P.S., Siy, A.B., Obremskey, W.T., Jahangir, A.A., Attum, B., Burgos, E.J., Molina, C.S., Rodriguez-Buitrago, A., Gajari, V., Trochez, K.M., Halvorson, J.J., Miller, A.N., Goodman, J.B., Holden, M.B., McAndrew, C.M., Gardner, M.J., Ricci, W.M., Spraggs-Hughes, A., Collins, S.C., Taylor, T.J. and Zadnik, M. (2021). “Effect of Intrawound Vancomycin Powder in Operatively Treated High-risk Tibia Fractures: A Randomized Clinical Trial.” JAMA Surg Mar 24;e207259. [Epub ahead of print]. e207259.

Full text of this article.

IMPORTANCE: Despite the widespread use of systemic antibiotics to prevent infections in surgically treated patients with fracture, high rates of surgical site infection persist. OBJECTIVE: To examine the effect of intrawound vancomycin powder in reducing deep surgical site infections. DESIGN, SETTING, AND PARTICIPANTS: This open-label randomized clinical trial enrolled adult patients with an operatively treated tibial plateau or pilon fracture who met the criteria for a high risk of infection from January 1, 2015, through June 30, 2017, with 12 months of follow-up (final follow-up assessments completed in April 2018) at 36 US trauma centers. INTERVENTIONS: A standard infection prevention protocol with (n = 481) or without (n = 499) 1000 mg of intrawound vancomycin powder. MAIN OUTCOMES AND MEASURES: The primary outcome was a deep surgical site infection within 182 days of definitive fracture fixation. A post hoc comparison assessed the treatment effect on gram-positive and gram-negative-only infections. Other secondary outcomes included superficial surgical site infection, nonunion, and wound dehiscence. RESULTS: The analysis included 980 patients (mean [SD] age, 45.7 [13.7] years; 617 [63.0%] male) with 91% of the expected person-time of follow-up for the primary outcome. Within 182 days, deep surgical site infection was observed in 29 of 481 patients in the treatment group and 46 of 499 patients in the control group. The time-to-event estimated probability of deep infection by 182 days was 6.4% in the treatment group and 9.8% in the control group (risk difference, -3.4%; 95% CI, -6.9% to 0.1%; P = .06). A post hoc analysis of the effect of treatment on gram-positive (risk difference, -3.7%; 95% CI, -6.7% to -0.8%; P = .02) and gram-negative-only (risk difference, 0.3%; 95% CI, -1.6% to 2.1%; P = .78) infections found that the effect of vancomycin powder was a result of its reduction in gram-positive infections. CONCLUSIONS AND RELEVANCE: Among patients with operatively treated tibial articular fractures at a high risk of infection, intrawound vancomycin powder at the time of definitive fracture fixation reduced the risk of a gram-positive deep surgical site infection, consistent with the activity of vancomycin. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02227446.