Syndesmosis injuries occur when there is a disruption of the distal attachment of the tibia and fibula. These injuries occur commonly (up to 18% of ankle sprains), and the incidence increases in the setting of athletic activity. Recognition of these injuries is key to preventing long-term morbidity. Diagnosis and treatment of these injuries requires a thorough understanding of the normal anatomy and the role it plays in the stability of the ankle. A complete history and physical examination is of paramount importance. Patients usually experience an external rotation mechanism of injury. Key physical exam features include detailed documentation about areas of focal tenderness (syndesmosis and deltoid) and provocative maneuvers such as the external rotation stress test. Imaging workup in all cases should consist of radiographs with the physiologic stress of weight bearing. If these images are inconclusive, then further imaging with external rotation stress testing or magnetic resonance imaging are warranted. Nonoperative treatment is appropriate for stable injuries. Unstable injuries should be treated operatively. This consists of stabilizing the syndesmosis with either trans-syndesmotic screw or tightrope fixation. In the setting of a concomitant Weber B or C fracture, the fibula is anatomically reduced and stabilized with a standard plate and screw construct. Proximal fibular fractures, as seen in the Maisonneuve fracture pattern, are not repaired operatively. Recent interest is moving toward repair of the deltoid ligament, which may provide increased stability, especially in rehabilitation protocols that involve early weight bearing. Rehabilitation is focused on allowing patients to return to their pre-injury activities as quickly and safely as possible. Protocols initially focus on controlling swelling and recovery from surgery. The protocols then progress to restoration of motion, early protected weight bearing, restoration of strength, and eventually a functional progression back to desired activities.

Optimal pain management is critical after knee surgery to avoid adverse events and to improve surgical outcomes. Pain may affect surgical outcomes by contributing to limitations in range of motion, strength, and functional recovery. The causes of postoperative pain are multifactorial; therefore, an appropriate pain management strategy must take into account preoperative, intraoperative, and postoperative factors to create a comprehensive and individualized plan for the patient. Preoperative assessment includes management of patient expectations, recognition of conditions and early counseling for high-risk patients (ie, opioid dependence, psychiatric comorbidities), and use of preemptive analgesia techniques (ie, preoperative IV medications, peripheral nerve blocks, incisional field blocks). Intraoperative strategies include meticulous surgical technique, limiting the use of tourniquets (ie, duration and pressure), and using preventive analgesia methods (ie, postoperative field block, continuous nerve catheters, intra-articular injection). Postoperative analgesia may be facilitated by cryotherapy, early mobilization, bracing, and rehabilitation. Certain modalities (ie, continuous passive motion devices, transcutaneous electrical nerve stimulation units, iontophoresis) may be important adjuncts in the perioperative period as well. There may be an evolving role for alternative medicine strategies. Early recognition and treatment of exaggerated postoperative pain responses may mitigate the effects of complex regional pain syndrome or the development of chronic pain.

Background: Postoperative shoulder infection (PSI) is a significant complication requiring timely identification and treatment. Indolent infections such as those involving Cutibacterium acnes (C. acnes, recently reclassified from Propionibacterium acnes 1 ) provide a diagnostic dilemma as they present differently without the acute symptoms associated with most postoperative bone and joint infections. Furthermore, C. acnes is thought to be a common contaminant isolated from intraoperative cultures. With no consensus algorithm, long hold cultures play a major role in guiding management decisions in potential PSI. Our study seeks to determine the incidence of positive cultures in both open and arthroscopic procedures in noninfected patients as well as clarify whether or not an increase in the incubation time frame leads to an increased rate of culture growth.Methodology: One hundred patients were prospectively enrolled into either an open and arthroscopic procedure group. Patients with abnormal inflammatory labs, history of previous shoulder surgery, or corticosteroid injection within six months of surgery were excluded from the study. Three cultures were obtained for each patient (1superficial tissue culture, 2-tissue culture, and 3-"sterile" control swab). Cultures were held for 28 days and checked on regular intervals. All patients were followed clinically for 6 months to ensure no signs of postoperative infection. Results: Ultimately ninety-five patients were included in the final analysis. The false-positive rate in open shoulder surgery was 17.02% and arthroscopic shoulder surgery was 10.4%. The incidence of positive C. acnes cultures was 6.4% in the open group while C. acnes was not isolated in the arthroscopic group. All positive bacterial cultures were reported within seven days of collection. One culture was positive for "mold" at 26 days. False Positive Cultures in Shoulder Surgery 4 Conclusion: A relatively high false-positive culture rate occurred in both open and arthroscopic shoulder surgery. C. acnes was the most commonly identified bacteria in cultures in the open surgery group. Knowledge of one's own institutional false-positive culture rate could be important in avoiding potentially inappropriate treatment. Additionally, we found that holding cultures longer than 14 days did not lead to an increased rate of false positive culture results.