Wellings, Elizabeth P.

Summary: Bone defects are among the most challenging problems treated by limb reconstruction surgeons and orthopaedic traumatologists. Bone transport is a biological reconstruction technique which harnesses distraction osteogenesis to create new bone in critical bone defect. This technique has been successfully performed with a variety of internal and external solutions. This work introduces a newly available technology which provides a fully implantable, all-internal solution (eg, without the need for external fixation) for bone transport with the option to simultaneously address residual limb length discrepancy.

Abstract Objective: Determine if automated struts can successfully power a balanced cable transport (BCT) during tibial bone transport and thus benefit from the advantages of automation. Design: Retrospective observational case series. Setting: Level 1 trauma center. Patients/Participants: A retrospective analysis of 7 tibial BCTs using automated struts was performed with an average defect size of 102 mm. Outcomes: Union rate, complications, external fixation index, bone healing index, and mechanical alignment. Results: The average bone healing index was found to be 21.9 days/cm in bifocal BCT and 13.7 days/cm in trifocal BCT. Automated struts successfully powered 7 BCTs but were not without complications. Four patients had strut malfunctions necessitating unscheduled return to clinic. Other complications not secondary to the struts included pin tract infections (n = 4) and unplanned return to the operating room (n = 2, docking site nonunion and revision ankle arthrodesis). Conclusions: Automated struts powering BCT is feasible but not without complications. This treatment strategy combines the advantages of automation with the advantages of BCT. Incorporating automation into these complex constructs will allow for ease of use for patient and caregiver during the long process of bone transport, theoretically decrease noncompliance, which otherwise can cause severe complications, and increased segmentation, which may improve quality of regenerate bone formation. Level of Evidence: Level 4.

Background/Objectives: Streptococcus intermedius, a member of the Streptococcus anginosus group, is characterized by a marked propensity for abscess formation but only rarely causes native-joint septic arthritis. Involvement of the acromioclavicular (AC) joint is particularly uncommon. We describe a case of native AC joint septic arthritis due to S. intermedius in a patient with multiple predisposing factors and highlight diagnostic and management considerations. Methods: We report the clinical course of a 72-year-old man with poorly controlled type 2 diabetes mellitus who presented with progressive right shoulder pain, erythema, and swelling following recurrent minor skin abrasions from a newly adopted dog. Initial management for presumed inflammatory shoulder pathology included brief systemic corticosteroids and an ultrasound-guided intra-articular ketorolac injection. Magnetic resonance imaging (MRI) was performed after symptom progression. The patient underwent operative irrigation and debridement with collection of synovial fluid and deep tissue cultures. Blood cultures and transthoracic echocardiography were obtained to evaluate for systemic involvement. Results: MRI demonstrated multiloculated periarticular abscesses and osteolysis centered on the AC joint. Operative cultures yielded high colony counts of S. intermedius from synovial fluid and deep tissues. Blood cultures and echocardiography were negative. The patient required multiple operative debridements with irrigation, adjunctive local antibiotic therapy, and prolonged targeted β-lactam treatment. Clinical and radiographic improvement was achieved following surgical source control and antimicrobial therapy. Conclusions: Native AC joint septic arthritis due to S. intermedius is rare. Older age, uncontrolled diabetes, recent intra-articular intervention, and possible zoonotic inoculation from canine wound licking may represent contributory risk factors. Early imaging, prompt surgical source control, and guideline-concordant antimicrobial therapy are essential when bone and soft tissue involvement is present.

Background: Acquired and congenital limb length discrepancies often coexist with deformities of the distal femur. Lengthening of the femur along its anatomic axis changes the limb's mechanical alignment. Angular correction and lengthening can be achieved at the same site if a retrograde lengthening nail is used with a specific preoperative planning method (“reverse planning”) which permits patient-specific selection of the final mechanical axis. Methods: A consecutive cohort series of children, adolescents, and young adults (mean 15.6 ± 4.8 years) undergoing retrograde implantable femoral lengthening between the years 2011 and 2024 were analyzed. Surgical details, lengthening parameters, Limb Lengthening and Reconstruction Society (LLRS)–AIM index, accuracy of final correction, and complications were reviewed and classified. Patients were eligible only if the distal femoral physis was closed. Results: Seventy-three lengthening were eligible in the study period. Average lengthening was 4.2 ± 1.4 cm (range 2.0-8.0 cm), and consolidation index was 39.4 ± 21.9 days/cm. Deformities and length discrepancies were moderately complex, with a mean LLRS AIM score of 6 (range 1-13). Complication rates were similar to previous reports of intramedullary femoral lengthening, comparable between congenital (12 of 31, 39%) and acquired etiologies (16 of 42, 38%). Preoperative coronal alignment ranged from 14° varus to 20° valgus, while final coronal alignment was 0.4° ± 3.4° of neutral (range 7° valgus to 13° varus). Coronal deformities up to 20° and sagittal deformities up to 23° were corrected acutely at the lengthening site. Conclusions: Retrograde intramedullary femoral lengthening with acute deformity correction at the same site is an alternative to antegrade lengthening with separate osteotomy of the distal femur in children and adolescents. The reverse planning method allows reproducible length and deformity correction at the same location. Specific intraoperative technical adjuncts are used to achieve and maintain the desired alignment. Level of Evidence: Diagnostic Level IV . See Instructions for Authors for a complete description of levels of evidence.

Background: Ankle arthroscopy (AA) is a commonly used operative technique to diagnose and treat a variety of intraarticular pathologies of the ankle joint. In AA, 2 portals are commonly established to achieve visualization of the joint: the anteromedial (AM) and anterolateral (AL) portals. However, the superficial peroneal nerve (SPN) runs near the anterolateral portal site; thus, creation of the AL portal is associated with neuropraxic injuries to the SPN. When AA is combined with additional procedures, such as a Brostrom-Gould ligament repair or open reduction internal fixation (ORIF), the use of a direct lateral incision is required. We present a novel approach to combining AA with lateral adjunct procedures which avoids creation of the AL portal; the AM portal and lateral incision are used for instrumentation instead. The primary objective of this study is to compare complication rates, such as SPN injury, between the lateral incision (LI) approach and conventional arthroscopy plus a lateral incision approach. Methods: Following IRB approval, a retrospective chart review was conducted spanning a time frame from January 2020 to October 2024. Patients were included if they underwent AA plus either a Brostrom-Gould repair or ORIF (AA+) or if they underwent AA plus adjunct procedures using the lateral portal instrumentation method (LI). Ninety-four patients were initially identified; 2 were excluded per criteria. Demographic information, intraoperative details, and any postoperative complications or reoperations were recorded. Descriptive statistics were used to describe demographics and operative data, and 2-tailed Student t tests were used to identify statistical differences between group metrics. Results: Ninety-two patients were included in the study. No statistical differences were observed between cohorts in either of the intraoperative metrics considered (procedural duration and tourniquet duration; P = .44 and .89, respectively). In addition, complication and reoperation rates were not statistically different between the LI and AA+ groups ( P = .94 and .40, respectively). The rate of SPN neuropathy or neurapraxia were also compared between groups, resulting in no statistical differences ( P = .37). Conclusion: In this retrospective cohort study, we observed no differences when only anteromedial and lateral portals are used for an ankle arthroscopy with adjunct procedures compared with the traditional 3-incision approach. We hypothesize that instances of infection or wound dehiscence would decrease given a large enough cohort because of the creation of 1 fewer portal. However, given the small, underpowered sample, we cannot determine whether the lateral approach alters complication risk; larger multicenter studies are needed. Level of Evidence: Level III, retrospective cohort study.

Abstract Case: A 42-year-old African-American woman sustained a type IIIA open pilon fracture requiring open reduction internal fixation complicated by wound dehiscence. Acute shortening for primary wound closure was performed followed by relengthening in a circular frame. Owing to the patient's intolerance to the circular frame, pre-existing osseous deformity, large body habitus, and soft tissue compromise, conversion to intramedullary stabilization with standard nailing was deemed exceedingly difficult. We describe the use of a photodynamic bone stabilization system allowing for percutaneous entry and implant flexibility for the purpose of early circular frame removal. Conclusion: This case demonstrates successful protection of immature regenerate using a photodynamic bone stabilization system, offering another tool to minimize time spent in a circular frame.

Objective: Lateral condyle fractures are the second most common pediatric elbow fracture after supracondylar humeral fractures. Early complications are frequent which can lead to development of long-term problems. Current literature has evaluated short-term outcomes, but few studies have investigated long-term outcomes into adulthood. Our hypothesis is that the majority of pediatric patients with a lateral condyle fracture will have minimal complications and few surgeries as they age. Methods: A population-based database was used to identify patients who sustained a lateral condyle fracture before the age of 18 between 1966 and 2012. Electronic medical records from all treatment centers in the county were reviewed for clinical and radiographic data. Analysis was performed to determine incidence and long term outcomes based on fracture type and treatment. Results: From 1966 to 2012, 227 pediatric lateral condyle fractures were identified. One hundred seventy-seven fractures (78%) had at least 10 year clinical follow up. Incidence was found to be 13.97 per 100,000. We identified 80 (45%) Weiss type 1, 61 (34%) type 2, and 37 (21%) type 3 fractures. The overall complication rate was 17%, of which 47% were identified >10 years from injury. There was no significant difference in complication rates based on fracture type (P = 0.18) or treatment type (P = 0.55). The most common complication was malunion (n = 15), followed by fishtail deformity (n = 4), stiffness (n = 3), lateral epicondylitis (n = 3), nonunion (n = 2), osteoarthritis (n = 2), and tardy ulnar nerve palsy (n = 1). Five patients underwent revision surgery for nonunion, cubitus valgus, malunion with loose bodies, capitellar osteochondral dessicans with malalignment, and ulnar nerve palsy. Conclusions: This population-based study estimated the overall incidence of pediatric lateral condyle fractures to be 14 per 100,000. Displaced fractures had a higher incidence than undisplaced fractures. Complications beyond 10 years are rare, but the need for future revision surgery is possible, therefore, proper patient and family education is necessary at the time of injury. This is the largest study with the longest follow-up for pediatric lateral condyle fractures. Complications were rare but resulted in a 17% complication rate and a 3% reoperation rate at a minimum. Level of Evidence: Level III.

OBJECTIVE Patients with ankylosing spinal disorders (ASDs), including ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH), have been shown to experience significantly increased rates of postoperative complications. Despite this, very few risk stratification tools have been validated for this population. As such, the purpose of this study was to identify predictors of adverse events and mortality in ASD patients undergoing surgery for 3-column fractures. METHODS All adult patients with a documented history of AS or DISH who underwent surgery for a traumatic 3-column fracture between 2000 and 2020 were identified. Perioperative variables, including comorbidities, time to diagnosis, and number of fused segments, were collected. Three instruments, including the Charlson Comorbidity Index (CCI), modified frailty index (mFI), and Injury Severity Score (ISS), were computed for each patient. The primary outcomes of interest included 1-year mortality, as well as postoperative complications. RESULTS A total of 108 patients were included, with a mean ± SD age of 73 ± 11 years. Of these, 41 (38%) experienced at least 1 postoperative complication and 22 (20.4%) died within 12 months after surgery. When the authors controlled for potential known confounders, the CCI score was significantly associated with postoperative adverse events (OR 1.20, 95% CI 1.00–1.42, p = 0.045) and trended toward significance for mortality (OR 1.19, 95% CI 0.97–1.45, p = 0.098). In contrast, mFI score and ISS were not significantly predictive of either outcome. CONCLUSIONS Complications in spine trauma patients with ASD may be driven by comorbidity burden rather than operative or injury-related factors. The CCI may be a valuable tool for the evaluation of this unique population.

Background: Tendons are primarily acellular, limiting their intrinsic regenerative capabilities. This limited regenerative potential contributes to delayed healing, rupture, and adhesion formation after tendon injury. Purpose: To determine if a tendon’s intrinsic regenerative potential could be improved after the application of a purified exosome product (PEP) when loaded onto a collagen scaffold. Study Design: Controlled laboratory study. Methods: An in vivo rabbit Achilles tendon model was used and consisted of 3 groups: (1) Achilles tenotomy with suture repair, (2) Achilles tenotomy with suture repair and collagen scaffold, and (3) Achilles tenotomy with suture repair and collagen scaffold loaded with PEP at 1 × 10 12 exosomes/mL. Each group consisted of 15 rabbits for a total of 45 specimens. Mechanical and histologic analyses were performed at both 3 and 6 weeks. Results: The load to failure and ultimate tensile stress were found to be similar across all groups ( P ≥ .15). The tendon cross-sectional area was significantly smaller for tendons treated with PEP compared with the control groups at 6 weeks, which was primarily related to an absence of external adhesions ( P = .04). Histologic analysis confirmed these findings, demonstrating significantly lower adhesion grade both macroscopically ( P = .0006) and microscopically ( P = .0062) when tendons were treated with PEP. Immunohistochemical staining showed a greater intensity for type 1 collagen for PEP-treated tendons compared with collagen-only or control tendons. Conclusion: Mechanical and histologic results suggested that healing in the PEP-treated group favored intrinsic healing (absence of adhesions) while control animals and animals treated with collagen only healed primarily via extrinsic scar formation. Despite a smaller cross-sectional area, treated tendons had the same ultimate tensile stress. This pilot investigation shows promise for PEP as a means of effectively treating tendon injuries and enhancing intrinsic healing. Clinical Relevance: The production of a cell-free, off-the-shelf product that can promote tendon regeneration would provide a viable solution for physicians and patients to enhance tendon healing and decrease adhesions as well as shorten the time required to return to work or sports.

Background. Limb-salvage surgery combined with radiotherapy has become the primary treatment for soft tissue sarcomas of the extremity. Free functional latissimus flaps (FFLF) are an option to restore function in the setting of volumetric muscle loss. The purpose of the current study was to examine the use of FFLF in patients undergoing resection of thigh sarcoma. Methods. Twelve patients with a sarcoma involving the hamstring (n = 6), quadriceps (n = 5), or combined (n = 1) defects which included multiple muscle groups were reviewed. This included 9 males and 3 females with a mean age and body mass index of 56 ± 12 years and 31.3 ± 5.7 kg/m2. Results. The mean defect volume and operative time was 3,689 ± 2,314 cm3 and 587 ± 73 minutes. Following reconstruction, the mean knee range of motion (ROM), MSTS93 score, and muscle strength was 89 ± 24°, 90 ± 15%, and 4 ± 1; with 75% of patients ambulating without gait aids. Seven (58%) patients sustained a complication, namely, delayed wound healing (n = 2). Conclusion. Although there was a high incidence of complications, FFLF can restore active knee ROM and function, with most patients ambulating without gait aids following reconstruction of large oncologic defects in the thigh.