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Dekhne MS, Stenquist D, Suneja N, Weaver MJ, Petersen MM, Singh UM, Von Keudell A. Optimizing Outcomes after Operative Treatment Bicondylar Tibial Plateau Fractures - Time for Innovation? THE ARCHIVES OF BONE AND JOINT SURGERY 2024; 12:80-91. [PMID: 38420520 PMCID: PMC10898803 DOI: 10.22038/abjs.2023.72836.3378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 10/30/2023] [Indexed: 03/02/2024]
Abstract
Bicondylar tibial plateau fractures are technically demanding fractures that have a high complication rate. We sought to review the recent literature with the aim to summarize the development of new classification systems that may enhance the surgeon's understanding of the fracture pattern and injury. We highlight the best methods for infection control and touch on new innovative solutions using 3D printer models and augmented mixed reality to provide potentially personalized solutions for each specific fracture configuration.
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Factor S, Druckmann I, Kazum E, Atlan F, Tordjman D, Rosenblatt Y, Eisenberg G, Pritsch T. A novel pulsed electromagnetic field device as an adjunct therapy to surgical treatment of distal radius fractures: a prospective, double-blind, sham-controlled, randomized pilot study. Arch Orthop Trauma Surg 2024; 144:543-550. [PMID: 37971511 DOI: 10.1007/s00402-023-05117-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 10/20/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION The purpose of this study is to evaluate whether using a Fracture Healing Patch (FHP) device that generates pulsed electromagnetic fields (PEMF), applied at the fracture site immediately after open reduction and internal fixation surgery, can accelerate healing of acute distal radius fractures. METHODS In a prospective, double-blind, randomized, and sham-controlled study, thirty-two patients with DRFs treated with ORIF were included. Patients were allocated to a PEMF (active) group (n = 15) or a control (sham) group (n = 17). All patients were assessed with regard to functional Patient-Rated Wrist Evaluation (PRWE), SF12, and radiological union outcomes (X-rays and computed tomography (CT) scans) at 2, 4, 6, and 12 weeks postoperatively. RESULTS Patients treated with the FHP demonstrated significantly bone bridging at 4 weeks as assessed by CT (70% vs 54%, p = 0.05). Mean grip strength in the active group was significantly higher as compared to control (16 ± 9 kg vs 7 ± 3.5 kg, respectively, p = 0. 02). The function subscale of the PRWE was significantly better in PEMF-treated group at 6 weeks after surgery (27.2 VS 35.5, p = 0.04). No statistically significant differences were found in SF12. CONCLUSION PEMF application after ORIF of DRFs is safe, may accelerate bone healing which could lead to an earlier return to daily life activities and work. LEVEL OF EVIDENCE I.
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Mallory N, Gibbs D, Belmonte A, Mallory TH, Santiago-Torres J. Utility of prophylactic closed suction drainage in open reduction and internal fixation for tibial plateau fracture. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:271-277. [PMID: 37452136 DOI: 10.1007/s00590-023-03581-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/10/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE The usefulness of closed suction drains (CSD) after open reduction and internal fixation (ORIF) of tibial plateau fractures is a contested topic. The purpose of this study was to examine the impact of CSD in postoperative outcomes after tibial plateau fracture. METHODS Data were retrospectively collected from patients who underwent primary repair of closed tibial plateau fractures via an anterolateral approach between June 2021 to May 2022 at a single academic center. Fifty-six patients were included and 28 received CSDs at time of surgery. P values less than 0.05 were considered significant. RESULTS Fifty-six patients were included. There was no significant difference in demographics, pre- and post-op hemoglobin, estimated blood loss during surgery, length of stay, postoperative MMEs and pain at 3 month follow-up, deep vein thrombosis (DVT), compartment syndrome, flexion contracture, use of incisional vac, infection rate, wound drainage, hematoma, neurologic pain, dehiscence, additional surgery, or range of motion at 3 months follow-up. We noted a significant difference in Defense and Veterans Pain Rating Scale (DVPRS) on POD1, demonstrating greater pain in those in the CSD group. CONCLUSION Our findings suggest that the use of CSD in ORIF of tibial plateau fractures may not be of significant prophylactic benefit. CSDs in ORIF patients were associated with increased early postoperative pain and had no identifiable benefits. LEVEL OF EVIDENCE III.
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Kalhor A. Scapular spine fracture, presentation of two cases and novel surgical treatment. JSES Int 2024; 8:1-5. [PMID: 38312276 PMCID: PMC10837727 DOI: 10.1016/j.jseint.2023.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
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Sherman N, Hill B, Nisbet B, Knox A, Mahoney A. Bilateral atraumatic acromial base fractures following reverse shoulder arthroplasty managed with open reduction and internal fixation: a case report. JSES Int 2024; 8:95-98. [PMID: 38312292 PMCID: PMC10837714 DOI: 10.1016/j.jseint.2023.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
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Leow J, Exley R, Holmes S, Bhatti N. How good is good enough? Lessons learned from review of outcomes of 50 patients following extraoral open reduction and internal fixation of condylar neck and base fractures at a regional major trauma centre. Br J Oral Maxillofac Surg 2024; 62:83-88. [PMID: 38101970 DOI: 10.1016/j.bjoms.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 11/08/2023] [Indexed: 12/17/2023]
Abstract
The management of mandibular fractures is routine owing to their frequency, particularly those of the mandibular condyle, which are invariably common. Notwithstanding disparities in the literature, the international consensus towards which fractures of the mandibular condyle benefit from open surgical intervention is almost universally accepted. Closed reduction or non-operative management may be utilised in certain circumstances. Whilst outcome research has addressed complications with respect to operative side effects, outcomes related to the quality of bone repair and the setting in which this is delivered have not been universally addressed. The aim of this study was to determine the predictability of translating an indicated operative treatment plan into an acceptable functional result. We evaluated the outcomes of 59 extracapsular condylar fractures in 50 patients who were treated by extraoral open reduction and internal fixation (ORIF) between March 2021 and August 2022. We reviewed demographic data, surgical approach, and plating strategy, and critically evaluated the clinical and radiological outcomes. Whilst we found that the quality of reduction was not universally perfect, the majority were within tolerance, which we set according to the Strasbourg Osteosynthesis Research Group (SORG) definition for minimal displacement (<2 mm overlap and 10° angulation). The cohort had good functional occlusion and minimal long-term postoperative complications. Two patients required re-operation for non-union, and we discuss causality in these cases. In conclusion, we found that ORIF of condylar neck and base fractures is predictable in real-time surgical practice with respect to functional outcome. However, if imperfectly reduced, there is a small risk of non-union.
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Sobel AD, Shah KN, Raducha J, Koeller E, Ibrahim LI, Paxton S. Failure of humeral shaft fixation: construct characteristics. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3637-3641. [PMID: 37268871 DOI: 10.1007/s00590-023-03587-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/10/2023] [Indexed: 06/04/2023]
Abstract
PURPOSE Fixation failure following open reduction and internal fixation (ORIF) of humeral shaft fractures can be a challenging complication. We aimed to identify the modes of failure and characteristics of failed fixation constructs. METHODS We queried our institutional database for patients > 18 years old with fixation failure after ORIF with single plate and screw constructs of humeral shaft fractures from 2006 to 2017. Demographics, fracture characteristics, fixation construct design and mode of failure were recorded. RESULTS Twenty-three failures were identified. Mean age was 55.9 years (SD 19.2 years) with 15 (65%) women. Twelve patients (52%) had midshaft fractures; the remainder had distal-third shaft (8 pts, 35%) or proximal-third shaft (3 pts, 13%) fractures. Midshaft fractures were most commonly fixed through an anterolateral approach with plates and all non-locking screws (83%), while distal-third shaft fractures were fixed with a combination of locking and non-locking screws from a posterior approach. Distal-third shaft fractures failed by plate breakage (63%) or screw pullout (38%) and all midshaft failures occurred by screw pullout proximal (92%) or distal (8%) to the fracture. Resultant varus deformity occurred in 20 (87%) fractures. CONCLUSION Screw pullout in midshaft fractures suggests that fixation to bone was insufficient or biomechanically disadvantageous. Varus moments contribute significantly to the failure of humeral shaft fracture ORIF. Plate breakage in distal fractures suggests high concentrations of stress over a narrow working length of constructs with inadequate plate strength. Recognizing how these constructs fail can aid proper implant selection and application for humeral shaft fracture. LEVEL OF EVIDENCE Treatment level IV.
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Tsotsolis S, Ha J, Fernandes ARC, Park JY, Dewhurst M, Walker T, Ilo K, Park SR, Patel A, Hester T, Poutoglidou F. To plate, or not to plate? A systematic review of functional outcomes and complications of plate fixation in patellar fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:3287-3297. [PMID: 37286819 DOI: 10.1007/s00590-023-03597-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 05/17/2023] [Indexed: 06/09/2023]
Abstract
PURPOSE Poor outcomes and high complication and reoperation rates have been reported with tension-band wiring (TBW) in the management of patellar fractures and particularly the comminuted ones. The purpose of this study was to investigate the functional outcomes and complication rates of patellar fractures managed with open reduction and internal fixation (ORIF) with a plate. METHODS MEDLINE, EMCare, CINAHL, AMED and HMIC were searched, and the PRISMA guidelines were followed. Two independent reviewers extracted the data from the included studies and assessed them for the risk of bias. RESULTS Plating of patellar fractures is associated with satisfactory range of movement (ROM) and postoperative function and low pain levels. We found a 10.44% complication rate and a low reoperation rate. Reoperations were mainly performed for metalwork removal. CONCLUSION ORIF with plating of patellar fractures is a safe alternative in the management of patellar fractures and may be associated with a lower complication and reoperation rate compared to TBW. Future randomized prospective studies are needed to validated the results of the present systematic review.
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Tanpure S, Chaughule C, Date J, Sonawane A, Lohiya M. How we do it? Trimalleolar Fractures: Posterolateral Approach for Fixing the Syndesmotic Ligament, Posterior Malleolus, and Fibula. J Orthop Case Rep 2023; 13:153-158. [PMID: 38162351 PMCID: PMC10753668 DOI: 10.13107/jocr.2023.v13.i12.4116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 10/10/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Syndesmotic injury in trimalleolar fracture is necessary to address intraoperatively by stability test, as it affects post-operative functional outcomes. Most of syndesmotic injuries are stable after fixation of the posterior malleolus, but in rare cases, syndesmosis is not stable after adequate fixation. In those rare conditions, we have to fix syndesmosis by corticocancellous (CC) screw throw lateral fibula plate. We emphasize this complex problem and offer solutions to overcome it. Case Report Case 1: A 45-year-old male suffered significant trauma to his right ankle from a slip and fall, resulting in a trimalleolar fracture. The open reduction and internal fixation (ORIF) throw posterolateral approach was performed after wrinkles were seen on the ankle. A four-hole Ellis plate was used in antiglide mode to reduce posterior malleolar fragments. The lateral malleolus is fixed with a 7-hole, 1/3-locking tubular plate with a tricortical syndesmotic CC screw. The medial malleolus was internally fixed by a 6-hole LC-DCP. Case 2: A 49-year-old female suffered significant trauma to her right ankle from a domestic fall, resulting in a trimalleolar fracture. The ORIF throw posterolateral approach was performed after wrinkles were seen on the ankle. A four-hole Ellis plate was used in antiglide mode to reduce posterior malleolar fragments. The lateral malleolus is fixed with an 8-hole, 1/3-locking tubular plate with a tricortical syndesmotic CC screw. The medial malleolus was internally fixed by a 2 CC screw with an 8-hole LC-DCP. The anterior distal tibia fragment was fixed with a 16-mm anteroposterior CC screw. Conclusion In a trimalleolar ankle fracture, fixation of the posterior malleolus is important for a better post-operative functional outcome, irrespective of the size of the posterior malleolus. The author recommends lateral fibula plate fixation by creating a window between the skin and the peroneus longus and brevis tendon, so we have a chance to put a syndesmotic screw into the lateral plate if syndesmosis is not stable.
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Hochreiter B, Saager LV, Zindel C, Calek AK, Stern C, Wieser K, Gerber C. Computer-assisted planning vs. conventional surgery for the correction of symptomatic mid-shaft clavicular nonunion and malunion. JSES Int 2023; 7:2321-2329. [PMID: 37969529 PMCID: PMC10638583 DOI: 10.1016/j.jseint.2023.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2023] Open
Abstract
Background The aim of this study was to compare the clinical and radiographic outcomes of treatment of symptomatic mal- and/or nonunion of midshaft clavicle fractures using radiographically based free-hand open reduction and internal fixation (ORIF) or computer-assisted 3D-planned, personalized corrective osteotomies performed using patient-specific instrumentation (PSI) and ORIF. The hypotheses were that (1) patients treated with computer-assisted planning and PSI would have a better clinical outcome, and (2) computer-assisted surgical planning would achieve a more accurate restoration of anatomy compared to the free-hand technique. Methods Between 1998 and 2020, 13 patients underwent PSI, and 34 patients underwent free-hand ORIF and/or corrective osteotomy. After application of exclusion criteria, 12/13 and 11/34 patients were included in the study. The clinical examination included measurement of the active range of motion and assessment of the absolute and relative Constant-Murley Scores and the subjective shoulder value. Subjective satisfaction with the cosmetic result was assessed on a Likert scale from 0 to 100 (subjective aesthetic value). 11/13 and 6/11 patients underwent postoperative computed tomography evaluation of both clavicles. Computed tomography scans were segmented to generate 3D surface models. After projection onto the mirrored contralateral side, displacement analysis was performed. Finally, bony union was documented. The average follow-up time was 43 months in the PSI and 50 months in the free-hand cohort. Results The clinical outcomes of both groups did not differ significantly. Median subjective shoulder value was 97.5% (70; 100) in the PSI group vs. 90% (0; 100) in the free-hand group; subjective aesthetic value was 86.4% (±10.7) vs. 75% (±18.7); aCS was 82.3 (±10.3) points vs. 74.9 (±26) points; and rCS was 86.7 (±11.3) points vs. 81.9 (±28.1) points. In the free-hand group, 2/11 patients had a postoperative neurological complication. In the PSI cohort, the 3D angle deviation was significantly smaller (PSI/planned vs. free-hand/contralateral: 10.8° (3.1; 23.8) vs. 17.4° (11.6; 42.4); P = .020)). There was also a trend toward a smaller 3D shift, which was not statistically significant (PSI/planned vs. free-hand/contralateral: 6 mm (3.4; 18.3) vs. 9.3 mm (5.1; 18.1); P = .342). There were no other significant differences. A bony union was achieved in all cases. Conclusion Surgical treatment of nonunion and malunions of the clavicle was associated with very good clinical results and a 100% union rate. This study, albeit in a relatively small cohort with a follow-up of 4 years, could not document any clinically relevant advantage of 3D planning and personalized operative templating over conventional radiographic planning and free-hand surgical fixation performed by experienced surgeons.
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Bastías GF, Sepúlveda S, Bruna S, Contreras M, Hube M, Cuchacovich N, Bergeret JP, Fuentes P. Comparison of complications and reoperations in AO/OTA 43.C3 pilon fractures treated with conventional ORIF versus minimally invasive hexapod ring fixation. Injury 2023; 54 Suppl 6:110884. [PMID: 38143151 DOI: 10.1016/j.injury.2023.110884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 06/04/2023] [Accepted: 06/04/2023] [Indexed: 12/26/2023]
Abstract
INTRODUCTION Controversy exists regarding the optimal management of AO/OTA 43. C3 pilon fractures. Open reduction and internal fixation (ORIF) is the gold standard treatment, but serious soft tissue and infectious complications have been previously reported. Minimally invasive strategies using hexapod ring fixation (HRF) with supplemental limited internal fixation have been used to reduce the incidence of complications. Previous studies have included heterogeneous types of pilon fractures, with non-comminuted injuries being more likely to be treated with ORIF and complex fractures receiving HRF treatment. To our knowledge, no studies have compared the complications and reoperation rates between ORIF and HRF exclusively for C3 fractures. METHODS Retrospective study comparing 53 patients treated for AO/OTA 43.C3 pilon fracture with ORIF or HRF in a trauma level I center with at least a two-year follow-up. Patients treated between January 2015 and January 2019 received ORIF and those treated between January 2019 and January 2021 received HRF. Complications were divided into two groups: minor (superficial infection and malalignment) and major (non-union, deep infection, and amputation). Reoperations, prevalence of ankle osteoarthritis, and requirement for ankle arthrodesis/total ankle replacement were registered. RESULTS We included 30 and 23 patients in the ORIF and HRF groups, respectively. The overall complication rate was similar in both groups, with 50% and 56,5% of the patients having complications in the ORIF and HRF groups, respectively (p:0,63). Minor complications were significantly more prevalent in the HRF group (p<0,001) whilst the ORIF group had a significantly higher rate of major complications (p<0,01). Superficial infections were highly prevalent in the HRF group (47,8%), as they were related to half-pin or K-wire infections. Deep infection was present only in the ORIF group, with 20% of the patients developing this major complication (p:0,03). Non-union rate, reoperations, ankle osteoarthritis, and the need for arthrodesis or ankle replacement showed no significant differences. CONCLUSION In AO/OTA 43.C3 fractures, HRF is safe and effective, achieving high union rates with a significantly lower rate of major complications compared to ORIF. According to our results, ORIF should be used cautiously for these types of fractures, considering the increased risk of deep infection.
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Roddy E, Kandemir U. High rate of avascular necrosis but excellent patient-reported outcomes after open reduction and internal fixation ( ORIF) of proximal humerus fracture dislocations: should ORIF be considered as primary treatment? J Shoulder Elbow Surg 2023; 32:2097-2104. [PMID: 37224914 DOI: 10.1016/j.jse.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 03/23/2023] [Accepted: 04/04/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Proximal humerus fracture dislocations, excluding 2-part greater tuberosity fracture dislocations, are rare injuries. Outcomes after open reduction and internal fixation (ORIF) of these injuries have not been well described in the literature. The purpose of this study was to report the radiographic and functional outcomes of patients who underwent ORIF of a proximal humerus fracture dislocation. METHODS All skeletally mature patients who underwent ORIF of a proximal humerus fracture dislocation between 2011 and 2020 were identified. Patients with isolated greater tuberosity fracture dislocations were excluded. The primary outcome was American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES) score at a minimum of 2 years. Secondary outcomes were the development of avascular necrosis (AVN) and reoperation rate. RESULTS Twenty-six patients met the inclusion criteria. The mean age was 45 years (standard deviation 16), and 77% were men. Median time to reduction and surgery was 1 day (interquartile range [IQR] 1-5). There were 2 (8%) Neer 2-part fractures, 7 (27%) 3-part, and 17 (65%) 4-part fractures. Fifty-four percent (54%) involved the anatomic neck and 31% included a head-split component. Thirty-nine percent (39%) were anterior dislocations. The rate of AVN was 19%. The reoperation rate was 15%. Reoperations included removal of hardware (2), subscapularis repair (1), and manipulation under anesthesia (1). No patients went on to arthroplasty. ASES scores were available for 22 patients (84%) including 4 of 5 patients with AVN. The median ASES score at a mean of 6.0 years postoperatively was 98.3 (IQR 86.7-100, range 63.3-100) and was not different in those with or without AVN (median 98.3 vs. 92.0, P = .175). Only the presence of medial comminution and nonanatomic head shaft alignment on postoperative radiographs were associated with increased risk of AVN. CONCLUSION Radiographic rates of AVN (19%) and reoperation (15%) were high in this series of patients undergoing ORIF of proximal humerus fracture dislocations. Despite this, none of the patients required arthroplasty, and patient-reported outcome scores at an average of 6 years postinjury were excellent, with a median ASES score of 98.5. ORIF should be considered as primary method of treatment in proximal humerus fracture dislocations not only in young patients but also middle-aged patients.
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Contreras ES, Lynch DJ, Hatef S, Speeckaert AL, Goyal KS. Risk Factors for Loss of Reduction After Open Reduction and Internal Fixation of Isolated Olecranon Fractures in Adults. Hand (N Y) 2023; 18:1169-1176. [PMID: 35264046 PMCID: PMC10798208 DOI: 10.1177/15589447221075667] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We sought to determine whether any relevant patient, fracture, surgical, or postoperative characteristics are associated with loss of reduction after plate fixation of isolated olecranon fractures in adults. METHODS Patients who underwent open reduction and internal fixation of an olecranon fracture at our institution over an 11-year period were analyzed. Electronic patient charts and radiographic images were reviewed to gather patient, fracture, surgical, and postoperative data. Statistical analysis to explore the differences between groups was performed. RESULTS Seven of 96 patients experienced a loss of fracture reduction diagnosed at a median of 19 days after their initial surgery (range: 4-116 days). The radiographic mode of failure of all patients who lost reduction was proximal migration of the proximal fracture fragment with or without implant failure. The group that lost reduction had a significantly smaller proximal fragment (14.2 vs 18.6 mm), a higher incidence of malreduction with a persistent articular step-off greater than 2 mm (6/7 vs 14/89), a greater distance between the most proximal screw and the olecranon tip (19.8 vs 13.5 mm), a higher proportion of constructs with screws placed outside of the primary plate (4/7 vs 14/89), and a higher proportion of patients that were not immobilized postoperatively (3/7 vs 8/89). CONCLUSIONS Our results suggest anatomical reduction at the articular surface and adequate fixation of the proximal fragment are key factors in maintenance of reduction, with smaller proximal fragments being at higher risk for failure. A period of postoperative immobilization may decrease the risk of loss of reduction.
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Caterini A, Luciano C, Rovere G, Ziranu A, Farsetti P, De Maio F. Periprosthetic distal femoral fractures after total knee replacement treated by ORIF. Mid to long-term follow-up study in 12 patients. Orthop Rev (Pavia) 2023; 15:87871. [PMID: 37786428 PMCID: PMC10542000 DOI: 10.52965/001c.87871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023] Open
Abstract
Periprosthetic fractures following total knee arthroplasty are a quite uncommon traumatic lesion that often are present in elderly patients with osteoporosis and comorbidities. The most common periprosthetic fracture affects the distal femur. The main internal fixation techniques are ORIF with a locking plate and retrograde intramedullary nailing. In the present study, we report the medium-long term results in 12 patients with a distal femoral periprosthetic fracture stabilized with a locking plate. We reviewed 12 patients affected by a periprosthetic distal femur fracture surgically treated between 2010 and 2016 by ORIF using a locking compression plate after an average follow-up of 5.75 years. The average age of the patients at diagnosis was 78 years. The mean interval time between knee arthroplasty and distal femoral fracture was 8.25 years. Clinical results were assessed using the WOMAC score, while radiographic results according to Beals and Tower's criteria. All fractures of our series were type II according to the Rorabeck and Taylor classification. At follow-up, the WOMAC score ranged from 40.5 to 76.5 points (average 53.92). Radiographic results, according to Beals and Tower's criteria, were excellent in 5 patients and good in 7. All patients returned to their previous daily activities. We believe that reduction and internal fixation with a locking plate is a surgical option of treatment that provides satisfactory clinical and radiological results in Rorabeck type II periprosthetic distal femoral fractures.
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Pesch S, Greve F, Zyskowski M, Müller M, Crönlein M, Biberthaler P, Kirchhoff C, Wurm M. High return to sports rates after operative treatment of patella fractures. Eur J Med Res 2023; 28:366. [PMID: 37736742 PMCID: PMC10514948 DOI: 10.1186/s40001-023-01359-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 09/10/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Patella fractures are relatively rare fractures and only little is known about the postoperative return to sports after patella fractures. METHODS This retrospective study presents information on functional outcome after operative treatment of patella fractures as well as time until return to sports and patients' complaints after open-reduction internal-fixation (ORIF) of patella fractures. RESULTS Overall, 39 patients after ORIF of patella fractures were evaluated at our Level-I trauma center with a mean follow-up of 42 months. The mean time until return to sports was 7 ± 3.9 months. No significant difference was found for functional outcome with respect to body mass index (BMI) or age. Fracture consolidation was accomplished after a mean of 6.9 ± 2.9 months besides a relatively low complication rate of 5.1% (n = 2). CONCLUSION The results demonstrate a high return to sports rate of 90.3%. However, only 51.6% were able to perform sports on their pre-injury level or above. Trial Registration The study was retrospectively registered at DRKS (No: DRKS00031146).
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Bhatnagar A, Rao SS. Mid-facial soft tissue re-suspension following skeletal fixation after maxillofacial trauma-a prospective case series study. Oral Maxillofac Surg 2023; 27:445-457. [PMID: 35672481 DOI: 10.1007/s10006-022-01083-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 05/27/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE Open reduction and internal fixation (ORIF) is used for reduction and stabilization of facial fractures. Despite perfect anatomic skeletal reduction, subtle asymmetries are seen in facial appearance as mid-facial soft tissue often reattaches to the respective facial bones in an aberrant, mostly lower in position. Thus, the present study evaluates the effectiveness of mid-facial soft tissue re-suspension procedure to prevent changes in mid-facial soft tissue profile after ORIF of maxillo-facial fractures. METHODS Fifteen patients with maxillo-facial fractures requiring ORIF were included. After ORIF, mid-facial soft tissue resuspension (STRP) was done by suspending the soft tissue and periosteum over cheek region from temporal fascia by polydioxanone suture material. The results were analyzed by patient satisfaction survey and doctor perspective form on photographs by three surgeons 6 months postoperatively. RESULTS All patients were male in the age range of 18-60 years. STRP was done unilaterally in 7 cases and bilaterally in 8 cases, with average time ranging from 10.6 to 20.5 min. The patient satisfaction survey revealed that 86.6% were pleased with their appearance and 93% said that there was no abnormal change in the esthetics postoperatively. The doctor perception form revealed almost 80% agreement, that there was minimal change in the appearance of cheek mound, nasolabial fold, corner of the mouth, and lateral canthus postoperatively. CONCLUSION STRP is a simple technique to perform with fewer complications, and helps in restoring facial esthetics, same as prior to facial trauma; as it prevents soft tissue sagging after degloving incisions for fracture reduction and fixation.
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Tuaño KR, Fisher MH, Lee N, Khatter NJ, Le E, Washington KM, Iorio ML. Analysis of Postoperative Distal Radius Fracture Outcomes in the Setting of Osteopenia and Osteoporosis for Patients with Comorbid Conditions. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2023; 5:601-605. [PMID: 37790836 PMCID: PMC10543796 DOI: 10.1016/j.jhsg.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 04/13/2023] [Indexed: 10/05/2023] Open
Abstract
Purpose Distal radius fractures (DRFs) are among the most common orthopedic injuries, especially in the elderly. A wide variety of approaches have been advocated as successful treatment modalities; yet, there remains variability in practice patterns of DRF in patients with osteoporosis and osteopenia. Using large data set analysis, we sought to determine the risk profile of operative fixation of DRF in patients with low bone mineral density. Methods A commercially available health care database, PearlDiver, was queried for all patients who underwent open reduction internal fixation of DRFs between 2010 and 2020. The study population was divided into groups based on the presence or absence of osteopenia or osteoporosis and was further classified by patients who were receiving bisphosphonate therapy. Complication rates were calculated, including rates of malunion, surgical site infection, osteomyelitis, hardware failure, and hardware removal. Five-year future fragility fractures were defined in hip, vertebrae, humerus, and wrist fractures. Chi-square analysis and logistic regression were performed to determine an association between these comorbidities and various postoperative complications. Results A total of 152,926 patients underwent open reduction internal fixation of a DRF during the study period. Chi-square analysis of major complications at 3 months showed a statistically significant increase in malunion in patients with osteopenia (P = .05) and patients with osteoporosis (P = .05) who underwent open reduction internal fixation. Logistic regression analysis at 12 months after surgery demonstrated that osteopenia was associated with an increased risk of hardware failure (P < .0001), hardware removal (P < .0001), surgical site infection (P < .0001), and malunion (P = .004). Osteoporosis was associated with a significantly increased risk of hardware failure (P = .01), surgical site infection (P < .0001), and malunion (P < .0001). Conclusions We demonstrated, using large data set analysis, that DRF patients with osteopenia and osteoporosis are predicted to be at increased risk of multiple postoperative complications, and thus, bone density should be strongly considered in treatment planning for these patients. Type of study/level of evidence Prognostic III.
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Orapiriyakul W, Apivatthakakul V, Theppariyapol B, Apivatthakakul T. Humerus shaft fractures, approaches and management. J Clin Orthop Trauma 2023; 43:102230. [PMID: 37588079 PMCID: PMC10425411 DOI: 10.1016/j.jcot.2023.102230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/30/2023] [Accepted: 08/03/2023] [Indexed: 08/18/2023] Open
Abstract
Humeral shaft fracture is a common injury which can be treated either conservatively with functional bracing or with surgical fixation. Current evidence shows an increase in the rate of nonunion after conservative treatment, suggesting that indications for conservative treatment may need to be re-examined. This article updates trends in treatment for humeral shaft fracture. Indications for surgery, both for plate osteosynthesis with open reduction and internal fixation (ORIF) as well as for minimally invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are described. Recognition of the advantages and disadvantages of each technique can better define the role of the plate or nail and can aid in the selection of an appropriate surgical approach. ORIF with compression plate continues to have a role in the treatment of simple or AO/OTA type A fractures. The primary goal of minimal invasive osteosynthesis, a surgical technique involving small incisions, closed reduction or mini-open reduction that minimizes soft tissue dissection and helps preserve the periosteal blood supply, is to achieve bone union and the best possible functional outcomes. MIPO of the humerus is now well accepted as being less invasive and providing relative stability to allow indirect (secondary) bone healing with callus formation. MIPO approaches can be performed circumferentially to the humerus, including the proximal, middle and distal shaft. The classic MIPO approach is anterior MIPO, followed by posterior, anterolateral and anteromedial MIPO. IMN is also an option for treating humerus fractures. In the past, IMN was not widely used due to the potential for complications such as shoulder impingement and elbow problems as well as the limited availability of implants and the steep learning curve of this surgical technique. Over the past decade, the launch of a new design of straight antegrade and retrograde IMN with established techniques has encouraged more surgeons to use IMN as an alternative option. Methods of dealing with concomitant and post-treatment radial nerve palsy have also been evolving, including the use of ultrasound for diagnosis of radial nerve conditions. Radial nerves with contusion, entrapment or laceration can be detected using ultrasound with reliability comparable to intraoperative findings. Trends in treatment of radial nerve palsy are described below. Future larger randomized controlled trials comparing conservative and operative management are necessary to further develop appropriate guidelines.
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Miksch RC, Herterich V, Barg A, Böcker W, Polzer H, Baumbach SF. Open Reduction and Internal Fixation of the Posterior Malleolus Fragment in Ankle Fractures Improves the Patient-Rated Outcome: A Systematic Review. Foot Ankle Int 2023; 44:727-737. [PMID: 37125766 PMCID: PMC10394961 DOI: 10.1177/10711007231165771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
BACKGROUND The best treatment strategy for fractures to the posterior malleolus (PM) is still intensively debated. The aim of this systematic review was to compare the patient-rated outcome following open reduction and internal fixation (ORIF) for fractures of the PM to either closed reduction using AP screws (CRIF) or no treatment in bi- or trimalleolar ankle fractures. METHODS Systematic literature research (MEDLINE (PubMed), CINAHL, Scopus, Central and EMBASE) according to the PICOS and PRISMA guidelines. Eligible were studies comparing the outcome following ORIF to any other treatment strategy for fractures to the posterior malleolus in isolated bi- or trimalleolar ankle fractures. RESULTS Twelve studies were eligible for a qualitative analysis and 6 for a quantitative analysis. Overall, a considerable heterogeneity among the studies was observed. The most commonly used outcome score was the American Orthopaedic Foot & Ankle Society ankle-hindfoot score (AOFAS). The final follow-up ranged from 12 to 160 months. Four studies compared ORIF to CRIF of the PM. The quantitative analysis revealed significantly better AOFAS scores for ORIF (90.9 vs 83.4 points; P < .001; I2 = 0%). Three studies compared ORIF to untreated PM fragment. The quantitative analysis again revealed superior AOFAS scores for ORIF (92.0 vs 82.5 points; P < .001; I2 = 99%). A similar trend was observed for the Ankle Fracture Scoring System and American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire scores as well as the quality of reduction. CONCLUSION Despite a considerable heterogeneity, the data available point to a superior outcome following ORIF for fractures to the PM when compared to CRIF or no treatment.
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Oldrini LM, Sangiorgio A, Feltri P, Marbach F, Filardo G, Candrian C. Proximal humerus fractures: deltopectoral open reduction and internal fixation vs deltosplit minimally invasive plate osteosynthesis: which surgical approach provides superior results? EFORT Open Rev 2023; 8:662-671. [PMID: 37526265 PMCID: PMC10441256 DOI: 10.1530/eor-22-0110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023] Open
Abstract
Purpose To compare the two main surgical approaches to address proximal humerus fractures (PHFs) stratified for Neer fracture types, to demonstrate which approach gives the best result for each fracture type. Methods A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in PubMed, Web of Science, and Cochrane databases up to 4 January 2022. Inclusion criteria were studies comparing open reduction and internal fixation (ORIF) with deltopectoral (DP) approach and minimally invasive plate osteosynthesis (MIPO) with deltosplit (DS) approach of PHFs. Patient's demographic data, fracture type, Constant-Murley Score (CMS), operation time, blood loss, length of hospital stay, complications, fluoroscopy time, and radiological outcomes were extracted. Results were stratified for each type of Neer fracture. Results Eleven studies (798 patients) were included in the meta-analysis. No functional difference was found in the CMS between the two groups for each type of Neer (P = n.s.): for PHFs Neer II, the mean CMS was 72.5 (s.e. 5.9) points in the ORIF group and 79.6 (s.e. 2.5) points in the MIPO group; for Neer III, 77.8 (s.e. 2.0) in the ORIF and 76.4 (se 3.0) in the MIPO; and for Neer IV, 70.6 (s.e. 2.7) in the ORIF and 60.9 (s.e. 6.3) in the MIPO. The operation time in the MIPO group was significantly lower than in the ORIF group for both Neer II (P = 0.0461) and Neer III (P = 0.0037) fractures. Conclusion The MIPO with DS approach demonstrated no significant differences in the results to the ORIF with DP approach for the different Neer fractures in terms of functional results, with a similar outcome, especially for the Neer II and III fracture types. The MIPO technique proved to be as safe and effective as the ORIF approach.
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Beckwitt CH, Monaco SJ, Gruen GS. Republication of "Primary Ankle Arthrodesis vs ORIF for Severely Comminuted Pilon Fractures: A Comparative Retrospective Study". FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231193391. [PMID: 37566683 PMCID: PMC10408335 DOI: 10.1177/24730114231193391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023] Open
Abstract
Background The treatment for highly comminuted pilon fractures remains controversial. The goal of this retrospective cohort study was to compare functional outcomes of primary arthrodesis of the tibiotalar joint (fusion) and open reduction internal fixation (ORIF). Methods Patients who underwent primary ORIF or fusion for pilon fractures at our institution since 2000 were identified by Current Procedural Terminology (CPT) code. Inclusion criteria for the ORIF cohort were patients with an AO/Orthopaedic Trauma Association type C3 pilon fracture. Additional inclusion criteria for the fusion cohort were patients whose fractures were deemed non-reconstructable by the treating surgeon. Outcome assessment was determined by the Foot and Ankle Outcome Score (FAOS) and Short Form 36-item health survey (SF-36), time to radiographic union or fusion, and wound-healing complications at a minimum of 2 years after their surgery. Results Nineteen ORIF and 16 fusion patients completed the study's outcome assessments. A higher rate of nonunion was observed in patients treated by primary ORIF than primary fusion (5/19 vs 1/16). Posttraumatic arthritis was observed in 11 of 19 primary ORIF patients. Primary fusion patients exhibited increased symptoms, pain, and physical role limits but were equivalent to primary ORIF patients on all other functional metrics examined. Conclusions Primary ankle arthrodesis achieves a lower rate of nonunion and comparable functional outcomes to ORIF in patients with severely comminuted pilon fractures. The higher rate of nonunion observed in the primary ORIF group suggests that primary fusion should be considered an effective procedure for severe injuries to decrease the need for further operative intervention. Level of Evidence Therapeutic Level III, retrospective cohort.
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Okulski J, Kozakiewicz M, Zieliński R, Krasowski M, Konieczny B. Evaluation of the Relationship of Screw Pullout and Plate Fracutre in Fixation of Mandible Condyle Fractures: A Mechanistic Study. J Clin Med 2023; 12:4380. [PMID: 37445415 DOI: 10.3390/jcm12134380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/24/2023] [Accepted: 06/26/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND The mandible is the most injured part of the facial skeleton, and 25-40% of mandibular fractures involve the condyle process. The aim of this study is to answer the question of the relationship between screw pullout and/or plate fracture during osteosynthesis. METHODS We tested polyurethane models of mandibles whose condylar process was cut (simulating a fracture) and fused using plates and screws. RESULTS A total of 672 plates were tested. A total of 25.6% of them were fractured during the test, with most being fractures of the base of the condyle. More screws (81.97%) are pulled out from the ramus than from the condyle-69.15%. CONCLUSIONS The gold standard in the osteosynthesis of condylar fractures is two straight plates. Other than these, there is no one-size-fits-all plate for every type of fracture. Plates fixed with fewer screws (smaller plates used in higher-lying fractures) are more likely to result in screw pullout. On the other hand, in plates fixed with more screws, plate fracture is more common.
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Cievet M, Buffard M, Kumble A, Ramos-Pascual S, Locquet V, Burnier M. Outcomes of arthroscopic versus open reduction and internal fixation for the treatment of acute traumatic lunate fractures: a systematic review. HAND SURGERY & REHABILITATION 2023:S2468-1229(23)00114-7. [PMID: 37364729 DOI: 10.1016/j.hansur.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/30/2023] [Accepted: 06/01/2023] [Indexed: 06/28/2023]
Abstract
The purpose of the study was to compare outcomes of fully-arthroscopic reduction and internal fixation (ARIF) versus open reduction and internal fixation (ORIF) to treat acute traumatic lunate fractures. A literature search was conducted using Medline and Embase. Demographic data and outcomes were extracted for included studies. The search identified 2,146 references: 17 articles were included, reporting on 20 cases (4 ARIF and 16 ORIF). No differences between ARIF and ORIF were found in rate of union (100% vs 93%, P = 1.000), grip strength (mean difference, 8%; 95%CI, -16-31; P = 0.592), rate of return to work (100% vs 100%, P = 1.000), or range of motion (mean difference, 28°; 95%CI, -25-80; P = 0.426). Lunate fractures were not identified in 6 of the 19 radiographs, but were identified in all CT scans. There were no differences in outcome between ARIF and ORIF for the treatment of fresh lunate fracture. The authors recommend surgeons to perform CT scans when diagnosing high-energy wrist trauma so as not to overlook lunate fractures. LEVEL OF EVIDENCE: Level IV.
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Sakellariou E, Galanis A, Vavourakis M, Papagrigorakis E, Vlachos C, Zachariou D, Vasiliadis E, Pneumaticos S. Peri-implant proximal femur fracture in a poliomyelitis survivor: A surgical and medical challenge. Clin Case Rep 2023; 11:e7465. [PMID: 37287621 PMCID: PMC10242085 DOI: 10.1002/ccr3.7465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 05/13/2023] [Accepted: 05/23/2023] [Indexed: 06/09/2023] Open
Abstract
Key Clinical Message The treatment of long bone fractures in post-polio survivors is indubitably an exacting task. Out of this complicated case presented in this paper, it can be deduced that it is attainable to repair a peri-implant subtrochanteric refracture or a complex non-union of the proximal femur with plate and screws with grafting. Abstract Post-polio survivors are prone to low-energy bone fractures. The management of such cases is exigent, as no literature data indicate the best surgical approach. This paper presents an intricate peri-implant proximal femoral fracture in a polio survivor treated in our institution and accentuates the various challenges we encountered.
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Fung M, Sivakumar B, Jiang E, Suthersan M, Wines A, Mittal R, Symes M. Trends in management of adult tarsometatarsal joint injuries in a contemporary Australian context: a nationwide study of claims data over 20 years. ANZ J Surg 2023; 93:1214-1219. [PMID: 37027316 DOI: 10.1111/ans.18456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 03/16/2023] [Accepted: 03/29/2023] [Indexed: 04/08/2023]
Abstract
BACKGROUND Traumatic tarsometatarsal joint (TMTJ) injuries are uncommon, but can cause significant morbidity due to delayed or missed diagnosis. Recent evidence highlights the importance of achieving anatomical reduction via operative management. This study aims to analyse trends in rates of open reduction internal fixation (ORIF) for Lisfranc injuries in Australia according to Nationwide claims data. METHODS Claims according to the Medicare Benefits Schedule (MBS) on ORIF of traumatic TMTJ injuries were collated for the period from January 2000 to December 2020. Paediatric patients were excluded. Two negative binomial models were utilized to analyse the trends in TMTJ injuries over time after controlling for sex, age group and population changes. Results were absolute and per 100 000 population. RESULTS 7840 patients underwent TMTJ ORIF over the period studied. There was a mean yearly increase of 12% (P < 0.001). Age group (P < 0.001) and year (P < 0.001) were significant predictors for TMTJ fixation, whilst sex was not (P = 0.48). Patients older than 65 years were noted to have a 53% lower rate of TMTJ ORIF per person, when compared to the reference group of 25-34 year-olds (P < 0.001). Five-year block analysis revealed increases in rate of fixation for all age groups. CONCLUSION Rates of operative fixation for TMTJ injuries are increasing in Australia. This is likely due to improved diagnostics, understanding of optimal treatment goals, and increased orthopaedic subspecialisation. Further studies with clinical and patient reported outcomes, as well as comparing rates of operative intervention to incidence, will be useful.
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