Classifications In Brief: The Tscherne Classification of Soft Tissue Injury

Changing trends in injury patterns of undocumented migrants along the Hungarian-Serbian border from 2018 to 2022

OBJECTIVE

The Traumatology Clinic of the University of Szeged is a level one Trauma center situated near the Hungarian - Serbian border, where a 4 m tall fence constructed in 2018 serves as a barricade leading to numerous trauma cases. The objective of this study is to characterize the epidemiology of injuries, challenges, and recent trends whilst treating these undocumented migrants in Hungary.

MATERIALS AND METHODS

A national retrospective mono-centrical study was performed, examining 982 patients who were admitted to the emergency trauma center in the University of Szeged between January 2018 and December 2022, using data from our electronic administrative system (eMedSol). Factors such as basic epidemiology, country of origin, fractures- according to the AO classification- and its respective treatments, mechanism of injury, duration of stay, and costs were assessed to set as a basis for prediction using a regression model.

RESULTS

A total of 982 patients from 2018 to 2022 were included in the study. Patterns of injury included calcaneal fractures in 2018 and 2019 whereas in 2021 and 2022 along with the exponential increase in patient number, bilateral calcaneal fractures, open and multi-fragmentary tibial fractures were also observed. Additionally, seasonal variations, favoring the months of September through November were observed. Treatment cost ratios, especially surgeries, have also been consistent with the pattern of proximalizing injuries; more proximal surgeries indicate higher surgical costs which is evidently visible in the significantly higher cost ratio dedicated to surgery in 2022.

CONCLUSION

While migration seems to be a global problem affecting governments and citizens alike, rarely do we understand the direct consequences of illegal migration affecting healthcare services. Hungary in particular created a 4 m tall wall between Serbia in 2019 with means of preventing illegal migration, which in turn led to gradual and later an exponential increase in the number of injured patients particularly in the years 2021 and 2022. Undocumented migrant cases have increased exponentially between 2018 and 2022, with certain patterns seen not only in the injury types but also in seasonal variations and cost expectations. Injuries have been showing a trend of proximalization and have been of more serious quality, including bilateral and/or open injuries. Revisions after surgery were virtually impossible due to the discharging of patients back to border control after their definitive treatment. The need for adequate quality surgical care, manpower and financial aid should be considered.

A Novel Uni- and Biplanar External Fixator for Initial and Definitive Complex Foot Trauma

Background

Evidence concerning the complex foot trauma, especially its definitive management, is scarce. Soft tissue envelope sequalae are the primary parameters that delay or make internal fixation implausible. Stability conferred by external fixators makes them a reasonable initial treatment choice. Although AO or circular fixators can be applied around the foot, this can involve a learning curve and substantial costs, especially for the circular fixator. There is little evidence as to how well external fixators work as a definite method of fixation in patients where progression to internal fixation cannot be made.

Methods

We prospectively evaluated 10 adult patients with severe and complex foot trauma who were consecutively treated at our clinic. Initial reduction and stabilization were performed with an external fixator that was initially conceived for distal radius fractures, applied during the initial procedure and mantained throughout the treatment.

Results

Fracture healing was obtained in all 10 cases, and both internal and external column length was restored. One of the patients developed chronic osteomyelitis. At the 1-year follow-up visit, these patients averaged 45.6 points in the physical and 44.8 points on the mental status sections of the 12-Item Short Form Health Survey (SF-12). The Foot Function Index findings for pain, disability, and daily activities limitations were 33.3, 39, and 41.5, respectively, which suggest moderate residual impairment.

Conclusion

In this relatively small case series of complex foot trauma, we found that the use of simple external fixation as definitive treatment worked reasonably well.

Level of Evidence

Level III, prospective cohort study.

Analysis of Calcaneal Avulsion Fractures Treated Surgically and Nonsurgically: A Retrospective Multicenter Study

Background

Calcaneal avulsion fractures (CAvFs) at the Achilles tendon insertion are among the more challenging fractures to treat. Although rare, they often require reoperation. The optimal treatment, including nonsurgical procedures and better implants for surgical procedures in the treatment of CAvFs, remains to be established. Therefore, our study aimed to (1) perform a descriptive evaluation of CAvFs, including cases managed nonsurgically, and (2) assess surgical procedures, including the incidence of complications and reoperation for surgically treated CAvFs.

Methods

In this multicenter retrospective study, we collected data of patients with CAvFs treated at 9 hospitals from 2012 to 2022. We performed a descriptive study of CAvFs and compared postoperative complications and reoperation rates for multiple surgical techniques and implants. The size of the bone fragments was quantified.

Results

The data of 70 patients with CAvFs were analyzed; 20 patients were treated nonsurgically, and 50 were treated surgically. The mean age of patients was 68.5 years; 67% of the patients were female. Nineteen percent of the patients had diabetes, and 19% had osteoporosis. The incidence of postoperative complications was 30%, with infection in 14%, necrosis in 26%, and loss of reduction in 18%. The reoperation rate was 22%. Surgical techniques with use of cannulated cancellous screws were performed in 80% of the surgical cases. Cannulated cancellous screw (CCS) fixation alone resulted in a reoperation rate of 35%, whereas additional augmentation, including washers with CCS fixation, resulted in a reoperation rate of 10%. CCS fixation was successfully performed, although suture anchors were used in some cases with smaller fragments.

Conclusions

CAvFs occurred more frequently in older women and had a high rate of postoperative complications. A combination of CCS with augmentation was more effective at reducing postoperative complications than CCS fixation alone, even when the bone fragment size was small.

Level of Evidence

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

A Novel Approach to Grade 2 Closed Olecranon Fractures (Oestern and Tscherne Classification) Through Percutaneous Tension Band Wiring: A Case Report

Introduction

Olecranon fractures with compromised overlying skin such as superficial and deep abrasions and puncture wounds pose a challenge to manage as they are at a higher risk of wound and hardware-associated complications such as wound dehiscence, infection, gaping, and prominent hardware. Management of such fractures requires a holistic approach with special attention to the skin and soft tissues.

Case Report

This case highlights a 28-year-old male with a history of falls from a bike resulting in the right comminuted displaced olecranon fracture with multiple superficial abrasions which was managed with a thorough wound wash, antibiotics for 3 days after which percutaneous tension band wiring was performed through a 3 cm incision to prevent any wound complications. Rehabilitation and physical therapy were started immediately and the patient restored the complete range of motion at the elbow thus resuming his activities of daily living.

Conclusion

Utilizing a percutaneous technique for fixation in closed olecranon fractures with compromised overlying skin is considered an innovative, secure, dependable, and effective approach.

Extruded talus injuries are associated with significant complications: A double center series with minimum 1-year follow up

BACKGROUND

Extruded talus (ET) injuries are rare, but high-energy open pantalar dislocations. Literature on these injuries is sparse and optimal treatment protocols are ill defined. The current study documents the clinical and radiological outcomes in cases seen at 2 centers, in an attempt to determine whether surgeons should choose primary reimplantation or primary talectomy and fusion for these injuries.

METHODS

Patients with ET injuries were identified from the database of two hospitals. Baseline demographics and treatment details were evaluated, and patients were called for follow-up. Radiological evaluation was conducted, and function was evaluated by the AOFAS hindfoot score. Outcomes and complications were compared between patients who had undergone primary talectomy versus primary reimplantation. Predictors of poor functional outcomes were determined.

RESULTS

Of 23 patients seen by us, 15 were available for follow-up at 45.7 ± 22.2 months. Of these 19 had undergone reimplantation and 4 had talectomy with tibio-calcaneal arthrodesis. The mean percentage AOFAS score was 66.2 ± 14.6 at follow up. AVN was noted in 5, ankle arthrosis in 10, subtalar arthrosis in 4 and infection in 4 cases; no patient needed salvage arthrodesis during this time. There was no difference in baseline demographics, range of motion, AOFAS scores or complication rates between patients undergoing primary reimplantation versus primary talectomy. The number of complications per patient showed a negative, moderate correlation with the AOFAS score (Pearson's correlation coefficient 0.6, P value = 0.02).

CONCLUSION

Despite best treatment, ET injuries result in significant impairment of functional outcomes and complications. Within the numbers available, no difference in outcomes or complication rates was noted between primary reimplantation or talectomy. However, we recommend reimplantation as the treatment of first choice as this offers the chance to salvage the ankle joint and preserves bone stock for future fusion or arthroplasty.

Surgical management of distal humerus gunshot fractures: descriptive case series

PURPOSE

The purpose of this study was to report our 5 years surgical experience and the rate of neurovascular injury following gunshot fractures of the distal humerus in a in level-1 Trauma Centre in South Africa.

METHODS

A retrospective case series of 25 consecutive adult gunshot injuries to the distal humerus. Demographic and injury data were extracted from clinical case notes and electronic operative records. Imaging archives were used to classify fractures according to the AO/OTA classification.

RESULTS

Twenty-five male patients, with mean age of 32-years-old, sustained gunshot injuries to the distal humerus. Eleven patients had multiple gunshots. Forty-four percent of patients underwent Computed Tomography Angiography (CTA), 20% had confirmed brachial artery injury. Limbs with vascular injury were salvaged with arterial repair and external fixation. Fractures were extra-articular in 20 cases (80%). Nineteen fractures were classified as highly comminuted. Nerve injuries occurred in 52% and were all managed expectantly. Only 32% of patients attended follow-up beyond 3 months.

CONCLUSIONS

These are rare challenging injuries with high rates of neurovascular damage. This demographic of patients is poorly compliant with follow up highlighting the need for high-quality early care. Brachial artery injury should be excluded with CTA and can be managed with arterial repair and external fixation. All fractures in this series were surgically managed with conventional anatomical plate and screw fixation techniques. For nerve injury, we advocate expectant management.

LEVEL OF EVIDENCE

IV.

Intramedullary Fibular Fixation in One-Stage Ankle Fracture Surgery With Soft Tissue Damage: A Study of 19 Cases

This study investigates the efficacy of one-stage surgical intramedullary fibular fixation in managing ankle fractures with associated soft tissue damage. Ankle fractures, often encountered, can lead to complications when coupled with soft tissue injury. Traditional plate and screw fixation can exacerbate infection risks and reduce wound healing. To address this, a minimally invasive approach employing intramedullary fixation of the fibula has been proposed. This retrospective analysis, conducted between 2019 and 2021, explores cases of intramedullary fibular fixation for ankle fractures with stage 2-3 soft tissue injuries. A total of 19 patients were included in the study. The procedure involved either ulna intramedullary nails or locking screws. Results indicate that the approach led to successful union (100%), one superficial infection (5.26%), and no complication was observed. While limitations include the retrospective nature and small sample size, this study contributes valuable insights into the use of intramedullary fibular fixation in one-stage surgery for ankle fractures with concurrent soft tissue damage.

Risk factors and nomogram predictive model of surgical site infection in closed pilon fractures

OBJECTIVES

In this study, we try to investigate the risk factors of postoperative surgical site infection (SSI) in closed pilon fractures and establish a nomogram prediction model.

METHODS

From January 2012 to June 2021, 516 closed pilon fracture patients were included in this study. Of these, 387 patients were randomly assigned to the training group and 129 patients were assigned to the validation group (3:1). By univariate and multivariate Cox analysis, we identified independent risk factors for postoperative SSI after Pilon fracture. We established a nomogram model and used receiver operating characteristic (ROC) and calibration chart to evaluate its discriminant and calibration.

RESULTS

SSI occurred in 71 patients in the training group and 23 patients in the validation group. Ultimately, age, preoperative blood sugar, operative time, Tscherne classification and fracture classification were identified as independent risk factors for SSI. The AUC values for SSI of the training and validation group were 0.898 and 0.880, and the P value of the Hosmer-Lemeshow test was 0.125. We established a nomogram prediction model based on age, preoperative blood sugar, operative time, Tscherne classification and fracture classification.

CONCLUSION

Our nomogram model had good discrimination and calibration power, so it could be used to predict SSI risk in patients with pilon fracture.

The incidence of deep vein thrombosis after anterior cruciate ligament reconstruction: An analysis using routine ultrasonography of 260 patients

BACKGROUND

Recent studies regarding deep vein thrombosis (DVT) after anterior cruciate ligament (ACL) reconstruction investigated only symptomatic complications. The purpose of this study was to assess the true incidence of DVT after ACL reconstruction, regardless of symptom manifestation.

MATERIALS AND METHODS

Medical records of 260 patients who underwent isolated ACL reconstruction between January 2014 and December 2019 were retrospectively reviewed. Regardless of symptom manifestation, DVT was examined for all patients at 1 week postoperatively using ultrasonography. Demographics, injury mechanism (high energy direct injury and low energy indirect injury), soft tissue injury, preoperative anterior laxity, tourniquet time, and surgical technique (transtibial, anteromedial portal, and outside-in techniques) were investigated. Soft tissue injury was evaluated on magnetic resonance imaging (MRI) scans, based on the Tscherne classification. Risk factors for proximal DVT were identified using logistic regression analyses.

RESULTS

A total of 21 (8.1%) patients showed DVT. 5 (1.9%) patients had thrombosis at the popliteal vein; however, none of them exhibited symptoms. The other 16 patients had thrombosis at the distal veins: 1 patient at the anterior tibial vein, 5 patients at the posterior tibial vein, 3 patients at the peroneal vein, 6 patients at the soleal vein, and 1 patient at the muscular branch vein. The risk factors for proximal DVT included high energy direct injury (p = 0.013, odds ratio = 10.62) and grade 2 soft tissue injury (p = 0.039, odds ratio = 6.78).

CONCLUSIONS

The true incidence of DVT, including symptomatic and asymptomatic complications, were 8.1% after ACL reconstruction. This rate is higher than the previously known incidence which has been investigated only for symptomatic patients. Injury mechanism and soft tissue injury should be assessed when considering thromboprophylaxis.

Silver-coated versus uncoated locking plates in subjects with fractures of the distal tibia: a randomized, subject and observer-blinded, multi-center non-inferiority study

BACKGROUND

Antimicrobial coatings of implants are of interest to reduce infection rate in orthopedic surgery. Demonstration of clinical effectiveness of such coated implants to obtain market approval is challenging. The objective of this article is to define a design for a randomized controlled trial to evaluate the clinical performance of a silver-coating for locking plates for fracture treatment.

METHODS

The study design has to respect different criteria, such as feasibility, focus on overall complications, such as functional impairment, fracture healing, and particularly on infection rates. Distal tibia fractures were chosen due to the high prevalence of infections in this type of injuries, which warrants a particular benefit of antimicrobial prophylaxis and thus might allow to see a statistical trend in favor of the coated product. The study design was defined as a randomized, controlled, subject and observer-blinded, multi-center study in subjects with fractures of the distal tibia with a total of 226 patients. A number of 113 patients are planned for each of the two treatment arms with treatment of the fracture with a silver-coated device (first arm) or with an uncoated device (second arm). Inclusion criteria are closed fractures of the distal tibia according to the Tscherne-Oestern classification or open fractures of the distal tibia according to the Gustilo-Anderson classification in subjects older than 18 years. Primary outcome parameter is the Anticipated Adverse Device Effects (AADE) including all typical complications of this type of injury, such as functional impairment of the affected limb, non-union, and infections based on a non-inferiority study design. Also, silver-typical complications, such as argyria, are included. Secondary parameters are infection rates and fracture healing. Follow-up of patients includes five visits with clinical and X-ray evaluations with a follow-up time of 12 months.

DISCUSSION

Demonstration of clinical effectiveness of antimicrobial coatings of fracture fixation devices remains a challenge. Definition of a prospective randomized pre-market trial design and recruitment of clinical sites for such a study is possible. A confirmative proof of the expected clinical benefit in terms of reduction of device-related infections will be addressed with a prospective post-market clinical follow-up study in a second step due to the large sample size required.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05260463. Registered on 02 March 2022.

Does mechanism of injury impact the outcome of operative fixation of geriatric proximal humerus fractures

BACKGROUND

The purpose of this study is to determine the effects of energy mechanism on outcomes following repair of proximal humerus fractures (PHF) in the middle aged and geriatric population.

METHODS

Two hundred sixty-nine patients who presented to our academic medical center between 2006 and 2020, and underwent operative treatment of a proximal humerus fracture were prospectively enrolled in an IRB-approved database. Patients above 55 were divided into high energy (motor vehicle accident, pedestrian struck, or fall > 2 stairs) or low energy mechanisms (fall from standing or < 2 stairs). Of 97 patients with complete documentation and follow-up, 72 were included in the low velocity (LV) group and 25 were included in the high velocity (HV) group. Demographic information, primary injury details, healing and time to union, range of motion (ROM), complications, and need for reoperation were assessed at initial presentation and subsequent follow-up appointments.

RESULTS

Mean age, BMI, and gender were significantly different between the LV and HV cohorts (p = 0.01, 0.04, 0.01). OTA/AO fracture patterns were similar between the groups. (p = 0.14). Bony healing and complications occurred with similar frequency between groups (p = 1.00, 0.062). The most common complications in the LV and HV groups included avascular necrosis (9.7%, 16.0%), and screw penetration (4.2%, 12.0%), while the HV group also had rotator cuff issues including weakness and tendonitis (12.0%). There was no significant difference in need for reoperation between cohorts (p = 0.45). Time to healing, shoulder ROM, and DASH scores did not differ between each group.

CONCLUSIONS

Energy and mechanism demonstrates similar outcomes in operatively treated proximal humerus fractures. These factors should not play a role in decisions for surgery in these patients and can help guide patient expectations.

Assessment of alternative techniques to quantify the effect of injury on soft tissue in closed ankle and pilon fractures

INTRODUCTION

Local soft tissue status (STS) guides the timing for definitive surgical treatment strategies of fracture fixation around the ankle joint. The aim of this study was to assess different types of new technical devices in relation to the surgical treatment in closed ankle and pilon fractures.

METHODS

This study was designed as a cohort study. Adult patients admitted between February 1, 2019 and December 31, 2020 presenting with closed ankle fracture requiring surgical treatment were eligible. The exclusion criteria were previous injuries to the lower extremity, acute deep venous thrombosis, skin diseases, and delayed presentation (admission >24 hours after injury). Moderate-energy trauma includes injuries sustained during team sports, biking, and running. The primary outcome was the assessment of the degree of soft tissue involvement following closed fractures by comparing different techniques focusing on the ankle region and including ankle and pilon fractures. The variables of interest included the circumference of soft tissue swelling around the ankle, determined within a 5-mm range in the area of the medial and lateral malleolus and the bone-skin distance on a plain radiograph, determined by the largest distance from the malleolus to the border of the soft-tissue shadow. STS assessment included optical measures of local perfusion (O2C, Lea Inc. Germany) and tactile measures of mechanical characteristics (Myoton® tensiometer AS, Estonia). Measurements of Group Temp (temporary stabilization) and Group Def (definitive surgery) were taken on admission and prior to the treatment strategy decision. The contralateral non-injured ankle served as a control. The quality of assessment tools was quantified by calculating the smallest detectable change (SDC).

RESULTS

In total, 38 patients with a mean age of 40.4 (SD 17.8) years were included. The SDC was 3.2% (95%CI 2.5 to 3.8) for local blood flow and 1.1% (95%CI 0.4 to 1.7) for soft tissue stiffness. The circumference of the injured area at admission was significantly higher than that of the healthy site (28.2 [SD 3.4] cm versus 23.9 [SD 2.4] cm, p < 0.001). The local perfusion (blood flow 107.5 (SD 40.79 A.U. vs. 80.1 [SD 13.8] A.U., p = 0.009), and local dynamic stiffness of the skin (668.1 (SD 148.0) N/m vs 449.5 (SD 87.7) N/m, p < 0.001) were significantly higher at the injured site. In Group Temp, the local blood flow was significantly higher when compared with Group Def (109.6 [SD 39.8] vs. 94.5 [SD 13.0], p = 0.023). The dynamic stiffness of the soft tissue was significantly higher in Group Temp (679.4 N/m [SD 147.0] N/m vs. 573.0 N/m (SD 93.8) N/m, p < 0.001). The physical properties of STS were comparable among the fracture types. None of the included patients had local soft tissue complications.

CONCLUSION

Closed fractures of the ankle and the pilon are associated with an increase in local circulation and local soft tissue stiffness and tension. These changes of the STS following injury can be quantified in a standardized and reproducible manner.

Degree of Soft Tissue Injury is a Major Determinant of Successful Arterial Repair in the Extremity: A New Classification of Extremity Arterial Injury?

BACKGROUND

This study aimed to investigate outcomes after extremity arterial injury repair and examined the association between outcomes and the degree of soft tissue injury and vascular repair methods.

METHODS

A retrospective study was conducted on 106 patients (108 cases) who underwent emergent microsurgical repair of extremity arterial injury due to trauma and non-perfusion of the affected extremity. The cases were divided into three groups by degree of associated soft tissue injuries: (A) adequate soft tissue coverage over the injured major vessels after radical debridement, (B) inadequate soft tissue coverage over the injured major vessels after radical debridement, and (C) radical debridement was not feasible due to unclear extent of injured soft tissue. Differences in vascular repair methods and outcomes among the three groups were analyzed.

RESULTS

In Group A (n = 61), microvascular suture and vessel graft achieved 95.1% and 85.0% successful limb reperfusion, respectively. In Group B (n = 31), vessel reconstruction with flap coverage achieved 100% successful reperfusion. Vessel graft achieved 28.6% successful limb reperfusion, while there were no cases of successful reperfusion using microvascular sutures. In Group C (n = 16), no vascular repair method achieved successful reperfusion. There were significant differences among the three groups in successful reperfusion (p < 0.001) and limb salvage (p < 0.001).

CONCLUSION

The extent of associated soft tissue injury was associated with different vascular repair methods and outcomes. We propose a new system for classifying these injuries according to the degree of associated soft tissue injury.

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.

Assessing Soft Tissue Perfusion Using Laser-Assisted Angiography in Tibial Plateau and Pilon Fractures: A Pilot Study

OBJECTIVES

To determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol.

DESIGN

Prospective cohort study.

SETTING

Academic trauma center.

PATIENTS

Eight pilon fracture patients and 19 tibial plateau fracture patients who underwent open reduction internal fixation.

MAIN OUTCOME MEASURES

Skin perfusion (fluorescence units) as measured by LA-ICGA.

RESULTS

Six patients were classified as Tscherne grade 0, 9 as grade 1, 10 as grade 2, and 2 as grade 3. Perfusion decreased by 14 fluorescence units (95% confidence interval, -21 to -6; P < 0.01) with each increase in Tscherne grade. Sixteen patients underwent staged fixation with an external fixator (mean time to definitive fixation 14.1 days). The mean perfusion increased significantly at the time of definitive fixation by a mean of 13.9 fluorescence units (95% confidence interval 4.8-22.9; P = 0.01).

CONCLUSIONS

LA-ICGA perfusion measures are associated with severity of soft tissue injury surrounding orthopaedic trauma fractures and appear to improve over time when fractures are stabilized in an external fixator. Further research is warranted to investigate whether objective perfusion measures are predictive of postoperative wound healing complications and whether this tool can be used to effectively guide timing of safe surgical fixation.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Triboelectric Nanogenerators for Therapeutic Electrical Stimulation

Current solutions developed for the purpose of in and on body (IOB) electrical stimulation (ES) lack autonomous qualities necessary for comfortable, practical, and self-dependent use. Consequently, recent focus has been placed on developing self-powered IOB therapeutic devices capable of generating therapeutic ES for human use. With the recent invention of the triboelectric nanogenerator (TENG), harnessing passive human biomechanical energy to develop self-powered systems has allowed for the introduction of novel therapeutic ES solutions. TENGs are especially effective at providing ES for IOB therapeutic systems given their bioconformability, low cost, simple manufacturability, and self-powering capabilities. Due to the key role of naturally induced electrical signals in many physiological functions, TENG-induced ES holds promise to provide a novel paradigm in therapeutic interventions. The aim here is to detail research on IOB TENG devices applied for ES-based therapy in the fields of regenerative medicine, neurology, rehabilitation, and pharmaceutical engineering. Furthermore, considering TENG-produced ES can be measured for sensing applications, this technology is paving the way to provide a fully autonomous personalized healthcare system, capable of IOB energy generation, sensing, and therapeutic intervention. Considering these grounds, it seems highly relevant to review TENG-ES research and applications, as they could constitute the foundation and future of personalized healthcare.

APPLICATION OF CHEN YUANGAO IN THE TREATMENT OF SOFT TISSUE INJURY OF FOOTBALL PLAYERS

ABSTRACT The treatment of soft tissue injury in football players generally includes physical therapy, anti-inflammatory and analgesic drug treatment, surgical treatment and early rest immobilization. Western medicine treatment of soft tissue injury can quickly heal the wound and relieve pain in a short time. The treatment of traditional Chinese medicine is based on the whole and must seek the root of the disease. It is believed that the occurrence of certain diseases is related to Qi, blood, liver and kidney deficiency, so we should pay attention to the overall adjustment during treatment of symptoms. In view of this, this study analyzed the effect of Chen Yuan ointment, from traditional Chinese medicine, in the treatment of soft tissue injury. Sixty-eight football players who completed ankle ligament reconstruction were divided into four groups according to the type of operation and whether Chen Yuangao-assisted rehabilitation was used or not. The results showed that the Ankle Hindfoot Function Score and the visual analog scale (VAS) score of patients in the fibula brevis tendon reconstruction Chen Yuan ointment group were 98.3 and 0.3, respectively, at the last follow-up, which were better than those in other groups, and had lower pain scores. This result shows that Chen Yuangao has a certain effect in the treatment of soft tissue injury, which can provide a research idea for the rapid rehabilitation of football players.

Prediction of delayed union of tibial shaft fracture treated with intramedullary nailing: multicenter-study analysis and literature review -the TRON study

PURPOSE

We aimed to 1) identify predictors of delayed and nonunion of tibial shaft fractures in patients treated with intramedullary nailing (IMN), including patient demographics and surgical factors, and 2) determine whether the nail/shaft ratio is associated with delayed and nonunion.

METHODS

This retrospective, multicenter study included 315 patients with tibial shaft fracture treated with IMN between 2014 and 2019 and excluded patients with insufficient follow-up for 12 months, lost data and inadequate radiographs. Finally, we analyzed 258 patients (184 males; 74 females). Main outcome measurements were delayed union at 6 and nonunion at 12 months after surgery as determined on anteroposterior and lateral radiographs. We extracted the following as risk factors of delayed and nonunion: age, sex, BMI, fracture site, fracture type, injury energy, smoking history, and nail/shaft ratio. We conducted logistic regression analysis to investigate risk factors of delayed and nonunion using these extracted items as explanatory variables.

RESULTS

Type C fracture was independently associated with delayed union (odds ratio 2.9, 95% confidential interval: 1.04-8.09, P = 0.04). Nail/shaft ratio was not an independent factor of delayed union. No independent explanatory factors were related to nonunion.

CONCLUSIONS

Type C fractures, which were unstable and fragmented, was associated with delayed union in tibia fractures treated with IMN, whereas nail thickness was not associated with delayed or nonunion fractures.

Soft Tissue Injury Considerations in the Treatment of Tibial Plateau Fractures

Tibial plateau fractures represent a highly variable spectrum of injury that requires a multifaceted diagnostic and therapeutic approach in order to adequately treat. Constant vigilance is required to consider all the injured structures and avoid focusing only on the bony aspect of the injury. Management of the soft tissue envelope and repair/reconstruction of critical stabilizing structures of the knee should be at the forefront of the thought process when approaching these complex injuries. This article aims to emphasize the high incidence of injury to associated soft tissue structures and provide general approach considerations to these complex injuries.

Two-Stage Surgery for the Malleolar Fracture-Dislocation With Severe Soft Tissue Injuries Does Not Affect the Functional Results

Soft tissue injuries associated with malleolar fracture-dislocations may increase postoperative rates of wound complication. Ankle-spanning frame plays a fundamental role in the local damage control orthopedics while gaining time for definitive surgery. The objective of this study was to evaluate the effect of a 2-stage surgery for the unstable malleolar fracture-dislocations with severe soft tissue injuries compared to a 1-stage surgery in terms of the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle and Olerud-Molander ankle scores (OMAS). We analyzed 45 patients who met our study criteria. The patients were divided into 2 groups according to staged surgeries. Demographic data of patients, comorbidities, alcohol and tobacco use, Tscherne soft tissue injury scores, the AOFAS hindfoot-ankle and OMAS, postoperative complications, total hospitalization times, waiting time between stages, and waiting time from admission to surgery times were investigated. There was a statistically significant difference between the groups in terms of the mean total hospitalization times (p = .007), waiting time from admission to surgery (p < .001), gender (p = .005), and Tscherne soft tissue injury scores (p < .001). The mean AOFAS hindfoot-ankle and OMAS of the groups did not differ statistically at a minimum of 12 months of the follow-up period (p = .094 and p = .126, respectively). A 2-stage surgery can be performed safely in the carefully selected patients with the unstable malleolar fracture-dislocations with Tscherne grades 2 and 3 soft tissue injuries, and this surgery does not affect the postoperative AOFAS hindfoot-ankle and OMAS statistically compared to a 1-stage surgery at a minimum of 12 months of the follow-up period.

Correlation of Soft Tissue Swelling and Timing to Surgery With Acute Wound Complications for Operatively Treated Ankle and Other Lower Extremity Fractures

BACKGROUND

Considerable debate exists regarding how soft-tissue edema should influence timing of surgery for ankle and other lower extremity fractures. Assessment of swelling is subjective, and timing varies among surgeons. However, timing of surgery is one of the few modifiable factors in fracture care. Ultrasonography can objectively measure swelling and help determine optimal timing. The purposes of this study were to determine whether objective measures of swelling, timing to surgery, and patient-specific risk factors correlated with wound complications and to try to create a prediction model for postoperative wound complications based on identified modifiable and nonmodifiable risk factors.

METHODS

Patients with closed ankle and other lower extremity fractures requiring surgery with an uninjured, contralateral extremity were included. Demographic information and sonographic measurements on both lower extremities were obtained pre-operatively. Subjects were followed for 3 months and wound complications were documented. A predictive algorithm of independent risk factors was constructed, determining wound complication risk. Given that patients with ankle fractures made up the majority of the study cohort (75/93 or 80%), a separate statistical analysis was performed on this group. A total of 93 subjects completed the study, with 75/93 sustaining ankle fractures.

RESULTS

Overall wound complication rate was 18.3%. Timing to surgery showed no correlation with wound complications. A heel-pad edema index >1.4 was independently associated with wound complications. Subgroup analysis of ankle fractures demonstrated a 3.4× increase in wound complications with a heel-pad edema index >1.4. Tobacco history and BMI >25 were independent predictors of wound complications. An algorithm was established based on heel-pad edema index, BMI >25, and tobacco history. Patients with none of the 3 factors had a 3% probability of a wound complication. Patients with 1/3, 2/3 and 3/3 factors had a 12-36%, 60-86% and 96% probability of a wound complication, respectively.

CONCLUSIONS

Timing to surgery had no correlation with wound complications. Heel-pad edema index >1.4, BMI >25, and tobacco-use correlated with wound complications. When separately analyzing the cohort that sustained ankle fractures, the heel-pad edema index of >1.4 was still demonstrated to be predictive of wound complications corresponding to a 3.4× increase in wound complication rates (11.1% vs 37.5%). Risk of wound complications significantly increased with each factor. In patients with increased BMI and/or tobacco use, resolution of heel edema may significantly reduce wound complications in lower extremity trauma.

LEVEL OF EVIDENCE

Level II, prognostic, prospective cohort study.

Tendon healing in the context of complex fractures

Tendons connect muscle to bone and play an integral role in bone and joint alignment and loading. Tendons act as pulleys that provide anchorage of muscle forces for joint motion and stability, as well as for fracture reduction and realignment. Patients that experience complex fractures also have concomitant soft tissue injuries, such as tendon damage or rupture. Tendon injuries that occur at the time of bone fracture have long-term ramifications on musculoskeletal health, yet these injuries are often disregarded in clinical treatment and diagnosis for patients with bone fractures as well as in basic science approaches for understanding bone repair processes. Delayed assessment of soft tissue injuries during evaluation of trauma can lead to chronic pain, dysfunction, and delayed bone healing even following successful fracture repair, highlighting the importance of identifying and treating damaged tendons early. Treatment strategies for bone repair, such as mechanical stabilization and biological therapeutics, can impact tendon healing and function. Because poor tendon healing following complex fracture can significantly impact the function of tendon during bone fracture healing, a need exists to understand the healing process of complex fractures more broadly, beyond the healing of bone. In this review, we explored the mechanical and biological interaction of bone and tendon in the context of complex fracture, as well as the relevance and potential ramifications of tendon damage following bone fracture, which has particular impact on patients that experience complex fractures, such as from combat, automobile accidents, and other trauma.