Treatment of tibial bone defects caused by infection: a retrospective comparative study of bone transport using a combined technique of unilateral external fixation over an intramedullary nail versus circular external fixation over an intramedullary nail

BACKGROUND

The purpose of the study was to assess and compare the clinical efficacy of bone transport with either circular or unilateral external fixators over an intramedullary nail in the treatment of tibial bone defects caused by infection.

METHODS

Between May 2010 and January 2019, clinical and radiographic data were collected and analyzed for patients with bone defects caused by infection. Thirteen patients underwent bone transport using a unilateral external fixator over an intramedullary nail (Group A), while 12 patients were treated with a circular external fixator over an intramedullary nail (Group B). The bone and functional outcomes of both groups were assessed and compared using the Association for the Study and Application of the Method of the Ilizarov criteria, and postoperative complications were evaluated according to the Paley classification.

RESULTS

A total of 25 patients were successfully treated with bone transport using external fixators over an intramedullary nail, with a mean follow-up time of 31.63 ± 5.88 months. There were no significant statistical differences in age, gender, previous surgery per patient, duration of infection, defect size, and follow-up time between Group A and Group B (P > 0.05). However, statistically significant differences were observed in operation time (187.13 ± 21.88 min vs. 255.76 ± 36.42 min, P = 0.002), intraoperative blood loss (39.26 ± 7.33 mL vs. 53.74 ± 10.69 mL, P < 0.001), external fixation time (2.02 ± 0.31 month vs. 2.57 ± 0.38 month, P = 0.045), external fixation index (0.27 ± 0.08 month/cm vs. 0.44 ± 0.09 month/cm, P = 0.042), and bone union time (8.37 ± 2.30 month vs. 9.07 ± 3.12, P = 0.032) between Group A and Group B. The excellent and good rate of bone and functional results were higher in Group A compared to Group B (76.9% vs. 75% and 84.6% vs. 58.3%). Statistically significant differences were observed in functional results (excellent/good/fair/poor, 5/6/2/0 vs. 2/5/4/1, P = 0.013) and complication per patient (0.38 vs. 1.16, P = 0.012) between Group A and Group B.

CONCLUSIONS

Bone transport using a combined technique of external fixators over an intramedullary nail proved to be an effective method in treating tibial bone defects caused by infection. In comparison to circular external fixators, bone transport utilizing a unilateral external fixator over an intramedullary nail resulted in less external fixation time, fewer complications, and better functional outcomes.

Short-term outcome after treatment of talocrural instability in cats using modified type II transarticular external skeletal fixation

Transarticular external skeletal fixation (TESF) is repeatedly used for temporary stabilisation of tarsal joint in cats. Hence, this study aimed to evaluate the use of temporary modified type II TESF for management of talocrural instability (TCI) in cats without joint arthrodesis and to rate short-term outcomes and complications. Medical records of all cats treated for TCI between January 2012 and December 2021 were reviewed. Information was collected including signalment, degree of lameness, type of TCI, accompanying soft tissue and bone injuries, and post-operative follow-up assessment including time of frame removal, complications, degree of lameness, range of joint motion and ankylosis. Surgical management didn't involve debridement of the articular cartilage. Eighty-five percent of cats had satisfactory joint stability at the time of frame removal. Eighteen cats exhibited minor complications, six cats had major complications, and 8 cats showed persistent lameness. All cats showed reduction of joint motion range by 20°-30° directly after frame removal while returned to normal in 79% of cats 4 weeks later. Variable degrees of joint ankylosis were reported. In conclusion, this study supports the use of temporary modified type II TESF for management of TCI in cats without joint involvement as an excellent alternative to tarsal arthrodesis.

The effect of valgus reduction on resistant subtrochanteric femoral non-unions: a single-centre report of twenty six cases

PURPOSE

Re-revision of subtrochanteric non-unions is technically challenging and lacks robust evidence. The results of managing subtrochanteric fractures after multiple failed procedures have rarely been reported in the literature. This study aims to evaluate the effect of valgus reduction on non-united subtrochanteric fractures with single or multiple failed revision surgeries.

METHODS

Twenty-six patients with aseptic subtrochanteric fracture non-union underwent failed single or multiple revision procedures after index fracture fixation surgery between 2011 and 2019. The exclusion criteria were as follows: septic non-union, peri-prosthetic, and pathological fractures. Lateral-based wedge valgus reduction and compression at the non-union site using a valgus-contoured DCS together with decortication, debridement, and bone grafting were used. The main outcome measurement was radiological union, pain, LLD, HHS, and restoration of pre-fracture activities.

RESULTS

The mean follow-up was 4.5 years (range 3 to 7); prior revision surgeries range from two to five and union at 6.5 months (range 3 to 10) and the delayed union in one case and an infected non-union in one case. The mean LLD was 4 cm (range 3 to 5), which improved to 1.5 cm (range 1 to 4) (P-value < 0.001). The mean VAS was 7 (range 6 to 8), and 24 patients achieved painless ambulation without a walking aid after the union. The mean HHS was 40 (range 25 to 65), which improved to 85 (range 55 to 95) (P-value < 001), achieving 15 excellent, ten good, and one poor results.

CONCLUSION

Mechanical optimisation by lateral closing wedge and stable fixation with pre-contoured DCS with biological enhancement resulted in a successful outcome in recalcitrant subtrochanteric non-unions.

Combined Anterior Odontoid Screw Fixation and C1-C2 Jefferson Fracture Anterior Fixation: A Step-by-Step Technical Note

BACKGROUND

Combined triple atlas (C1)-axis (C2) fixation has been described in previous literature as a safe, effective, and minimally invasive procedure for complex atlas and odontoid fractures that allows for a greater range of motion compared with posterior approaches and atlanto-occipital fusion. However, it is rarely performed due to the occipital-cervical diastasis resulting from often-fractured C1 joint masses. No evidence-based consensus has been reached regarding the treatment of complex atlantoaxial fractures, and the choice of surgical strategy is based only on clinical experience.

METHODS

We report the combined triple C1-C2 fixation technique with manual reduction of the joint masses during patient positioning on the operating table, which allowed for effective stabilization during a single surgical session. We describe our experience in the management of a 75-year-old patient presenting with an acute complex type II fracture of C1, which also involved 1 lateral mass, combined with a type II odontoid fracture and occipital-cervical diastasis.

RESULTS

We provide a step-by-step guide for combined triple C1-C2 anterior fixation with manual fracture reduction and describe the clinical case of an acute complex type II fracture of C1, which also involved 1 lateral mass, combined with a type II odontoid fracture and occipital-cervical diastasis.

CONCLUSIONS

Combined triple C1-C2 fixation represents a safe and efficient minimally invasive anterior approach for complex type II fractures of C1 with type II odontoid fractures. Manual reduction of the joint masses during patient positioning allows for effective stabilization in a single surgical session.

BoneTape: A novel osteosynthetic device for the stabilization of zygomatic fractures

BACKGROUND

The study aims to assess the safety and effectiveness of BoneTape™, a new resorbable bone fixation device, using a zygomatic fracture model in rabbits.

METHODS

The study followed BoneTape™ samples and control (sham) groups over 2-, 6-, and 12-week periods post-zygomaticomaxillary (ZM) osteotomy and zygomaticofrontal (ZF) disarticulation. The osteotomized segments were analyzed for bone healing, inflammatory response, and tissue healing. µCT imaging and histological analysis were used to examine the axial alignment, offset, and quality of new bone formation.

RESULTS

BoneTape™ samples demonstrated enhanced maintenance of the initial intraoperative positioning, reduced axial offset, and better alignment when compared with the control group, enabling stable bone healing under physiological loading conditions. Complete union was observed at 12-weeks in both groups. The BoneTape™ group experienced minimal immune and tissue reactions, classically associated with wound healing, and showed an increased number of giant cells at 6 and 12-weeks.

CONCLUSION

BoneTape™ represents a promising advancement in osteosynthesis, demonstrating efficacy in maintaining stable zygomatic reconstruction and eliciting minimal immune response in a rabbit model. This study introduces BoneTape™ as a disruptive solution specifically designed for clinical application in cranio-maxillofacial fracture fixation, with the potential to eliminate the use of over-engineered solutions while offering benefits such as ease of application and fewer biologically disruptive steps.

Early posterior column internal fixation: A staged treatment of type C3 tibial pilon fracture

Pilon fractures represent a challenging subset of tibial fractures. The management of AO/OTA Type C3 fractures remains complex due to associated complications and lack of clear guidelines for surgical timing and methods. A prospective cohort study was conducted to evaluate two staged treatment strategies for AO/OTA Type C3 tibial pilon fractures. The study focused on assessing surgical difficulty, complications, and patient prognosis. One group of patients received early internal fixation of the fibula and tibial posterior column combined with external fixation, while the other group received external fixation alone in the first stage. Patients who received early internal fixation of the fibula and tibial posterior column combined with external fixation had better outcomes, including lower rate of allogeneic bone grafting (67.74 % versus 94.64 %), reduced incidence of wound delay and skin necrosis (3.23 % versus 21.43 %), shorter surgical time (133.06 ± 23.99 min versus 163.04 ± 26.83 min), shorter hospital stay (13.77 ± 2.53 days versus 18.25 ± 3.67 days), and higher AOFAS (83.05 ± 8.68 versus 79.36 ± 8.92). Additionally, avoiding fibular shortening was shown to be crucial in preventing prolonged surgery and improving patient function. The study demonstrated that the staged treatment approach with early internal fixation led to shorter operative times, improved ankle function, and reduced complications, including a lower risk of infection. The findings support the use of this treatment to optimize outcomes in AO/OTA Type C3 pilon fractures.

Outcomes of Preperitoneal Packing and Angioembolization for Hemorrhage Control in Hemodynamically Unstable Pelvic Fractures: A Systematic Review and Meta-Analysis

BACKGROUND

Hemodynamically unstable pelvic fractures are often life-threatening injuries; however, the optimal management remains uncertain. This systematic review and meta-analysis aim to evaluate the most appropriate primary management of hemorrhage in adult patients with hemodynamically unstable pelvic fractures by comparing outcomes following the initial use of preperitoneal packing (PPP) vs angioembolization (AE).

METHODS

A systematic search of PubMed, Embase, Google Scholar, and ProQuest databases was conducted following PRISMA guidelines. Studies assessing hemorrhage management in trauma patients with hemodynamically unstable pelvic fractures were included. The data extracted from selected articles included patient demographics, study design, and outcomes such as 24-hour PRBC transfusions, in-hospital mortality, and DVT rate.

RESULTS

Eight articles were included in the systematic review. Among the included studies, 2040 patients with hemodynamically unstable pelvic fractures were analyzed. Meta-analyses revealed that treatment with PPP was associated with fewer 24-hour PRBC transfusions (mean difference = -1.0, 95% CI: -1.8 to -.2) than AE. However, no significant differences were noted in in-hospital mortality (RR: .91, 95% CI: .80-1.05) and the rate of deep vein thrombosis (RR: .89, 95% CI: .62-1.28) between groups.

CONCLUSION

The findings of this study suggest that primary management with PPP was associated with fewer 24-hour PRBC transfusions compared to AE. The choice of primary management with PPP or AE did not significantly impact in-hospital mortality. Future studies should address clinical outcomes and the factors that affect them to better understand the impact of different management strategies and direct the creation of practice management guidelines.

[The role of capsuloligamentotaxis and minimally invasive percutaneous osteosynthesis with rigid and dynamic unilateral external fixation of the intra-articular pilon fracture]

Fractures of the tibial pilon are severe injuries which can be accompanied by articular impaction, comminution and soft tissue injury. Soft tissue injury with already existing skin damage can further complicate the method of treatment. In these cases, the method of unilateral or circular external fixation can be used as an alternative method of treatment. Minimally invasive percutaneous osteosynthesis with spanning rigid and dynamic unilateral external fixation as a one-stage method has been used for the treatment of intra-articular pilon fractures. We report a case of a patient with an intra-articular pilon fracture with chronic venous insufficiency and venous ulcer, who was injured after falling from a height and who had emergency surgery based on capsuloligamentotaxis and percutaneous osteosynthesis with a spanning unilateral external fixator. The patient was mobilized postoperatively for walking without weight bearing on the injured leg. The initial rigid spanning external fixation was transformed into dynamic fixation to enable ankle joint movements 8 weeks after surgery. The external fixator was removed 4.5 months after surgery and the Kirschner wire and screws were removed 7 months after surgery. The final functional result 1 year after the injury was good and motion of upper ankle joint was moderately restricted without pain. Swelling occurred after walking for longer distances.

The necessity of removal of third molars involved in mandibular fractures: A retrospective study

This retrospective analysis aimed to investigate the necessity of removing the wisdom tooth in cases of angle fractures of the mandible. The study retrieved 595 mandible fractures from January 2006 to December 2021 through the Hospital Inpatient Enquiry System, of which 303 involved a fracture through the angle of the mandible, including the wisdom tooth socket. Of these, 203 (66.9%) underwent open reduction and internal fixation with retention of the third molar. The authors found that only four (2%) patients returned for the removal of plates and the retained third molar during the follow-up period. Therefore, the authors concluded that wisdom teeth removal should remain an exception during open reduction and internal fixation of mandibular angle fractures unless they hinder fracture reduction, pose a potential infection risk, or interfere with occlusal stability.

Preliminary fracture reduction in children with type III supracondylar humerus fractures during the COVID-19 pandemic

During the COVID-19 pandemic, the time elapsed from injury to definitive surgery necessitated delay in type III pediatric supracondylar humerus fractures. Preliminary fracture reduction was recommended in these fractures while waiting for operative treatment. The purpose of this study was to evaluate whether preliminary reduction afforded a better treatment experience and improved outcomes. A retrospective cohort analysis of 161 type III supracondylar humerus fractures compared treatment with preliminary closed fracture reduction and delayed percutaneous pin placement (110 children) to delayed combined closed reduction and pin placement (51 children) in a children's medical center. Of the preliminary reduction group, 22 (20%) required analgesic pain relief, compared to 18 (35%) in the non-preliminary reduction group ( P  = 0.037), and the preliminary reduction group had statistically less pain (assessed using the Faces Pain Scale-Revised rating) the first night after injury and the first-night post-CRPP ( P  = 0.019, P  = 0.008). Cast splitting was more frequent in the non-preliminary reduction group, 11 patients (22%) than in the preliminary reduction group, 10 patients (9%; P  = 0.029). The operative times in the preliminary reduction group were shorter ( P  < 0.001). If delay is necessary for complete repair of type III supracondylar humerus fractures, a preliminary fracture reduction with a temporary cast can be recommended, as these children will experience a more comfortable interval, with less swelling and pain, and potentially a shorter operation. Level of Evidence: Level III-therapeutic study.

Comparison of splinting immobilization and K-wire fixation in children with type II phalange neck fracture

To compare outcomes of type II phalangeal neck fractures in children who received closed reduction followed by splinting immobilization or by K-wire fixation. Furthermore, we analyzed the remodeling potential of residual deformities and the relationship between age and outcomes. Patients in Children's Hospital of Fudan University, Xiamen Hospital were included in the study from October 2015 to October 2018. We compared outcomes between the conservation group and operation group. Remodeling of residual deformities was calculated on a series of anteroposterior and lateral radiography. The correlation between age and outcomes was analyzed using Spearman's rank correlation coefficient. Forty patients (25 males) were enrolled. Nineteen patients had subtype IIa, 19 subtype IIb, and two subtype IIc fractures. Left hands were affected more than right hands, and small finger and proximal phalanx were more frequently involved. There were no significant differences between conservation group and operation group among excellent, good, and fair outcomes. And the outcomes were not significantly different between the IIa and IIb subtypes. An average sagittal remodeling rate was 88.5%, and coronal remodeling rate was 56.71%, respectively, in 13 patients with residual deformities. There was a significant correlation between age and final outcomes. Closed reduction and stable splint fixation may be an effective and economical initial treatment option. Fracture subtype does not seem to be a key factor for choosing treatment options. The fractured phalangeal neck had remodeling potential whether on sagittal or coronal plane. Younger age might be a predictor of better outcomes in children with type II phalanx neck fractures.

Usefulness of external fixation and reverse Sural fasciocutaneous flap: Treatment of grade III B open tibial fractures in resource-limited settings

PURPOSE

Sierra Leone is a low-income country located on the west coast of Africa where the majority of the population does not have free access to emergency medical and surgical services, the principal cause of open tibia fractures is motorcycle collision. Open fractures of the middle and distal third of the tibial segments, particularly those classified as type III B, represent a challenge for orthopedic surgeons because of the loss of soft tissue coverage. The Reverse Sural Fasciocutaneous Flap (RSFF) has been shown to be an ideal and reproducible option for the treatment of soft tissue defects. The main aim of this study was to demonstrate the experience in Resource Limited Settings (RLS) by means of a short series of the efficacy of using a combination of external fixation and RSFF in the treatment of grade III B open tibia fractures where plastic surgeons were not available.

METHODS

This retrospective, descriptive, and non-experimental study included 8 patients who underwent surgical intervention between September 2020 and September 2021.

RESULTS

The skin defects were of various sizes; the smallest size was 4 × 7 cm, and the biggest size of 12 × 18 cm. We obtained a success rate in seven of the eight cases.

CONCLUSIONS

External fixation and reverse sural fasciocutaneous sural flap are excellent therapeutic options for the treatment of open grade III B diaphyseal and metaphyseal distal tibial fractures.

Calcaneal tuberosity avulsion fractures - A review

Calcaneal tuberosity avulsion fracture, an extra-articular injury, is a rare fracture caused internally by Achilles tendon driven following intense contraction of gastrocnemius-soleus complex, and externally by low-energy (possibly high-energy). Moreover, the risk of injuries of the skin and Achilles tendon around calcaneal tuberosity is closely related to Lee classification and Carnero-Martín de Soto Classification of calcaneal tuberosity avulsion fracture. Although the diagnosis confirmed by X-ray, digital imaging and computed tomography (CT), magnetic resonance imaging (MRI) should also be used to evaluate soft tissue. In recent years, the understanding of this fracture has witnessed the development of different internal fixation devices and surgical procedures. These advances have been further elaborated scientifically in terms of their ability to provide stable fracture reduction ad resistance to Achilles tendon forces. In order to obtain a comprehensive knowledge of the disease, this article reviewed the new understanding of the anatomy, typing, risk factors, and treatment modalities of calcaneal tuberosity avulsion fracture in recent years.

Skin Antisepsis before Surgical Fixation of Extremity Fractures

BACKGROUND

Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture).

METHODS

In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications.

RESULTS

A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups.

CONCLUSIONS

Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

A practical definition of pin site infection

Pin Site Infection (PSI) is the most common complication of external fixation treatment. Several classifications and diagnostic approaches have been used with reported incidences varying widely from 1 to 100 %. The quality of the existing literature is limited by the absence of a definition. This renders comparing literature and developing evidence-based algorithms for prevention, diagnostics, and treatment difficult to impossible. Similar problems were identified with prosthetic joint infection (PJI) and fracture-related infection (FRI) in recent years, resulting in new, validated definitions. PSI is complicated by the complexity of the issue. Numerous factors in PSI need consideration. Factors may be related to the patient, the surgical technique, the pin-bone interface, the pin-skin interface, the choice of external fixation device and/or the material used and its properties. Reliably diagnosing PSI is one of the most pressing issues. New definitions for FRI or PJI have diagnostic criteria which can be either confirmatory or suggestive. Any positive finding of a confirmatory criterion constitutes an infection. Although PSI resembles PJI and FRI, distinct differences are present. The skin is never closed, and bacterial colonization is inevitable along the treatment duration. The external fixator is only temporarily in place; thus, the goal of all measures is to continue the external fixator until the intended indication is reached. This paper proposes the principles of a definition of PSI. This definition is not designed to guide any treatment of PSI. Its purpose is to create common ground for clinical investigations and publishing further research.

[Commentary on the Article of S. Deininger et al.: Functional Outcome of Peripheral Nerve Injury after Pediatric Supracondylar Humerus Fracture: Comparison of Surgical and Conservative Treatment]

Ich gratuliere den Autoren zu den zu 100% guten Ergebnissen nach konservativer Behandlung bei spontaner Besserung und nach operativer Therapie bei ausbleibender Besserung. Das spricht für einen gut funktionierenden Behandlungsalgorithmus. Auf zwei Aspekte möchte ich jedoch hinweisen.

Complications of operatively treated distal radial fractures

Distal radial fractures represent the most common fractures of the upper extremity. Operative treatment is performed for approximately one-third of distal radial fractures in the adult population. Complications following operative treatment of distal radial fractures vary depending on the treatment modality and can be stratified into preoperative and postoperative complications. Complications can occur in the near, intermediate and long term. The most common complications seen are tendon irritation and rupture, chronic regional pain syndrome (CRPS), carpal tunnel syndrome, ulnar or radial neuropathy, compartment syndrome, malunion, inadequate fixation or loss of fixation, symptomatic hardware, post-traumatic arthritis, stiffness and infection. Careful planning, treatment and patient selection can help to mitigate these complications.Level of evidence: V.

Does using 3D printed models for pre-operative planning improve surgical outcomes of foot and ankle fracture fixation? A systematic review and meta-analysis

PURPOSE

The systematic review aims to establish the value of using 3D printing-assisted pre-operative planning, compared to conventional planning, for the operative management of foot and ankle fractures.

METHODS

The systematic review was performed according to PRISMA guidelines. Two authors performed searches on three electronic databases. Studies were included if they conformed to pre-established eligibility criteria. Primary outcome measures included intraoperative blood loss, operation duration, and fluoroscopy time. The American orthopaedic foot and ankle score (AOFAS) was used as a secondary outcome. Quality assessment was completed using the Cochrane RoB2 form and a meta-analysis was performed to assess heterogeneity.

RESULTS

Five studies met the inclusion and exclusion criteria and were eventually included in the review. A meta-analysis established that using 3D printed models for pre-operative planning resulted in a significant reduction in operation duration (mean difference [MD] = - 23.52 min, 95% CI [- 39.31, - 7.74], p = 0.003), intraoperative blood loss (MD = - 30.59 mL, 95% CI [- 46.31, - 14.87], p = 0.0001), and number of times fluoroscopy was used (MD = - 3.20 times, 95% CI [- 4.69, - 1.72], p < 0.0001). Using 3D printed models also significantly increased AOFAS score results (MD = 2.24, 95% CI [0.69, 3.78], p = 0.005), demonstrating improved ankle health.

CONCLUSION

The systematic review provides promising evidence that 3D printing-assisted surgery significantly improves treatment for foot and ankle fractures in terms of operation duration, intraoperative blood loss, number of times fluoroscopy was used intraoperatively, and improved overall ankle health as measured by the AOFAS score.

Comprehensive Study on the Age-Strengthened Mg-Zn-Mn-Ca/ZnO Composites for Fracture Fixation: Microstructure, Mechanical, and In Vitro Biocompatibility Evaluation

The present work investigates the use of age-strengthened Mg-Zn-Mn-Ca/xZnO as resorbable materials in temporary orthopedic implants. Quaternary Mg-Zn-Mn-Ca alloy, reinforced with zinc oxide particles, was stir-cast, followed by solution treatment and a range of aging treatments. Optical and electron microscopy, mechanical, electrochemical, immersion, and dynamic mechanical testing, with biocompatibility assessment were carried out. The observed 2θ shift in the (101) peaks of ZMX611/ZnO-ST and ZMX611/ZnO-H indicated lattice shrinkage. The formation of Mg7Zn3 and Ca2Mg6Zn3 in the grain boundary compositions was observed. ZMX611/ZnO-ST had a smaller β-phase fraction, indicating a finer microstructure. ZMX611/ZnO-H had the highest tensile yield strength (102.97 ± 3.92 MPa), and ZMX611/ZnO-ST showed the highest ultimate tensile strength (127.21 ± 7.48 MPa), indicating precipitation hardening of Zn enrichment. The uniformly dispersed secondary phases played a dual role in corrosion behavior. ZMX611/ZnO-ST showed a better cytocompatibility response among all samples. Composite materials exhibited satisfactory biocompatibility and mechanical compatibility as indicated by in silico results of deviatoric strain-based mechanical stimuli at the fracture interface.

Circular External Fixation of Ankle and Pilon Fractures Using Novel Polyaxial Locking Struts

Ankle fractures and pilon fractures are common injuries and can range in severity from low-energy rotational injuries to high-energy fractures of the articular surface. External fixation can be used in a staged treatment strategy to allow for a closed reduction and soft tissue rest before definitive internal fixation or as a definitive treatment method. We describe a technique that involves the use of novel polyaxial locking struts in conjunction with circular external fixation that can be used as a temporary form of external fixation or as definitive treatment of high-energy ankle and pilon fractures.

Financial Analysis of Preoperative Nasal Decolonization With Povidone-Iodine in Closed Pilon Fracture Definitive Fixation

The purpose of this study is to determine the financial practicality for the use of nasal povidone-iodine (NP-I) in the preoperative holding area in attempt to decrease the rate of infection that is associated with operative fixation of closed pilon fractures. Institutional costs for treating postoperative infection following a closed pilon fracture, along with costs associated with preoperative NP-I use, were obtained. A break-even equation was used to analyze these costs to determine if the use of NP-I would decrease the current infection rate (17%) enough to be financially beneficial for routine use preoperatively. The total cost of treating a postoperative infection was found to be $18,912, with the cost of NP-I being $30 per patient dose. Considering a 17% infection rate and utilizing the break-even equation, NP-I was found to be economically viable if it decreased the current infection rate by 0.0016% (Number Needed to Treat = 63,051.7). This break-even model suggests that the use of NP-I in the preoperative holding area is financially beneficial for decreasing the rate of infection associated with the treatment of closed pilon fractures.

External fixation in intra-articular fractures of the calcaneus: Is it a valid option as definitive treatment?

INTRODUCTION

The therapeutic management of calcaneal fractures is currently a major source of controversy in the literature. There is no consensus on the need to treat these injuries conservatively or surgically, nor on the criteria for deciding one option or the other. Although the gold standard has classically been the open approach and osteosynthesis, there are currently minimally invasive techniques that also report good results. Our objective is to present our results and experience with the MBA® Orthofix external fixator in a series of cases of calcaneal fractures.

METHODS

We performed a retrospective observational study in our center, between the years 2019 and 2021, of Sanders types II-IV calcaneal fractures operated with MBA® Orthofix external fixator. We recorded a total of 38 patients, 42 fractures. We registered demographic information, intraoperative, postoperative, radiological and functional parameters, using the American Orthopedic Foot and Ankle Society (AOFAS), Manchester-Oxford Foot Questionnaire (MOXFQ), EQ-5D and VAS scales.

RESULTS

A total of 26 men and 12 women were included, and the median age was 38 years. Mean follow-up was 24,4 months (6, 8-40, 1). The average time to surgery was 7 days and partial loading was started at 2.5 weeks after external fixation, which was removed at 9.2 weeks. The average Böhler angle correction was 7, 4°, Gissane - 12,2°, length 2 mm and calcaneal width was reduced by 5 mm. We recorded two superficial infections, one peroneal entrapment and three subtalar arthrodesis due to post-traumatic osteoarthritis. The AOFAS obtained was 79.1 + / - 15.7 points, MOXFQ 20.1 + / - 16.1 points, EQ-5D 0.84 + / - 0.2 and VAS 3.3 + / - 1.9.

CONCLUSION

The external fixator is an excellent surgical alternative for complex articular fractures of the calcaneus, obtaining clinical and radiological results comparable to other osteosynthesis techniques and significantly reducing soft tissue complications.

The Pitfalls of Difficult Distal Radius Fractures and Provisional Reduction

Distal radius fractures are some of the most common injuries encountered in orthopedics and require careful consideration when determining the appropriate treatment options. These fractures can be difficult injuries to treat surgically based on a large variability of fracture patterns, bone quality, and anatomy. It is important to understand the potential pitfalls associated with the treatment of difficult distal radius fractures to prevent avoidable complications. Some of these pitfalls include but are not limited to appropriate surgical exposure and soft tissue handling, provisional reduction, fixation type, and augmentation of fracture fixation.

Unstable pelvic fractures in women: implications on obstetric outcome

PURPOSE

Obstetric outcomes in women following pelvic injuries requiring surgical fixation is not thoroughly known. We aimed to evaluate if radiographic measurements (RMs) can be used to provide information on delivery methods outcome after these injuries, and to evaluate if metal work removal is required prior to delivery.

METHOD

A retrospective study in a level 1 trauma centre of female patients with pelvic fractures treated operatively, aged 16-45 at the time of injury. Participants completed a questionnaire regarding their obstetric history. RM evaluating pelvic symmetry, displacement, and pelvimetry were conducted on postoperative radiographs and CT scans. Patients who gave birth after the injury were divided to two groups according to the delivery method: vaginal delivery (VD) and caesarean section (CS). These two groups RM were compared.

RESULTS

Forty-four patients were included, comparison of the RM of patients who delivered by CS (9) and patients who had only VD (11) showed no significant difference between the groups. Two patients underwent a trial of VD who subsequently underwent urgent CS due to prolonged labour, their RM were below the average and their pelvimetry measurements were above the cut-off for CS recommendation. Eleven patients had uncomplicated VD, all had retained sacroiliac screws at the time of delivery and one patient had an anterior pubic plate.

CONCLUSION

Postoperative RM did not show an effect on delivery method of women after pelvic fracture fixation. A relatively high number of patients who underwent normal vaginal delivery had retained sacroiliac screws. These findings can form the foundation for larger cohort studies.

Surgically reducing displaced distal radial fractures in children

Displaced fractures of the distal radius in children are usually reduced under sedation or general anaesthesia to restore anatomical alignment before the limb is immobilized. However, there is growing evidence of the ability of the distal radius to remodel rapidly, raising doubts over the benefit to these children of restoring alignment. There is now clinical equipoise concerning whether or not young children with displaced distal radial fractures benefit from reduction, as they have the greatest ability to remodel. The Children's Radius Acute Fracture Fixation Trial (CRAFFT), funded by the National Institute for Health and Care Research, aims to definitively answer this question and determine how best to manage severely displaced distal radial fractures in children aged up to ten years.

Functionally graded 3D printed plates for rib fracture fixation

BACKGROUND

Design freedom offered by additive manufacturing allows for the implementation of functional gradients - where mechanical stiffness is decreased along the length of the implant. It is unclear if such changes will influence failure mechanisms in the context of rib fracture repair. We hypothesized that our novel functionally graded rib implants would be less stiff than controls and decrease occurrence of secondary fracture at implant ends.

METHODS

Five novel additively manufactured rib implants were tested along with a clinically used Control implant. Fracture reconstructions were modeled with custom synthetic rib bones with a transverse B1 fracture. Ribs were compressed in a cyclic two-point bend test for 360,000 cycles followed by a ramp to failure test. Differences in cyclic stiffness, 3D interfragmentary motions, ramp-to-failure stiffness, maximum load, and work to failure were determined.

FINDINGS

The Control group had lower construct stiffness (0.76 ± 0.28 N/mm), compared to all novel implant designs (means: 1.35-1.61 N/mm, p < 0.05) and rotated significantly more about the bending axis (2.7° ± 1.3°) than the additively manufactured groups (means between 1.2° - 1.6°, p < 0.05). All constructs failed via bone fracture at the most posterior screw hole. Experimental implants were stiffer than Controls, and there were few significant differences between functional gradient groups.

INTERPRETATION

Additively manufactured, functionally graded designs have the potential to change the form and function of trauma implants. Here, the impact of functional gradients was limited because implants had small cross-sectional areas.

Physeal Bar Formation After Pediatric Medial Malleolus Fractures

Pediatric medial malleolus fractures are commonly Salter-Harris (SH) type III or IV fractures of the distal tibia and are associated with a risk of physeal bar formation and subsequent growth disturbance. The purpose of this study was to determine the incidence of physeal bar formation following pediatric medial malleolus fracture and evaluate for patient and fracture characteristics predictive of physeal bar formation. Seventy-eight consecutive pediatric patients during a 6-year period who had either an isolated medial malleolar or a bimalleolar ankle fracture were retrospectively reviewed. Forty-one of 78 patients had greater than 3 months of radiographic follow-up and comprised the study population. Medical records were reviewed for demographic information, mechanism of injury, treatment, and need for further surgery. Radiographs were reviewed to assess for initial fracture displacement, adequacy of fracture reduction, SH type, percentage of the physeal disruption from the fracture, and physeal bar formation. Twenty-two of 41 patients (53.7%) developed a physeal bar. The mean time to diagnosis of physeal bar was 4.9 months (range, 1.6-11.8 months). Twenty-seven percent (6 of 22) of bars were diagnosed at greater than 6 months from injury. Adequacy of reduction was predictive of physeal bar formation, although all patients were reduced to within 2 mm. The mean residual displacement of patients with a bar was 1.2 mm compared with 0.8 mm for those without a bar (P=.03). Because the bar formation rate is greater than 50% on radiographs, routine radiographic assessment of all pediatric medial malleolar fractures should continue for at least 12 months after injury. [Orthopedics. 2024;47(1):e33-e37.].

Predicting Which Species of Bacteria Will Cause an Infection After Fracture Surgery

The aim of this study was to develop and validate risk prediction models for deep surgical site infection (SSI) caused by specific bacterial pathogens after fracture fixation. A retrospective case-control study was conducted at a level I trauma center. Fifteen candidate predictors of the bacterial pathogens in deep SSI were evaluated to develop models of bacterial risk. The study included 441 patients with orthopedic trauma with deep SSI after fracture fixation and 576 control patients. The main outcome measurement was deep SSI cultures positive for methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), gram-negative rods (GNRs), anaerobes, or polymicrobial infection within 1 year of injury. Prognostic models were developed for five bacterial pathogen outcomes. Mean area under the curve ranged from 0.70 (GNRs) to 0.74 (polymicrobial). Strong predictors of MRSA were American Society of Anesthesiologists (ASA) classification of III or greater (odds ratio [OR], 3.4; 95% CI, 1.6-8.0) and time to fixation greater than 7 days (OR, 3.4; 95% CI, 1.9-5.9). Gustilo type III fracture was the strongest predictor of MSSA (OR, 2.5; 95% CI, 1.6-3.9) and GNRs (OR, 3.4; 95% CI, 2.3-5.0). ASA classification of III or greater was the strongest predictor of polymicrobial infection (OR, 5.9; 95% CI, 2.7-15.5) and was associated with increased odds of GNRs (OR, 2.7; 95% CI, 1.5-5.5). Our models predict the risk of MRSA, MSSA, GNR, anaerobe, and polymicrobial infections in patients with fractures. The models might allow for modification of preoperative antibiotic selection based on the particular pathogen posing greatest risk for this patient population. [Orthopedics. 2024;47(1):e19-e25.].

The effect of spanning external fixation on entrapped structures in tibial pilon fractures

PURPOSE

Pilon fractures are often complex injuries involving severe soft tissue injury. Studies have shown pilon fractures may entrap soft tissue structures between fracture fragments. Staged fixation of pilon fractures with spanning external fixation (SEF) is important for soft tissue rest and plays an important role in the management of these injuries. While SEF has been shown to promote soft tissue rest prior to definitive fixation, no studies have shown the effect SEF has on entrapped structures (ES). The purpose of this study was to evaluate how SEF effects ES in pilon fractures.

METHODS

A retrospective review of 212 pilon fractures treated at our institution between 2010 and 2022 was performed. Patients with a CT scan pre-SEF and post-SEF met inclusion criteria. CTs were reviewed to characterize ES in pre- and post-SEF imaging.

RESULTS

Of the 19 patients with ES identified on CT pre-SEF, seven (36.8%) had full release of ES post-SEF and 12 (63.2%) had no release of ES. The posterior tibial tendon was the most commonly ES and remained entrapped in 62.5% of cases. Only 25% of 43-C3 fractures had release of ES post-SEF, while 100% of 43-C1 and 43-C2 fractures demonstrated complete release of ES post-SEF.

CONCLUSION

Entrapped structures in pilon fractures are likely to remain entrapped post-SEF, with only one-third of our cohort demonstrating release. In 43-C3 patterns, if ES are identified on CT pre-SEF, surgeons should consider addressing these either through mini open versus open approaches at the time of SEF as they are likely to remain entrapped post-SEF.

Successful Reduction of Unilateral Zygoma Fracture Following Bilateral Malar Reduction Surgery

Malar reduction surgery can increase its susceptibility to fractures in case of trauma. Patients who had malar reduction surgery and sustained a zygoma fracture pose unique challenges for treatment and management. This is a case of a 28-year-old female patient who presented with a unilateral zygoma fracture following bilateral malar reduction and augmentation rhinoplasty 6 years ago. Physical examination revealed a clicking sound when opening the mouth at the right zygomatic buttress and a depressed preauricular area, suggesting arch fracture. Computed tomography imaging demonstrated a loosened screw at the right zygomatic buttress and a depressed arch fracture. She wanted to remove all plates and treat her right fractured zygoma with absorbable materials. Through the bilateral intraoral incisions, the authors removed the plates and screws and reduced the depression with the Langenbeck elevator through the same right intraoral incision without fixation. The reduction was well-maintained without complications based on postoperative plain x-rays 1 month after surgery. She reported that the pain was mostly gone and that she did not hear any abnormal sounds when opening her mouth after the surgery. In this case, if the zygomaticomaxillary buttress is minimally displaced, but the zygomatic arch fracture is significantly depressed, the authors believe that fracture reduction with only an intraoral incision would be enough to achieve an optimal outcome. If the plates and screws used in the previous malar reduction are not well maintained, it may be necessary to remove them.

Early hip fracture surgery and rehabilitation. How to improve functional quality outcomes. A retrospective study

INTRODUCTION

Hip fractures are one of the major disability causes associated with a high morbidity and mortality rate. Early surgery and stable fixation could be associated with better pain control, possibly lower mortality rates, and early recovery of autonomy.

Long-term conservative treatment outcomes for midshaft clavicle fractures: a 10-to-30-year follow-up

BACKGROUND

Few reports exist on the long-term outcomes of midshaft clavicle fracture conservative treatments. Therefore, this study investigated the long-term outcome of this treatment in patients with midshaft clavicle fractures.

METHODS

Patients were treated conservatively for midshaft clavicle fractures with a figure-of-eight bandage between 10 and 30 years ago. Subsequently, a telephone survey was used to follow-up these patients, and 38 were successfully evaluated. The mean term after trauma was 17.0 years. Afterward, the American Shoulder and Elbow Surgeons Shoulder (ASES) score and Shoulder pain and disability index (SPADI) on the affected and unaffected sides were calculated based on the filled questionnaires. We defined patients whose ASES and SPADI on the affected side were worse than the unaffected side as the symptomatic group. Furthermore, plain radiographs measured proportional changes in clavicular length and displacement.

RESULTS

The ASES scores of the affected side were significantly lower than those of the unaffected side, and the SPADI of the affected side was significantly higher than that of the unaffected side. Furthermore, the symptomatic group's proportional changes in clavicular length and displacement were significantly larger than the asymptomatic group.

CONCLUSION

The affected shoulder side was more symptomatic than the unaffected side 10 to 30 years after the trauma when midshaft clavicle fractures were treated conservatively. Moreover, several patients became symptomatic for fractures with a larger proportional change in clavicular length or displacement.

Effect of screw angulation and multiple insertions on load-to-failure of polyaxial locking system

PURPOSE

Polyaxial locking plates rely on the alignment between the thread-to-thread connections of the screw head and the plate hole. These implants have provided substantial support for surgeons. In particular, extended screw positioning have proven to be beneficial in the fixation of challenging fractures. This study aimed to investigate the mechanical properties of ChM 5.0 ChLP polyaxial screws inserted in off-axis trajectories, including multiple insertions and to correlate these parameters with the screw head and the plate hole thread-to-thread engagement.

METHODS

Polyaxial locking screws were inserted into the plates at various angles (0°,10°,15°, -15° off-axis). Multiple time inserted screws were placed firstly at 15°, then 0° and finally -15° off-axis in the same plate hole. A microCT scan of the plate-hole and screw-head interface was conducted before destructive tests. Representative screws from each group were also examined by Scanning Electron Microscope.

RESULTS

The standard insertion at 0° sustained the greatest maximum bending strength without relocation in the screw hole. Screws inserted at 10° and 15° (one time) showed a significant reduction in load-to-failure of up to 36% and 55%, (p = 0.001) (p = 0.001) respectively. Screws inserted at -15° after a maximum of three multiple insertions with angle shift, showed a total reduction in force of up to 70% (p = 0.001). A microCT analysis of thread engagement showed significant correlations. However, the results obtained for multiple insertions were highly variable.

CONCLUSIONS

ChM 5.0 ChLP polyaxial locking system has valuable properties that foster fracture fixation, providing various surgical options. Nevertheless, the freedom of off-axis placement and multiple insertions of the screws comes at the price of reduced force. When possible surgeons should minimize the angles of insertions.

Poor socioeconomic status is associated with delayed femoral fracture fixation in adolescent patients

INTRODUCTION

Healthcare disparities continue to exist in pediatric orthopedic care. Femur fractures are the most common diaphyseal fracture and the leading cause of pediatric orthopedic hospitalization. Prompt time to surgical fixation of femur fractures is associated with improved outcomes.

OBJECTIVE

The objective of this study was to evaluate associations between socioeconomic status and timing of femoral fixation in adolescents on a nationwide level.

METHODS

The 2016-2020 National Inpatient Sample (NIS) database was queried using International Classification of Disease, 10th edition (ICD-10) codes for repair of femur fractures. Patients between the ages of 10 and 19 years of age with a principal diagnosis of femur fracture were selected. Patients transferred from outside hospitals were excluded. Baseline demographics and characteristics were described. Patients were categorized as poor socioeconomic status (PSES) if they were classified in the Healthcare Cost and Utilization Project's (HCUP) lowest 50th percentile median income household categories and on Medicaid insurance. The primary outcome studied was timing to femur fixation. Delayed fixation was defined as fixation occurring after 24 h of admission. Secondary outcomes included length of stay (LOS) and discharge disposition.

RESULTS

From 2016-2020, 10,715 adolescent patients underwent femur fracture repair throughout the United States. Of those, 765 (7.1 %) underwent late fixation. PSES and non-white race were consistently associated with late fixation, even when controlling for injury severity. Late fixation was associated with decreased rate of routine discharge (p < 0.01), increased LOS (p < 0.01) and increased total charges (p < 0.01).

CONCLUSION

Patients of PSES or non-white race were more likely to experience delayed femoral fracture fixation. Delayed fixation led to worse outcomes and increased healthcare resource utilization. Research studying healthcare disparities may provide insight for improved provider education, implicit bias training, and comprehensive standardization of care.

A New Technology Using Mixed Reality Surgical Navigation with the Unlocking Closed Reduction Technique Frame to Assist Pelvic Fracture Reduction and Fixation: Technical Note

BACKGROUND

Pelvic ring disruption (PRD) is a serious trauma associated with high mortality and disability rates. Poor reduction can lead to complications such as pelvic deformity and delayed fracture healing. Here, we introduce a new technology using mixed reality surgical navigation (MRSN) with an unlocking closed reduction technique (UCRT) frame to assist pelvic fracture reduction and fixation.

METHODS

Thirty patients with PRD were enrolled in this study. All of the patients underwent preoperative CT scans, with the pelvis and tracker segmented into three-dimensional models. Under MRSN guidance, auxiliary reduction screws were inserted to grasp the pelvic bone. An ideal trajectory for closed reduction was planned, and suitable CS screws were used for stable fixation after good reduction. Operation time, fluoroscopy frequency, and both Matta and Majeed scores were analyzed.

RESULTS

The mean follow-up period was 10.8 months (7.5, 12.25 months) (range 6-24 months). The average duration of operation was 212.5 min (187.5, 272.8 min) (range 133-562 min), and the average reduction time was 23.0 min (15.0, 42.5 min) (range 10-70). The average fluoroscopy frequency was 34.0 times (31.5, 52.5 times) (range 23-68 times). One hundred and fifty screws were successfully inserted on the first attempt. All the fractures healed well with no complications. Excellent reduction quality (Matta score ≤4 mm) was achieved in 29/30 cases, and good reduction quality (Matta score between 4 and 10 mm) was achieved in 1/30 cases. All patients achieved bone healing after an average of 4.0 months (3.5, 5.9 months) (range 3-6), as well as good function recovery with an average Majeed score of 91.0 (87.8, 95.0) (range 71-100).

CONCLUSION

The MRSN technique described improved reduction accuracy and radiation exposure without considerable extension of operation time.

Standard versus low-dose computed tomography for assessment of acetabular fracture reduction using novel step and gap measurement technique

PURPOSE

Quality of reduction is of paramount importance after acetabular fracture and is best assessed on computed tomography (CT). A recently proposed measurement technique for assessment of step and gap displacement is reproducible but has not been validated. The purpose of this study is to validate a well-established measurement technique against known displacements and to determine if it can be used with low dose CT.

METHODS

Posterior wall acetabular fractures were created in 8 cadaveric hips and fixed at known step and gap displacements. CT was performed at multiple radiation doses for each hip. Four surgeons measured step and gap displacement for each hip at all doses, and the measurements were compared to known values.

RESULTS

There were no significant differences in measurements across surgeons, and all measurements were found to have positive agreement. Measurement error < 1.5 mm was present in 58% of gap measurements and 46% of step measurements. Only for step measurements at a dose of 120 kVp did we observe a statistically significant measurement error. There was a significant difference in step measurements made by those with greater and those with fewer years in practice.

CONCLUSION

Our study suggests this technique is valid and accurate across all doses. This is important as it may reduce the amount of radiation exposure for patients with acetabular fractures.

Cemented K-wire external fixation in juxta-articular enchondroma-related phalangeal pathological fracture

PURPOSE

This study aimed to introduce a technique of external fixation using a combination of bone cement and K-wires, to treat pathological fractures related to solitary digital enchondroma close to the finger joints.

METHODS

From October 2015 to January 2021, 21 patients (8 males and 13 females) with acute pathological fracture due to solitary digital enchondroma close to the finger joints were treated with cemented K-wire external fixators. Mean age was 32 (19-51) years. The digits involved were the index (n = 4), long (n = 4), ring (n = 6), and little (n = 7) fingers. Time to bone healing and complications were assessed. At final follow-up, active range of motion, grip strength and key pinch strength of the tumor-involved and contralateral healthy digits were measured and compared. Functional outcomes were evaluated on Takigawa criteria. Pain was measured on a 10-cm visual analog scale. We assessed the affected upper extremity on the Musculoskeletal Tumor Society score questionnaire.

RESULTS

Mean bone healing time was 5.5 (4-8) weeks. Pin site infection was observed in 1 patient and cured with dressing changes. Mean follow-up was 34 months, with no recurrences or refractures. Mean active range of motion of the proximal interphalangeal joint, grip and key pinch strength of the involved digits reached 92%, 97%, and 99% of the contralateral digits, respectively. On Takigawa criteria, 20 functional results were excellent and 1 good. Mean pain score was 1 (0-3) cm. Mean Musculoskeletal Tumor Society score was 95 (80-100).

CONCLUSION

The combination of bone cement and K-wires is a reliable technique for pathological fracture related to solitary enchondroma close to the joints of the digits, leading to good functional outcomes.

LEVEL OF EVIDENCE

Therapeutic study, Level IVa.

External fixation versus intramedullary nailing for the management of open tibial fracture: meta-analysis of randomized controlled trials

AIM

Tibial shaft fractures are the most common type of long-bone fractures. External fixation (EF) and intramedullary nailing (IMN) are widely used surgical techniques for the definitive fixation of open tibial shaft fractures. The aim of this systematic review and meta-analysis was to compare EF to IMN for the definitive fixation of open tibial fractures.

METHODS

Medline, Embase, and CENTRAL databases were searched for eligible studies. We included randomized controlled trials (RCTs) that compared EF to IMN for skeletally mature adults with open tibial fracture (Gustilo I, II, and III). We evaluated the following outcomes: superficial infection, pin-track infection, deep infection, malunion, nonunion, delayed union, and implant/hardware failure. The risk ratio (RR) was used to represent the desired outcomes. The statistical analysis was performed using the random-effects model.

RESULTS

A total of 12 RCTs that enrolled 1090 participants were deemed eligible for the analysis. EF showed a significantly higher rate of superficial infection, pin track infection, and malunion compared to IMN (RR = 2.30, 95% confidence interval (CI): 1.34 to 3.95; RR = 13.52, 95% CI: 6.16 to 29.66; RR = 2.29, 95% CI 1.41 to 3.73, respectively). No substantial difference was found between EF and IMN in terms of deep infection, nonunion, delayed union, or implant/hardware failure (RR = 1.15, 95% CI 0.67 to 1.98; RR = 0.92, 95% CI 0.77 to 1.10; RR = 1.50, 95% CI 0.98 to 3.33; RR = 0.96, 95% CI 0.36 to 2.60, respectively).

DISCUSSION

The findings of our meta-analysis are consistent with the previous systematic reviews excepts for the implant/hardware failure which was found to be significant in favour of IMN by one of the previous reviews.

CONCLUSION

This meta-analysis confirms that IMN is better than EF with respect to clinical outcomes and complication rate for the definitive fixation of open tibial fracture.

Percutaneous plate fixation of displaced proximal humerus fractures: Do minimally invasive techniques improve outcomes and reduce complications?

OBJECTIVE

The aim of this study was to analyze the outcomes and complications of minimally invasive plate osteosynthesis (MIPO) for displaced proximal humerus fractures and elucidate if the percutaneous technique reduces the rate of avascular necrosis (AVN) without jeopardizing fracture reduction.

MATERIAL AND METHODS

118 patients with a displaced proximal humerus fracture were treated with a polyaxial locking-plate through a standardized percutaneous approach. 73 % were women and mean age was 63 years (18-89) with an average follow-up of 51 months (12-256). There were 32 two-part fractures (27 %), 57 three-part fractures (48 %) and 24 four-part fractures (25 %). Shoulder function at the last follow-up, including ROM and ability to perform daily living activities, was objectively evaluated with an adjusted Constant Score (CS). Subjective patient satisfaction was rated with an Visual Analogic Scale from 0 to 10 and the degree of residual pain with a Verbal Rating Scale (VRS). Radiographic analysis at the most recent follow-up evaluated the presence of AVN, degree of residual medial calcar displacement, and the cervicodiaphiseal angle.

RESULTS

Forty patients (34 %) had a complication, 25 of them (21 %) requiring further surgery. ROM at the last follow-up was 131° of elevation (40°-180°), 38° of external rotation (SD: 17.7) and internal rotation to L3. Average adjusted Constant Score was 68 (SD: 17.76). Twenty-one patients (18 %) complained of shoulder pain (14 moderate and 7 severe) and seven were not satisfied. Radiographically, 29 patients (25 %) had varus malunion and 17 patients (14 %) showed some degree of AVN. Patients with varus malunion (CS 64.3 versus 69.8, p = 0.16) and AVN (CS 56.9 versus 70.4, p = 0.005) had lower CS. The presence of a varus malunion was directly related to the degree of initial medial calcar displacement (p = 0.001) and deficient calcar reduction at surgery (p = 0.004). AVN was statistically more prevalent when the medial calcar was inadequately reduced (p = 0.01).

CONCLUSIONS

MIPO surgery for proximal humerus fractures through an anterolateral approach does not reduce the rate of mechanical complications or AVN compared with standard ORIF techniques. Moreover, percutaneous plating may preclude adequate medial calcar reduction, leading to humeral head malunion and a worse clinical outcome.

Disparity in sex in ankle fracture treatment

BACKGROUND

Literature has shown implicit bias in the treatment between non-operative and surgical treatment in patients with certain types of ankle fractures, which comprise 7.6% of all adult fractures. An understanding of any bias across all ankle fracture management may prove to be critical for the understanding of potential correlations between treatment methods and outcomes of patients with ankle fractures. Therefore, this study aimed to determine whether there is a sex-based bias in the operative and non-operative treatment of all ankle fractures.

METHODS

A retrospective study of 1175 adult patients with ankle fractures was conducted. Data extracted included sex, race, age, type of treatment (non-operative/operative), fracture type (displaced/non-displaced), fracture class, BMI, and length of hospital stay. Odds ratio (OR), Chi-squared, t-test, and Pearson's correlation tests were used with p < 0.05 considered significant.

RESULTS

The study population consisted of 750 females (63.8%) and 425 males (36.2%). The study demonstrated a sex-based disparity in operative and non-operative treatment revealing that women are less likely than men to receive operative treatment for displaced ankle fractures (OR = 0.7, 95% CI: 0.5-0.9, p = 0.01). Of the 750 females, 417 (55.6%) underwent non-operative treatment, while 333 (44.4%) females had an operation. Of the 425 males, 204 (48%) had non-operative treatment, while 221 (52%) underwent operative treatment. The distribution of ankle fracture classes between both sexes was similar, suggesting fracture class did not influence the observed disparity.

CONCLUSION

Our results suggest sex correlates with the treatment type for ankle fractures, with women more likely to receive non-operative treatment for displaced fractures. As post-treatment outcomes often reflect the chosen form of treatment, it is imperative to determine if a disparity in sex explicates differences in clinical outcomes.

[Possibilities and limits of intraoperative 2D imaging in trauma surgery]

BACKGROUND

The two-dimensional (2D) imaging represents an essential and cost-effective component of intraoperative position control in fracture stabilization, even in the era of new three-dimensional (3D) imaging capabilities.

OBJECTIVE

The aim of the present study, in addition to a current literature review, was to examine whether the intraoperative use of 2D images leads to a quality of fracture reduction comparable to postoperative computed tomographic (CT) analysis including 3D reconstructions.

MATERIAL AND METHODS

A comparative retrospective analysis of intraoperative 2D and postoperative 3D image data was performed on 21 acetabular fractures stabilized via a pararectus approach according to an established protocol using the Matta criteria.

RESULTS

The assessment of fracture reduction in intraoperative fluoroscopy compared with postoperative CT revealed a difference only in one case with respect to the categorization of the joint step reduction in the main loading zone.

CONCLUSION

In the intraoperative use of 2D imaging for fracture treatment it is important to select the correct adjustment planes taking the anatomical conditions into account in order to achieve optimum assessability. In this way, the reduction result can be adequately displayed in fluoroscopy and is also comparable to the postoperative CT control. In addition, depending on the findings, optional intraoperative dynamic fluoroscopic assessment can have a direct influence on the further surgical procedure.

Modern osteosynthesis of periarticular fractures: The role of provisional fixation revisited

Periarticular fractures are complex injuries affecting the joint articular surface, the subchondral area, the metaphyseal region, the surrounding soft tissue envelope and not infrequently the ligamentous structures. The management of these injuries has evolved over the years, from one stage to two stage procedures thus facilitating soft tissue resuscitation, adequate pre-operative planning and the use of biologics optimizing the conditions for definitive fixation for a successful long-term outcome. Provisional fixation constitutes an essential step in the surgical treatment of these fractures. Herein, the role of provisional fixation as well as strategies on how they should be applied are discussed. The aim is to revisit this important step of provisional fracture fixation since its introduction by Albin Lambotte, in the early 1900's.

Ultrasound Directed Reduction of Colles' type distal radial fractures in ED (UDiReCT): a feasibility randomised controlled trial

BACKGROUND

There is a high rate of surgical fixation of displaced Colles' type distal radial wrist fractures despite fracture manipulation in the ED. Point-of-care ultrasound has been used to guide ED manipulations but its effect on the quality of fracture reduction or subsequent need for surgical fixation is unknown. This study aims to assess the feasibility of conducting a definitive randomised controlled trial to assess the use of ultrasound to guide these fracture manipulations.

METHODS

We conducted a pragmatic randomised controlled feasibility trial in two EDs in England over a 6-month period (7 October 2019 to 6 April 2020). Adult patients with wrist fractures undergoing manipulation in the ED were randomised 1:1 to ultrasound-guided distal radial fracture manipulation or manipulation with sham ultrasound. The primary outcome for this study was trial recruitment rate. Other measures were recorded to assess potential future definitive trial outcomes and feasibility.

RESULTS

Of 120 patients meeting inclusion criteria, 48 (40%) were recruited and randomised in the two centres, giving overall recruitment rates of 0.3 and 1.8 participants per week at each site, respectively, and 1 participant per week overall. The most common reason that patients were not included was research staff availability. After 6 weeks, six patients in each group (26% intervention, 24% control) had undergone surgical fixation, with 98% data completeness for this potential definitive trial primary outcome. Randomisation, blinding and data collection processes were effective but there were data limitations in the X-ray assessment of fracture positions.

CONCLUSION

A definitive study of a similar design would be feasible within UK ED practice but organisational factors and research staff availability should be considered when estimating the predicted recruitment rate and required sites. 6-week surgical fixation rate was the most reliable outcome measure.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT03868696).

Patient and staff perceptions of short procedural sedation with propofol for joint and fracture reductions in the Emergency Department: A qualitative study

BACKGROUND

Emergency Department (ED) propofol sedation is widely used to facilitate reduction of fractures and dislocations, but little is known about patient and staff perceptions of the practice. Better understanding of these aspects may improve patient care.

METHODS

A qualitative exploratory study involving semi-structured patient interviews and ED healthcare professional focus groups. Interviews with adult patients (≥16 years) >1 hour after their sedation episode were audio-recorded, anonymised and transcribed verbatim to an electronic database. Thematic analysis using a general inductive method led to development of codes and themes. ED focus groups recordings were similarly transcribed and triangulated to patient interview outcomes.

RESULTS

Data saturation was reached after 16 patient interviews. Emergent central themes from a patient perspective were: 'fear of the unknown' and 'expressed relief that the procedure was comfortable.' Key themes included 'trust in the clinical team,' 'efficacy of pain management prior to sedation' and 'quality of the information delivered to patients.' Focus group discussions around patient interview outcomes identified triage, analgesia delivery, communication, and consideration of the environment as areas for improvement.

CONCLUSIONS

ED procedural sedation with propofol is generally very well accepted by patients and clinical staff but there is scope to improve patient-focus and increase satisfaction.

Do Surgeons Accurately Predict Level of Activity in Patients With Distal Radius Fractures?

PURPOSE

One factor influencing the management of distal radius fractures is the functional status of the patient. The purpose of this study was to assess the agreement between patient and surgeon assessments of patient activity level in patients sustaining a distal radius fracture.

METHODS

Ninety-seven patients were included, with a mean age of 58.5 years (range, 18-92 years). Patients completed the International Physical Activity Questionnaire, a validated survey that provides a score of low, moderate, or high activity levels. Treating surgeons provided an independent assessment using the same scale. Agreement between patient and surgeon assessments was evaluated using a weighted kappa-statistic, with a secondary analysis using logistic regression models to assess odds of surgical treatment.

RESULTS

Interrater agreement between surgeons and patients demonstrated only "fair" agreement, with a kappa-statistic of 0.33. Predictive models showed that surgeons accurately identified 73% of "high activity" patients but failed to correctly identify more than 41% of patients rated as "moderate activity" or "low activity." There was a correlation between surgical intervention and increasing physical activity status as assessed by the surgeon; however, the magnitude of this effect was unclear (odds ratio, 2.14; 95% confidence interval, 1.07-4.30). This relationship was no longer significant after adjusting for age, Charlson comorbidity index, and fracture class. There was no association between surgical intervention and physical activity status when using the status provided by the patient.

CONCLUSIONS

Surgeon assessment of patient activity level does not have strong agreement with patients' independent assessment. Surgeons are most accurate at identifying "high activity level" patients but lack the ability to identify "moderate activity level" or "low activity level" patients.

CLINICAL RELEVANCE

Recognition of surgeon assessment of patient activity level as flawed can stimulate improved dialog between patients and physicians, ultimately improving the shared decision-making process.

Staple Technology for Fracture Fixation and Joint Arthrodesis

The use of staple technology in the upper extremity has continued to evolve with the development of shape-memory alloys (SMAs) such as Nitinol that display superelastic properties that can be exploited for persistent compression. Clinical and biomechanical studies support the use of SMA staples for upper extremity fracture fixation and joint arthrodesis. To optimize biomechanical strength and clinical outcomes, it is recommended to place two staples, if possible, at the site of interest as well as to trough the staples to prevent hardware prominence.