Postoperative wound complications in extensile lateral approach versus sinus tarsi approach for calcaneal fractures: Are we improving? Updated meta-analysis of recent literature

INTRODUCTION

To analyze recent literature comparing clinical outcomes of displaced intra-articular calcaneal fractures (DIACF) treated with open reduction and internal fixation using the extensile lateral approach (ELA) vs the minimally invasive sinus tarsi approach (STA), with a focus on wound complications.

MATERIALS AND METHODS

A comprehensive literature search was conducted utilizing PubMed, EMBASE, and Cochrane Library databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies published between 2013 and 2022, level of evidence (LOE) I-III, head-to-head comparative studies reporting on clinical outcomes after DIACFs treated with ORIF using ELA versus STA, and literature with full-text written in English were included. Data collection included: publication year, study design, number of surgeons, number of participants, demographic data (mean age at time of surgery, percent male, body mass index, medical co-morbidities), preoperative data (mechanism of injury, Sanders classification, time from injury to surgical fixation), intraoperative data, and postoperative clinical and radiographic outcomes (Böhler angle, angle of Gissane, calcaneal height/length/width).

RESULTS

A total of 21 articles (4 randomized control trials, 17 cohort studies) comprising of 2086 patients with calcaneal fractures, treated with either ELA (n = 1129) or STA (n = 957) met inclusion criteria. The risk of postoperative wound-related complications (RR 2.82, 95 % CI: 2.00-3.98, I2=27 %) and the risk of reoperation (RR 1.85, 95 % CI: 0.69-5.00, I2=67 %) was higher in ELA patients comparted to STA patients. However, the increased risk of postoperative wound-related complications with an ELA vs. STA was shown to be trending downward in recent publications. The ELA group also experienced longer time to surgery, extended operative times, and prolonged hospital stays when compared to the STA group. Radiographic measurements at final follow-up, including Böhler angle, angle of Gissane, as well as calcaneal height, length, and width, showed no statistically significant differences between the two groups.

CONCLUSION

Surgical treatment of calcaneal fractures utilizing the ELA continues to have an increased rate of complications and reoperation when compared to the less invasive STA, yet recent trends in the literature show that this rate is decreasing. Operative treatment of calcaneal fractures via either an ELA or STA can both achieve comparable postoperative radiographic outcomes.

LEVEL OF EVIDENCE

Therapeutic Level III.

What Do We Know So Far About Ventricular Arrhythmias and Sudden Cardiac Death Prediction in the Mitral Valve Prolapse Population? Could Biomarkers Help Us Predict Their Occurrence?

PURPOSE OF THE REVIEW

To summarize currently available data on the topic of mitral valve prolapse (MVP) and its correlation to the occurrence of atrial and ventricular arrhythmias. To assess the prognostic value of several diagnostic methods such as transthoracic echocardiography, transesophageal echocardiography, cardiac magnetic resonance, cardiac computed tomography, electrocardiography, and electrophysiology concerning arrhythmic episodes. To explore intra and extracellular biochemistry of the cardiovascular system and its biomarkers as diagnostic tools to predict rhythm disturbances in the MVP population.

RECENT FINDINGS

MVP is a common and mainly benign valvular disorder. It affects 2-3% of the general population. MVP is a heterogeneous and highly variable phenomenon with three structural phenotypes: myxomatous degeneration, fibroelastic deficiency, and forme fruste. Exercise intolerance, supraventricular tachycardia, and chest discomfort are the symptoms that are often paired with psychosomatic components. Though MVP is thought to be benign, the association between isolated MVP without mitral regurgitation (MR) or left ventricle dysfunction, with ventricular arrhythmia (VA) and sudden cardiac death (SCD) has been observed. The incidence of SCD in the MVP population is around 0.6% per year, which is 6 times higher than the occurrence of SCD in the general population. Often asymptomatic MVP population poses a challenge to screen for VA and prevent SCD. Therefore, it is crucial to carefully assess the risk of VA and SCD in patients with MVP with the use of various tools such as diagnostic imaging and biochemical and genetic screening.

Distal Tibia Apex Posterior Angulation: A Normal Anatomic Variant with Side-To-Side Symmetry

Category:

Trauma; Ankle

Introduction/Purpose:

The native sagittal plane alignment of the distal tibia has not been well-described and has implications during the fixation of tibia fractures. Cavovarus foot alignment has been previously thought to influence gastrocsoleus tightness and the potential for anterior talar escape in the setting of an osseous injury in this region. However, the relationship between midfoot alignment and sagittal distal tibia morphology is undescribed. Characterization of this osseous anatomy may be helpful to achieve adequate sagittal alignment during the reduction of distal tibia fractures. The purpose of this study was primarily to characterize distal tibia sagittal morphology and ankle radiographic parameters, determine whether symmetry exists from side-to- side, and secondarily to identify any differences based on midfoot alignment.

Methods:

112 patients (60 females, mean age 45.8 years) with bilateral lateral weight-bearing ankle radiographs were retrospectively evaluated (224 ankles). Midfoot morphology was classified as normal, planus, or cavus using Meary's angle (MA) (Planus: MA <-4°, Normal: MA -4°≤x≤4°, Cavus: MA>4°). The angle between the proximal diaphyseal (Line 1) and distal tibia (Line 2) axes was measured, and the location of the center of rotation of angulation (CORA) relative to the plafond was recorded (Figure 1). The horizontal distance (via a line parallel to the floor) from the distal tibia axis (Line 2) to the lateral talar process was measured, as well as the anterior distal tibial angle, and the plafond radius of curvature (ROC). Bilateral ankles and midfoot morphologies were compared using a Mann-Whitney U test and ANOVA, respectively. Correlation was assessed using linear regression.

Results:

The average distal tibia had 2° of apex posterior angulation with the CORA located 8.0 cm proximal to the plafond. There was no difference by laterality in magnitude of the angulation (p=.358) or distance from the plafond to the CORA (p=.901). The angulation increased as foot alignment transitioned from cavus (1.25°), to normal (1.89°), to planus (3.05°) alignment (r=.32; R2=.102; p<.001). The angulation was larger in men (2.8°) than in women (1.4°) (p<.001) and decreased with increasing patient age (r=.279, R2=.078, p<.001). The lateral talar process was on average 5.9 mm anterior to the distal tibia axis (Line 2), more anterior with cavus versus planus alignment (6.7mm vs. 4.8mm) (p<.001). The average anterior distal tibial angle and plafond ROC were 83.6° and 22.9 mm, respectively, with no significant differences by laterality or midfoot morphology (p>.05 for both).

Conclusion:

The distal tibia has a consistent apex posterior bow that is symmetric from side-to-side, but variable from patient- to-patient. Distal tibia osseous morphology is related to midfoot alignment, sex, and age. Cavus alignment is additionally correlated with anterior translation of the lateral talar process relative to the distal tibia axis. Surgeons treating distal tibia fractures may consider the use of contralateral imaging as a reduction template to help restore patient-specific sagittal alignment. A tibial nail that ends anterior in the distal segment of a distal tibia fracture should prompt the surgeon to carefully evaluate whether sagittal alignment has been restored.

The Effect of Nonsteroidal Anti-inflammatory Drugs and Selective COX-2 Inhibitors on Bone Healing

A recently published study, "Risk of Nonunion With Nonselective NSAIDs, COX-2 Inhibitors, and Opioids" by George et al (J Bone Joint Surg Am. 2020;102:1230-1238), assesses whether the use of nonselective nonsteroidal anti-inflammatory drugs (NSAIDs), selective cyclooxygenase 2 (COX-2) enzyme inhibitors, or opioids was associated with a risk of long bone fracture nonunion in Optum's deidentified private health database. This review analyzes the study, including strengths, weaknesses, and areas for future research. The study found an association between COX-2 inhibitor and opioid use with fracture nonunion but not with nonselective NSAID use. Although the literature on this topic is varied, these results are at least partially aligned with several animal studies that show COX-2 inhibitors to be associated with fracture nonunion. The George et al study design has several important limitations, indicating that further research is needed on this topic.

A comprehensive update on current fixation options for two-part proximal humerus fractures: a biomechanical investigation

BACKGROUND

Recent advancements in implant technology offer updated options for surgical management that have been rapidly adopted into clinical practice. The objective of this study is to biomechanically test and compare the current fixation options available for surgical fixation of two-part proximal humerus fractures and establish load to failure and stiffness values.

METHODS

Sixteen match-paired (32 total) fresh-frozen, cadaveric specimens were randomized to receive 1 of 4 fixation constructs following creation of an AO/OTA Type 11A3 (two-part) proximal humerus fractures. Fixation constructs tested consisted of 3.5 mm fixed angle plate (3.5-FAP), 4.5 mm fixed angle plate (4.5-FAP), humeral intramedullary nail (IMN), and a humeral intramedullary nail with a fixed angle blade (IMN-FAB). Specimen bone density was measured to ensure no adequate, non-osteoporotic bone. Constructs were tested for stiffness and ultimate load to failure and compared via one-way ANOVA analysis with subsequent post hoc Tukey HSD multiple group comparison statistical analysis.

RESULTS

The IMN-FAB construct was significantly stiffer than the 3.5-FAP construct (123.8 vs. 23.9, p<0.0001), the 4.5-FAP construct (123.8 vs. 33.3, p<0.0001) and the IMN construct (123.8 vs. 60.1, p=0.005). The IMN-FAB construct reported a significantly higher load to failure than the 3.5-FAB construct (4667.3 N vs. 1756.9 N, p<0.0001), and the 4.5-FAP construct (4667.3 N vs. 2829.4 N, p=0.019, Table 2). The IMN construct had a significantly higher load to failure than the 3.5-FAP construct (3946.8 vs. 1756.9, p=0.001, Table 2).

CONCLUSION

Biomechanical testing of modern fixation options for two-part proximal humerus fracture exhibited that the stiffest and highest load to failure construct was the IMN-FAB followed by the IMN, 3.5-FAP and then the 4.5-FAP constructs. However, prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures.