The impact of lag screw in the healing time of distal tibia fractures treated with minimally invasive plate osteosynthesis: A randomized clinical trial

Second and Third Pandemic Waves in Apulia: How COVID-19 Affected Orthopedic and Trauma Care-A Single-Center Study

PURPOSE

In orthopedics and traumatology, as a direct consequence of the COVID-19 first wave, there was a massive reorganization and a stop to all elective activities, which were postponed. In this study, we aimed to analyze the impact of the COVID-19 pandemic on orthopedic surgery in Apulia during the second wave, from March to June 2021 (when Apulia was under social distancing restrictions), and during the third wave, from September to December 2021 (when Apulia was under no restrictions). We compared these months to the same periods in 2019 for an evaluation of the surgical decrease during the pandemic period.

METHODS

We performed a retrospective analysis of major orthopedic procedures, day-surgery procedures and urgent procedures (trauma and non-traumatic amputation) performed during the second and third waves of the pandemic in our clinic, and we compared these data with the same procedures performed in the corresponding periods of 2019, before the pandemic.

RESULTS

Surgical activity was significantly decreased during both periods; the only increase in surgical activity in 2021 compared to 2019 was in total hip, knee and shoulder arthroplasty, with a surge of +7.69% registered in the period September-December 2021.

CONCLUSIONS

Longer waiting lists and limited healthcare resources were the big challenges for the orthopedic community, and they still represent a substantial issue to confront today.

A Novel Approach Combined with MIPO Technique for the Treatment of Type C Pilon Fractures

Objective

Type C fracture is a complete intra-articular fracture, and the mainstay of treatment remains open reduction and internal fixation. The purpose of the study is to observe the clinical effect of an anterior ankle C approach (ankle-C) combined with minimal invasive plate osteosystems (MIPO) for tibial pilon fractures (AO/OTA 43C, combined with fibula fractures).

Methods

A retrospective comparative analysis was performed on the clinical data of 33 patients with C-type pilon fractures (combined fibula fractures) admitted to our department from July 2018 to July 2021, including 12 cases treated with ankle-C (a-C) approach and 21 cases with conventional approach (including combined approach). All patients were followed up for over 6 months. Visual Analogue Scale (VAS), AOFAS Ankle-Hindfoot Scale (AOFAS-AHS), wound healing time, fracture healing time, and complications were used to evaluate the clinical efficacy.

Results

The scores of VAS and AOFAS in the a-C group scored better than the conventional group (P < 0.05), especially in the extent of limited range of motion (LROM) of ankle dorsiflexion-plantarflexion in 1 month after operation and at the last follow-up (P < 0.01). Bone healing was achieved in both groups 6 months after operation, with no implant exposure or infection. Among them, 4 cases in the conventional approach group had wound healing time exceeding 2 weeks.

Conclusions

For type C pilon fractures (combined with fibula fractures), ankle-C approach combined with MIPO technique has certain advantages in ankle function recovery and soft tissue repair, which provides an alternative for the treatment of type C pilon fractures.

Management of Pilon Fractures-Current Concepts

Tibial pilon fractures were first described by Étienne Destot in 1911. He used the French word “pilon” (i.e., pestle), to describe the mechanical function of the distal tibia in the ankle joint. This term has further been used to portray the mechanism involved in tibial pilon fractures in which the distal tibia acts as a pestle with heavy axial forces over the talus basically causing the tibia to burst. Many different classification systems exist so far, with the AO Classification being the most commonly used classification in the clinical setting. Especially Type C fractures are extremely difficult to manage as the high energy involved in developing this type of injury frequently damages the soft tissue surrounding the fracture zone severely. Therefore, long -term outcome is often poor and correct initial management crucial. In the early years of this century treatment has evolved to a two–staged protocol, which nowadays is the gold standard of care. Additional methods of treating the soft tissue envelope are currently being investigated and have shown promising results for the future. The aim of this review is therefore to summarize protocols in managing these difficult fractures, review the literature on recent developments and therefore give surgeons a better understanding and ability to handle tibial pilon fractures.

Minimally invasive plate osteosynthesis for short oblique diaphyseal tibia fractures: does fracture site affect the outcomes?

OBJECTIVE

To report the results of patients with short oblique diaphyseal tibia fractures treated with minimally invasive plate osteosynthesis (MIPO). The secondary aim was to understand the effect of fracture location (midshaft or distal 1/3) on outcomes.

METHODS

Twenty-eight patients with short oblique (>30°) tibial shaft fractures (AO/OTA 42A2) treated with plate and MIPO technique between 2015 and 2019 were retrospectively assessed. Age, gender, follow-up time, fracture type (open or closed), operation time, postoperative infection rate, union time, ankle joint range of motion, and complications were analyzed. Patients' radiographs at a minimum 1-year follow-up were evaluated for malunion, nonunion, and implant-related complications.

RESULTS

Mean age and follow-up time were 47.0 ± 15.7 years and 18.3 ± 12.1 months, respectively. Mean bone union time was 3.66 ± 1.04 months in middle 1/3 diaphysis and 4.23 ± 1.48 months in distal 1/3 tibia fractures. Seven (25%) patients developed superficial infections. Mean union time, malunion rate, coronal and sagittal angulation, operation length, and infection rate were similar between the groups.

CONCLUSION

MIPO is an effective method for treatment of short oblique diaphyseal tibia fractures, and results in few complications. Both distal and midshaft fractures have similar union and malunion rates.

Development of the Italian fractures registry (RIFra): A call for action to improve quality and safety

In recent years, there has been an increasing interest in the development of arthroplasty registries, therefore, in our country, the Italian Arthroplasty Registry (RIAP), was issued by the National Law No. 221/2012. In the last decade, however, some European countries -namely Sweden, Denmark, Norway, and Germany (in development)- have introduced another nationwide orthopaedic registry than arthroplasty registers: the fracture registry. The development of this new tool aims to improve quality and safety in fracture management, thus trying to provide a better postoperative quality of life in trauma patients. Based on these findings, the AO-Trauma Italy Council encouraged the development of a national fracture registry in Italy. The present study aims to (1) provide an overview of the fracture registries in Europe and (2) to develop, for the first time, a pilot Italian Fracture Registry (RIFra). Thirteen AO-Trauma Italy members, chairmen of Level-I orthopaedic and trauma centres, diffused throughout Italy, were involved in the RIFra project. The RIFra form, developed between November 2019 and March 2020, consists of 5 main sections, namely: epidemiologic data, previous surgical procedure (if any), patient and fracture features, surgical procedure, surgical implant details. This study constitutes the first step to start, in future years, the bureaucratic procedure leading to the final establishment of a RIAP-like fracture registry in Italy.

Optimum timing of conversion from DCO to definitive fixation in closed fractures of the lower limb: When and how?

INTRODUCTION

In damage control orthopaedics (DCO), fractures are initially stabilised with external fixation followed by delayed conversion to definitive internal fixation. The aim of this study is to determine whether the timing of the conversion influences the development of deep infection and fracture healing in a cohort of patients treated by DCO after a closed fracture of the lower limb. Furthermore, we wanted to evaluate whether the one-stage conversion procedure is always safe.

MATERIALS AND METHODS

A retrospective cohort study was conducted at a single level 1 trauma centre. Ninety-four cases of closed fractures of lower limb treated by DCO subsequently converted to internal fixation from 2012 to 2019 were included. Development of deep infection, superficial infection, non-union and time to union were recorded. Patients were then divided into three groups according to the timing of conversion: Group A (<7 days), Group B (7-13 days), Group C (> 14 days). Comparison between groups was performed to assess intergroup variabilty.

RESULTS

The mean number of days between DCO and conversion was 6.7±4.52 (range 1-22). We observed one case of deep infection (1.1%), one case of non-union (1.1%), four cases of superficial infection (4.3%) and mean time to union was ±1.38 months. Comparison between groups demonstrated no significant correlation between timing of conversion and development of superficial or deep infection and non-union, while it highlighted that complexity of the fracture and longer surgical time of conversion procedure were significantly higher in Group C.

CONCLUSIONS

One-stage conversion to definitive internal fixation within 22 days from DCO is a safe and feasible procedure, which does not influence the incidence of infection or non-union.