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Objective: Ankle fractures are often combined with syndesmotic instability, requiring reduction and stabilization. However, the optimal level for syndesmotic screw positioning remains unclear. This study aims to evaluate the effect of different syndesmotic screw insertion levels on postoperative clinical outcomes and determine whether an optimal level exists. Methods: This retrospective study included data from 43 adult patients with acute closed ankle fractures combined with intraoperative evidence of unstable syndesmotic injuries who underwent open reduction internal fixation from January 1, 2017 to March 1, 2018 according to the inclusion and exclusion criteria. All 43 patients were divided into three groups based on the syndesmotic screw placement level: trans‐syndesmotic group: screw level of 2–3 cm; inferior‐syndesmotic group: screw level <2 cm; and supra‐syndesmotic group: screw level >3 cm. Clinical outcomes were measured at the final follow‐up, including the American Orthopedic Foot and Ankle Society (AOFAS) ankle‐hindfoot score, Olerud–Molander Ankle Score (OMAS), short‐form 36‐item questionnaire (SF‐36), visual analogue scale (VAS) score and restrictions in ankle range of motion (ROM). The relationships between screw placement level and clinical outcomes were analyzed with the Kruskal–Wallis H‐test and Spearman correlation analysis. Results: The median follow‐up duration was 15 months (range, 10–22 months). No patients developed fracture nonunion or malunion or experienced hardware failure. The outcome scoring systems showed an overall score for the entire group of 94.91 points for the AOFAS ankle‐hindfoot score, 83.14 for the OMAS, 96.65 for the SF‐36, 1.77 for the VAS, 9.14° for the restrictions in dorsiflexion, and 1.30° for the restrictions in plantarflexion. There were no significant differences among three groups in clinical outcomes (P > 0.05). Neither the AOFAS score nor OMAS had significant correlations with screw insertion level (P = 0.825 and P = 0.585, respectively). No postoperative arthritis or widening of the tibiofibular space was observed at the final follow‐up. Conclusion: Different syndesmotic screw placement levels appear not to affect the clinical outcomes of ankle fractures with syndesmotic instability. No optimal level was observed in this study. Our findings suggest other clinically acceptable options apart from syndesmotic screw placement 2–3 cm above the ankle. [ABSTRACT FROM AUTHOR]

Congenital pain insensitivity is a rare genetic disease and its clinical manifestations are many. In orthopaedics, common complications of this disease include painless fracture and Charcot's arthropathy. We followed up a case of multiple fractures of the lower extremity in two years, during which time he came to the clinic for five painless fractures of the lower extremity in a total of six parts. A mutation was found on the NTKRI gene (chr1:156813923(hg19), NM_001007792.1: c.1221938C > T). We have developed a combination of surgery and conservative treatments for his condition, focusing on the mental state of the child and considering comprehensive treatment to be the best option for this type of patient. Occult fractures caused by pain insensitivity are often treated only as fractures, however their complications require routine examination and cleaning, suitable protective shoes, splint fixation, stretching, guided exercise planning, and early treatment of injuries. Due to the risk of fracture in the future, it is important that parents pay attention to the behavior and psychology of the child, such as not letting the child participate in exercise with a risk of injury, protective measures while playing, engaging in psychological counseling, and inducing interest in mental activity. These interventions will play a very important role in preventing the recurrence of fracture. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this retrospective study was to determine the incidence of fibular fractures as an associated injury in tibial plateau fractures according to CT scan. We also attempt to introduce a new morphological sub‐classification on this associated injury and to analyze the correlation between this classification and tibial plateau fractures. Methods: We selected cases with fibular fractures from all the tibial plateau fracture patients. The cases were further divided into 2 groups: unicondylar group and bicondylar group. On the basis of our new classification system of fibular fracture, all the included cases were divided into 5 subgroups. Results: Finally, a total of 150 cases associated with fibular fractures in 502 tibial plateau fracture cases were identified from our institution database. The incidence of fibular head fracture in tibial plateau fractures was 29.88% (150/502). Seventy‐one cases (47.3%) were involved one condyle, and 79 cases (52.7%) involved both. It shows significant difference in the subgroup of avulsion fracture with horizontal fracture line (Type A) which is ratio of 16.9% in unicondylar group and 1.27% in bicondylar group. Conclusion: A new classification of this associated injury describing the morphology of the fracture fragments may improve operative planning. [ABSTRACT FROM AUTHOR]

Instead of extensive dissection of soft tissue around the fracture site, percutaneous techniques have unique advantages in managing displaced fragments, including preservation of soft tissues, less blood loss, lower risk of complications, and earlier functional rehabilitation. However, there are few systematic reviews on the effects of percutaneous reduction and internal fixation (PRIF) for tibial plateau fractures. A systematic search of Cochrane, EMBASE, and MEDLINE databases was performed for all publicly available data in March 2017 regarding the use of PRIF in treating monocondylar tibial plateau fractures. Basic information of included articles, surgical information, clinical outcomes, and concomitant soft tissue injuries were collected for analysis. Finally, a total of 20 articles including 561 patients were retrieved. Traffic accident was the most common cause of injury. Percutaneous techniques using bone tamp reduction were described in all studies. The majority (≥85%) of patients were classified as excellent or good according to clinical and radiological Rasmussen scores. The overall complication rate was 6.6%, with loss of reduction the most frequent complication with an incidence of 2.4%. This systematic review indicated that PRIF was an optimal alternative that physicians should consider for the treatment of monocondylar tibial plateau fractures. [ABSTRACT FROM AUTHOR]

Tibial cortex transverse transport (TTT) surgery is an extension of the Ilizarov technique. Based on the law of tension‐stress, its primary function is to rebuild microcirculation which can relieve ischemic symptoms and promote wound healing. It has received more and more scholars' attention and has experienced a series of changes for 20 years since it entered PR China. The mechanisms involved have gradually become clear, such as the reconstruction of the polarization balance of macrophages, the promotion of vascular tissue regeneration, and the mobilization and regulation of bone marrow‐derived stem cells. TTT technique is mainly used in the treatment of chronic ischemic diseases of the lower extremities. It has recently been successfully used in the treatment of primary lymphedema of the lower extremities. A series of improvements have been made in the external fixator's style, the size of skin incision and osteotomy, and distraction method. For example, the annular external fixator has been redesigned as a unilateral external fixator, and accordion technology has been introduced. For distraction methods after surgery, there was no uniform standard in the past. The technique can also be used in combination with other treatments to achieve better effects, such as interventional therapy, negative pressure sealed drainage, 3D printing technology, traditional Chinese medicine. Nevertheless, the surgery may bring some complications, such as secondary fracture, nail infection, skin necrosis at the surgical site, etc. Reports of complications and doubts about the technique have made the TTT technique controversial. In 2020, the relevant expert consensus was published with treatment and management principles, which might guide the better application and development of this technique. [ABSTRACT FROM AUTHOR]

Objective: Open tibial fractures are frequently encountered in high‐energy traumas and can result in significant complications such as nonunion, osteomyelitis, and even amputation. Among open tibial fractures, Gustilo type IIIC cases are particularly challenging due to the concomitant occurrence of neurovascular injuries and soft tissue defects. This study aimed to assess factors that affect union time and complications in Gustilo IIIC tibial fractures. Methods: Patients who presented at our center with IIIC open tibial fractures from January 2000 to October 2020 were eligible for this retrospective analysis. Patient demographics, fracture characteristics, and the timing, number, and type of surgical intervention were documented. Outcomes of interest included union time, occurrence of osteomyelitis, and amputation. We performed univariate analyses including chi‐squared test, Fischer's exact test, analysis of variance, and Kruskal–Wallis test based on the normality of the data and multivariate analyses including Cox proportional hazards model and logistic regression analyses. Results: Fifty‐eight patients were enrolled and grouped by fracture healing time; eight had timely union (13.8%); 27 had late union (46.6%); eight had delayed union (13.8%); three had nonunion (5.2%); and 12 underwent amputation (20.7%). Nine fractures (15.5%) were complicated by osteomyelitis. Union time was prolonged in cases of triple arterial injury, distal third fractures, multiple trauma with injury severity score (ISS) ≥ 16 points, and increased bone defect length. Additionally, a bone gap >50 mm, diabetes mellitus, low body mass index, and triple arterial injury in the lower leg were significant risk factors for amputation. A time from injury to definitive soft tissue coverage of more than 22 days was the major risk factor for osteomyelitis. A scoring system to predict union time was devised and the predicted probability of union within 2 years was stratified based on this score. Conclusion: IIIC tibial fractures involving the distal third of the tibia, fractures with bone defects, triple arterial injury, and multiple trauma with ISS ≥16 points demonstrated delayed union, and an effective prediction system for union time was introduced in this study. Early soft tissue coverage can reduce the risk of osteomyelitis. Finally, diabetes and severe bone and soft tissue defects pose a higher risk of amputation. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the clinical efficacy of internal fixation versus hemiarthroplasty in the treatment of unstable intertrochanteric fractures in the elderly. Methods: A search was conducted in PubMed, Web of Science, Embase, and Cochrane Library databases up to April 2020. The present study compared internal fixation and hemiarthroplasty in the treatment of unstable intertrochanteric fractures in the elderly. RevMan5.3 software provided by the International Cochrane Group was used for the meta‐analysis. To compare the differences in the operation time, intraoperative bleeding, length of hospital stay, superficial infection, Harris hip score, mortality within 1 year, mortality within 2 years, reoperation, incidence of deep venous thrombosis (DVT), partial weight‐bearing time, non‐union, and implant‐related complications between an internal fixation group and an hemiarthroplasty group. Results: A total of 1300 patients were included in nine studies. The results showed that the operation time (MD = −18.09, 95% CI: −27.85–−8.34, P = 0.0003), intraoperative bleeding (MD = −195.31, 95% CI: −244.8–−147.74, P < 0.0001), implant‐related complications (MD = 3.83, 95% CI: 1.74–8.45, P = 0.0008), and partial weight‐bearing time (MD = 17.21, 95% CI: 1.63–32.79, P = 0.03) have statistical significance. However, there is not statistical significance for the Harris hip joint function scale (HHS) (MD = 5.60, 95% CI: −1.13–12.33, P = 0.10), DVT (MD = 1.02, 95% CI: 0.45–2.27, P = 0.97), length of hospital stay (MD = ‐1.08, 95% CI: −2.82–0.66, P = 0.22), superficial Infection (OR = 0.92, 95% CI: 0.43–1.98, P = 0.89), mortality within 1 year (OR = 0.95, 95% CI: 0.61–1.48, P = 0.81), mortality within 2 years (OR = 0.93, 95% CI: 0.61–1.43, P = 0.75), reoperation (MD = 1.80, 95% CI: 0.64–5.04, P = 0.26), and non‐union (OR = 1.20, 95% CI: 0.48–3.03, P = 0.70). The result of the subgroup analysis showed no significant differences between the less than 2 years follow‐up and the 2 years or more follow‐up group. The only difference was for the Harris hip score: the internal fixation group was superior to the hemiarthroplasty group in the less than 2 years subgroup analysis, while there was no difference between the internal fixation group hemiarthroplasty group in the 2 years or more subgroup analysis. Conclusion: Compared with the internal fixation group, those in the hemiarthroplasty group could carry out weight‐bearing training early and implant‐related complications were reduced, but it requires longer operation time and there is greater intraoperative blood loss. There is no difference in mortality, the incidence of DVT, non‐union, HHS, reoperation, length of hospital stay, and superficial infection. Hemiarthroplasty may be a better choice for unstable intertrochanteric fractures in the elderly. [ABSTRACT FROM AUTHOR]

Several modifications of the induced membrane technique (IMT) have been reported, but there is no consensus regarding their results and prognosis. Moreover, most studies have focused on tibial defects; no meta‐analysis of the treatment of femoral defects using the IMT has been reported. This systematic review and meta‐analysis aimed to identify the potential risk factors of post‐procedural complications following the treatment of segmental femoral defects using the IMT. A comprehensive search was performed on the Cochrane Library, EBSCO, EMBASE, Ovid, PubMed, Scopus, and Web of Science databases, using the keywords "femur," "Masquelet technique," and "induced membrane technique." Original articles composed in English, having accessible individual patient data, and reporting more than two cases of bony defect or nonunion of femur or more than five cases of any body part were included. Post‐procedural bone graft infections, final union status, and union time after second‐stage operation were analyzed. Fourteen reports, including 90 patients, were used in this study. External fixation in second‐stage surgery had an odds ratio of 9.267 for post‐procedural bone graft infection (p = 0.047). The odds ratio of post‐procedural bone graft infection and age >65 years for final non‐union status was 51.05 (p = 0.003) and 9.18 (p = 0.042). Shorter union time was related to impregnated antibiotics in the spacer (p = 0.005), transplanting all‐autologous grafts (p = 0.042), and the application of intramedullary nails as the second‐stage fixation method (p = 0.050). The IMT appears to be reasonable and reproducible for femoral segmental bone defects. Several preoperative and surgical factors may affect post‐procedural complications and union time. [ABSTRACT FROM AUTHOR]

Objective: With or without screw stabilization for diastatic syndesmosis in advanced pronation‐external rotation (PE) ankle injuries has not yet been well‐determined. Both techniques were retrospectively compared to investigate the superiority of either of the two. Methods: A retrospective cohort study was carried out. From January 1, 2008, to December 31, 2017, 81 consecutive adult patients (average, 42 years; range, 18–78 years; 44 men and 37 women) with advanced PE ankle injuries (stage 3 or 4 PE type) were treated. After malleolar fractures were internally stabilized with screws and plates, the syndesmotic stability was rechecked by external rotation and hook tests. The necessity of cortical screw insertion to stabilize diastatic syndesmosis was decided by the individual orthopaedic surgeon. Postoperatively, a short leg splint was used for 6 weeks. The syndesmotic screw was removed based on the surgeon's policy. The removal of internal fixation for malleolar fractures was required after 1 year. The outcomes of both approaches were compared clinically, and ankle function was compared using the American Orthopaedic Foot and Ankle Society (AOFAS) score. For statistical comparison, the chi‐square test was used for categorical data and the Mann–Whitney U test was used for numerical data. Results: Seventy‐one patients (average, 40 years; range, 18–78 years; 40 men and 31 women) were followed for at least 1 year (87.7%; average, 2 years; range, 1–11 years). Group 1 (with syndesmotic stabilization) had 22 patients and Group 2 (without syndesmotic stabilization), 49 patients. The union rate in Group 1 patients was 100% (22/22), and in Group 2 patients, 91.8% (45/49; p = 0.17). One deep wound infection occurred in Group 1 patients and two in Group 2 patients. Syndesmosis re‐diastasis occurred in 13.6% (3/22) of Group 1 patients and 30.6% (15/49) of Group 2 patients (p = 0.13). One syndesmotic screw broke at 6 months. Satisfactory ankle function according to the AOFAS score was noted in 86.4% (19/22) of Group 1 patients and 65.3% (32/49) of Group 2 patients (p = 0.07). Conclusion: Insertion of syndesmotic screws to promote ligament healing after internal fixation of malleolar fractures in advanced PE ankle injuries may be reasonable. [ABSTRACT FROM AUTHOR]