Which surgical approach provides maximum visualization and access for open reduction and internal fixation (ORIF) of femoral neck fractures?

OBJECTIVES

Appropriate visualization of the femoral neck is critical when performing open reduction and internal fixation (ORIF) of a femoral neck fracture. The purpose of this study was to objectively identify which surgical approach provided the most extensive visualization of the femoral neck during ORIF. Our hypothesis was that the Smith-Petersen approach with rectus release would provide the most extensive visualization.

METHODS

Ten cadaveric hips were utilized to compare 4 different surgical approaches to the femoral neck: Smith-Petersen (SP), Smith-Petersen with rectus release (SPwR), Watson-Jones (WJ), and Hueter approach. After surgical exposure, calibrated digital images were captured and analyzed using a computer software program to determine the percent-area visualized. Three trained investigators separately assessed each specimen to determine clinical visualization and ability of the surgeon to manually outline anatomic locations of the femoral neck: subcapital, trans-cervical, and basicervical. Data were analyzed for significant (p < 0.05) differences using ANOVA and Fisher Exact tests.

RESULTS

For calculated percent-visualization, SP and SPwR allowed for significantly more (p = 0.003) visualization than the Hueter and WJ approaches. For surgeon visualization, SP and SPwR were significantly higher (p < 0.029) when compared to WJ. The ability for the individual surgeon to outline the femoral neck's anatomical landmarks was significantly higher (p < 0.049) with SP and Hueter approaches compared with SPwR.

CONCLUSION

The SP and SPwR provided superior visualization of femoral neck anatomy compared to Hueter and WJ approaches. Similarly, the SP approach allowed for optimal surgeon visualization of and access to clinically relevant femoral neck anatomic landmarks compared to other approaches assessed.

Outcome and technical consideration of conversion total hip arthroplasty after failed fixation of intracapsular and extracapsular hip fractures: Are they really that different?

INTRODUCTION

Conversion Total Hip Arthroplasty (cTHA) is a rescue strategy for proximal femur osteosynthesis failures. However, it is unclear whether cTHAs performed for extra-capsular fracture fixation failures (ECF) or for intra-capsular fracture fixation failures (ICF) share the same complexity and efficacy. The purpose of our study was to compare cTHAs performed on pre-existing ICFs and pre-existing ECFs, focusing on surgical complications and functional outcomes in both groups.

METHODS

An observational retrospective study was conducted on cTHA patients, treated between 2014 and 2018, divided into 2 groups: ICF-group and ECF-group. The main outcomes were: type of implant used, duration of surgery, need for transfusions, incidence of complications, functional outcomes.

RESULTS

28 patients were included (15 in the ECF group and 13 in the ICF group); the average follow-up was of 31 ± 17.3 months. No significant differences were identified in terms of the type of implant used and duration of surgery. The number of transfused patients was 4 in the ICF group and 12 in the ECF group (p = 0.02); the average transfused units were 0.4 ± 0.7 in the ICF group and 1.3 ± 0.9 in the ECF group (p = 0.01). The incidence of complications - an infection and a dislocation, both of which occurred in the ICF group - and functional outcomes did not present significant differences.

CONCLUSION

The conversion surgery on ECFs patients is technically more difficult for the surgeon and prone to greater blood loss. The outcomes are satisfactory and overlap between the two groups.

Radiological, Clinical and Functional Outcomes of Combined Dorsal and Volar Locking Plate Osteosynthesis for Complex Distal Radius Fractures

PURPOSE

The purpose of this study was to assess the short- to mid-term radiologic, clinical, and functional outcomes of patients treated with combined dorsal and volar locking plating for internal fixation of complex, comminuted, intra-articular, distal radius fractures.

METHODS

We performed a retrospective review of 34 patients treated with combined dorsal and volar locking plates for the internal fixation of complex, comminuted, intra-articular distal radius fractures. Radiographic and clinical parameters were recorded at a mean of 48 months after surgery. Activities of daily living and quality of life were assessed by the Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation questionnaires.

RESULTS

Compared with the contralateral wrist, the treated wrist regained 73% of flexion, 81% of extension, 86% of ulnar deviation, 90% of radial deviation, 98% of pronation, 99% of supination, and 93% of grip strength. Mean Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores were 11 (range, 0-78) and 11 (range, 0-77), respectively. Radial height and radial inclination were restored anatomically in 24% and 41% of patients, respectively, while volar tilt and ulnar variance were restored in 68% of patients.

CONCLUSION

The overall functional and radiologic outcome of patients with comminuted intra-articular complex distal radius fractures treated with the combined dorsovolar plate osteosynthesis was good to excellent.

LEVEL OF EVIDENCE

Therapeutic IV.

Radiological and Functional Assessment of Treatment Outcomes in Patients after Open Reduction with Internal Fixation (ORIF) of Acetabular Fractures

(1) Fracture of the pelvis usually happens in young men and results from high-energy trauma. It generates high social and economic costs and results in further health problems. It is therefore important to assess long-term treatment results. (2) The study (NCT04902209) involved 31 patients (mean age 43.6 ± 14.8 years). We conducted fixation assessment on the basis of radiographs and CT scans and functional assessment based on functional scales. (3) We observed more degenerative changes in the less precise reconstruction of the acetabulum (p = 0.075). We did not find statistically significant relationships between the area of surgical approach, the gravity of fracture, and the development of degenerative changes. We did not find statistically significant relationships between patients' functional states and the type of surgical approach or the complexity of the fracture. We found a positive correlation between the time of surgical treatment and patients' functional state (p = 0.04). Patients whose joint surfaces were reconstructed anatomically had significantly higher scores in functional scales (HHS p = 0.05, Merle p = 0.03). (4) Patients after surgical fixation of the acetabulum have low functional abilities. The quality of reconstruction of the loaded surface as well as the length of time post-surgery seems to be essential for the patients' functional state.

A nomogram for predicting skin necrosis risk after open reduction and internal fixation for tibia fractures

The purpose of our study was to determine the risk factors for skin necrosis after open reduction and internal fixation (ORIF) for tibia fracture and establish a nomogram prediction model. We retrospectively analysed the clinical data of patients who suffered from tibia fractures and had been surgically treated by ORIF in our institution between August 2015 and October 2020. Perioperative information was obtained through the electronic medical record system, univariate and multivariate analyses were performed to determine the risk factors of skin necrosis, and a nomogram model was constructed to predict the risk of skin necrosis. The predictive performance and consistency of the model were evaluated by the Hosmer‐Lemeshow (H‐L) test and the calibration curve. In total, 444 patients were enrolled in our study. Multivariate analysis results showed that limb swelling, time until the operation, operation time, distance from fracture end to the skin, and soft‐tissue injury (Tscherne classification type 3) were independent risk factors for skin necrosis. The AUC value for skin necrosis risk was 0.906 (95% confidence interval 0.88~0.94). The H‐L test revealed that the nomogram prediction model had good calibration ability (P = .467). Finally, we found a correlation between skin necrosis and limb swelling, time until the operation, operation time, distance from fracture end to the skin, and soft‐tissue injury (Tscherne classification type 3) after ORIF for tibia fracture patients. Our nomogram prediction model might be helpful for clinicians to identify high‐risk patients, as interventions could be taken early to reduce the incidence of skin necrosis.

Good functional outcomes after open reduction and internal fixation for AO/OTA type 13-C2 and -C3 acute distal humeral fractures in patients aged over 45 years

BACKGROUND

The purpose of this study was to report the functional outcomes and complications after open reduction and internal fixation (ORIF) for Arbeitsgemeinschaft für Osteosynthesefragen (AO)/Orthopaedic Trauma Association (OTA) type 13-C2 and -C3 acute distal humeral fractures with minimum 2-year follow-up. Our hypothesis was that ORIF would provide functional outcomes that are comparable to those of total elbow arthroplasty and elbow hemiarthroplasty reported in the literature.

MATERIALS AND METHODS

During a 6-year period, 23 patients aged > 45 years were treated with double plating for AO/OTA type 13-C2 or -C3 fractures. The mean age was 62 years (range, 46-80 years). The Oxford Elbow Score was used as the primary outcome; the Mayo Elbow Performance Score, pain severity score (on a visual analog scale), range of motion, reoperations, and complications were used as secondary outcomes.

RESULTS

The median Oxford Elbow Score was 42 (range, 25-48), where a score of 48 represents a normal elbow; 20 patients achieved good to excellent outcomes, and 3 achieved fair outcomes. The median Mayo Elbow Performance Score was 85 (range, 60-100), where a score of 100 represents a normal elbow; 18 patients achieved good to excellent outcomes, and 5 achieved fair outcomes. The median visual analog scale score was 2 (range, 0-5). The median flexion-extension and supination-pronation arcs were 120° (range, 70°-155°) and 160° (range, 75°-170°), respectively. Eight complications were recorded in 7 patients; 4 of them required reoperation because of fracture pseudarthrosis or elbow stiffness. Ten patients were working at the time of trauma, and nine of them returned to the same occupation. Our results are comparable to the results of previously published studies regarding the outcome of ORIF, elbow hemiarthroplasty, or total elbow arthroplasty for AO/OTA type 13-C fractures.

CONCLUSION

ORIF is a reliable treatment option for AO/OTA type 13-C2 and -C3 acute distal humeral fractures in middle-aged and elderly patients, despite the considerable rate of complications. Good to excellent results can be obtained in most patients.

Endoscopically Assisted Treatment of Condylar Base and Neck Fractures: A Single Institution Analysis of Outcomes and Complications

Background

Conservative treatment, including observation and closed treatment, as well as open reduction and internal fixation are existing options for treating condylar process fractures. Extraoral approaches are widely preferred for open reduction and internal fixation. Transoral access for condylar base and neck fractures is not yet commonly used as it is technically demanding and requires special equipment.

Purpose

In this study, the transoral endoscopically assisted approach is described, and its outcomes and complications were investigated. Imaging data and clinical records of 187 patients with condylar process fractures, treated via endoscopically assisted transoral approach between 2007 and 2017 were analyzed. Parameters included diagnosis and fracture classification, treatment, osteosynthesis configuration and postoperative complications.

Results

Early complications, including infection, transient postoperative malocclusion, pain and limited mouth opening, occurred in 35 patients (18.7%). Late onset complications, such as screw loosening were documented in only 4 patients (2.1%). Revision surgery following postoperative 3D imaging was required in only 3 cases (1.6%). Fragment length ranged from 15.5 to 38.3 mm. In 57.7% of patients with condylar fragment length < 20 mm, a single osteosynthesis plate was used, with no elevated complication rate. Two osteosynthesis plates with 4 screws each was used as standard in longer fragments.

Conclusion

Endoscopically assisted transoral treatment of condylar process fractures is a reliable, yet technical demanding technique. It allows for reduction and fixation of fractures with a condylar fragment length of > 15 mm with low postoperative complication and revision rates.

Excellent clinical and radiological outcome following locking compression plate fixation of displaced medial clavicle fractures

BACKGROUND

Treatment of medial clavicle fractures is still controversially discussed in the community of upper extremity surgeons. An increasing number of symptomatic non-unions following conservative treatment of displaced fractures led to the development of various surgical approaches. Aim of this study was to evaluate the clinical and radiological outcome following operative treatment of displaced medial end clavicle fractures.

METHODS

Patients who presented with a displaced fracture of the medial clavicle between September 2012 and December 2019 were retrospectively enrolled in this study. All patients were operatively treated with open reduction and internal fixation (ORIF) using an anatomically precontoured locking compression plate (LCP) originally designed for the lateral clavicle (Synthes®, Umkirch, Germany). Functional outcome was recorded using the American Shoulder and Elbow Surgeons (ASES) Score, the Munich Shoulder Questionnaire (MSQ), Shoulder Pain and Disability Index (SPADI) and Constant Score.

RESULTS

Overall 18 patients with a mean age of 54.5 ± 23.5 years suffering from a displaced fracture of the medial clavicle were identified. The mean follow-up was 40.9 ± 26.2 months. The mean ASES accounted for 88.3 ± 20.8 points, the mean MSQ was 83.1 ± 21.7 points, the mean SPADI was 85.6 ± 22.5 and a mean normative age- and sex-specific Constant Score of 77.5 ± 19.1 points resulted. No minor or major complications were observed. Radiologic fracture consolidation was achieved in all patients after a mean of 6.4 months.

CONCLUSION

Surgical treatment of displaced medial clavicle fractures using an anatomically precontoured locking plate originally designed for the lateral clavicle led to very good to excellent clinical and functional results.

TRIAL REGISTRATION

No: DRKS00024813 , retrospectively registered 19.03.2021 ( www.drks.de ).

Comparison of therapeutic results of closed and open repair of mandibular condylar fractures

BACKGROUND

Mandibular condylar fractures mostly result from traumatic accidents or strife. There is still dispute on the effectiveness of various therapeutic methods. Here we aimed to evaluate and compare the open or closed repair methods for mandibular condylar fractures.

METHODS

This is a clinical trial that was performed in 2015-2021 in Iran on all patients that referred to our medical centers with mandibular fractures due to traumatic events. Those cases with severe lateral dislocation of the mandibular condyles or severe dislocations of the fractured parts were assigned to the open surgical treatment group. The other patients were treated using Arch bar + intermaxillary fixation (IMF). The patient's abilities of mouth opening were assessed in centimeters within 1 month, 3 months, 6 months, 1 year and 2 years after the operations.

RESULTS

726 mandibular fractures were evaluated. Our data showed that 302 fractures (41.6%) were in the mandibular condyles. Of the 302 condylar fractures, 172 fractures (57.1%) occurred due to automobile accidents and 82 fractures (27.5%) occurred due to direct trauma. 203 patients (67.2%) underwent the close surgical procedures using maxillary and mandibular fixation using arch bar + IMF. 99 patients (32.8%) underwent open mandibular fixation operation and internal fixation (ORIF). Assessments of mouth opening showed significant improvements in this ability within the follow-up period in both groups (P<0.001 for both). Furthermore, we observed that patients treated by the open mandibular fixation procedure had significantly better results within the 6 months and 1 year after the procedures but after 2 years, no significant differences could be observed between groups.

CONCLUSION

Both open and closed surgical approaches for condylar fractures are associated with significant improvements, however, patients that were treated with ORIF had better clinical results in the first year after the surgical procedures.

Good to Excellent Functional Outcome and High Return to Sports Rate after Operative Treatment of Unstable Lateral Clavicle Fractures: Comparison of Two Coracoclavicular Button Fixation Techniques

Purpose: Operative therapy for unstable lateral clavicle fractures is necessary to reduce the risk of bony non-union. Irritation and restriction during sportive activities due to the implanted materials are a common reason for impaired function and implant removal. The aim of this study was to gain information on functional outcome and time until return to sport (RTS) after surgical treatment of unstable lateral clavicle fractures, comparing two coracoclavicular button techniques. Methods: A retrospective chart review of patients who were consecutively treated for unstable lateral clavicle fractures at our level one trauma center from 2014 to 2018 was conducted. Two different surgical techniques were evaluated and compared. Group 1 was treated using a locking compression plate and knotted DogBone™ Button, while group 2 received an LCP and knotless DogBone™ Button. Functional outcome (ASES (American Shoulder and Elbow Score), Constant-Score, DASH (Disability of Arm, Shoulder and Hand), MSQ (Munich Shoulder Questionnaire) and SPADI (Shoulder Pain and Disability Index) and time until RTS were investigated and compared between both groups, 1 year postoperatively. Results: A total of 56 patients (n = 35 group 1, n = 21 group 2) with a mean age of 45.1 ± 14.6 years met the inclusion criteria. Functional outcome reached good to excellent results (ASES 94.7 ± 9.8, Constant Score 85.1 ± 8.1, DASH 5.5 ± 8.4, MSQ 90.9 ± 7.2, SPADI 96.1 ± 5.7). Implant removal rates were higher in group 1 (48.3% vs. 35.3%) yet without statistical significance (p = 0.122). All patients returned to sports postoperatively with a mean time period until return to sport of 4.6 (3–9) months. Conclusion: Locking compression plating and coracoclavicular fixation using a knotless Dogbone™ technique provides good to excellent functional outcomes, a high and fast rate of return to sport and lower irritation rates compared to the knotted DogBone™ technique.

Lisfranc injuries: fix or fuse? : a systematic review and meta-analysis of current literature presenting outcome after surgical treatment for Lisfranc injuries

AIMS

This systematic review and meta-analysis was conducted to compare open reduction and internal fixation (ORIF) with primary arthrodesis (PA) in the treatment of Lisfranc injuries, regarding patient-reported outcome measures (PROMs), and risk of secondary surgery. The aim was to conclusively determine the best available treatment based on the most complete and recent evidence available.

METHODS

A systematic search was conducted in PubMed, Cochrane Controlled Register of Trials (CENTRAL), EMBASE, CINAHL, PEDro, and SPORTDiscus. Additionally, ongoing trial registers and reference lists of included articles were screened. Risk of bias (RoB) and level of evidence were assessed using the Cochrane risk of bias tools and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. The random and fixed-effect models were used for the statistical analysis.

RESULTS

A total of 20 studies were selected for this review, of which 12 were comparative studies fit for meta-analysis, including three randomized controlled trials (RCTs). This resulted in a total analyzed population of 392 patients treated with ORIF and 249 patients treated with PA. The mean differences between the two groups in American Orthopedic Foot and Ankle Society (AOFAS), VAS, and SF-36 scores were -7.41 (95% confidence interval (CI) -13.31 to -1.51), 0.77 (95% CI -0.85 to 2.39), and -1.20 (95% CI -3.86 to 1.46), respectively.

CONCLUSION

This is the first study to find a statistically significant difference in PROMs, as measured by the AOFAS score, in favour of PA for the treatment of Lisfranc injuries. However, this difference may not be clinically relevant, and therefore drawing a definitive conclusion requires confirmation by a large prospective high-quality RCT. Such a study should also assess cost-effectiveness, as cost considerations might be decisive in decision-making. Level of Evidence: I Cite this article: Bone Jt Open 2021;2(10):842-849.

A Review of Periprosthetic Tibial Fractures: Diagnosis and Treatment

Periprosthetic fracture occurring during or after total knee arthroplasty is a rare injury. Literature concerning periprosthetic tibial factures is sparse, and there is limited guidance for evidence-based management. This review aims to provide readers with an overview of the epidemiology, risk factors, and classification of these fractures. Management includes nonoperative treatment of nondisplaced fractures, fixation for those with stable implants, and revision for those with loose implants.

Increased Revisions in Conversion Total Knee Arthroplasty After Periarticular Open Reduction Internal Fixation Compared With Primary Total Knee Arthroplasty: A Matched Cohort Analysis

BACKGROUND

Prior studies on conversion total knee arthroplasty (cTKA) have reported increased technical challenges and risk of complications compared with primary knee arthroplasty. The purpose of this study was to compare two-year postoperative complication/revision rates between patients undergoing cTKA after prior periarticular open reduction and internal fixation (ORIF) and those undergoing primary TKA.

METHODS

Patients who underwent cTKA after prior periarticular ORIF of the ipsilateral knee were identified in a national all-payer claims database from 2010 to 2018. This ORIF-cTKA cohort was propensity matched to participants undergoing primary TKA based on age, gender, Charlson comorbidity index, and obesity status. Univariate analysis was performed to analyze differences in two-year complication and revision rates.

RESULTS

After propensity matching, 823 patients were included in the ORIF-cTKA cohort and 1640 patients in the primary TKA cohort. No differences in demographics or comorbidities existed between cohorts. Relative to the primary TKA cohort, the ORIF-cTKA cohort had significantly higher incidences of all-cause revision (5.47% vs 2.47%, P = .001), periprosthetic joint infection (PJI; 4.74% vs 1.34%, P < .001), and intraoperative or postoperative periprosthetic fracture (1.58% vs 0.55%, P = .01) at two years postoperatively. There was also a nonsignificant trend toward increased rates of aseptic loosening (1.82% vs 0.91%, P = .052) in the ORIF-cTKA.

CONCLUSION

Relative to primary TKA, cTKA after periarticular ORIF is associated with significantly increased rates of all-cause revision, PJI, and periprosthetic fracture at two years postoperatively. Surgeons should counsel these patients about the increased risks of these postoperative complications and consider treating them as high risk for PJI in the perioperative period.

Patient reported outcome of 33 operatively treated talar fractures

BACKGROUND

Management of talar fractures remains to be one of the most challenging aspects in trauma surgery. Unfortunately, the evidence regarding the correct treatment of these fractures is mainly based on retrospective case series, while studies assessing the patient-reported outcome are rare. Therefore, the aim of this trial was to analyze the patient reported outcome in context of trauma mechanism and concomitant injuries following operative treatment of talar fractures.

METHODS

A retrospective outcome study of patients with operatively treated talar fractures between 2003 and 2015 was conducted. The fractures were classified according to AO-/Hawkins classification system and to the Marti-Weber classification. Data was collected via patient registry, radiographs and a validated patient-reported outcome measure (PROM) for foot and ankle pathologies (Foot and Ankle Outcome Score = FOAS). An analysis regarding the functional outcome, concomitant injury and timing of surgery using the nonparametric Mann-Whitney U test and Spearman`s rank correlation was performed.

RESULTS

In total the functional outcome of 32 patients suffering from fractures to the talus were analyzed. The median age of the study cohort was 35±12.2 years, including 9 female (28 %) and 23 male (72 %) patients. The median FAOS score was 72±22.7 (range 13-94). Patients with an isolated talar fracture had an FAOS of 87±20 and with concomitant injury a score of 60±23.4 (p = 0.016). Patients with a closed talar fracture without emergency operation due to dislocation or polytrauma, showed no correlation between timing of surgery and FAOS (r= -0.17, p = 0.43). 10 % of the patients developed an avascular necrosis and 25 % showed signs of a posttraumatic arthritis. The follow-up time was 41 months (range: 16-145).

CONCLUSIONS

Talar fractures were typically caused by high-energy trauma often associated with additional injuries of the lower extremity. The majority of the patients showed a fair to poor functional long-term outcome. Concomitant injuries of the lower extremity led to a lower FAOS. In closed talar fractures without the necessity of an emergency surgical intervention, time to surgery did not influence the patient reported outcome. Relating to the presented data, delayed surgery after soft tissue consolidation was not associated with a higher risk of developing an avascular necrosis.

Effectiveness and cost-effectiveness of primary arthrodesis versus open reduction and internal fixation in patients with Lisfranc fracture instability (The BFF Study) study protocol for a multicenter randomized controlled trial

Background

The Lisfranc injury is a complex injury of the midfoot. It can result in persistent pain and functional impairment if treated inappropriately. In Lisfranc fracture dislocation, treatment options are primary arthrodesis of the midfoot joints or open reduction and internal fixation. The purpose of the proposed study is to define the optimal treatment for the Lisfranc fracture dislocation, either primary arthrodesis or open reduction and internal fixation, in regard to quality of life, complications, functional outcomes, and cost effectiveness.

Methods

Study design: A prospective multicenter RCT. Study population: All patients of 18 years and older with an acute (< 6 weeks) traumatic fracture dislocation in the Lisfranc midfoot joints, displaced on static radiographic evaluation or unstable with dynamic evaluation, weight bearing radiographs or fluoroscopic stress testing under anesthesia, and eligible for either one of the surgical procedures. In total, this study will include n = 112 patients with Lisfranc fracture dislocation. Interventions: Patients with Lisfranc fracture dislocation will be randomly allocated to treatment in “The Better to Fix or Fuse Study” (The BFF Study) with either PA or ORIF. Main study parameters/endpoints: Primary outcome parameter: the quality of life. Secondary outcomes: complications, functional outcomes, secondary surgical interventions and cost effectiveness. Nature and extent of the burden: PA is expected to have a better outcome, however both treatments are accepted for this injury with a similar low risk of complications. Follow up is standardized and therefore this study will not add extra burden to the patient.

Discussion

This study protocol provides a comprehensive overview of the aims and methods of the attached clinical study. Limitations of this study are the absence of patient blinding since it is impossible in surgical intervention, and the outcome measure (AOFAS) that has limited validity not for these injuries. This study will be the first with enough power to define optimal treatment for Lisfranc fracture dislocations. This is necessary since current literature is unclear on this topic.

Trial registration Current controlled Trial: NCT04519242 with registration date: 08/13/2020. Retrospectively registered; Protocol date and version: Version 4 05/06/2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-021-01320-1.

Reduced pre-operative skin oxygen saturation predicts revision after open reduction and internal fixation in calcaneal fractures : A reduced pre-operative oxygen saturation as measured by laser-Doppler spectrophotometry in 8 mm depth is associated with revision surgery after open reduction and internal fixation of calcaneal fractures through an extended lateral approach

PURPOSE

To assess which pre-operative parameters correlate with wound revisions after an extended lateral approach to the calcaneus.

METHODS

Pre-operative laser-Doppler spectrophotometry was applied in patients undergoing open reduction and internal fixation. The number of wound revisions was recorded during pos-toperative follow-up. Spearman rho analysis was used to identify factors associated with wound revision and receiver operator characteristics curves were calculated for the identified factors.

RESULTS

Thirty-four patients (29 men, 5 women; 37 calcanei) with a mean patient age of 43 ± 14 years were analyzed. The minimal oxygen saturation value at the five measurement locations as well as the minimal value for flow correlated negatively with wound revisions (p value = 0.025 and 0.038, respectively). The area under the curve for the pre-operative minimal value of oxygen saturation was 0.841 (95%CI 0.64-1.00, p = 0.028), indicating a good accuracy as a test to predict wound revision.

CONCLUSION

A pre-operative oxygen saturation of at least 20.5% across five measurement points along the anticipated incision identified all patients not needing a wound revision (negative predictive value 100%). On the other hand, patients with at least one measurement below 20.5% were at risk for wound revision surgery (sensitivity 100%, specificity 48.5%). ClinicalTrials.gov NCT01264146.

Double plating - surgical technique and good clinical results in complex and highly unstable proximal humeral fractures

INTRODUCTION

A stable fixation of highly unstable proximal humerus fractures remains challenging and complication rates, especially secondary varus dislocation, remains high. Different techniques of double plate osteosynthesis have been suggested for the treatment of complex proximal humeral fractures as they are well established for other fractures. The aim of this study was to evaluate an operative technique using an angular stable lateral plate supported by a one-third tubular plate positioned anteriorly at the lesser tuberosity for unstable proximal humeral fractures.

PATIENTS AND METHODS

Retrospectively, patients treated with a double plate osteosynthesis were included between January 2014 and December 2017. Out of 31, 25 patients (80.6%) with an average age of 53.1 years ± 12.5 were available for follow-up. 60% of the patients were male. The clinical evaluation consisted of a physical examination and standardised questionnaire including subjective and objective shoulder scores like the Constant-Murley Shoulder Score, Simple Shoulder Score, and Subjective Shoulder Value.

RESULTS

After a mean follow-up of 30.9 months (range, 12-76 months) eighteen patients (72%) had either excellent or good results regarding the Constant-Murley Shoulder Score with a mean value of 77 points ± 17. Average Simple Shoulder Score was 76% ± 0.2 and Subjective Shoulder Value 72% ± 0.2%. Mean NSA at time of follow-up 135° ± 13°. Nine patients had an implant-removal, five in combination with arthrolysis after a mean of 7.2 months. Three patients underwent surgery for secondary arthroplasty. The study shows a complication rate of 16%. No revision-surgery because of secondary varus dislocation was reported.

DISCUSSION

Arthroplasty is the less favourable treatment for a younger, active cohort of patients with highly unstable proximal humeral fractures as results are not as good and options for revision are limited. Double plate osteosynthesis can be used in addition to calcar screws, bone graft augmentation, cement augmentation and additional free screws for more multidirectional stability and shows good clinical results despite a higher rate of avascular necrosis and high primary stability with comparable complication-rates to single plate osteosynthesis. It seems to be a valid alternative to primary fracture arthroplasty and can prevent secondary varus displacement.

Plate Fixation for Irreducible Proximal Humeral Fractures in Children and Adolescents-A Single-Center Case Series of Six Patients

Background: Recommended treatment for severely displaced proximal humeral fractures in children is the closed reduction and percutaneous fixation by K-wires or intramedullary nailing. Methods: From January 2016 to January 2017 6, 21 children/adolescents (range 8 to 16 years) with proximal humeral fractures were treated surgically for severe displacement. In these six patients, several attempts of closed reduction were unsuccessful, and an open reduction was performed. The humeral head was fixed with a 3.5 mm T-plate without affecting the growth plate. Plate removal was performed at a mean interval of 132 days after initial surgery. Two years after initial surgery, the clinical outcome was assessed by the Constant–Murley score and QuickDASH score (including sport/music and work) and the shoulder joint was evaluated with a standardized sonographic examination for the rotator cuff and the conjoint tendon. Results: In all six patients, dorsal displacement of the fracture was irreducible due to the interposition of tendinous or osseous structures. Intraoperatively, the interposed structures were the long biceps tendon in two, periosteal tissue in two, a bony fragment in one, and the long biceps tendon together with the conjoint tendon in one case. At mean follow-up of 26 months (range 22 months to 29 months), patients showed very good clinical results with an excellent mean Constant–Murley score of 97.5 (range 91 to 100) and mean QuickDASH score (including sport/music and work) of 5.5 (range 0–20.8). An X-ray follow-up 6 weeks after surgery demonstrated early consolidation and correct alignment in all patients. A sonographic evaluation at 2 years post injury showed that the biceps and the conjoined tendon were intact in all patients. Conclusions: If a proximal humeral fracture is not reducible by closed means, a tissue entrapment (most likely biceps tendon) should be considered. Treatment with an open reduction and plate fixation yields very good clinical and radiological results and preserves interposed structures as the biceps and conjoint tendon.

Open plate fixation versus nailing for humeral shaft fractures: a meta-analysis and systematic review of randomised clinical trials and observational studies

PURPOSE

This meta-analysis compares open reduction and internal fixation with a plate (ORIF) versus nailing for humeral shaft fractures with regard to union, complications, general quality of life and shoulder/elbow function.

METHODS

PubMed/Medline/Embase/CENTRAL/CINAHL was searched for observational studies and randomised clinical trials (RCT). Effect estimates were pooled across studies using random effects models. Results were presented as weighted odds ratio (OR) or risk difference (RD) with corresponding 95% confidence interval (95% CI). Subgroup analysis was performed stratified for study design (RCTs and observational studies).

RESULTS

Eighteen observational studies (4906 patients) and ten RCT's (525 patients) were included. The pooled effect estimates of observational studies were similar to those obtained from RCT's. More patients treated with nailing required re-intervention (RD 2%; OR 2.0, 95% CI 1.0-3.8) with shoulder impingement being the most predominant indication (17%). Temporary radial nerve palsy secondary to operation occurred less frequently in the nailing group (RD 2%; OR 0.4, 95% CI 0.3-0.6). Notably, all but one of the radial nerve palsies resolved spontaneously in each groups. Nailing leads to a faster time to union (mean difference - 1.9 weeks, 95% CI - 2.9 to - 0.9), lower infection rate (RD 2%; OR 0.5, 95% CI 0.3-0.7) and shorter operation duration (mean difference - 26 min, 95% CI - 37 to - 14). No differences were found regarding non-union, general quality of life, functional shoulder scores, and total upper extremity scores.

CONCLUSION

Nailing carries a lower risk of infection, postoperative radial nerve palsy, has a shorter operation duration and possibly a shorter time to union. Shoulder impingement requiring re-intervention, however, is an inherent disadvantage of nail fixation. Notably, absolute differences are small and almost all patients with radial nerve palsy recovered spontaneously. Satisfactory results can be achieved with both treatment modalities.

Is Minimally Invasive Plating Osteosynthesis Better Than Conventional Open Plating for Humeral Shaft Fractures? A Systematic Review and Meta-Analysis of Comparative Studies

INTRODUCTION

The aim of systematic review and meta-analysis was to find out whether minimally invasive plate osteosynthesis (MIPO) is better than open reduction and internal plate fixation (ORIF) in terms of functional outcome, achieving union (union time and incidence of non-union), intraoperative parameters (surgical duration, blood loss, and radiation exposure), and complications (iatrogenic radial nerve palsy and infection) for humeral shaft fractures.

MATERIALS AND METHODS

We searched online databases (Pubmed, Embase, Scopus, and The Cochrane Library) from inception till 3rd September 2020 for articles comparing MIPO with ORIF for humeral shaft fractures. The methodological quality of randomized controlled trials (RCTs) was done by Cochrane Risk of Bias assessment tool 2 (RoB2) and of non-randomized studies (case-control and cohort studies) by Methodological Index for non-randomized studies (MINORS). Meta-analysis was performed using Review Manager 5.4 software.

RESULTS

11 studies (5 RCTs and 6 non-randomized comparative studies) involving a total of 582 patients (MIPO-290, ORIF-292) meeting our inclusion criteria were included in the study. There was no statistically significant difference in pooled analysis of functional outcome scores between MIPO and ORIF. Union time was significantly lesser (mean difference = 3.12 weeks) and incidence of non-union lower (odd's ratio = 0.27) in MIPO group. Surgical duration and intraoperative blood loss were significantly lesser in MIPO group. Iatrogenic radial nerve palsy and infection were higher in ORIF group.

CONCLUSIONS

This study showed that MIPO gives similar functional outcomes as compared to ORIF but causes significantly lesser blood loss, requires lesser operative duration and has a lesser incidence of major complications.

TRIAL REGISTRATION

International prospective register of systematic reviews (PROSPERO)-CRD42020208346, Date of registration 09/10/2020.

SUPPLEMENTARY INFORMATION

The online version contains supplementary material available at 10.1007/s43465-021-00413-6.

Locked Dorsal Compression Plate Arthrodesis for Degenerative Arthritis of the Midfoot

Midfoot arthrodesis is the accepted surgical treatment for symptomatic midfoot arthritis. The published literature has focused on joint-spanning static fixation. Several companies have developed diamond-shaped locked dorsal compression plates, which allow for longitudinal joint compression. After dorsal plate insertion, a spreader device opens the arms of the plate mediolaterally, which allows the plate to compress longitudinally. This work describes outcomes of such locked dorsal compression plates for midfoot arthritis at a single institution. We reviewed 62 patients who underwent midfoot arthrodesis for symptomatic midfoot arthritis using locked dorsal compression plates over a 7-year period. A total of 173 joints were spanned for fusion. The primary outcome measure was radiographic union and visual analog scale pain scores. Characteristics of patients who experienced nonunion versus those who had union were evaluated. Of the 173 joints, there was a 81.5% fusion rate (141/173 joints) and 14 patients experienced nonunion. There was a statistically significant difference in the average number of joints spanned in patients with nonunion (3.6) and patients with union (2.5) (p = .02). Locked dorsal compression plate arthrodesis is a viable technique for achieving midfoot fusion. This mechanical method of compression does not, however, lend itself to improved fusion rates compared with prior reports. A greater number of arthrodesis sites is associated with a higher nonunion rate. Emerging technology using newer materials and improved biomechanical designs may show improved results.

Fine wire versus locking plate fixation of type C pilon fractures

PURPOSE

The successful treatment of high energy pilon fractures (AO-OTA 43C) can be achieved with a fine wire circular external fixator (CEF) or locking plate construct (ORIF). There is no consensus on whether ORIF or CEF achieves superior outcomes, and both have unique complications. We report early to mid-term outcomes comparing type C pilon fractures treated with ORIF and CEF.

METHODS

An 8-year retrospective review was performed on all patients who underwent ORIF or CEF for closed 43C fractures in a tertiary orthoplastic centre. Outcomes included unplanned return to theatre prior to union including superficial and deep surgical site infections (SSI), non-union and post-traumatic osteoarthritis (PTOA) needing fusion.

RESULTS

76 patients underwent ORIF and 59 patients had CEF, with a mean follow-up of 2 years. 7/76 (9.2%) patients who underwent ORIF had a superficial SSI; 2 patients (2.6%) required a formal debridement for deep SSI; none required a flap. 13/59 patients (22%) had a pin track infection following CEF. With the numbers available, there was no significant difference in rates of unplanned return to theatre before bone healing (ORIF 7/76, 9.2%, CEF 9/59, 15.2%, p = 0.7), rates of mal-union (1.7% CEF, 3.9% ORIF, p = 0.7), deep SSI (p = 0.9), time to union (ORIF: 8.1 months v CEF 10.8 months, p = 0.51), non-union (p = 0.24) and fusion for PTOA (ORIF: 6/76, CEF 2/59, p = 0.46).

CONCLUSION

With correct patient selection, both ORIF and CEF offer equivalent and favourable early to mid-term outcomes with regard to deep SSI, non-union, mal-union and PTOA. Although statistically insignificant, ORIF with more than 2 plates carries a risk of superficial and deep SSI, whilst CEF is associated with a 22% pin track infection rate. These unique risks must be discussed with the patient as part of a shared decision-making process.

Lack of Surgeon Standardization on Implant Selection in Ankle Fracture Fixation May Increase Costs and Decrease Contribution Margin

BACKGROUND

Surgical standardization has been shown to decrease costs without impacting quality; however, there is limited literature on this subject regarding ankle fracture fixation. Methods. Between October 5, 2015 and September 27, 2017, a total of 168 patients with isolated ankle fractures who underwent open reduction, internal fixation (ORIF) were analyzed. Financial data were analyzed across ankle fracture classification type, implant characteristics, and surgeons. Bivariate analyses were conducted. One-way analysis of variance was used to compare hardware costs across all 5 surgeons. Linear regression analysis was used to determine if hardware cost differed by surgeon when accounting for fracture type.

RESULTS

The mean contribution margin was $4853 (SD $6446). There was a significant difference in implant costs by surgeon (range, lowest-cost surgeon: $471 [SD $283] to $1609 [SD $819]; P < .001). There was no difference in the use of a suture button or locking plate by fracture type (P = .13); however, the cost of the implant was significantly higher if a suture button or locking plate was used ($1014 [SD $666] vs $338 [SD $176]; P < .001). There was an association between surgeon 3 (β = 200.32 [95% CI 6.18-394.47]; P = .043) and surgeon 4 (β = 1131.07 [95% CI 906.84-1355.30]; P < .001) and higher hardware costs.

CONCLUSIONS

Even for the same ankle fracture type, a wide variation in implant costs exists. The lack of standardization among surgeons accounted for a nearly 3.5-fold difference, on average, between the lowest- and highest-cost surgeons, negatively affecting contribution margin.

LEVELS OF EVIDENCE

Level IV.

A comparison of clinical, radiological, and quality-of-life outcomes of double-plate internal and Ilizarov external fixations for Schatzker type 5 and 6 tibia plateau fractures

PURPOSE

To compare clinical, functional, and radiological outcomes in patients with bicondylar tibial fractures treated with either double-plate or Ilizarov external fixation.

METHODS

Patients with Schatzker type 5 and 6 tibial plateau fractures who were treated with double-plate (Group O) and Ilizarov external fixations (Group E) between March 2012 and April 2018 were selected. Demographic data and preoperative, intraoperative, and postoperative variables were analyzed and compared. In the last follow-up, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Oxford Knee Score (OKS), Knee Society Score-Knee (KSS-Knee), KSS-Function (KSS-F), and Short-Form Health Survey (SF-36) were used to measure clinical and functional outcomes. Treatment costs and complication rates were also recorded and compared.

RESULTS

A total of 64 patients (43 men and 21 women) were included in the study (group O: 36, group E: 28). WOMAC, KSS-F, KSS-Knee, and OKS scores were similar between the two groups (P > 0.05). The role limitations due to emotional problems, emotional well-being, and social functioning domains of SF-36 were higher in group O (P < 0.001). Three (8.3%) deep infections occurred in group O, whereas no deep infection was observed in group E (P = 0.035). The treatment cost was higher in group O (P < 0.001).

CONCLUSION

In bicondylar tibial plateau fractures, functional outcomes of ORIF and Ilizarov method milar were sibut, role limitations due to emotional problems, emotional well-being and social functioning domains of SF-36 score were higher in ORIF group. However, Ilizarov method is more cost-effective and related with lesser complications.

Locked Intramedullary Nailing versus Compression Plating for Stable Ulna Fractures: A Comparative Study

BACKGROUND

Isolated ulna shaft fractures (USFs) are a relatively uncommon, but significant, injury. For unstable USF treatment, open reduction and internal fixation (ORIF) is the gold standard, while for stable USFs several procedures were described. The aim of this study is to compare the outcomes in patients with stable USFs treated by either ORIF or intramedullary nail (IMN).

METHODS

According to their surgical treatment, 23 eligible USF-affected patients were divided into ORIF (14 subjects) and IMN (nine subjects) groups. The subjects underwent postoperative clinical follow-up at 1, 3, 6, and 12 months, which included calculation of the Disabilities of the Arm, Shoulder and Hand (DASH) score and radiological follow-up. Time to union, time to return to sporting and occupational activities, duration of physical therapy, and surgical complications were recorded.

RESULTS

DASH scores improved in both groups at the 6-month follow-up (p < 0.001). The IMN cohort recorded better DASH scores at the 1- and 3-month follow-ups, while similar results were reported at the 6- and 12-month follow-ups. Earlier fracture union (p = 0.001) and return to sporting activities and work (p = 0.002) were seen in the IMN group, compared with the ORIF group. No complications were observed in the IMN group.

CONCLUSIONS

The surgical treatment of isolated USF results in excellent functional and radiographic outcomes. IMN may be preferable, compared with ORIF, due to its faster recovery time, expedited union, and reduced likelihood of complications.