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Level IV, retrospective case series.

Objectives: The purpose of this study was to compare the static and dynamic mechanical properties of a modified crossed cannulated screw configuration (CS), the inverted triangle cannulated screw configuration (IT) and a compression hip screw with derotation screw (CHS) in Pauwels Type III femoral neck fractures. Methods: Thirty synthetic femora were divided into three groups and vertical femoral neck osteotomies were made. Ten osteotomized femora were fixed with a modified cross screw (CS) configuration, ten were fixed with three parallel screws in an inverted triangle (IT) configuration, and the remaining ten osteotomized femora were fixed with a compression hip screw (CHS) construct. All groups were tested using a cyclic (up to 15,000 load cycles) axial loading protocol and survivors were statically loaded to failure. Cycles to failure, load to failure and stiffness were calculated. The Kaplan-Meier method was used to estimate survival functions and were compared among fixation methods. The relationship between construct structural properties (maximum load and stiffness) and treatment were assessed using general linear modeling. Results: All CHS fixation constructs survived the 15,000 cycle loading protocol. They endured longer (p = 0.034) than the CS fixation constructs (mean failure 13,332 cycles), but were not different from IT fixation constructs (mean failure 13,592 cycles). Maximum loads to failure for CS (3,870 N) and IT (3,756 N) fixation constructs were not different, but were less (p<0.0001) than the maximum loads to failure for the CHS fixation constructs (5,654 N). These findings parallel the results of the axial stiffness measurements: CS fixation constructs (663.01 N/mm) were not stiffer than IT fixation constructs (620.0 N/mm), but were less (p=0.0005) than the axial stiffness of the CHS fixation constructs (1,241.86 N/mm). Conclusions: The biomechanical performance of the compression hip screw (CHS) fixation method was superior to both the modified cross screw (CS) fixation method and the inverted triangle (IT) fixation method using a synthetic femoral model and this test protocol. Biomechanical performance of the latter two groups was indistinguishable. We recommend the use of CHS with derotational screw construct for Pauwels III femoral neck fractures whenever possible.

Procedural sedation options in the emergency department now allow for more effective and safer care and facilitate the delivery of orthopaedic care that would otherwise require operating room anesthesia. Traditional sedation agents, such as nitrous oxide, midazolam, fentanyl, and ketamine, have a persistent role. Etomidate and propofol are relatively recent additions that are highly effective. Combination regimens, such as ketamine-midazolam and ketamine-propofol, may be superior because they benefit from synergistic traits. Despite these sedation regimens, use of local blocks in adults continues to be effective, and intranasal delivery in children has emerged as a viable option. Orthopaedic surgeons should be aware of the appropriateness of different sedation regimens and other options for specific clinical scenarios.

Deltoid compartment syndrome can occur from operative positioning, with poor long-term outcomes as a result. Expeditious surgery, additional padding, and repeat checks are necessary for at-risk patients.

Although necrotizing fasciitis is a life-threatening entity that needs expeditious treatment, cases involving the lower extremity are less commonly encountered than in the upper extremity. Surgical intervention is often required and likely lead to amputation (below-knee or above-knee) vs debridement in the lower extremity. Coverage options in the foot and ankle after serial debridements can present many challenges for limb salvage. Patients are often left with large soft tissue defects requiring coverage with a subsequent increase in relative morbidity. Treatment options for coverage in these cases include negative-pressure wound therapy, split-thickness skin grafting, free flap coverage, or higher-level amputation. In the diabetic population, who present with a lower extremity necrotizing infection, limb salvage is often a challenge given the multiple comorbidities associated with these patients including peripheral vascular disease, immunocompromised state, and neuropathy. Optimal treatment strategies for these necrotizing infections in the foot and ankle remain uncertain. We offer a technique tip for utilization of a dermal regeneration matrix to allow coverage of large soft tissue defect with exposed tendon and/or bone without the need for free flap coverage or higher-level amputation, thus allowing for an additional limb salvage option. Level of Evidence: Level V, expert opinion.

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