A recent paradigm shift in microbiology affects orthopaedic surgery and most other medical and dental disciplines because more than 65% of bacterial infections treated by clinicians in the developed world are now known to be caused by organisms growing in biofilms. These slime-enclosed communities of bacteria are inherently resistant to host defenses and to conventional antibacterial therapy, and these device-related and other chronic bacterial infections are unaffected by the vaccines and antibiotics that have virtually eliminated acute infections caused by planktonic (floating) bacteria. We examine the lessons that can be learned, within this biofilm paradigm, by the study of problems (e.g. non-culturability) shared by all biofilm infections and by the study of new therapeutic options aimed specifically at sessile bacteria in biofilms. Orthopaedic surgery has deduced some of the therapeutic strategies based on assiduous attention to patient outcomes, but much can still be learned by attention to modern research in related disciplines in medicine and dentistry. These perceptions will lead to practical improvements in the detection, management, and treatment of infections in orthopaedic surgery.

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Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Plain radiographs are often insufficient for detecting posterior malleolus fractures in conjunction with ipsilateral distal third diaphyseal tibia fractures. Using a preoperative CT protocol for tibial shaft fractures can significantly improve the ability to diagnose associated intra-articular fractures that may not be evident on plain radiographs. Knowledge of these associated intra-articular fractures may prompt fracture stabilization and can prevent displacement during intramedullary nailing of tibia shaft fractures.

The purpose of our study was to correlate radiographic characteristics with rotator cuff tendon injury on magnetic resonance imaging after fractures of the proximal humerus. We prospectively obtained magnetic resonance imaging on 30 patients with proximal humerus fractures after classifying each fracture radiographically using Neer and AO systems and determining the displacement of the greater tuberosity. Twelve patients (40.0%) had either complete ruptures or avulsions of at least one of the rotator cuff muscles. No abnormality was identified in the rotator cuff musculature in nine patients (29%). Severity of injury to the rotator cuff tendons increased substantially with respect to increasing AO and Neer classes and 5 mm or greater displacement of the greater tuberosity fragment. Additional study is needed to determine the exact role of rotator cuff tendon injury in the ultimate function attained by patients with proximal humerus fractures.

Percutaneous fixation of an unstable pelvic ring injury is becoming a popular method of pelvic stabilization. As posterior pelvic percutaneous techniques become more common, the possibility of iatrogenic complications increases. This case report describes an injury to the superior gluteal artery during percutaneous iliosacral screw insertion and the treatment of this potentially devastating injury.

Computed tomography (CT) scan imaging of the bony spine has advanced with helical and currently multidetector images to allow reformatted axial collimation of images into two-dimensional and three-dimensional images. As a result, bony injuries to the TLS are commonly being identified. Most blunt trauma patients require CT to screen for other injuries. This has allowed the single admitting series of CT scans to also include screening for bony spine injuries. However, all of the publications fail to clearly define the criteria used to decide who gets radiographs or CT scans. No study has carefully conducted long-term follow-up on all of their trauma patients to identify all cases of TLS injury missed in the acute setting.

Sacroiliac joint (SIJ)-based pain can be difficult to diagnose definitively through physical examination and conventional radiography. A fluoroscopically guided injection into the SIJ can be both diagnostic and therapeutic. The initial phase of treatment involves nonsurgical modalities such as activity modification, use of a sacroiliac (SI) belt, NSAIDs, and physical therapy. Prolotherapy and radiofrequency ablation may offer a potential benefit as therapeutic modalities, although limited data support their use as a primary treatment modality. Surgical treatment is indicated for patients with a positive response to an SI injection with >75% relief, failure of nonsurgical treatment, and continued or recurrent SIJ pain. Percutaneous SI arthrodesis may be recommended as a first-line surgical treatment because of its improved safety profile compared with open arthrodesis; however, in the case of revision surgery, nonunion, and aberrant anatomy, open arthrodesis should be performed.