Evaluating the stability of external fixators following pelvic injury: A systematic review of biomechanical testing methods

INTRODUCTION

This systematic review aims to identify previously used techniques in biomechanics to assess pelvic instability following pelvic injury, focusing on external fixation constructs.

METHODS

A systematic literature search was conducted to include biomechanical studies and to exclude clinical trials.

RESULTS

Of an initial 4666 studies found, 38 met the inclusion criteria. 84% of the included studies were retrieved from PubMed, Scopus, and Web of Science. The studies analysed 106 postmortem specimens, 154 synthetic bones, and 103 computational models. Most specimens were male (97% synthetic, 70% postmortem specimens). Both the type of injury and the classification system employed varied across studies. About 82% of the injuries assessed were of type C. Two different fixators were tested for FFPII and type A injury, five for type B injury, and fifteen for type C injury. Large variability was observed for external fixation constructs concerning device type and configuration, pin size, and geometry. Biomechanical studies deployed various methods to assess injury displacement, deformation, stiffness, and motion. Thereby, loading protocols differed and inconsistent definitions of failure were determined. Measurement techniques applied in biomechanical test setups included strain gauges, force transducers, and motion tracking techniques.

DISCUSSION AND CONCLUSION

An ideal fixation method should be safe, stable, non-obstructive, and have low complication rates. Although biomechanical testing should ensure that the load applied during testing is representative of a physiological load, a high degree of variability was found in the current literature in both the loading and measurement equipment. The lack of a standardised test design for fixation constructs in pelvic injuries across the studies challenges comparisons between them. When interpreting the results of biomechanical studies, it seems crucial to consider the limitations in cross-study comparability, with implications on their applicability to the clinical setting.

Damage-control orthopedics or early total care: What you need to know

ABSTRACT

Patients with multisystem injuries are defined as multiply injured patients and may need multiple surgical procedures from more than one specialty. The importance of evaluating and understanding the resuscitation status of a multiple-injury patient is critical. Orthopedic strategies when caring for these patients include temporary stabilization or definitive early fixation of fractures while preventing further insult to other organ systems. This article will define multiple injuries and discuss specific markers used in assessing patients' hemodynamic and resuscitation status. The decision to use damage-control orthopedics or early total care for treatment of the patient are based on these factors, and an algorithm is presented to guide treatment. We will also discuss principles of external fixation and the management of pelvic trauma in a multiple-injury patient.

Angioembolization Has Similar Efficacy and Lower Total Charges than Preperitoneal Pelvic Packing in Patients With Pelvic Ring or Acetabulum Fractures

OBJECTIVES

To compare cost, hospital-related outcomes, and mortality between angioembolization (AE) and preperitoneal pelvic packing (PPP) in the setting of pelvic ring or acetabulum fractures.

METHODS

.

DESIGN

Retrospective database review.

SETTING

National Inpatient Sample, years 2016-2020.

PATIENT SELECTION CRITERIA

Hospitalized adult patients who underwent AE or PPP in the setting of a pelvic ring or acetabulum fracture.

OUTCOME MEASURES AND COMPARISONS

Mortality and hospital-associated outcomes, including total charges, following AE versus PPP in the setting of pelvic ring or acetabulum fractures.

RESULTS

A total of 3780 patients, 3620 undergoing AE and 160 undergoing PPP, were included. No significant differences in mortality, length of stay, time to procedure, or discharge disposition were found ( P > 0.05); however, PPP was associated with significantly greater charges than AE ( P = 0.04). Patients who underwent AE had a mean total charge of $250,062.88 while those undergoing PPP had a mean total charge of $369,137.16.

CONCLUSIONS

Despite equivalent clinical efficacy in terms of mortality and hospital-related outcomes, PPP was associated with significantly greater charges than AE in the setting of pelvic ring or acetabulum fractures. This data information can inform clinical management of these patients and assist trauma centers in resource allocation.

LEVEL OF EVIDENCE

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

Biomechanical comparative study on external fixators of new configurations in the treatment of Tile C pelvic injury

To compare the biomechanical properties of several anterior pelvic ring external fixators with two new configurations in the treatment of Tile C pelvic fractures, in order to evaluate the effectiveness of the new configurations and provide a reference for their clinical application. A finite element model of a Tile C pelvic ring injury (unilateral longitudinal sacral fracture and ipsilateral pubic fracture) was constructed. The pelvis was fixed with iliac crest external fixator (IC), anterior inferior iliac spine external fixator (AIIS), combination of IC and AIIS, combination of anterior superior iliac spine external fixator (ASIS) and AIIS, and S1 sacroiliac screw in 5 types of models. The stability indices of the anterior and posterior pelvic rings under vertical longitudinal load, left-right compression load and anterior-posterior shear load were quantified and compared. In the simulated bipedal standing position, the results of the vertical displacement of the midpoint on the upper surface of the sacrum are consistent with the displacement of the posterior rotation angle, and the order from largest to smallest is IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. The longitudinal displacement of IC is greater than that of the other models. The displacements of ASIS + AIIS and IC + AIIS are similar and the latter is smaller. In the simulated semi-recumbent position, the vertical displacement and posterior rotation angle displacement of the midpoint on the upper surface of the sacrum are also consistent, ranking from large to small: IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. Under the simulated left-right compression load state, the lateral displacements of the highest point of the lateral sacral fracture end are consistent with the highest point of the lateral pubic fracture end, and the order from large to small is S1 screw, IC, AIIS, ASIS + AIIS and IC + AIIS, among which the displacements of S1 screw and IC are larger, and the displacements of ASIS + AIIS and IC + AIIS are similar and smaller than those of other models. The displacements of IC + AIIS are smaller than those of ASIS + AIIS. Under the simulated anterior-posterior shear load condition, the posterior displacements of the highest point of the lateral sacral fracture end and the highest point of the lateral pubic fracture end are also consistent, ranking from large to small: IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. Among them, the displacements of IC and AIIS are larger. The displacements of ASIS + AIIS and IC + AIIS are similar and the latter are smaller. For the unstable pelvic injury represented by Tile C pelvic fracture, the biomechanical various stabilities of the combination of IC and AIIS are superior to those of the external fixators of conventional configurations. The biomechanical stabilities of the combination of ASIS and AIIS are also better than those of the external fixators of conventional configurations, and slightly worse than those of the combination of IC and AIIS. Compared with sacroiliac screw and conventional external fixators, the lateral stabilities of IC + AIIS and ASIS + AIIS are particularly prominent.

Five-Year Follow-Up of Surgery vs Functional Bracing for Closed Displaced Humeral Shaft Fractures

This study compares outcomes of surgery and functional bracing for closed humeral shaft fractures after 5 years of follow-up.

Incidence of surgical rib fixation at chest wall injury society collaborative centers and a guide for expected number of cases (CWIS-CC1)

PURPOSE

Surgical stabilization of rib fractures (SSRF) improves outcomes in certain patient populations. The Chest Wall Injury Society (CWIS) began a new initiative to recognize centers who epitomize their mission as CWIS Collaborative Centers (CWIS-CC). We sought to describe incidence and epidemiology of SSRF at our institutions.

METHODS

A retrospective registry evaluation of all patients (age > 15 years) treated at international trauma centers from 1/1/20 to 7/30/2021 was performed. Variables included: age, gender, mechanism of injury, injury severity score, abbreviated injury severity score (AIS), emergency department disposition, length of stay, presence of rib/sternal fractures, and surgical stabilization of rib/sternal fractures. Classification and regression tree analysis (CART) was used for analysis.

RESULTS

Data were collected from 9 centers, 26,084 patient encounters. Rib fractures were present in 24% (n = 6294). Overall, 2% of all patients underwent SSRF and 8% of patients with rib fractures underwent SSRF. CART analysis of SSRF by AIS-Chest demonstrated a difference in management by age group. AIS-Chest 3 had an SSRF rate of 3.7, 7.3, and 12.9% based on the age ranges (16-19; 80-110), (20-49; 70-79), and (50-69), respectively (p = 0.003). AIS-Chest > 3 demonstrated an SSRF rate of 9.6, 23.3, and 39.3% for age ranges (16-39; 90-99), (40-49; 80-89), and (50-79), respectively (p = 0.001).

CONCLUSION

Anticipated rate of SSRF can be calculated based on number of rib fractures, AIS-Chest, and age. The disproportionate rate of SSRF in patients age 50-69 with AIS-Chest 3 and age 50-79 with AIS-Chest > 3 should be further investigated, as lower frequency of SSRF in the other age ranges may lead to care inequalities.

Trends in the Management of Fifth Metacarpal Neck Fractures

PURPOSE

To describe management trends of fifth metacarpal neck (5MCN) fractures within a large health care system. We aimed to define patient and surgeon factors associated with nonsurgical versus surgical treatment, as well as to identify factors associated with receiving care only in the emergency department (ED).

METHODS

We identified all 5MCN fractures within our system for the years 2012-2020 and recorded baseline demographics for cases. Injury, treatment, and fracture characteristics were all recorded. For fractures treated nonsurgically, we determined the type of immobilization used (if any) and recorded whether patients were seen only in the ED or received subsequent outpatient follow-up. Demographic comparisons were made between groups, and adjusted logistic regression models were generated to predict the odds of having a surgical 5MCN fracture or being seen in the ED only.

RESULTS

There were 611 5MCN fractures over an 8-year period, of which 10% were treated surgically. During the first half of the study period, 8% of isolated cases were treated surgically compared with 7% of cases in the second half. Soft dressings were increasingly used. There were no nonsurgically managed cases that underwent subsequent surgical procedures for symptomatic nonunion or malunion. Twenty-one percent of patients were seen only in the ED. Fracture angulation, associated injuries, insurance status, and treatment by a hand surgeon were all significantly associated with an increased likelihood of surgery.

CONCLUSIONS

Of the 611 5MCN fractures identified, 90% were treated nonsurgically. Patient and surgeon factors were associated with increased odds of surgery. Of patients who sought care for 5MCN injuries, >20% received no follow-up care outside of the ED. These data can be used to assess future changes in management trends and suggest that nonunion and symptomatic malunions are uncommon occurrences.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

In-vitro external fixation pin-site model proof of concept: A novel approach to studying wound healing in transcutaneous implants

External fixation is an essential surgical technique for treating trauma, limb lengthening and deformity correction, however infection is common, with infection rates ranging from 4.5 to 100% of cases. Throughout the literature researchers and clinicians have highlighted a relationship between excessive movement of the pin and skin and an increase in the patient's risk of infection, however, currently no studies have addressed this role of pin-movement on pin-site wounds. This preliminary study describes a novel in vitro pin-site model, developed using a full-thickness human skin equivalent (HSE) model in conjunction with a bespoke mechanical system which simulates pin-movement. The effect of pin-movement on the wound healing response of the skin equivalents was assessed by measuring the expression of pro-inflammatory cytokines. Six human skin equivalent models were divided into three test groups: no pin as the control, static pin-site wound and dynamic pin-site wound (n = 3). On day 3 concentrations of IL-1α and IL-8 showed a significant increase compared to the control when a static fixation pin was implanted into the skin equivalent (p < 0.05) and (p < 0.005) respectively. Levels of IL-1α and IL-8 increased further in the dynamic sample compared to the static sample (p < 0.05) and (p < 0.0005). This study demonstrates for the first time the application of HSE model to study external-fixation pin-movement in vitro. The results of this study demonstrated pin-movement has a negative effect on soft-tissue wound-healing, supporting the anecdotal evidence reported in the literature, however further analysis of wound heading would be required to verify this hypothesis.

Effect of damage control strategy combining pre-hospital emergency treatment with in-hospital treatment on pelvic fracture complicated by multiple injuries

OBJECTIVE

To analyze the application value of damage control strategies combining pre-hospital emergency treatment with in-hospital treatment for multiple injuries in treating pelvic fracture complicated by multiple injuries.

METHODS

120 patients with pelvic fracture complicated by multiple injuries admitted to our hospital from January 2020 to January 2023 were selected and divided into a damage control group (early temporary reduction after resuscitation, n = 60) and a control group (no reduction and resuscitation only, n = 60) by treatment methods. The control group was treated with conventional methods, while the damage control group was treated with the damage control strategy combining pre-hospital emergency treatment combined with in-hospital treatment in addition to conventional methods. The mortality rate, complication rate, fracture reduction quality, long-term efficacy, and patient satisfaction of the two groups were compared.

RESULTS

The mortality rate of the damage control group was lower than that of the control group, and the difference has statistical significance (P<0.05); the incidence of infection, DIC, and MODS of the damage control group were lower than that of the control group, with the difference being statistically significant (P<0.05); the incidence of ARDS in the two groups is not that different (P>0.05); the fracture reduction quality and long-term therapeutic effect of patients in the two groups were statistically different, with the damage control group outperforming the control group in both aspects; the difference between the two groups in terms of patient satisfaction was statistically significant (P<0.05), with the patient satisfaction of the damage control group being higher than that of the control group.

CONCLUSION

For patients with pelvic fracture, the application of the damage control strategy combining pre-hospital emergency treatment and in-hospital treatment is a boon to the standardization of the treatment process, the improvement of the treatment success rate and fracture reduction quality and the reduction of complications, and therefore is worth promoting in clinical practice. the early application of external fixation has helped with the definitive reduction at a time when the patuent was stable.

Sexual Dysfunction in Women After Tibial Fracture: A Retrospective Comparative Study

BACKGROUND Tibial fractures, common in adults, are often treated with external or internal fixation methods. While effective, external fixation (EF) can lead to sexual dysfunction (SD), especially in young patients. This study aimed to assess SD in women undergoing EF versus internal fixation for tibial fractures. MATERIAL AND METHODS Sexual function and frequency of monthly sexual intercourse (SI) were evaluated using the Female Sexual Function Index (FSFI) before surgery, with the fixator, after at least 6 months following fixator removal in EF group, and after achieving bone union for at least 3 months in the IF group. RESULTS The EF group consisted of 107 (mean age 28.5 years; 19-40 years) and IF group consisted of 106 patients (mean age 32.1 years; 18-40 years). The duration of EF was an average of 4.7 months (range, 2.5-13 months). FSFI scores were significantly lower in the EF group compared to the IF group (9.33 versus 27.3, P<0.001). Also, there was no significant difference between the FSFI scores before EF and after EF was removed (34.22 versus 33.8, P=0.413). FSFI sub-group scores such as desire, arousal, lubrication, and orgasm were significantly lower in the EF group (P<0.001). The monthly average frequency of SI before surgery and after the removal of EF was 10.2 and 9.1, respectively, while this frequency was 2.56 when EF was present (P<0.001). CONCLUSIONS The quality and frequency of SI in women significantly deteriorate and decrease during the period of extremity fixation following tibial diaphyseal fractures treated with EF, but return to normal after removal.

Morphology of Proximal Ulna Bare Area: A Guide for Olecranon Osteotomy

PURPOSE

Olecranon osteotomy is commonly used to obtain access to the distal humerus for fracture fixation. The goal of this study was to accurately describe the anatomy of the bare area to minimize articular cartilage damage while performing olecranon osteotomies.

METHODS

Twenty cadaveric ulnae were denuded to expose the bare area. Laser surface mapping was used to create 3-dimensional models, and the nonarticular portions of the ulnae were digitally measured.

RESULTS

The morphology of the bare area from all aspects of the proximal ulna was defined. The central bare area was consistent in its location, 4.9 ± 1.5 mm distal to the deepest portion of the trochlear notch and 23.2 ± 2.3 mm distal to the olecranon tip. The maximum chevron osteotomy apical angle to stay within the bare area averaged 110° ± 11.8°. However, there was little tolerance for error without the risk of violating the articular cartilage. With transverse osteotomy, averaging 18° ± 10.6° in the coronal plane, there is less risk of damaging the articular cartilage.

CONCLUSIONS

Transverse osteotomy perpendicular to the posterior surface of the ulna aiming at the visible bare area on the medial and lateral sides of the greater sigmoid notch may reduce the chances of violating the nonvisible articular cartilage of the proximal ulna. Based on the findings of this study, if chevron osteotomy is used, a shallow apex distal angle of more than 110° is recommended.

CLINICAL RELEVANCE

This study provides intraoperative landmarks to guide surgeons performing olecranon osteotomies to stay within the bare area.

Risk factors for surgical site infection after surgical treatment of closed distal radial fractures

We assessed operatively treated closed distal radial fractures to identify independent risk factors for surgical site infection after treatment. A retrospective review was carried out of 531 operatively treated closed distal radial fractures over a 5-year period. Multiple logistic regression was performed with infection as the dependent variable, using a stepwise regression procedure to select variables to construct the final model. In total, 19 (3.6%) fractures were complicated by postoperative surgical site infection. Uncontrolled diabetes with HbA1c >7, the presence of external fixation or external Kirschner wires, and tobacco use were significant independent predictors of infection. Age and time in the operating room were also statistically significant predictors but deemed to be not clinically meaningful.Level of evidence: IV.

Early Versus Delayed Weight Bearing and Mobilization After Ankle Fracture Fixation Surgery: A Systematic Review and Meta-analysis of Randomized Controlled Trials

The purpose of this review was to determine whether there is a benefit to early weight bearing or mobilization in surgically treated ankle fractures. All randomized controlled trials that analyzed early vs delayed weight bearing and/or mobilization after an ankle surgery were included. The primary outcome measure was the pooled Olerud Molander Ankle Score 1 year postoperatively. No significant differences in ankle function were found at 1 year postoperatively between early and delayed weight bearing and mobilization. The 12-week results demonstrated superior early ankle function scores for patients who had early weight bearing. Patients who had early mobilization were at increased risk for postoperative complications. In surgically treated ankle fractures, early weight bearing resulted in improved short-term ankle function scores. [Orthopedics. 2024;47(2):71-78.].

Functional and union outcome of combined column tibial plateau fracture treated with hybrid external fixator

Objective

To determine the combined column tibial plateau fracture treated with a hybrid external fixator in terms of knee functionality, union outcome and complications.

METHODS

The quasi-experimental study was conducted at the Department of Orthopaedic Surgery, Mayo Hospital, Lahore, Pakistan, from July 5, 2019, to December 31, 2021, and comprised patients of either gender aged 20-50 years who presented with 2-column or 3-column fractures of proximal tibia classified according to the 3-column classification system after being diagnosed using radiographs and three-dimensional computed tomography scan. Knee function, union and complications, like neural, vascular, infection, delayed union, nonunion, malunion and implant failure, were evaluated. The Knee Society Score was used to assess knee function, and modified Rasmussen score for the union, while complications were assessed clinically on the 2nd, 6th, 12th, 16th, 24th, 36th weeks and one year post-operatively. Data was analysed using SPSS 26.

RESULTS

Of the 113 patients, 91(80.53%) were males and 22(19.47%) were females. The overall mean age was 35.56±9.00 years. From the 12th week to the 24th week 45(39.83%) patients had good and 59(52.21%) patients had excellent functional outcomes. Union outcome in the 16th and 24th week was good in 57(50.44%) patients and excellent in 47(41.59%) patients. No neurovascular injury was observed. Superficial pin tract infection was observed in 21(18.6%) cases that healed with wound debridement and antibiotics. No delayed union, malunion and implant failure was observed.

CONCLUSIONS

Good to excellent functional and union outcomes with minimum complications were observed with the hybrid external fixator.

Regional Anesthesia as an Alternative to Procedural Sedation for Forearm Fracture Reductions in the Pediatric Emergency Department

BACKGROUND

Pediatric forearm fractures are common injuries in the pediatric emergency department (PED). Pediatric procedural sedation (PPS) is often required for forearm fracture reductions and pain control for casting. Bier blocks and hematoma blocks are types of regional anesthesia (RA) procedures that can be performed as a potential alternative to PPS.

OBJECTIVE

The objective of this study is to compare the safety of RA with that of PPS. We hypothesized that RA has a safety profile that is equal or superior to PPS as well as a shorter duration of treatment in the PED.

METHODS

Pediatric emergency department encounters in patients presenting with a diagnosis of radius fracture, ulna fracture, distal "both-bone" fracture, Monteggia fracture, and/or Galeazzi fracture were included. Outcomes of interest included patient adverse events (AEs), sedation medications used, PED duration of treatment (arrival time to disposition time), sedation failures, and reduction failures.

RESULTS

Propensity matching was performed resulting in 632 well-matched RA-PPS pairs. The PPS cohort had 13% of encounters with at least 1 AE compared with 0.2% in the RA cohort, P < 0.001. The most common AE in the PPS group was hypoxia (9.8%), and the only AE in the RA group was an intravenous infiltrate (0.16%). Within the matched cohorts, PPS required more medications than RA (100% vs 60%, P < 0.001). Ketamine alone was more commonly used in the PPS group than the RA group (86% vs 0.2%, P < 0.001). Propofol was used only in the PPS group. The average duration of treatment was 205 (SD, 81) minutes in the PPS group and 178 (SD, 75) minutes in the RA group ( P < 0.001). There were no reduction failures in either group.

CONCLUSIONS

Bier blocks and hematoma blocks are an acceptable alternative to PPS for children requiring forearm reductions. The AE rate is low and the reduction success rate is high. Duration of treatment in the PED is shorter for patients receiving RA compared with PPS.

Comparing pediatric femoral shaft fracture repair patient outcomes between pediatric and non-pediatric orthopedic surgeons

INTRODUCTION

While pediatric femoral shaft fractures account for less than 2% of all fractures in children, they are the most common pediatric fracture requiring hospitalization. Management of pediatric femoral shaft fractures is challenging, with various treatment options relating to severity and patient age. The last few decades have seen an increased supply of pediatric orthopedic surgeons (POS) along with increased referral rates. However, there continues to be a maldistribution of POS throughout the country. This study sought to determine outcomes following femoral shaft fracture repair by POS compared to non-pediatric trained orthopedic surgeons.

METHODS

The National Surgical Quality Improvement Program-Pediatric database was queried to identify pediatric patients who underwent open treatment of femoral shaft fracture from 2012 to 2019. Differences in patient demographics, comorbidities, and postoperative complications were assessed and compared between patients who were treated by pediatric subspecialty-trained orthopedic surgeons and those treated by non-pediatric orthopedic surgeons. Bivariate and multivariable regression analyses were utilized.

RESULTS

Of the 5862 pediatric patients who underwent femoral shaft fracture treatment, 4875 (83.2%) had their surgeries performed by a POS whereas 987 (16.8%) were operated on by a non-pediatric surgeon. POS were more likely to operate on patients with a higher American Society of Anesthesiologists classification (p < 0.001) and those with medical comorbidities, including gastrointestinal (p = 0.022) and neurological (p < 0.001). After controlling for baseline patient characteristics on multivariable regression analysis, patients treated by non-pediatric orthopaedic surgeons are at an increased risk of prolonged hospital stay (OR 2.595; p < 0.001) when compared to patients operated on by POS.

CONCLUSION

The results indicated that patients undergoing surgical treatment for a femoral shaft fracture by a non-pediatric trained orthopedic surgeon were at increased risk of a prolonged hospital stay compared to those being treated by POS. Additionally, POS were more likely to operate on more difficult patients with increased comorbidities.

Tibial fractures treated with mono-lateral fixation: Principles of design and application

This paper presents the outcome of a data review of patients treated with the IOS external fixation system at the Royal Stoke University Hospital: a fixation designed to meet four requirements for external fixation proposed in this paper. Demographic data and outcome were collected and assessed. From 69 initial patients, 64 patients (55 males and 9 females) had an average age of 35.9 years. The mean time to union was 127 days. There were no incidences of malunion, or refracture post fixation removal attributable to the treatment method. In addition, in this cohort, there was no incidence of pin tract infection resulting in osteomyelitis. Of all the factors assessed the only factor to have any significant effect on healing was smoking: an average delay of 31 days. An examination of RUST (radiographic union score tibia) and modified RUST scores illustrated a potential false negative of up to 80%. Hence, this study cannot support the use of either scoring system to diagnose fracture healing. IOS external fixation was shown to be an effective method for the treatment of unstable tibial fractures. The reduction at fixation removal was shown to be very good. There was no incidence of osteomyelitis. It is, therefore, suggested that appropriately used external fixation is a viable alternative to intramedullary nailing if designed and surgically applied using four design principles outlined in this paper. Furthermore, it is proposed that external fixation be designed and applied to meet these four principles.

Docking site interventions following bone transport using external fixation: a systematic review of the literature

PURPOSE

Although bone transport is a well-recognised technique to address segmental bone defects, optimal management of docking sites is not absolutely determined. Some surgeons routinely intervene in all cases, and others prefer to observe and intervene only if spontaneous union does not occur. Primary aim of the study was to compare rates of docking site union between patients who underwent routine docking site intervention and those who did not.

METHODS

A systematic literature review using the keywords "bone transport", "docking", "tibia", and "femur" was performed in PubMed using PRISMA guidelines. Studies published in English from January 2000 to August 2022 were included and assessed independently by two reviewers. Pooled analysis was undertaken dividing patients into two groups: those managed by routine intervention and those initially observed.

RESULTS

Twenty-three clinical studies met the eligibility criteria for pooled analysis, including 1153 patients, 407 in the routine intervention and 746 in the observed group. The rate of union after initial treatment was 90% in the routine intervention group and 66% in the observed group (p < 0.0001). Overall union rates at the end of treatment were similar at 99% in both groups. Patients in the observed group required an average of 2.2 procedures to achieve union overall compared with 3.8 in the routine intervention group. Time in frame was similar between groups.

CONCLUSION

Based on the current literature, routine docking site interventions cannot be recommended, since this may lead to unnecessary interventions in two thirds of patients. Timely selective intervention in those at high risk or after a defined period of observation would appear to be a logical approach.

Monolateral external fixation versus internal fixation of Gustilo IIIB open tibial fractures: a multicenter comparative study

PURPOSE

Gustilo IIIB open tibial fractures are associated with significant risks of complications particularly nonunion and fracture-related infections (FRI) due to the severity of the injuries. The commonly adopted viewpoint is that a Gustilo IIIB open tibial fracture is a relative contraindication for internal fixation. However, this study aims to assess the veracity of this viewpoint. The objective of this study was to evaluate the impact of the definitive fixation technique on fracture nonunion and FRI rates in Gustilo IIIB open tibial fractures. In this study, we compared the rates of nonunion and FRI rates in grade IIIB open tibial fractures managed definitively with either mono-lateral external fixation or internal fixation.

METHODS

The study was a multicenter retrospective comparative study undertaken in seven Nigerian tertiary hospitals. Following ethical approval, medical records of patients diagnosed with Gustilo IIIB open tibial fractures (between 2019 and 2021) were retrieved, patients who had a minimum of nine months of follow-up period and were found eligible had their relevant data entered into an online data collection form. Data obtained was analysed with SPSS version 23, and chi-square test was used to determine the statistical significance of differences observed between the two groups with regard to nonunion and FRI rates. P values less than 0.05 were considered statistically significant.

RESULTS

Out of a total of 47 eligible patients, 25 patients were managed definitively with mono-lateral external fixation whilst 22 patients were managed with internal fixation. Five of the 25 patients (20%) managed with external fixation had nonunion whilst two cases of nonunion were recorded amongst the 22 patients (9.1%) treated with internal fixation. The difference between the two techniques with regard to nonunion rates was not statistically significant (P = 0.295). 12 out of 25 patients (48%) in the external fixation group had FRIs whilst 6 out of 22 patients (27.3%) in the internal fixation group had FRIs. The rates of FRIs of the two groups were not significantly different (P = 0.145).

CONCLUSION

Our findings suggest that mono-lateral external fixation and internal fixation do not differ significantly with respect to rates of nonunion and fracture-related infections in Gustilo IIIB open tibial fractures.

Clinical application of instant 3D printed cast versus polymer orthosis in the treatment of colles fracture: a randomized controlled trial

BACKGROUND

The shortcomings of plaster in water resistance, air permeability, skin comfort, fixed stability and weight of wearing are still to be solved. 3D printed cast can overcome the above shortcomings. At present, there is a relative lack of data on the clinical application of 3D printed cast, probably due to its complexity, relatively long operating time, and high price. We aimed to compare and evaluate the short-term effectiveness, safety and advantages of 3D printed wrist cast versus polymer orthosis in the treatment of Colles fracture.

METHODS

Forty patients with Colles fracture in our hospital from June to December 2022 were selected and divided into an observation group (20 patients, treated with instant 3D printed cast) and a control group (20 cases, treated with polymer orthosis). Both groups treated with manual reduction and external fixation. The visual analogue scale (VAS), immobilization effectiveness and satisfaction scores, Disability of the Arm, Shoulder and Hand (DASH) score, complications and imaging data were collected and compared before immobilization and at 2, 6 and 12 weeks after the fracture.

RESULTS

VAS at 2 weeks after the fracture was significantly lower in the observation group than in the control group ( P < 0.05). The immobilization effectiveness and satisfaction scores at 6 weeks after the fracture were significantly higher in the observation group than in the control group (all P < 0.05). The DASH scores at 2 and 6 weeks after the fracture were significantly lower in the observation group than in the control group (all P < 0.05). There wasn't rupture of the printed cast or orthosis in both groups. There were 2 cases of skin irritation in the control group, and no skin irritation occurred in the observation group. The palmar tilt angle and ulnar inclination angle at 2 weeks and 12 weeks after the fracture were significantly higher in the observation group than in the control group (all P < 0.05).

CONCLUSIONS

Both instant 3D printed cast and polymer orthosis are effective in the treatment of Colles fracture. But instant 3D printed cast is better than polymer orthosis in areas of good clinical and imaging performance, and high patient satisfaction and comfort.

Modified Kapandji technique in pediatric displaced distal radius fractures: results in 195 patients

PURPOSE

The modified Kapandji technique has been proposed for fracture reduction in pediatric displaced distal radius fractures (DDRFs), but evidence is sparse. The purpose of this study was to evaluate our outcomes and complications, critically and systematically, when performing the modified Kapandji technique in pediatric DDRFs. Using this technique since 2011, we asked: (1) What is the quality of fracture reduction using this technique? (2) How stable is fracture alignment with this technique? (3) What are the postoperative complications and complication rates?

METHODS

Retrospective observational study of 195 pediatric patients treated with the modified Kapandji technique. Quality of fracture reduction, fixation type (intrafocal, combined, or extrafocal), and coronal/sagittal angulation were recorded at surgery and healing. Perioperative complications were graded. Patients were stratified by fracture (metaphyseal or Salter-Harris) and fixation type, as well as age (≤ 6 years; 6 to 10 years; > 10 years).

RESULTS

Fracture reduction was 'good' to 'anatomical' in 85% of patients. 'Anatomical' fracture reduction was less frequent in metaphyseal fractures (21% vs. 51%; p < .001). Mean angulation change was higher in metaphyseal fractures in both the sagittal (p = .011) and coronal (p = .021) planes. Metaphyseal fractures showed a higher mean change in sagittal angulation during fracture healing for the 'intrafocal' group. We observed a 15% overall complication rate with 1% being modified Sink Grade 3.

CONCLUSION

The modified Kapandji technique for pediatric DDRFs is a safe and effective treatment option. Metaphyseal fractures that do not involve the physis should be treated with extrafocal or combined wire fixation. Complications that require additional surgical treatment are rare.

LEVEL OF EVIDENCE

Level of evidence IV.

Circular external fixation for revision of failed tibia internal fixation

BACKGROUND

The management of failed tibial fracture fixation remains a challenge for orthopaedic surgeons. This study investigate the utility and outcomes of circular external fixation in the management of failed internal fixation of tibial fractures.

METHODS

Retrospective review of a prospectively collected database of a complex limb reconstruction unit at a major trauma centre was done during December 2022. Patients with failed internal fixation of tibial fracture who underwent revision surgery with circular external fixation frame were included.

RESULTS

20 patients with a mean age of 47.8 ± 16.5 years (range: 15-69) were included. Fourteen (70.0%) patients had failed plate and screws fixations, and the remaining six (30.0%) failed intramedullary nail fixation. The most common indication for revision surgery was development of early postoperative surgical site infection (5 patients; 25.0%). The mean duration of frame treatment was 199.5 ± 80.1 days (range = 49-364), while the mean follow-up duration following frame removal was 3.2 ± 1.8 years (range = 2-8). The overall union rate in this series was 100%; and all infected cases had complete resolution from infection. The total number of complications was 11, however, only two complications required surgical intervention. The most common complications reported were pin site infection (6; 30.0%) and limb length discrepancy of 2 cm (2; 10.0%).

CONCLUSIONS

Circular external fixation is a reliable surgical option in the treatment of failed internal fixation of tibia fractures. This technique can provide limb salvage in complex infected and noninfected cases with a high union rate and minimal major complications.

Factors Associated with Re-Displacement after Nonsurgical Treatment of Distal Radius Fractures in Adults: A Retrospective Study

OBJECTIVE

Closed reduction combined with external fixation is a frequently utilized approach for treating distal radial fractures in adults. Nonetheless, the potential for re-displacement following external fixation remains. Analyzing the factors influencing re-displacement after nonsurgical treatment of distal radial fractures in adults is vital for preventing re-displacement and making prognostic assessments.

METHODS

A retrospective analysis was performed on 884 patients who underwent nonsurgical treatment for distal radius fractures in the reduction room of the Orthopedics and Traumatology Department of Integrated Traditional Chinese and Western Medicine at Tianjin Hospital, Tianjin, China, between July 2019 and December 2022. Patients were categorized into two groups, namely displaced and nondisplaced, based on radiographic outcomes. Factors affecting fracture re-displacement were examined, including sex, age, side, AO/OTA type, external fixation, and radiographic outcomes at pre-reduction and immediate reduction. Logistic regression analysis was employed to identify the risk factors for fracture re-displacement, and ROC curves were constructed.

RESULTS

Among the 884 patients, 563 (63.69%) experienced re-displacement after fracture reduction. There were no statistically significant differences (p > 0.05) between the two groups in terms of gender, external fixation method, and palmar tilt angle at pre-reduction and immediate reduction, while significant differences (p < 0.05) were observed in age, side, AO/OTA type, and radial inclination, radial length, and radiographic outcomes of ulnar variance at pre-reduction and immediate reduction. Multifactorial logistic regression analysis revealed that age (odds ratio [OR] = 1.027, p < 0.001), AO/OTA type (OR = 2.327, p = 0.005), ulnar variance at pre-reduction (OR = 1.142, p = 0.048), and ulnar variance at immediate reduction (OR = 1.685, p < 0.001) were significant factors (p < 0.05) associated with re-displacement following nonoperative treatment of adult distal radius fractures. For patients aged ≥60 years, the amount of missing radiographic outcomes was positively correlated with age. The receiver operating characteristic curve demonstrated that age ≥65.5 years, ulnar variance >3.26 mm at pre-reduction, and ulnar variance >2.055 mm at immediate reduction were high-risk factors for fracture re-displacement.

CONCLUSIONS

Nonsurgical treatment of distal radius fractures exhibits a higher rate of re-displacement. Age, AO/OTA type, pre-reduction, and immediate reduction ulnar variance are key factors predicting fracture re-displacement.

Multidimensional Fluoroscopy to Assess Closed Reduction in Displaced Young Femoral Neck Fractures: A Report of 3 Cases

CASE

The authors present 3 physiologically young patients with displaced femoral neck fractures who underwent initial closed reduction and provisional fixation. Multidimensional fluoroscopy was used to assess fracture reduction before definitive fixation, with 1 patient requiring an open approach because of inadequate fracture reduction after closed attempts.

CONCLUSION

Displaced femoral neck fractures in young patients remain difficult injuries to treat. Reduction quality is a significant predictor of patient outcomes. Intraoperative multidimensional fluoroscopy provides treating surgeons with a tool to assess fracture reduction after closed reduction maneuvers and allows for intraoperative treatment adjustment as needed.

Mangled Thumb Injury Reconstruction with the Use of Definitive External Fixation and the Masquelet Technique: A Case Report

CASE

A 23-year-old right-hand dominant man presented with a high-velocity gunshot wound injury to the right thumb with severe soft-tissue damage, vascular injury, and large osseous defect of the right thumb metacarpal. The patient was successfully treated with metacarpophalangeal joint arthrodesis and metacarpal reconstruction using definitive external fixation, an intramedullary Kirschner wire, and use of the Masquelet bone grafting technique.

CONCLUSION

The authors' treatment approach for a mangled thumb injury with definitive external fixation and utilization of the Masquelet technique resulted in restoration of a large osseous defect, avoidance of infection, and limited loss of mobility.

Fracture blisters: predictors for time to definitive fixation in pilon fractures

PURPOSE

Fracture blisters, a common soft-tissue complication of pilon fractures, are associated with post-operative wound infections, delays in definitive fixation, and alterations in surgical plan. The purpose of this study was to (1) identify the delay in surgery attributable to the presence fracture blisters and (2) investigate the relationship of fracture blisters to comorbidities and fracture severity.

METHODS

Patients with pilon fractures at an urban level 1 Trauma center from 2010 to 2021 were identified. The presence or absence of fracture blisters was noted, along with location. Demographic information, time from injury to external fixator placement, and time to definitive open reduction internal fixation (ORIF) were collected. Pilon fractures were classified according to AO/OTA guidelines using CT imaging and plain radiographs.

RESULTS

314 patients with pilon fractures were available for analysis, eighty (25%) of whom were found to have fracture blisters. Patients with fracture blisters had longer time to surgery compared to those without fracture blisters (14.2 days vs 7.9 days, p < 0.001). A greater proportion of patients with fracture blisters had AO/OTA 43C fracture patterns, compared with those without fracture blisters (71.3% vs 53.8%, p = 0.03). Fractures blisters were less likely to be localized over the posterior ankle (12%, p = 0.007).

CONCLUSION

The presence of fracture blisters in pilon fractures are associated with significant delays in time to definitive fixation and higher energy fracture patterns. Fracture blisters are less commonly located over the posterior ankle which may support the implementation of a staged posterolateral approach when managing these injures.

Infectious profiles in civilian gunshot associated long bone fractures

PURPOSE

There is a paucity of literature on infections in civilian gunshot associated with long bone fractures with the reported rates ranging from 0-15.7%.This study aimed to investigate the rates of infection associated with long bone fractures caused by civilian gunshots. The specific objectives were to determine if certain extremities were at a higher risk for infection and to identify the types of bacteria present in these infections by analyzing culture isolates.

METHODS

We conducted a retrospective review of consecutive patients aged 18-64 who sustained gunshot-associated long bone fractures at an urban Level I trauma centre from 2010 to 2017. Patient selection was based done through a institutional trauma centre database using international classification of diseases (ICD) 9 and 10 codes. We included patients who underwent surgical treatment, specifically fracture fixation, at our institution and excluded patients with fractures involving the pelvis, spine, foot, and hand. A total of 384 gunshot-associated long bone fractures in 347 patients were identified for analysis. Relevant patient-, injury-, and treatment-related variables were extracted from clinical records and radiographic reviews. Outcomes of interest included bony union, repeat operative procedures, and the development of deep infection.

RESULTS

347 patients with 384 long bone fractures were included. 32 fractures in 32 patients developed an infection for an incidence of 9.3% of patients and 8.3% of fractures. Gram-positive bacteria were present in 23/32 (72.0%) culture isolates, gram-negative bacteria in 10/32 (31.3%) culture isolates, and six infections were polymicrobial. Staphylococcus 16/32 (50.0%) and Enterobacter 6/32 (18.8%) species were the most common isolates. Of the Staphylococcus species, 5/16 (31.3%) were MRSA. Lower extremity fractures had a greater risk for infection compared to the upper extremity (11.7% vs 3.7% p < 0.01) and fractures that developed an infection had a larger average zone of comminution (63.9 mm vs 48.5 mm p < 0.05).

CONCLUSION

This study investigated the rates of infection associated with long bone fractures caused by civilian gunshots. The overall infection rate observed in our series aligns with existing literature. Gram-positive bacteria were the predominant isolates, with a notable incidence of MRSA in our patient population, highlighting the need for considering empiric coverage. Additionally, gram-negative organisms were found in a significant proportion of infections, and a notable percentage of infections were polymicrobial. Our findings emphasize the importance of carefully assessing highly comminuted lower extremity fractures and implementing appropriate antibiotic coverage and operative debridement for patients with gunshot-related long bone fractures. While current prophylaxis algorithms for open fractures lack specific inclusion of gunshot wounds, we propose incorporating these injuries to reduce the incidence of infections associated with such fractures.

Comparative analysis of external locking plate and combined frame external fixator for open distal tibial fractures: a comprehensive assessment of clinical outcomes and financial implications

BACKGROUND

Open distal tibial fractures pose significant challenges regarding treatment options and patient outcomes. This retrospective single-centre study aimed to compare the stability, clinical outcomes, complications, and financial implications of two surgical interventions, namely the external locking plate and the combined frame external fixator, to manage open distal tibial fractures.

METHODS

Forty-four patients with distal open tibial (metaphyseal extraarticular) fractures treated between 2020 and 2022 were selected and formed into two main groups, Group A and Group B. Group A (19 patients) are patients that underwent treatment using the external locking plate technique, while Group B (25 patients) received the combined frame external fixator approach. Age, gender, inpatient stay, re-operation rates, complications, functional recovery (measured by the Johner-Wrush score), pain ratings (measured by the Visual Analogue Scale [VAS]), and cost analyses were evaluated for each group. Statistical analyses using SPSS were conducted to compare the outcomes between the two groups.

RESULTS

The research found significant variations in clinical outcomes, complications, and cost consequences between Group A and Group B. Group A had fewer hospitalisation periods (23.687.74) than Group B (33.5619.47). Re-operation rates were also considerably lower in Group A (26.3%) than in Group B (48%), owing to a greater prevalence of pin-tract infections and subsequent pin loosening in the combination frame external fixator group. The estimated cost of both techniques was recorded and analysed with the locking average of 26,619.69 ± 9,602.352 and the combined frame average of 39,095.64 ± 20,070.077.

CONCLUSION

This study suggests that although the two approaches effectively manage open distal tibia fractures, the locking compression plate approach (Group A) has an advantage in treating open distal tibia fractures. Shorter hospitalisation times, reduced re-operation rates, and fewer complications will benefit patients, healthcare systems, and budget allocation. Group A's functional recovery results demonstrate the locking plate technique's ability to improve recovery and patient quality of life. According to the cost analysis, the locking plate technique's economic viability and cost-effectiveness may optimise healthcare resources for open distal tibia fractures. These findings might improve patient outcomes and inform evidence-based orthopaedic surgery.

A novel primary antibiotic cement-coated locking plate as a temporary fixation for the treatment of open tibial fracture

Complex lower extremity trauma reconstruction remains a challenge. This study used an internal fixation composite structure of antibiotic cement plates as a temporary fixation to treat lower extremity Grade III open fractures; thus, reducing the treatment period and complications of external fixation. We aimed to assess the safety and efficacy of this technique in the initial surgery stage. Between January 2018 and March 2021, 20 patients with Gustilo grade IIIB/C open fractures received an antibiotic cement-coated locking plate as a temporary internal fixator during initial surgery. Thorough debridement and temporary internal fixation were performed with a 3.5-mm system antibiotic cement-coated locking plate. Ten patients required free bone fragment removal, followed by bone cement packing. The final stage involved internal fixation and wound repair with a free anterolateral thigh flap. Clinical and imaging results were retrospectively analysed. The repair time ranged 1-7 days. All flaps survived. Two patients experienced wound infection, and one developed severe bone infection 3 months after three-stage bone graft surgery. Autologous cancellous bone grafting was performed on 10 patients with bone defects 6 weeks after surgery. Bone union was universally achieved after 1 year. This method proved safe and effective, successfully repairing Grade III open fractures of the lower extremity 1-7 days post-treatment.

Splint versus no splint after ankle fracture fixation; Results from the multi-centre post-operative ankle splint trial (PAST)

BACKGROUND

There is considerable variation in the rehabilitation of ankle fractures. Ankle fractures treated surgically are often immobilized or splinted in the early post-operative period, despite the lack of robust evidence supporting this intervention. Thus, this randomized controlled trial aims to investigate the anecdote that splinting reduces pain and oedema.

METHODS

A prospective multi-centre randomized controlled trial was performed in three trauma centres. Eligible patients were over 18 years of age that have sustained an isolated unilateral ankle fracture requiring surgical intervention. Patients were randomized to two groups receiving either; a plaster of Paris posterior back-slab or compressive bandage dressing. The post-operative rehabilitation protocol was standardized across both groups. Baseline demographics and fracture characteristics and classifications were analysed. Primary outcomes included; oedema measured by the figure-of-eight-20 technique and pain at multiple time points. Secondary outcomes included; the American Orthopaedic Foot and Ankle Society (AOFAS) score, satisfaction, unplanned emergency room (ER) visits and complications.

RESULTS

A total of 104 comparable participants were included; 54 in the non-splint group and 50 in the splint group. There was no significance difference in ankle oedema, ankle oedema compared to contralateral ankle and pain scores between the two groups (P = 0.56, P = 0.25, P = 0.39 respectively). Patient satisfaction was higher in the early postoperative period in the non-splint group (P = 0.016). The AOFAS score was not significantly different across any time point (P = 0.534). In the splint group, there was a 46% rate of splint-related complaints and complications. Unplanned ER visits occurred in 46% of the splint group and 7.4% of the non-splint group (P < 0.001). There were 2 wound infections, 1 non-union and 1 deep vein thrombosis in the splint group. There was 1 wound infection and 1 deep vein thrombosis in the no-splint group (P = 0.481) CONCLUSION: The routine use of a splint does not add any perceivable benefit to the postoperative course of an ankle fracture fixation, particularly in the reduction of oedema and postoperative pain. Another key finding is that the absence of a splint does not appear to result in higher complication rates, instead leads to higher unplanned ER visits and lower early satisfaction rates.

Perioperative considerations for patients undergoing surgical stabilization of rib fractures: A narrative review

Surgical stabilization of rib fractures (SSRF) has become an increasingly common management strategy for traumatic rib fractures. Although historically managed with supportive care, patients with multiple rib fractures and flail chest increasingly undergo SSRF, and so the anesthesiologist must be well-versed in the perioperative management and pain control for these patients, as controlling pain in this population is associated with decreased length of stay and improved outcomes. There are multiple modalities that can be used for both pain control and as part of the anesthetic plan in patients undergoing SSRF. This narrative review provides a comprehensive summary of anesthetic considerations for surgical rib fracture patients, covering the preoperative, intraoperative, and postoperative periods. We describe an approach to the assessment of high-risk patients, analgesic and anesthetic techniques including emerging techniques within locoregional anesthesia, ventilation strategies, and potential complications. This review also identifies areas where additional research is needed to ensure optimal anesthetic management for patients undergoing SSRF.

[Conservative treatment of distal radial fractures]

OBJECTIVE

Distal fracture of the radius is common in all age groups. Under careful consideration of individual indications and contraindications, conservative treatment with reduction and immobilization can have significant advantages over the frequently applied surgical approach, particularly in older patients.

THERAPEUTIC GOAL

Immobilization after closed reduction enables satisfactory wrist function to be achieved according to individual patient expectations.

INDICATIONS

A. Patients with a. significant comorbidities, b. high surgical risk from an anesthesiology perspective (ASA > 3), c. low functional requirements, d. low cosmetic expectations regarding residual visible deformity. B. Young patients with an extension fracture and additional a. < 10° dorsal tilt in the case of extraarticular fractures after closed reduction, b. < 5 mm radial shortening after closed reduction, c. < 2 mm intraarticular displacement after closed reduction.

CONTRAINDICATIONS

A. Patient age < 65 years with an extension fracture and additional a. > 10° dorsal tilt in the case of extraarticular fractures after closed reduction, b. > 5 mm radial shortening after closed reduction, c. > 2 mm intraarticular displacement after closed reduction. B. Flexion fracture for which ligamentotaxis for closed reduction is not possible. C. Open distal radial fracture. D. Fracture dislocations. E. Impairments of peripheral circulation, motor or sensory function of the hand after reduction.

TECHNIQUE

After puncturing the fracture hematoma and infiltrating the fracture gap with local anesthetic, the forearm is suspended using Chinese finger traps on the thumb and middle finger. Constant traction in the longitudinal axis of the forearm is ensured by a weight applied via a wide cushioned cuff to the distal upper arm. Reduction then is enabled with the additional reductive effect of ligamentotaxis. After minimal cushioning of the forearm with cotton wool and crepe bandage, a dorsal gypsum longuette is applied. After the plaster bandage has hardened, peripheral circulation, motor function, and sensitivity are checked. The reduction is controlled by X‑ray and documented.

POSTPROCEDURAL MANAGEMENT

A. General procedures to reduce swelling; sufficient analgesics should be prescribed. B. The circular plaster cast is applied once swelling has subsided sufficiently, generally after 2-3 days. C. The duration of cast wearing should be planned at 5 weeks.

RESULTS

A total of 73 patients (55 women and 18 men) aged 65-88 years were followed up for 12 months to investigate functional outcomes after surgical and conservative therapy. While surgical patients had better functional scores up to 12 weeks after treatment begin, there was no longer a significant difference in the 6‑ and 12-month follow-up results. The measured grip strength was consistently better in the surgically treated group. Clinically visible deformities were present in 78% of the conservatively treated patients; however, the patients were satisfied with the functional or cosmetic results. No deformities were seen in the surgically treated patients. All fractures were completely healed after 6 months. The rate of complications was significantly higher in the surgery group, with 13 complications compared to 5 in the conservative treatment group.

Clinical and radiographic outcomes after paediatric supracondylar humeral fractures treated with combined intramedullary and lateral wire fixation: our experience in fifty-one cases

PURPOSE

Displaced supracondylar humerus fractures in children are known for their high rate of complications and require urgent surgical treatment. Basically, there are two methods of fracture fixation: the lateral pin technique and the crossed pin technique. However, the best technique remains debated. The aim of this study was to evaluate the clinical and radiographic outcomes of our method of fixation using combined intramedullary and lateral wires for treatment of displaced supracondylar humeral fractures in paediatric patients.

METHOD

Fifty-one paediatric patients were treated for displaced supracondylar humeral fractures. The method of fracture fixation used consists of two Kirschner wires inserted one intramedullary and the other laterally. Clinical and radiographic outcomes were assessed at last follow-up.

RESULTS

According to Gartland's classification, 17 fractures (33%) were type 2 and 34 (67%) were type 3. The mean follow-up period was 7.8 months. Functional outcome according to Flynn's criteria was satisfactory in all cases with 92% graded as excellent or good. Cosmetic outcome according to Flynn's criteria was satisfactory in all cases. Radiologically, at last follow-up, the mean Baumann angle was 69° (63-82°) and the mean lateral capitellohumeral angle was 41° (32-50°).

CONCLUSION

Patients managed with combined intramedullary and lateral wires experience satisfactory results. Moreover, this technique, without risk for the ulnar nerve, can be interesting in the treatment of infrafossal fractures and fractures with anterior displacement.

Comparison of temporary external and percutaneous k-wire fixations for treatment of ankle fracture-dislocations

PURPOSE

Ankle fracture-dislocations are among the most severe injuries, and the use of an external fixator as a recommended fixation method has some disadvantages. The aim of this study was to compare the clinical outcomes and complication rates of external and K-wire fixations in the treatment of ankle fracture dislocations.

METHODS

A total of 67 patients with ankle fracture-dislocations requiring temporary external or percutaneous K-wire fixation were included. The exclusion criteria were pilon fractures, open fractures, and those who required acute open reduction internal fixation (ORIF). The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, a 10-point visual analog scale (VAS) score (range 0-10), and complications before and after the definitive surgery were recorded.

RESULTS

A significant difference between the two groups was not observed for age, sex, affected side, fracture type, smoking status, or diabetes. The average AOFAS scores were 83.2 and 83.3, the median VAS scores were 3 and 3, and the complication rates were 32.4% and 6.7% in the external and K-wire fixation groups, respectively (p = 0.010). However, skin necrosis, re-dislocation of the ankle, surgical wound infection, and posttraumatic ankle osteoarthritis frequency were not significantly different between the groups, except for pin-sites infection (p = 0.036).

CONCLUSION

Ankle fracture-dislocations using percutaneous k-wire fixation showed a low rate of complications and favorable clinical outcomes. This method could be a good alternative treatment option for ankle fracture-dislocations.

Factor structure of the Oxford Shoulder Score: secondary analyses of the UK FROST and PROFHER trial populations

AIMS

Frozen shoulder and proximal humeral fracture can cause pain, stiffness and loss of function. The impact of these symptoms on patients can be measured using the comprehensively validated, 12-item Oxford Shoulder Score (OSS). Evidence suggests that pain and function may have a differential impact on patients' experience of shoulder conditions, and this may be important for clinical management. We therefore explored the factor structure of the OSS within the UK FROST and PROFHER trial populations.

METHODS

We performed exploratory factor analysis (EFA), followed by confirmatory factor analysis (CFA), on baseline UK FROST data from 490 of the 503 trial participants. Data at 6 months post-randomisation were used for 228 of the 250 participants for the PROFHER trial.

RESULTS

UK FROST factor extraction results, using Velicer's Minimum Average Partial and Horn's Parallel Analysis tests, suggested a unifactorial solution, but two factors were weakly indicated by the less reliable 'Kaiser's eigenvalue > 1' and scree tests. We explored this further using EFA. Eight items (2 to 7, 9 and 10) loaded onto a 'Function' factor, three on a 'Pain' factor (1, 8 and 12) and item 11 cross-loaded. However, one- and two-factor models were rejected in CFA. Factor extraction of PROFHER data at 6 months demonstrated a single first-order factor solution, which was also subsequently rejected in CFA.

CONCLUSION

Insufficient evidence was found, within the constraints of the data available, to support the use of 'Pain' and 'Function' sub-scales of the OSS in either patient population.

Surgery with locking plate or hemiarthroplasty versus nonoperative treatment of 3-4-part proximal humerus fractures in older patients (NITEP): An open-label randomized trial

BACKGROUND

Proximal humerus fractures (PHFs) are common fractures, especially in older female patients. These fractures are commonly treated surgically, but the consensus on the best treatment is still lacking.

METHODS AND FINDINGS

The primary aim of this multicenter, randomized 3-arm superiority, open-label trial was to assess the results of nonoperative treatment and operative treatment either with locking plate (LP) or hemiarthroplasty (HA) of 3- and 4-part PHF with the primary outcome of Disabilities of the Arm, Shoulder, and Hand (DASH) at 2-year follow-up. Between February 2011 and December 2019, 160 patients 60 years and older with 3- and 4-part PHFs were randomly assigned in 1:1:1 fashion in block size of 10 to undergo nonoperative treatment (control) or operative intervention with LP or HA. In total, 54 patients were assigned to the nonoperative group, 52 to the LP group, and 54 to the HA group. Five patients assigned to the LP group were reassigned to the HA group perioperatively due to high comminution, and all of these patients had 4-part fractures. In the intention-to-treat analysis, there were 42 patients in the nonoperative group, 44 in the LP group, and 37 in the HA group. The outcome assessors were blinded to the study group. The mean DASH score at 2-year follow-up was 30.4 (standard error (SE) 3.25), 31.4 (SE 3.11), and 26.6 (SE 3.23) points for the nonoperative, LP, and HA groups, respectively. At 2 years, the between-group differences were 1.07 points (95% CI [-9.5,11.7]; p = 0.97) between nonoperative and LP, 3.78 points (95% CI [-7.0,14.6]; p = 0.69) between nonoperative and HA, and 4.84 points (95% CI [-5.7,15.4]; p = 0.53) between LP and HA. No significant differences in primary or secondary outcomes were seen in stratified age groups (60 to 70 years and 71 years and over). At 2 years, we found 30 complications (3/52, 5.8% in nonoperative; 22/49, 45% in LP; and 5/49, 10% in HA group, p = 0.0004) and 16 severe pain-related adverse events. There was a revision rate of 22% in the LP group. The limitation of the trial was that the recruitment period was longer than expected due to a high number of exclusions after the assessment of eligibility and a larger exclusion rate than anticipated toward the end of the trial. Therefore, the trial was ended prematurely.

CONCLUSIONS

In this study, no benefit was observed between operative treatment with LP or HA and nonoperative treatment in displaced 3- and 4-part PHFs in patients aged 60 years and older. Further, we observed a high rate of complications related to operative treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01246167.

Technique for facilitating closed reduction of difficult flexion type supracondylar humeral fracture in children

The displaced flexion type supracondylar humeral fractures (SCHF) are inherently unstable and there is great intraoperative difficulty in obtaining and maintaining the fracture reduction by closed means. We introduced a technique for closed reduction and K-wires pinning of displaced flexion type SCHF. Fourteen patients with flexion-type SCHF (9 boys and 5 girls) underwent a reduction technique using a construct of three K-wires. The proximal wire was used for rotational control of the proximal fragment and the two distal wires were used for correction of the flexion and rotational deformity of the distal fragment. The patient's mean age was 7 (6-11) years. Results were evaluated by the anterior humeral line, Baumann's angle, carrying angle radiographically and Flynn's criteria clinically. The mean time for the union was 4.8 (4-6)  weeks. The anterior humeral line passed through the middle one-third of the capitulum in 12 patients and the anterior third in two patients. The mean Baumann's angle was 19.60 ± 3.8 and the mean carrying angle was 14.21 ± 3.04. We reported no cases of failed closed reduction. The median operation time in this study was 30 (25-40)  min. The mean number of C-arm images was 33.5 ± 5.23. According to Flynn's criteria; 10 cases (71.4%) were excellent and 4 (28.6%) were good. This technique can achieve the accurate reduction of flexion type SCHF and avoid the complications of both repeated closed reduction trials and open reduction. Level of Evidence: Level IV, case series.

Perfecting the Outcome of Nasal Bone Fracture in the Pediatric Population With a Navigation System

BACKGROUND

The trend of using navigation systems for treating facial bone fractures is increasing. Nevertheless, any detailed recommendation on using a navigation system to treat nasal bone fracture has never been discussed. Plastic surgeons are prone to do closed reduction of nasal bone fractures with remnant posttraumatic edema in the pediatric population. This study hypothesized that the navigation system benefits this population's treatment of nasal bone fractures.

METHODS

The authors evaluated the medical records, plain x-ray, and facial computed tomography scans of 44 pediatric patients (below the age of 18) with nasal bone fractures treated with a closed reduction from May 2021 to December 2022. Preoperative and postoperative computed tomography scan were used to assess the outcome.

RESULTS

The average age for 44 pediatric nasal bone fracture patients was 10. Fifteen were female, while males were 29. All cases were successfully corrected clinically and radiologically without noticeable complications.

CONCLUSIONS

Using navigation systems to correct nasal bone fractures provides additional benefits for the pediatric population. This technique is especially useful if the fracture is located at the junction between the nasal bone and nasal process of the maxilla and is combined with concurrent old nasal bone fractures.

Early complications of percutaneous K-wire fixation in pediatric distal radius fractures-a prospective cohort study

INTRODUCTION

Distal radius fractures (DRF) are the most common pediatric fractures, but the current evidence for management remains inconclusive. Closed reduction and percutaneous pinning (CRPP) provide excellent stability but are not complications-free. Therefore, a thorough evaluation of their adverse events is necessary to provide reliable information on risks and benefits in different clinical scenarios. The current literature lacks studies conducted with rigorous grading systems and uniform follow-up protocols on this topic. This prospective cohort study used a validated grading scheme to analyze complications associated with CRPP in an unselected pediatric population with displaced, unstable distal third radius fractures.

MATERIALS AND METHODS

One hundred and nineteen DRFs (one hundred and sixteen patients) treated with CRPP were enrolled in the study. All patients were followed 4 weeks, 5 weeks, 3 months, and 6 months after the surgery. The same protocol, comprising structured history, physical and radiological assessment, was used throughout the study. All data were prospectively abstracted. The Clavien-Dindo-Sink grading system was used to assess the complications and the Dahl score to evaluate the pin sites.

RESULTS

Forty-two wrists (35,3%) had CDS grade I or II complications, and two (1,7%) had a grade III complication. The general complication rate for the study group was 37% (44 complications). Two patients required repeated surgery-deep bone pin-track infection treated with the Masquelet technique and surgical removal of a migrated pin. Among minor complications, pin-site inflammations were the most common-40 wrists (33,6%).

CONCLUSIONS

The CRPP is a safe treatment method for DRF in pediatric patients, with a low major complication rate. However, minor adverse events are frequent and can significantly burden the patient's postoperative well-being. The application of rigorous definitions and grading systems should not only lead to the obtainment of high-quality data but also to higher awareness of possible pin tract infections and therefore allow for better therapeutic decisions.

Minimally invasive plate osteosynthesis for displaced midshaft clavicle fractures: An indirect reduction using joystick technique

BACKGROUND

A minimally invasive plate osteosynthesis (MIPO) technique has become increasingly popular in long bone fracture fixation as it could eliminate postoperative complications. However, the most challenging aspect of employing the MIPO for midshaft clavicle fractures among general orthopedic surgeons is the technically demanding that indirect reduction is typically a closed maneuver.

METHODS

We present a consecutive series of patients with displaced midshaft clavicle fractures undergoing clavicular fixation using the MIPO technique between January 2017 and October 2019. The joystick technique was used to obtain anatomical reduction. Clinical outcomes were assessed using the Constant-Murley and the American shoulder and elbow surgeons shoulder scores.

RESULTS

Thirty patients with a mean age of 42.44 years were included. The functional shoulder scores showed no disabilities compared with those of a healthy population. No major complications requiring re-operation were noted, and all fractures were completely healed with an average time of 12.53 weeks.

CONCLUSION

This study demonstrated that facilitating the MIPO for midshaft clavicle fractures using simple operative devices and techniques was possible. The joystick technique with the use of an external fixator for temporary stabilization is a safe and effective method that can be added to achieve anatomical alignment with the fracture site unexposed. This technique could be performed either in a fresh fracture or a delayed case with failed conservative treatment.

Racial Disparities in the Operative Management of Orthopedic Trauma: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this study was to investigate if race is associated with the likelihood of operative management of acute fractures.

METHODS

A systematic review of the literature was performed using the PubMed, EMBASE, and Cochrane databases to identify studies associated with social disparities and acute orthopedic trauma. Peer-reviewed studies commenting on social disparities and the decision to pursue operative or non-operative management of acute fractures were identified for detailed review. Study characteristics and odds ratios were extracted from each article. The Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed. A quality analysis of the data was also performed.

RESULTS

In total, 13 studies were identified and 8 were included in the meta-analysis totaling 743,846 fractures. Hip, distal radius, pelvic, tibial plateau, clavicle, femoral neck, and femoral shaft fractures were represented in this patient population. The meta-analysis demonstrated that White race is associated with a higher likelihood of operative intervention compared to all other races pooled together (odds ratio, 1.31; 95% confidence interval 1.16 to 1.47; p < .0001) as well as Black race (odds ratio 1.39; 95% confidence interval 1.12 to 1.72; p = .0025).

CONCLUSIONS

Non-White race and Black race are associated with a lower likelihood of receiving surgical management of acute orthopedic trauma. Surgeons and health systems should be aware of these inequities and consider strategies to mitigate bias and ensure all patients receive appropriate and timely care regardless of race.

Pediatric Panfacial Fractures

Pediatric panfacial trauma is a rare occurrence with poorly understood implications for the growing child. Treatment algorithms largely mirror adult panfacial protocols with notable exceptions including augmented healing and remodeling capacities that favor nonoperative management, limited exposure to avoid disruption of osseous suture and synchondroses growth centers, and creative fracture fixation techniques in the setting of an immature craniomaxillofacial skeleton. The following article provides a review of our institutional philosophy in the management of these challenges injuries with important anatomic, epidemiologic, examination, sequencing, and postoperative considerations.

The 50 most influential publications in clavicle fractures

PURPOSE

Clavicle fractures are among the most common orthopedic fractures, and treatment methods, operative versus nonoperative, have been a point of contention. The purpose of this study was to evaluate the 50 most influential articles regarding clavicle fractures to better understand past focuses of research and to identify any gaps in knowledge.

METHODS

A review of the most cited articles related to clavicle fractures was conducted using Web of Science database. A search was conducted in April 2022 by one trained researcher. Two independent researchers evaluated each article based on relevance to clavicle fracture.

RESULTS

The mean number of citations was 179.1, ranging from 576 to 81 citations, and collectively cited 8954 times. The decade from 2000 to 2009 contributed the greatest portion of articles, with only a small portion coming from before 1980. The Journal of Bone and Joint Surgery-American Volume contributed the greatest number of articles (20%). The majority of the articles were therapeutic (n = 37) and focused on treatment and outcome (n = 32). Most of the clinically focused articles had a level of evidence of IV (n = 26).

CONCLUSION

There is an increased influence of recent articles focused on clavicle fracture and management, due to the idea that conventional nonoperative treatment has a high rate of nonunion. Many of the most influential studies evaluate the outcomes of various treatments. Many of these studies, however, are lower levels of evidence, leaving a paucity of high level of evidence articles to support these conclusions.

LEVEL OF EVIDENCE

V.

The absence of immediate stimulation delays bone healing

AIM

Secondary bone healing requires an adequate level of mechanical stimulation expressed by the extent of interfragmentary motion in the fracture. However, there is no consensus about when the mechanical stimulation should be initiated to ensure a timely healing response. Therefore, this study aims to compare the effect of the immediate and delayed application of mechanical stimulation in a large animal model.

METHODS

Twelve Swiss White Alpine sheep underwent partial osteotomy of a tibia that was stabilised with an active fixator inducing well-controlled mechanical stimulation. Animals were randomly assigned into two groups with different stimulation protocols. The immediate group received daily stimulation (1000 cycles/day) from the first day post-operation, while in the delayed group, stimulation began only on the 22nd day post-operation. Healing progression was evaluated daily by measuring the in vivo stiffness of the repair tissue and by quantifying callus area on weekly radiographs. All animals were euthanised five weeks post-op. Post-mortem callus volume was determined from high-resolution computer tomography (HRCT).

RESULTS

Fracture stiffness (p < 0.05) and callus area (p < 0.01) were significantly larger for the immediate group compared to the delayed stimulation group. In addition, the callus volume measured on the post-mortem HRCT showed 319 % greater callus volume for the immediate stimulation group (p < 0.01).

CONCLUSIONS

This study demonstrates that a delay in the onset of mechanical stimulation retards fracture callus development and that mechanical stimulation already applied in the early post-op phase promotes bone healing.

Why treatment of proximal humeral fractures remains unresolved despite randomized trials

Most proximal humeral fractures can be treated nonoperatively, but there are specific indications to perform surgery for some of these fractures. Optimal treatment remains subject to debate, since no consensus has been reached for the best therapy for these fractures. This review provides an overview of randomized controlled trials (RCTs) comparing treatment for proximal humeral fractures. Fourteen RCTs comparing different operative and nonoperative types of treatment for PHF are included. Different RCTs comparing the same interventions for PHF have drawn different conclusions. It also highlights reasons why consensus has not been reached based on these data, and how this could be addressed in future research. Previous RCTs have included different patient groups and fracture patterns, may have been prone to selection bias, often were underpowered for subgroup analysis, and showed inconsistency in the outcome measures used. Based on this, and appreciating that treatment may be tailored to specific fracture types and patient characteristic like age, a better way to move forward could be to use a (international) multicenter prospective cohort study. Such a registry-type study should use accurate patient selection and enrollment, well-defined fracture patterns, standardized surgical techniques performed according to the preferences of the surgeon, and with a standardized follow-up.

Simultaneous ipsilateral floating hip and knee: the double floating extremity-a systematic review and proposal of a treatment algorithm

PURPOSE

To systematically review the currently available existing evidence related to the presentation and management of simultaneous floating hip and knee injuries to identify injury characteristics, treatment strategies, and complications.

METHODS

Data sources: Relevant articles were identified by searching Medline, PubMed, and Google Scholar databases with no language restrictions. Manual searches of other relevant databases (SciELO and grey literature databases) and reference lists of primary articles found from initial searches were also conducted.

STUDY SELECTION

All types of study designs published from January 1st, 2000 to October 1st, 2022 involving skeletally mature patients with simultaneous floating hip and knee injuries were included.

DATA EXTRACTION

Basic information and specific injury-related information were collected.

RESULTS

Eight case reports were included. No study adequately reported the case with sufficient detail to allow other investigators to make inferences, nor was the result properly calculated, nor was the follow-up considered adequate for adequate functional assessment to occur in 80% of the studies.

CONCLUSION

The exact treatment strategy and the follow-up time are not uniform across the included studies; therefore, they are not sufficient to adequately recommend surgical approach, timing of fixation, and fixation method. Our findings warrant the need for better documentation and reporting information about the mode of treatment of simultaneous floating hip and knee injuries.

[Exploration and consideration on establishing a core outcome set of Traditional Chinese Medicine clinical trials in distal radius fracture]

There are inconsistencies in treatment outcomes, measurement instruments, and criteria for assessing clinical effectiveness in studies related to distal radius fractures (DRF), resulting in potential biases and failing to provide high-quality clinical evidence. To address these challenges, international researchers have reached a consensus on developing the core outcome indicator set for distal radius fractures(COS-DRF). However, it's important to note that the existing COS-DRF framework could not reflect the unique characteristics of Traditional Chinese Medicine (TCM) treatment. Currently, there are no established standards for treatment outcomes and measurement instruments specific to TCM clinical research, nor has a COS-DRF been established for TCM clinical studies in China. In light of these gaps, our research team aims to construct a core set of treatment outcomes for TCM clinical research on distal radius fractures. This involves compiling a comprehensive list of treatment outcomes and measurement instruments, initially derived from a thorough literature review and expert consensus, which will then undergo further refinement and updates based on real-world clinical experiences, incorporating feedback from 2 to 3 rounds of expert consensus or Delphi questionnaire surveys. Our goal is to establish a COS-DRF or CMS-DRF that aligns with the principles and practices of TCM, and provide high-quality evidence for clinical practice.

[A retrospective study on manual reduction combined with Chinese Orthopaedic ankle external fixator in the treatment of trimalleolar fracture]

OBJECTIVE

To evaluate the needle puncture safety and clinical efficacy of manual reduction combined with external fixation of ankle frame in the treatment of trimalleolar fracture under the guidance of Chinese Osteosynthesis (CO) theory.

METHODS

The clinical data of 118 patients with trimalleolar fractures admitted from December 2010 to December 2021 were retrospectively analyzed. Fifty-three patients were treated with manual reduction combined with external fixation of ankle frame(observation group). Sixty-five patients were treated with open reduction and internal fixation with plate and screws(control group). The operation time, hospitalization days, non-weight-bearing time of the affected limb, clinical healing time of fracture, incidence of complications, visual analogue scale (VAS) before and 1 month after operation, and American Orthopedic Foot and Ankle Society(AOFAS) score of ankle joint before and 1 year after operation were compared between the two groups.

RESULTS

Patients in both groups were followed up for more than 1 year. All patients were followed up, and the duration ranged from 14 to 70 months, with an average of(35.28±14.66) months. There were statistically significant in operation time, hospitalization days, non-load-bearing time of affected limbs, clinical healing time of fractures and VAS score one month after operation between the two groups. One month after operation, the VAS score of the observation group was lower than that of the control group(t=3.343, P=0.001). The operation time of the observation group was significantly shorter than that of the control group(t=9.091, P=0.000). The hospitalization days in the observation group were significantly less than those in the control group(t=5.034, P=0.000). The non-load-bearing time of the affected limb in the observation group was significantly shorter than that in the control group(t=11.960, P=0.000). The clinical healing time of fracture in the observation group was significantly shorter than that in the control group(t=4.007, P=0.000). There was no significant difference in AOFAS score between the two groups one year after operation(t=0.417, P=0.678). In the observation group, there were 2 cases of pinhole infection and 3 cases of loss of reduction less than 2 mm. There were 3 cases of surgical incision infection in the control group. There was no significant difference in the incidence of complications between the two groups(χ2=0.446, P=0.504).

CONCLUSION

Manual reduction combined with external fixation is safe and effective in the treatment of trimalleolar fracture under the guidance of CO theory, and the function of ankle joint recovers well after operation. This therapy has good clinical value.