A prospective, randomised trial comparing the use of absorbable and metallic screws in the fixation of distal tibiofibular syndesmosis injuries: mid-term follow-up

Clinical outcomes of an olive wire and external fixator versus a metallic screw in the treatment of inferior tibiofibular syndesmosis injuries in ankle fractures

BACKGROUND

Metal screws are the most widely used in treating syndesmotic injuries, but failure and the rigidity of the screws can threaten the success of the treatment and increase the cost of care. We have provided an alternative with an olive wire and external fixator(OWEF) used for syndesmotic fixation.

METHODS

A retrospective longitudinal follow-up study was conducted. From February 2011 to January 2018, 58 of 72 patients with ankle fractures and associated syndesmotic disruption were treated with either screw or OWEF fixation. The costs, complications, and clinical outcomes using Olerud-Molander score and Visual Analog score in screw and OWEF fixation group were compared.

RESULTS

We found the severity of the injury, BMI of the patients and the different fixation methods were determinants of the complications and clinical outcomes. But if no malreduction of the syndesmosis was present, no difference in clinical result was detected.

CONCLUSION

The OWEF method appeared to be at least equally functional and effective to screw fixation while maintaining possible lower complication rate.

LEVELS OF CLINICAL EVIDENCE

Level 3.

Application of an arched, Ni-Ti shape-memory connector in repairing distal tibiofibular syndesmosis ligament injury

Objective

To investigate the clinical effect of internal fixation of a Ni–Ti arched shape-memory connector in the treatment of distal tibiofibular syndesmosis ligament injury.

Methods

From January 2013 to January 2016, 108 cases of ankle fracture with distal tibiofibular syndesmosis ligament injury in our hospital were selected, and all of them were fixed with ASCs or screw fixation. The functional evaluation and efficacy evaluation were performed according to the Olerud Molander Ankle Score (Omas) and SF-36. At the same time, follow-ups recorded the incidence of postoperative complications: osteoarthritis, superficial infection, symptomatic hard and soft tissue irritation, early removal and poor reduction of internal fixation, and later loss of reduction.

Results

In the ASC(Ni–Ti Arched shape-memory Connector) group, the incidence of symptomatic hardware, soft tissue or superficial infection decreased to 2.77%(from 13.8% or 11.1% in SCREW group). The early removal rate(2.77%) of internal fixation was also lower than that of the screw group. While the incidence of osteoarthritis is 13.8% in SCREW group, the incidence of osteoarthritis in the later follow-up was also as low as 1.38% in ASC group. Loss of fracture reduction due to removal of the fixation device for the distal tibiofibular syndesmosis ligament was not observed in the ASC group. With two postoperative scoring systems (OMAS and SF-36), patients in the ASC group significantly get higher score than that in SCREW group.

Conclusion

The design of the Ni–Ti arched shape-memory connector can be adapted to the irregular anatomical structure of the malleolus and the ability to continue to contract by body temperature. The use of ASCs in fixation of articular ligaments can preserve a slight range of motion, and the results suggest that ASCs can effectively reduce the incidence of fixation looseness, fracture, infection and other complications.

Ossifying pilomatricoma and a novel hypothesis for its pathogenesis: A case report and comprehensive literature review

RATIONALE

Pilomatricoma is a benign skin appendageal tumor derived from hair follicle matrix cells that commonly affects the head, neck, and upper extremities of the pediatric population. Since the original tumor description, diverse variants have been reported in the literature. Pilomatricoma with florid osseous metaplasia is described as an ossifying pilomatricoma and is recognized as a distinct variant of this benign tumor. However, the pathogenesis of this variant remains unclear. In this study, we present an uncommon case of ossifying pilomatricoma and address the pathogenesis of metaplastic ossification through a comprehensive literature review.

PATIENT CONCERNS

A 14-year-old boy presented with an asymptomatic protuberant mass in the preauricular region.

DIAGNOSIS

Based on its clinicopathological features, we diagnosed the lesion as an ossifying pilomatricoma.

INTERVENTIONS AND OUTCOMES

The lesion was surgically removed under local anesthesia. The postoperative course was uneventful during the 6-month postoperative follow-up.

LESSONS

We suggest that metaplastic ossification in ossifying pilomatricoma represents another feature of foreign body reaction to keratinous materials containing shadow cells in old lesions and a walling-off phenomenon to prevent exposure of surrounding tissues to keratinous materials.

Management of Ankle Fractures With Syndesmotic Disruption: A Survey of Orthopaedic Surgeons

Introduction: With no current “gold standard” fixation strategy for syndesmotic injuries and differences in preferred preoperative and intraoperative diagnostic techniques and criteria, methods of reduction, fixation constructs, and postoperative management, the goals of this study were to determine how orthopaedic surgeons currently manage ankle fractures with concomitant syndesmotic disruption, as well as to identify surgeon demographics predictive of syndesmotic management techniques.

Methods: This study was conducted as a web-based survey of foot and ankle fellowship-trained surgeons, Orthopaedic Trauma Association (OTA) members, and Canadian Orthopaedic Association (COA) members. The survey, sent and completed via the HIPAA-compliant Research Electronic Data Capture (REDCap) system, consisted of 18 questions: 6 surgeon demographic questions and 12 specific syndesmotic management questions regarding perioperative protocols and syndesmotic fixation construct techniques.

Results: One hundred and ten orthopaedic surgeons completed our survey. Years of practice and type of fellowship were found to be the variables that influenced perioperative syndesmotic management strategies the most, while a number of fractures operated on per year, country of practice, and practice setting also influenced management decisions. Additionally, 59% (65/110) surgeons indicated that the way they have managed syndesmotic injuries has changed at some point in their career, while 33% (36/110) specified that they could foresee themselves changing their management of these injuries in the future.

Conclusions: There was significant variability among responders in preoperative and intraoperative assessment technique, fixation construct, screw removal protocol, and postoperative weightbearing protocol. This study raises awareness of differences in and factors predictive of management strategies and should be used for further discussion when determining a potential gold standard for the management of these complex injuries.

Acute syndesmotic injuries in ankle fractures: From diagnosis to treatment and current concepts

A stable and precise articulation of the distal tibiofibular syndesmosis maintains the tibiofibular relationship, and it is essential for normal motion of the ankle joint. The disruption of this joint is frequently accompanied by rotational ankle fracture, such as pronation-external rotation, and rarely occurs without ankle fracture. The diagnosis is not simple, and ideal management of the various presentations of syndesmotic injury remains controversial to this day. Anatomical restoration and stabilization of the disrupted tibiofibular syndesmosis is essential to improve functional outcomes. In such an injury, including inadequately treated, misdiagnosed and correctly diagnosed cases, a chronic pattern characterized by persistent ankle pain, function disability and early osteoarthritis can result. This paper reviews anatomical and biomechanical characteristics of this syndesmosis, the mechanism of its acute injury associated to fractures, radiological and arthroscopic diagnosis and surgical treatment.

A meta-analysis comparing the outcomes of syndesmotic injury treated with metal screw, dynamic fixation, and bioabsorbable screw

Background

Currently there is significant controversy regarding which fixation method is most effective for the treatment of syndesmotic ankle injuries.

Objective

This meta-analysis was designed to compare the metal screw, dynamic, and bioabsorbable screw fixation methods for treatment of syndesmotic ankle injuries.

Methods

An online search for RCT and prospective/retrospective clinical comparison studies between January 1998 and December 2018 on syndesmotic fixation was conducted. The main parameters collected include functional scores, mean time to full weightbearing, postoperative tibiofibular clear spaces, tibiofibular overlap, medial clear spaces, and complication rates. Statistical analysis was conducted using One Way ANOVAs and Chi-Squared tests using Review Manager and Excel.

Results

A total of 18 comparison studies, with 509 patients in the metal screw fixation group, 275 in the dynamic fixation group, and 226 in the bioabsorbable screw fixation group, were included in this meta-analysis. For the metal screw group, dynamic fixation group, and bioabsorbable screw group, the mean AOFAS score were 83.8, 87.2, and 84.3 (p < 0.05), the mean time to full weightbearing were 9.0 weeks, 7.2 weeks, and 7.7 weeks (p < 0.05), and the complication rates were 0.19, 0.09, and 0.19, respectively (p < 0.05). Similarly, the mean postoperative TFCS were 4.85, 3.87, and 5.70 for the metal screw group, dynamic fixation group, and bioabsorbable screw fixation group, respectively (p < 0.05).

Conclusion

The dynamic fixation group was found to have significantly improved functional scores, lower complication rates, and lower mean time to full weight-bearing than the metal screw and bioabsorbable screw fixation methods.

Level of evidence

Meta-analysis of all relevant Level 1-3 Evidence Comparative Studies.

Effect of Intraoperative Multidimensional Fluoroscopy Versus Conventional Fluoroscopy on Syndesmotic Reduction

BACKGROUND

Despite multiple techniques to improve syndesmotic reduction accuracy, syndesmotic malreduction in unstable ankle fractures remains prevalent. We performed a prospective, observational study to assess the ability of intraoperative multidimensional fluoroscopy to lead a surgeon to change the syndesmotic reduction obtained by conventional fluoroscopic techniques with the goal of achieving an accurate reduction.

METHODS

Thirty patients with unilateral malleolar ankle fractures and syndesmotic instability were enrolled. Following fixation of the malleollar fractures, the syndesmosis was provisionally reduced. Once the surgeon believed acceptable reduction was obtained by comparison with the contralateral, uninjured ankle mortise and lateral fluoroscopic images, provisional fixation was used to maintain reduction. Intraoperative, multidimensional fluoroscopy was used to generate cross-sectional images to assess the reduction. The surgeon then decided if a change in the reduction was needed, and fixation proceeded per surgeon preference. Postoperative bilateral computed tomography (CT) scans of the ankles were used to assess the reduction.

RESULTS

The main outcome recorded was syndesmotic reduction change by the attending surgeon following 3-dimensional (3D) fluoroscopic imaging. The secondary outcome was syndesmotic reduction accuracy on postoperative CT scan. Fourteen of 30 patients had intraoperative reduction change following 3D fluoroscopic imaging. Three of 30 patients had residual malreduction compared with the contralateral ankle on bilateral postoperative CT scan.

CONCLUSION

Intraoperative 3D fluoroscopy frequently led the surgeon to change the syndesmotic reduction obtained by conventional techniques and provided additional information not available with 2-dimensional fluoroscopy. A 10% syndesmotic malreduction rate was obtained with this technique.

LEVEL OF EVIDENCE

Diagnostic level II, prospective comparative study.

[Research progress in diagnosis and treatment of distal tibiofibular syndesmosis injury]

Objective

To review the research progress in the diagnosis and treatment of distal tibiofibular syndesmosis injury.

Methods

The recent literature about distal tibiofibular syndesmosis injury was reviewed and analyzed.

Results

Distal tibiofibular syndesmosis injury is commonly seen in ankle joint injury, the anatomical complexities make diagnosis and treatment difficult. Preoperative physical examination, radiologic evaluation, and intraoperative stress-testing are important for the diagnosis. Aggressive treatment is also recommended for these injuries to prevent long-term chronic instability. Internal fixation is the main treatment, including metal screw, degradable screw, elastic fixation, and hybrid techniques. Metal screw fixation is still the current mainstream, but elastic fixation represented by Suture-button is more in line with the physiological characteristics of ankle joint, and the rate of secondary operation is low while the clinical outcome is satisfactory. The application prospect of elastic fixation is worthy of expectation.

Conclusion

It's crucial for patient with ankle fracture to repair the distal tibiofibular syndesmosis injury. How to diagnose the injury more accurately and simply, how to increase the success rate of reduction, and how to reduce the complications of surgery are still worthy for further exploration.

Biomechanical comparison of biodegradable magnesium screws and titanium screws for operative stabilization of displaced capitellar fractures

BACKGROUND

Displaced fractures of the humeral capitellum are commonly treated operatively and fixed by titanium screws (TSs) either directly or indirectly. In the case of direct transcartilaginous fixation, biodegradable screws with the ability to be countersunk can be favorable regarding implant impingement and cartilage destruction. Hence, the goal of this study was to biomechanically compare headless compression screws made from titanium with a biodegradable equivalent made from a magnesium alloy.

METHODS

This biomechanical in vitro study was conducted on 13 pairs of fresh-frozen human cadaveric humeri, in which a standardized Bryan-Morrey type I fracture was fixed using 2 magnesium screws (MSs) or 2 TSs. First, construct stiffness was measured during 10 cycles of static loading between 10 and 50 N. Second, continuous loading was applied at 4 Hz between 10 and 50 N, increasing the maximum load every 10,000 cycles by 25 N until construct failure occurred. This was defined by fragment displacement >3 mm.

RESULTS

Comparison of the 2 screw types showed no differences related to construct stiffness (0.50 ± 0.25 kN/mm in MS group and 0.47 ± 0.13 kN/mm in TS group, P = .701), failure cycle (43,944 ± 21,625 and 41,202 ± 16,457, respectively; P = .701), and load to failure (152 ± 53 N and 150 ± 42 N, respectively; P = .915).

CONCLUSION

Biomechanical comparison showed that simple capitellar fractures are equally stabilized by headless compression screws made from titanium or a biodegradable magnesium alloy. Therefore, in view of the advantages of biodegradable implants for transcartilaginous fracture stabilization, their clinical application should be considered and evaluated.

Acute and Chronic Syndesmotic Instability: Role of Surgical Stabilization

Acute and chronic syndesmotic injuries significantly impact athletic function and activities of daily living. Patient history, examination, and judicious use of imaging modalities aid diagnosis. Surgical management should be used when frank diastasis, instability, and/or chronic pain and disability ensue. Screw and suture-button fixation remain the mainstay of treatment of acute injuries, but novel syndesmotic reconstruction techniques hold promise for treatment of acute and chronic injuries, especially for athletes. This article focuses on anatomy, mechanisms of injury, diagnosis, and surgical reduction and stabilization of acute and chronic syndesmotic instability. Fixation methods with a focus on considerations for athletes are discussed.

[Comparison of bioabsorbable screw and metallic screw for Maisonneuve fracture]

Objective

To compare the clinical and radiographic outcomes of bioabsorbable screw and metallic screw for Maisonneuve fracture.

Methods

The clinical data of 68 patients of Maisonneuve fracture treated with open reduction and internal fixation between October 2012 and October 2016 were retrospectively analyzed. Metallic screw fixation was used in 37 cases (group A) and absorbable screw fixation was used in 31 cases (group B). There was no significant difference in age, gender, weight, operated side, cause of injury, time from injury to operation, and complications between the two groups ( P>0.05). At last follow-up, the tibiafibular clear space (TFCS), tibiafibular overlap (TFO), medial clear space (MCS), and syndesmotic malreduction rate were recorded. And the dorsiflexion and plantar-flexion range of motion, pain visual analogue scale (VAS) score, ankle and hind foot score of American Orthopaedic Foot and Ankle Society (AOFAS), and Olerud-Molander (OM) score were recorded.

Results

All patients were followed up 25-43 months, with an average of 32.3 months. There was no significant difference in the operation time between the two groups ( t=1.229, P=0.282). All the fractures healed, and there was no significant difference in fracture healing time between the two groups ( t=1.367, P=0.413). At last follow-up, the syndesmotic malreduction rate of group A was 16.2% (6/37), showing no significant difference when compared with group B [6.2% (2/31)] ( χ ²=1.549, P=0.213). There were 3 complications in group A, 1 was superficial wound infection, 1 was local heterotopic ossification due to failure to remove the screws in time, 1 was local heterotopic ossification of the screws; and there were 2 complications in group B, 1 was rejection and 1 was local heterotopic ossification of the screws. There was no significant difference in the incidence of complications between the two groups ( χ ²=0.068, P=0.794). There was no significant difference in TFCS, MCS, TFO, ankle dorsiflexion and plantar-flexion range of motion, AOFAS score, OM score, and VAS score between the two groups at last follow-up ( P>0.05).

Conclusion

Compared with metallic screw, absorbable screws provide adequate fixation and functional recovery with avoiding screw removal and lower syndesmotic malreduction.

Clinical Evidence for Treatment of Distal Tibiofibular Syndesmosis Injury: A Systematic Review of Clinical Studies

No consensus had been reached about the optimal treatment for syndesmotic fixation. We performed a review of randomized controlled trials (RCTs) to assist in clarifying many of the controversies that were debated for years despite new technology and options. PubMed, Embase, and the Cochrane Library were searched through specific terms and limits. Only RCTs were selected for final inclusion. Study screening and data extraction were performed independently by 2 reviewers. Thirteen RCTs, including 828 cases, met the inclusion criteria and are summarized in this review. Pooled results demonstrated that dynamic fixation had better functional outcomes as well as lower rates of malreduction and complications compared with syndesmotic screw fixation. Both absorbable screw and tricortical screw fixation showed similar results to quadricortical metallic screws. Therefore, dynamic fixation is recommended for the treatment of syndesmosis injuries.

Diagnosis and treatment of ankle syndesmosis injuries with associated interosseous membrane injury: a current concept review

BACKGROUND

Tibiofibular syndesmosis injury leads to ankle pain and dysfunction when ankle injuries are not treated properly. Despite several studies having been performed, many questions about diagnosis and treatment remain unanswered, especially in ankle syndesmosis injury with interosseous membrane injury. Therefore, the purpose of this study was to help guide best practice recommendations.

METHODS

This review explores the mechanism of injury, clinical features, diagnosis methods, and the treatment strategy for ankle syndesmosis injury with interosseous membrane injury to highlight the current evidence in terms of the controversies surrounding the management of these injuries.

RESULTS

Radiological and CT examination are an important basis for diagnosing ankle syndesmosis injury. Physical examination combined with MRI to determine the damage to the interosseous membrane is significant in guiding the treatment of ankle syndesmosis injury with interosseous membrane injury. In the past, inserting syndesmosis screws was the gold standard for treating ankle syndesmosis injury. However, there were increasingly more controversies regarding loss of reduction and broken nails, so elastic fixation has become more popular in recent years.

CONCLUSIONS

Anatomical reduction and effective fixation are the main aspects to be considered in the treatment of ankle syndesmosis injury with interosseous membrane injury and are the key to reducing postsurgery complications.

An Alternative Strategy for Treatment of Distal Tibiofibular Syndesmotic Disruption: A Technical Note

Metal screws are the most widely used in treating syndesmotic injuries; however, failure and the rigidity of the screws can threaten the success of the treatment and increase the cost of care. We performed open reduction and internal fixation of a fibula fracture followed by fixation of the tibiofibular joint with an olive wire and one half of an external fixator. We present a review of 1 patient treated with this material. We believe this method to be a physiologic fixation system with the advantage of being safe, inexpensive, adjustable, and effective; however, further clinical investigation and comparison to other methods is needed in order to better understand it clinical utility.

Clinical Applications of Bone Tissue Engineering in Orthopedic Trauma

Purpose of Review

Orthopaedic trauma is a major cause of morbidity and mortality worldwide. Although many fractures tend to heal if treated appropriately either by nonoperative or operative methods, delayed or failed healing, as well as infections, can lead to devastating complications. Tissue engineering is an exciting, emerging field with much scientific and clinical relevance in potentially overcoming the current limitations in the treatment of orthopaedic injuries.

Recent Findings

While direct translation of bone tissue engineering technologies to clinical use remains challenging, considerable research has been done in studying how cells, scaffolds, and signals may be used to enhance acute fracture healing and to address the problematic scenarios of nonunion and critical-sized bone defects. Taken together, the research findings suggest that tissue engineering may be considered to stimulate angiogenesis and osteogenesis, to modulate the immune response to fractures, to improve the biocompatibility of implants, to prevent or combat infection, and to fill large gaps created by traumatic bone loss. The abundance of preclinical data supports the high potential of bone tissue engineering for clinical application, although a number of barriers to translation must first be overcome.

Summary

This review focuses on the current and potential applications of bone tissue engineering approaches in orthopaedic trauma with specific attention paid to acute fracture healing, nonunion, and critical-sized bone defects.

Syndesmotic Ankle Fractures

OBJECTIVES

The diagnosis and treatment of syndesmotic ankle fractures is controversial. This systematic review was performed to clarify the current understanding addressing several clinical questions that arise in the treatment of such injuries.

DATA SOURCES

The English language literature was searched using PubMed, EMBASE, and Web of Science. The search terms were "syndesmosis" or "syndesmotic" in combination with the terms "ankle fracture" or "fracture." The included dates were between 1967 and July 2015.

STUDY SELECTION

Inclusion criteria were number of patients >20, patient age ≥18 years, follow-up ≥1 year, ankle fracture classification was reported, criteria for surgery was reported, technique of surgery was reported, and a validated outcome measure was used. Studies limited to biomechanical or imaging investigations were excluded.

DATA EXTRACTION

Information was abstracted using a standardized template, which encompassed the inclusion criteria together with the study type, postoperative regimen, and complications. Study quality was evaluated using the modified CONSORT statement and Coleman criteria. Study bias was assessed, and methodological quality was rated. Any difference in ratings was resolved by consensus.

DATA SYNTHESIS

None.

CONCLUSIONS

The overall quality of the studies was poor. The number or placement of syndesmotic screws or the breakage of trans-syndesmotic screws postoperatively had no adverse effect on outcomes (both with moderate strength of evidence). The use of alternative fixation devices (bioabsorbable and endobutton) had poor strength of evidence, as did the opinion that nondisplaced, unstable by stress test, syndesmotic injuries required fixation. There are insufficient data that link subtle rotational syndesmotic malreduction to clinical outcomes.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Osteosynthesis of a cranio-osteoplasty with a biodegradable magnesium plate system in miniature pigs

Biodegradable magnesium alloys are a new class of implant material suitable for bone surgery. The aim of this study was to investigate plates and screws made of magnesium for osteosynthesis in comparison to titanium in a cranial fracture model. Implants were used for internal fixation of a cranio-osteoplasty in nine minipigs. Computed tomography was conducted repeatedly after surgery. The implants and the adjacent tissues were harvested 10, 20 and 30weeks after surgery and investigated by micro-computed tomography and histological analysis. The surgical procedure and the inserted osteosynthesis material were well tolerated by the animals, and the bone healing of the osteoplasty was undisturbed at all times. The adjacent bone showed formation of lacunas in the magnesium group, resulting in a lower bone-to-implant contact ratio than that of titanium (72 vs. 94% at week 30), but this did not lead to clinical side effects. Radiological measurements showed no reduction in osteosynthesis material volume, but indicated signs of degradation: distinct volumes within the magnesium osteosynthesis group had lower density in micro-computed tomography, and these volumes increased up to 9% at week 30. The histological preparations showed areas of translucency and porosity inside the magnesium, but the outer shape of the osteosynthesis material remained unchanged. No fracture or loosening of the osteosynthesis devices appeared. Soft tissue probes confirmed sufficient biocompatibility. Given their biodegradable capacity, biocompatibility, mechanical strength and visibility on radiographs, osteosynthesis plates made of magnesium alloys are suitable for internal fixation procedures.

STATEMENT OF SIGNIFICANCE

To the best of our knowledge this is the first study that used biodegradable magnesium implants for osteosynthesis in a cranial fracture model. The cranio-osteoplasty in miniature pigs allowed in vivo application of plate and screw osteosynthesis of standard-sized implants and the implementation of surgical procedures similar to those conducted on human beings. The osteosynthesis configuration, size, and mechanical properties of the magnesium implants within this study were comparable to those of titanium-based osteosynthesis materials. The results clearly show that bone healing was undisturbed in all cases and that the biocompatibility to hard- and soft tissue was sufficient. Magnesium implants might help to avoid long-term complications and secondary removal procedures due to their biodegradable properties.

Effects of degradable osteosynthesis plates of MgYREZr alloy on cell function of human osteoblasts, fibroblasts and osteosarcoma cells

The aim was to evaluate the biocompatibility of osteosynthesis plates of the MgYREZr/WE43 alloy by using human cells in vitro. Eluates of degradable magnesium osteosynthesis plates as well as halved plates were used for incubation with human osteoblasts, fibroblasts and osteosarcoma cells. The cell viability was evaluated by using FDA/PI-Staining and LDH analysis. Cell proliferation was assessed by MTT, WST-Test and BrdU-ELISA. Scanning electron microscope was used for investigation of the cell adhesion. The number of devitalized cells in all treatment groups did not significantly deviate from the control group. According to MTT results, the number of metabolically active cells was not significantly affected by the addition of the eluates. The number of metabolically active cells was reduced by 24 to 38% compared to the control on incubation in direct contact with the osteosynthesis plates. The proliferation of the cells was inhibited by the addition of the eluates. While the eluate of the half-hour elution has only a very small effect, the 24 h eluate significantly inhibits proliferation by 23-25% compared to the control. The roughened surface of the magnesium osteosynthesis plate after incubation showed adherent cells. However, some areas of the plates were also free of adherent cells. WE43 based magnesium alloys showed favorable biocompatibility considering the viability of the cells evaluated; however, proliferation rates were reduced in a time dependent manner, especially in fibroblast group. This might be a potential clinical benefit of magnesium osteosynthesis plates and their superiority to titanium, thus the fibroblastic ingrowth might negatively influence the bone-plate contact.

Management of acute injuries of the tibiofibular syndesmosis

The syndesmosis is important for ankle stability and load transmission and is commonly injured in association with ankle sprains and fractures. Syndesmotic disruption is associated with between 5 and 10% of ankle sprains and 11-20% of operative ankle fractures. Failure to recognize and appropriately treat syndesmotic disruption can portend poor functional outcomes for patients; therefore, early recognition and appropriate treatment are critical. Syndesmotic injuries are difficult to diagnose, and even when identified and treated, a slightly malreduced syndesmosis can lead to joint destruction and poor functional outcomes. This review will discuss the relevant anatomy, biomechanics, mechanism of injury, clinical evaluation, and treatment of acute injuries to the ankle syndesmosis.

Should syndesmotic screws be removed after surgical fixation of unstable ankle fractures? a systematic review

AIMS

In approximately 20% of patients with ankle fractures, there is an concomitant injury to the syndesmosis which requires stabilisation, usually with one or more syndesmotic screws. The aim of this review is to evaluate whether removal of the syndesmotic screw is required in order for the patient to obtain optimal functional recovery.

MATERIALS AND METHODS

A literature search was conducted in Medline, Embase and the Cochrane Library for articles in which the syndesmotic screw was retained. Articles describing both removal and retaining of syndesmotic screws were included. Excluded were biomechanical studies, studies not providing patient related outcome measures, case reports, studies on skeletally immature patients and reviews. No restrictions regarding year of publication and language were applied.

RESULTS

A total of 329 studies were identified, of which nine were of interest, and another two articles were added after screening the references. In all, two randomised controlled trials (RCT) and nine case-control series were found. The two RCTs found no difference in functional outcome between routine removal and retaining the syndesmotic screw. All but one of the case-control series found equal or better outcomes when the syndesmotic screw was retained. However, all included studies had substantial methodological flaws.

CONCLUSIONS

The currently available literature does not support routine elective removal of syndesmotic screws. However, the literature is of insufficient quality to be able to draw definitive conclusions. Secondary procedures incur a provider and institutional cost and expose the patient to the risk of complications. Therefore, in the absence of high quality evidence there appears to be little justification for routine removal of syndesmotic screws. Cite this article: Bone Joint J 2016;98-B:1497-1504.

Diagnosis and rehabilitation of deep wound infection and internal fixation rejection in elbow: A case report

This study aims at diagnosis and rehabilitation of a rare case of deep wound infection and internal fixation rejection in elbow. The patient sustained a distal fracture in the humerus 1 year ago, which was internal fixed. The wound always effused and the elbow had pain and swelling; joint motion was limited. Blood sedimentation rate and C reactive protein level increased, bacterial culture suggested deep wound infection, and ultrasound indicated inflammation. The main diagnoses were deep wound infection and internal fixation rejection. Therapeutics interventions were antibiotic agents, physical therapy, operative debridement, incision, drainage, and exercise and physical therapy. One year later, the internal fixation was taken out. His elbow was fully mobilized and the fracture healed. He got back to his former job. When encountered deep wound infection again and again after internal fixation, rejection should be considered. Except for anti-infection treatment, rehabilitation cannot be neglected, or the healing process may be delayed.

Interventions for treating ankle fractures in children

BACKGROUND

Ankle fractures, which usually occur after a twisting incident, are a diverse collection of injuries with different levels of complexity and severity. They have an incidence of 1 in 1000 a year in children. Treatment generally involves splints and casts for minor fractures and surgical fixation with screws, plates and pins followed by immobilisation for more serious fractures.

OBJECTIVES

To assess the effects (benefits and harms) of different interventions for treating ankle fractures in children.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (22 September 2015), the Cochrane Central Register of Controlled Trials (CENTRAL) (2015, Issue 8), MEDLINE (1946 to September Week 2 2015), MEDLINE In-Process & Other Non-Indexed Citations (21 September 2015), EMBASE (1980 to 2015 Week 38), CINAHL (1937 to 22 September 2015), trial registers (17 February 2015), conference proceedings and reference lists of articles.

SELECTION CRITERIA

We included randomised and quasi-randomised controlled trials evaluating interventions for treating ankle fractures in children.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles, abstracts and full articles for inclusion, assessed risk of bias and collected data. We undertook no meta-analysis.

MAIN RESULTS

We included three randomised controlled trials reporting results for 189 children, all of whom had a clinical diagnosis of a "low risk" ankle fracture. These were predominantly classified as undisplaced Salter-Harris type I fractures of the distal fibula. All three trials compared non-surgical management options. The three trials were at high risk of bias, primarily relating to the impracticality of blinding participants and treating clinicians to the allocated interventions.Two trials compared the Aircast Air-Stirrup ankle brace versus a rigid cast, which was a removable fibreglass posterior splint in one trial (trial A) and a below-knee fibreglass walking cast in the other trial (trial B). In trial A, both devices were removed at around two weeks. In trial B, removal of the brace was optional after five days, while the walking cast was removed after three weeks. There was low-quality evidence of clinically important differences in function scores at four weeks in favour of the brace groups of both trials. Function was measured using the Activities Scale for Kids-performance (ASKp; score range 0 to 100, higher scores mean better function) in trial A and using a modified version of the ASKp score (range 0 to 100%, higher percentages mean better function) in trial B. The results for trial A (40 participants) were median 91.9 in the brace group versus 84.2 in the splint group. The results for trial B (104 participants) were 91.3% versus 85.3%; mean difference (MD) 6.00% favouring brace (95% confidence interval (CI) 1.38% to 10.62%). Trial B indicated that 5% amounted to a clinically relevant difference in the modified ASKp score. Neither trial reported on unacceptable anatomy or related outcomes or long-term follow-up. There was very low-quality evidence relating to adverse events, none of which were serious. Trial A found twice as many children with pressure-related complications in the brace group (10 of 20 versus 5 of 20). In contrast, trial B found four times as many children in the cast group had adverse outcomes assessed in terms of an unscheduled visit to a healthcare provider (4 of 54 versus 16 of 50). Both trials linked some of the adverse events in the brace group with the failure to wear a protective sock. There was very low-quality evidence indicating an earlier return to pre-injury activity in the brace groups in both trials. Trial B provided low-quality evidence that children much prefer five days or more wearing an ankle brace than three weeks immobilised in a walking ankle cast. There was moderate-quality evidence of a lack of difference between the two groups in pain at four weeks.The third trial compared the Tubigrip bandage plus crutches and advice versus a plaster of Paris walking cast for two weeks and reported results at four weeks' follow-up for 45 children with an inversion injury of the ankle. The trial found very low-quality evidence of little difference in pain and function between the two groups, measured using a non-validated pain and function score at four weeks. The trial did not report on adverse effects. There was very low-quality evidence of an earlier return to normal activities, averaging six days, in children treated with Tubigrip (mean 14.17 days for Tubigrip versus 20.19 days for cast; MD -6.02 days, 95% CI -8.92 to -3.12 days).Recent evidence from magnetic resonance imaging studies of the main category of injury evaluated in these three trials suggests that most of the injuries in these trials were sprains or bone bruises rather than fractures of the distal fibular growth plate.

AUTHORS' CONCLUSIONS

There is low-quality evidence of a quicker recovery of self reported function at four weeks in children with clinically diagnosed low-risk ankle fractures who are treated with an ankle brace compared with those treated with a rigid cast, especially a non-removable walking cast. There is otherwise a lack of evidence from randomised controlled trials to inform clinical practice for children with ankle fractures. Research to identify and address priority questions on the treatment of these common fractures is needed.

Bioabsorbable Versus Metallic Screw Fixation for Tibiofibular Syndesmotic Ruptures: A Meta-Analysis

Ankle fractures with syndesmotic rupture require operative treatment. In most cases, this consists of fixation of the tibiofibular joint with 1 or more screws. Bioabsorbable screws are used for the same purpose but have the advantage that screw removal is unnecessary. The aim of the present study was to compare the results of bioabsorbable and metallic syndesmotic screws. A systematic search was performed in the Ovid MEDLINE electronic database and Google Scholar. Three randomized controlled trials and one comparison study, with 260 patients, were included. The experimental group consisted of patients with syndesmotic injuries treated with bioabsorbable screws versus the control group (patients treated with metallic screws). The primary outcomes were complications and wound infections. No statistically significant difference was demonstrable in the overall number of complications between the 2 groups. In the group of patients with a bioabsorbable screw, 32 of 137 (23.4%) experienced a complication versus 7 of 123 patients (5.7%) with a metallic screw. Data on wound-related complications showed no statistically significant difference, 19.7% versus 5.7%. The average maximum range of motion in both groups was comparable. Bioabsorbable syndesmotic screws and metallic syndesmotic screws were comparable with respect to the incidence of complications and range of motion. However, the absolute number of complications was greater with bioabsorbable screws.

Absorbable Screws Versus Metallic Screws for Distal Tibiofibular Syndesmosis Injuries: A Meta-Analysis

A meta-analysis was performed to investigate the outcomes between absorbable screw (AS) and metallic screw (MS) fixation for distal tibiofibular syndesmosis injuries (DTSIs). Randomized controlled trials comparing AS versus MS fixation in DTSIs were searched systematically, and the outcomes were analyzed using Review Manager Software, version 5.2. The risk ratio (RR) or mean difference with the 95% confidence interval (CI) was calculated using the fixed effects or random effects model. A total of 16 studies were included in the meta-analysis. No statistically significant difference was found between AS and MS fixation in excellent and good functional recovery rate (RR 1.11, 95% CI 1.00 to 1.23, I(2) = 60%, p = .06), infection (RR 1.66, 95% CI 0.73 to 3.79, I(2) = 0%, p = .23), incidence of pain (RR 0.68, 95% CI 0.24 to 1.92, I(2) = 12%, p = .47), screw broken (RR 0.31, 95% CI 0.03 to 2.93, I(2) = %, p = .31), heterotopic ossification (RR 1.93, 95% CI 0.21 to 17.62, I(2) = 51%, p = .56; 472 cases in 4 studies), fracture healing time (mean difference -1.88, 95% CI -3.51 to -0.26, I(2) = 93%, p = .02,), duration of operation time (mean difference 7.64, 95% CI -3.80 to 19.09, I(2) = 98%, p = .19). The incidence of foreign body reaction was higher with AS fixation (RR 6.07, 95% CI 2.54 to 14.50, I(2) = 0%, p < .001). The reoperation rate was higher with MS fixation (RR 0.08, 95% CI 0.03 to 0.18, I(2) = 77%, p < .01). The functional outcomes of AS were as good as those with MS for DTSIs. Other than the foreign body reaction, the complications occurring after AS fixation were not as serious as those with MS fixation. AS fixation might be a preferable alternative for reconstruction of DTSIs.

Analysis of PITFL injuries in rotationally unstable ankle fractures

BACKGROUND

Reduction and stabilization of the syndesmosis in unstable ankle fractures is important for ankle mortise congruity and restoration of normal tibiotalar contact forces. Of the syndesmotic ligaments, the posterior inferior tibiofibular ligament (PITFL) provides the most strength for maintaining syndesmotic stability, and previous work has demonstrated the significance of restoring PITFL function when it remains attached to a posterior malleolus fracture fragment. However, little is known regarding the nature of a PITFL injury in the absence of a posterior malleolus fracture. The goal of this study was to describe the PITFL injury pattern based on magnetic resonance imaging (MRI) and intraoperative observation.

METHODS

A prospective database of all operatively treated ankle fractures by a single surgeon was used to identify all supination-external rotation (SER) types III and IV ankle fracture patients with complete preoperative orthogonal ankle radiographs and MRI. All patients with a posterior malleolus fracture were excluded. Using a combination of preoperative imaging and intraoperative findings, we analyzed the nature of injuries to the PITFL. In total, 185 SER III and IV operatively treated ankle fractures with complete imaging were initially identified.

RESULTS

Analysis of the preoperative imaging and operative reports revealed 34% (63/185) had a posterior malleolus fracture and were excluded. From the remaining 122 ankle fractures, the PITFL was delaminated from the posterior malleolus in 97% (119/122) of cases. A smaller proportion (3%; 3/122) had an intrasubstance PITFL rupture.

CONCLUSIONS

Accurate and stable syndesmotic reduction is a significant component of restoring the ankle mortise after unstable ankle fractures. In our large cohort of rotationally unstable ankle fractures without posterior malleolus fractures, we found that most PITFL injuries occur as a delamination off the posterior malleolus. This predictable PITFL injury pattern may be used to guide new methods for stabilizing the syndesmosis in these patients.

LEVEL OF EVIDENCE

Level IV, case series.