Minimizing Posttraumatic Osteoarthritis After High-Energy Intra-Articular Fracture

Extensible lateral approach versus sinus tarsi approach for sanders type II and III calcaneal fractures osteosynthesis: a randomized controlled trial of 186 fractures

AIMS

Which is the best extensile lateral (ELA) or sinus tarsi (STA) approach for osteosynthesis displaced intraarticular calcaneal fracture (DIACF) is still debatable. The current RCT's primary objective was to compare the complications incidence after open reduction and internal fixation of DIACFs through STA vs. ELA. The secondary objectives were the differences in intraoperative radiation exposure, time to fracture union, functional and radiological outcomes.

METHODS

Between August 2020 and February 2023, 157 patients with Sanders type II and III fractures were randomly assigned to either ELA (81 patients with 95 fractures) or STA (76 patients with 91 fractures). The primary outcome was the incidence of complications. The secondary outcomes were Böhler's and Gissane angles angle, fracture union, and American Orthopaedic Foot and Ankle Society (AOFAS) score.

RESULTS

No statistical differences between both groups regarding basic demographic data, injury characteristics, and fracture classification; however, patients in the STA group were operated upon significantly earlier (4.43 ± 7.37 vs. 7 ± 6.42 days, p = 0.001). STA's operative time was significantly shorter (55.83 ± 7.35 vs. 89.66 ± 7.12 min, p < 0.05), and no statistical difference regarding intraoperative radiation exposure. The time to fracture union was significantly shorter in STA (6.33 ± 0.8 vs. 7.13 ± 0.7 weeks, p = 0.000). Skin complications (superficial or deep infection) and Subtalar osteoarthritis were significantly higher in ELA (18.9% vs. 3.3%, p = 0.001) and (32.6% vs. 9.9%, p = 0.001), respectively. The radiological parameters were significantly better in STA postoperatively and at the last follow up. The AOFAS scores were significantly better in STA (83.49 ± 7.71 vs. 68.62 ± 7.05, respectively, p = 0.000).

CONCLUSION

During osteosynthesis of Sanders type II and III DIACFs, STA is superior to ELA in terms of operating earlier, shorter operative time, fewer complications, and better radiological and functional outcomes.

Functional Outcomes of Pilon Fractures Treated by External Fixation, Delayed Plating, and Open Reduction and Internal Fixation (ORIF): A Prospective Cohort Study

OBJECTIVE

This study aimed to evaluate the functional outcomes of three surgical management strategies for pilon fractures, including primary external fixation with delayed plating, external fixation with minimal internal fixation, and single-stage open reduction and internal fixation (ORIF) with plating.

METHODS

This prospective cohort study included 34 patients with complex intra-articular fractures of the distal tibia (AO-OTA type 43-C) treated between June 2018 and December 2019. Patients were managed surgically based on the local skin condition and swelling, employing either primary-stage external fixation with delayed plating (Group A), external fixation with minimal internal fixation (Group B), or single-stage ORIF with plating (Group C). Patients were followed up at regular intervals (six weeks, three months, six months, and 12 months post-surgery). Functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society Hindfoot Score (AOFAS) and Foot and Ankle Disability Index (FADI). Statistical significance was set at p<0.05.

RESULTS

The mean age of patients was 41±12.34 years. Group C included 23 patients (67.7%), Group B included five patients (14.7%), and Group A included six patients (17.6%). There were no significant differences between groups regarding the mechanism of injury, hospital stay duration, complications, or final functional scores (p>0.05). Group C showed significantly better AOFAS and FADI scores at six weeks and three months compared to the other groups; however, by six and 12 months, no significant differences were observed between the groups.

CONCLUSION

While ORIF with plating (Group C) demonstrated superior short-term functional outcomes, no long-term differences were observed between the three surgical approaches for pilon fractures. These findings suggest that all three methods can be viable options, with choice depending on individual patient factors and surgeon preference.

A Register Analysis after Tibial Plateau Fracture in Statutory Accident Insurance

OBJECTIVE

To analyse the results after tibial plateau fractures with a focus on socioeconomic consequences.

METHODS

On the basis of the data from the rehabilitation documentation of the German Statutory Accident Insurance (DGUV) on tibial plateau fractures (Code 83), a retrospective anonymised evaluation of the injuries which occurred in 2010 and 2016 was carried out. The registry data allowed subdivision into 3 groups: Medial, lateral and bicondylar tibial plateau fractures. The data have been analysed with regard to the following parameters: age, gender, treatment, time of return to work (AU), costs per case, total costs, workers compensation (MdE) and total payments.

RESULTS

The analysis includes 1046 isolated tibial plateau fractures for 2010 and 1072 for 2016. In 2016, 798 fractures could be assigned to the medial, lateral or bicondylar fracture groups. In 551 cases, both condyles were involved. In another 221 cases, the lateral plateau and in 26 the medial plateau was injured. There were 476 (59.7%) men and 322 (40.4%) women. The mean age was 43.4 (SD ± 16.7) years with a peak of 180 cases in the 55-60 year subgroup and 98 aged 15-20 years. The mean age of the cases with isolated lateral plateau involvement was 48.1 (SD ± 13.8) and was 47.5 (SD ± 16.6) in those with medial plateau fractures and 41.4 (SD ± 17.2) years in the subgroup with bicondylar patterns. The mean time of return to work was 39.4 (SD ± 25.3) weeks for the bicondylar tibial plateau fractures, 28.1 (SD ± 27.2) weeks for the medial and 24.5 (SD ± 22.8) weeks for the lateral groups. For the 2016 group, the mean costs were 5212 € for outpatient, 10358 € for inpatient and 7622 € for rehab costs per case (total costs over three years of 4247443 € for outpatient and 7506508 € for acute inpatient treatment). The highest costs per case were caused by the inpatient acute treatment of bicondylar tibial plateau fractures, at a mean of 22292 €. 17.6% of the 2016 casualty group resulted in compensation of at least 20%. The treatment costs for the 2010 group over 9 years (2010-2019) amounted to 4190855 € for outpatient treatments and € 9565313 for inpatient treatments. In addition, compensations of 8632448 € and lump-sum payments of 483289 € were paid from 2010 to 2019. Over a period of 9 years, 456 (66%) of 692 patients needed another in patient follow-up treatment. A total of 51% (n = 353) needed these treatments within the first year.

CONCLUSION

Tibial plateau fractures, in particular bicondylar tibial plateau fractures, show long-term, cost-intensive healing processes with reduced occupational capacity. Tibial plateau fractures are of economic importance in the statutory accident insurance in the long term. Preventive measures, optimal care and rehabilitation are therefore essential, together with innovative research to improve clinical outcomes.

Application of Virtual Reality Systems in Bone Trauma Procedures

Background and Objectives: Bone fractures contribute significantly to the global disease and disability burden and are associated with a high and escalating incidence and tremendous economic consequences. The increasingly challenging climate of orthopaedic training and practice re-echoes the established potential of leveraging computer-based reality technologies to support patient-specific simulations for procedural teaching and surgical precision. Unfortunately, despite the recognised potential of virtual reality technologies in orthopaedic surgery, its adoption and integration, particularly in fracture procedures, have lagged behind other surgical specialities. We aimed to review the available virtual reality systems adapted for orthopaedic trauma procedures. Materials and Methods: We performed an extensive literature search in Medline (PubMed), Science Direct, SpringerLink, and Google Scholar and presented a narrative synthesis of the state of the art on virtual reality systems for bone trauma procedures. Results: We categorised existing simulation modalities into those for fracture fixation techniques, drilling procedures, and prosthetic design and implantation and described the important technical features, as well as their clinical validity and applications. Conclusions: Over the past decade, an increasing number of high- and low-fidelity virtual reality systems for bone trauma procedures have been introduced, demonstrating important benefits with regard to improving procedural teaching and learning, preoperative planning and rehearsal, intraoperative precision and efficiency, and postoperative outcomes. However, further technical developments in line with industry benchmarks and metrics are needed in addition to more standardised and rigorous clinical validation.

Application of 3D modeling in a personalized approach to bone osteosynthesis (A literature review)

Three-dimensional printing opens up many opportunities for use in traumatology and orthopedics, because it takes into account personal characteristics of the patients. Modern methods of high-resolution medical imaging can process data to create threedimensional images for printing physical objects. Today, three-dimensional printers are able to create a model of any complexity of shape and geometry. The article provides a review of the literature about three-dimensional digital modeling in shaping implants for osteosynthesis. Data search was carried out on the Scopus, Web of Scince, Pubmed, RSCI databases for the period 2012–2022. The effectiveness of three-dimensional printing for preoperative modeling of bone plates has been confirmed: implants perfectly corresponds with the unique anatomy of the patient, since the template for it is based on the materials of computed tomography. Individual templates can be useful when the geometry of patients' bones goes beyond the standard, and when improved results of surgery are expected due to better matching of implants to the anatomical needs of patients. 

Management of deltoid ligament injuries in acute ankle fracture: a systematic review

BACKGROUND

Deltoid ligament repair (DLR) was historically a common adjunct to ankle fracture fixation; however, prevailing clinical practice is to explore the medial side of the ankle only if reduction is blocked. We performed a systematic review to determine the breadth and quality of the literature evaluating DLR in the context of ankle fractures.

METHODS

We searched the MEDLINE and Embase databases in May 2020 for English-language articles evaluating DLR versus no repair or syndesmotic fixation in patients with acute ankle fractures. We used descriptive statistics to compare studies and draw conclusions.

RESULTS

Of 362 articles identified, 8 (3 randomized controlled trials [RCTs] and 5 retrospective cohort studies) were included in our final analysis. Five studies compared DLR to conservative management, and 3 compared DLR to transsyndesmotic fixation. Functional outcomes were equivalent between groups. Five of the 6 studies that included radiographic outcomes showed a statistically significant decrease in the medial clear space and decreased malreduction rates postoperatively in the DLR groups.

CONCLUSION

High-quality evidence guiding treatment of deltoid ligament injury in acute ankle fractures is lacking; currently available evidence appears to support DLR. Given recent increased interest in DLR and syndesmotic fixation, a comprehensive multicentre RCT is warranted. Although radiographic evidence indicates the potential benefit of DLR, further research is required to establish the superiority of DLR versus clinical equipoise.

Pathomechanisms of Posttraumatic Osteoarthritis: Chondrocyte Behavior and Fate in a Precarious Environment

Traumatic injuries of the knee joint result in a wide variety of pathomechanisms, which contribute to the development of so-called posttraumatic osteoarthritis (PTOA). These pathogenetic processes include oxidative stress, excessive expression of catabolic enzymes, release of damage-associated molecular patterns (DAMPs), and synovial inflammation. The present review focuses on the underlying pathomechanisms of PTOA and in particular the behavior and fate of the surviving chondrocytes, comprising chondrocyte metabolism, regulated cell death, and phenotypical changes comprising hypertrophy and senescence. Moreover, possible therapeutic strategies, such as chondroanabolic stimulation, anti-oxidative and anti-inflammatory treatment, as well as novel therapeutic targets are discussed.