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Mandibular fractures are rare in infants, and diagnosis can be easily missed due to the difficulty in obtaining an adequate history and the subtle signs. A high index of suspicion and detailed history taking from the caregiver are mandatory to pick up these cases.There are a plethora of management options that have been reported in dealing with such fractures. They range from conservative management to internal fixation by absorbable plates. While conservative management does not interfere with mandibular growth and teeth development, any surgical intervention can carry this risk. Nevertheless, a severely displaced fracture may need anatomical reduction and fixation to allow early nutrition.This study reports a 3-month-old male infant with a fracture in the mandibular symphysis who underwent reduction of the fracture and circummandibular fixation using immobilisation by an acrylic splint for 4 weeks. His long-term follow-up after 20 months showed adequate dentition with proper healing of the fracture site.

Charcot’s joint is a type of neuro-arthropathy, where asymmetrical damage of the involved joint happens haphazardly, without following any described pattern. We present a rare case of Charcot’s joint involving the knee joint in an adult male following spina bifida. His knee joint was successfully fused after two surgeries. Later, he sustained a fracture through the arthrodesis after a fall, which we managed surgically. The fracture through the knee arthrodesis was managed surgically by an open reduction and internal fixation, using a 14-hole broad low contact dynamic compression locking plate with bone grafting. Union was achieved at the knee arthrodesis site in 6 months. Fracture through a fused knee requires surgical management. Re-arthrodesis was done using a stable fixation. Postoperative rehabilitation should include protected weight bearing with braces and splints until a sound bony union is achieved.

Background: Management of scaphoid nonunions with bone loss varies substantially. Commonly, internal fixation consists of a single headless compression screw. Recently, some authors have reported on the theoretical benefits of dual-screw fixation. We hypothesized that using 2 headless compression screws would impart improved stiffness over a single-screw construct. Methods: Using a cadaveric model, we compared biomechanical characteristics of a single tapered 3.5- to 3.6-mm headless compression screw with 2 tapered 2.5- to 2.8-mm headless compression screws in a scaphoid waist nonunion model. The primary outcome measurement was construct stiffness. Secondary outcome measurements included load at 1 and 2 mm of displacement, load to failure for each specimen, and qualitative assessment of mode of failure. Results: Stiffness during load to failure was not significantly different between single- and double-screw configurations ( P = .8). Load to failure demonstrated no statistically significant difference between single- and double-screw configurations. Using a qualitative assessment, the double-screw construct maintained rotational stability more than the single-screw construct ( P = .029). Conclusions: Single- and double-screw fixation constructs in a cadaveric scaphoid nonunion model demonstrate similar construct stiffness, load to failure, and load to 1- and 2-mm displacement. Modes of failure may differ between constructs and represent an area for further study. The theoretical benefit of dual-screw fixation should be weighed against the morphologic limitations to placing 2 screws in a scaphoid nonunion.

Background There is a need for a novel therapeutic strategy for an earlier prediction of long bone union failure as compared to previous methodologies. This study aimed to determine whether a combination of two diagnostic tools would result in a more accurate diagnosis of delayed union. Methods The inclusion criteria were as follows: patients with tibial shaft fracture who underwent treatment with intramedullary nailing (IMN) as definitive internal fixation (IF). The study included a total of 114 patients with 116 tibial shaft fractures treated with IMN as definitive IF. Radiographic apparent bone gap (RABG) and nonunion risk determination score (NURDS) can be used to predict nonunion. However, this study aimed to determine whether combination of RABG and NURDS could help deduce a more accurate prediction of delayed union. Results The union rate was found to be 85% (99 fractures), the delayed union rate was found to be 15% (17 fractures), and the rate of nonunion requiring additional surgical intervention was estimated to be 4% (5 out of the 17 delayed union cases). Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of RABG were found to be 82.3%, 76.0%, 36.8%, and 96.2%, respectively, when an RABG cutoff value of 5.0 mm was applied to our patient cohort. The sensitivity, specificity, PPV, and NPV of NURDS were found to be 47.1%, 82.0%, 30.8%, and 90.1%, respectively, when a NURDS cutoff value of 8.0% was applied to our patient cohort. When RABG and NURDS were above their respective cutoff values, the sensitivity and PPV were estimated to be 90.0% and 56.3%, respectively. When RABG and NURDS were below their respective cutoff values, the specificity and NPV were estimated to be 90.1% and 98.5%, respectively. Conclusions The combination of RABG and NURDS evaluation immediately after surgery helps surgeons identify patients who are at a high risk of delayed union, facilitating careful monitoring of these patients and consideration of additional treatments.

Unstable ankle fractures are traditionally treated with open reduction and internal fixation. An alternative surgical option is primary tibio-talar-calcaneal fusion. Our aims were to determine the indication, complication rates, and functional outcomes, of tibio-talar-calcaneal nailing when used as the primary treatment of ankle fractures. A multi-database literature search was performed on 14th December 2019 according to PRISMA guidelines. All studies in the English language reporting complications and outcomes involving tibio-talar-calcaneal nailing for primary treatment of ankle fractures were included. Ten studies with 252 ankle fractures were included. Mean age of patients was 75.5 (32-101) years. Mean follow-up duration was 79 weeks (36 – 104 weeks). Surgical site infection occurred in 11.2% (95% CI 6.3% - 19%) of patients, implant failure occurred in 8.1% (95% CI 5% - 12.8%) of patients, and unplanned return to theatre occurred in 10.1% (95% CI 6.1% - 16.2%) of patients. There were no cases of wound dehiscence. All-cause mortality rate at the end of follow-up was 26.6% (95% CI 19.7% - 34.9%). Average reduction in Olerud-Molander Ankle Score after surgery was 7.9 points (5.0-11.8). Eighty-one point five percent (81.5%) (95%CI: 67.4% - 90.4%) of patients were able to return to similar pre-operative mobility aid after surgery. Tibio-talar-calcaneal nailing is an alternative procedure for patients who have sustained fractures unsuitable for non-operative management, but have low functional demands and at increased risks of complications after open reduction and internal fixation. 81.5% (95%CI: 67.4% - 90.4%) of patients were able to return to a similar pre-injury mobility status after tibio-talar-calcaneal nailing.

Peripheral nerve blocks (PNB) have become an important modality for pain management in ankle fracture surgery. Previous studies have reported their efficacy, but concerns with rebound pain and readmissions have been cited as possible deterrents. The purpose of this study was to evaluate the effects of PNB on hospital length of stay (LOS), narcotic intake, visual analog scale (VAS) for pain, and associated complications in patients undergoing outpatient ankle open reduction internal fixation (ORIF). Adult patients undergoing ankle ORIF were matched 2:1 (no block:block) using propensity-score matching. Preoperative patient characteristics and postoperative outcomes were compared between cohorts. VAS and total narcotic intake were evaluated for each of the first 3 postoperative 8-hour shifts. Narcotic medication was converted to morphine milligram equivalents (MME). Thirty-two patients who received PNB were matched to 64 patients who did not. The PNB group had lower VAS and MME during each of the 8-hour shifts after surgery: 0 to 8 hours (VAS 1.8 vs 6.3; MME 10.6 vs 77.9; p.001), 8 to 16 hours (VAS 1.2 vs 5.9; MME 9.2 vs 28.2; p.001), 16 to 24 hours (VAS 3.7 vs 6.2; MME 13.2 vs 24.2; p = .006 and 0.019). PNB had a shorter LOS (average 16.7 hours vs 26.8 hours; p.001). There were no differences in rates of ED presentations after discharge, hospital readmissions, or complications between cohorts. Peripheral nerve blocks after ankle ORIF are associated with shorter hospital LOS, lower VAS, and reduced narcotic intake without increasing rates of ED visits, hospital readmissions, or complications.

Background Type I open distal radius fractures treated with open reduction internal fixation (ORIF) have demonstrated minimal risk of infection. For this reason, they may not require urgent surgical treatment. The purpose of this study was to evaluate the outcomes of patients with type I open distal radius fractures treated with delayed ORIF compared with urgent ORIF. Methods We identified all Gustilo-Anderson type I open distal radius fractures that had undergone ORIF using volar plating over a 5-year period. Patients were stratified into those treated urgently within 24 hours and those scheduled for delayed surgery. Outcomes including functional scores, complications, reoperations, and radiographic measures were compared. Results Twenty-four patients (17 treated urgently and 7 treated delayed) had open type I distal radius fractures. All patients were started on empiric antibiotics at initial presentation—patients in the delayed treatment group were prescribed oral antibiotics, whereas those admitted for urgent treatment received intravenous antibiotics. There were no infections in either group and a single reoperation in each group. The mean postoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 29 (range = 0-77) and did not differ significantly between delayed (mean = 19) and urgent (mean = 38) treatment. Rate of complications and radiographic measures did not differ significantly between the groups. Conclusions Type I open distal radius fractures appear amenable to delayed outpatient ORIF provided that the wound is clean at the time of initial presentation and that antibiotics are initiated appropriately. Further prospective studies comparing delayed and urgent treatment strategies are warranted.

Background: Distal radius fractures (DRF) are the most common upper extremity fractures in adults. The purpose of this study was to determine the incidence, causes, and independent predictors for unplanned return to the operating room (URTO) in a single institution within 90 days following distal radius open reduction internal fixation (ORIF). Methods: A retrospective study of 2933 consecutive patients from January 2015 to December 2019 who underwent distal radius ORIF was undertaken. Patients who returned to the operating room within 90 days of the index procedure were identified. Patients with planned return to the operating room for staged procedures were excluded, yielding a patient cohort of those with URTO. Demographic data, causes for reoperation, and final Quick Disabilities of the Arm, Shoulder and Hand DASH (QuickDASH) scores were collected. Results: Overall, 45 patients had URTO (1.5%) occurring a mean of 44 (6-89) days from the index procedure. Reasons for reoperation included nerve complications (n = 14), loss of fixation (n = 11), hardware complications (n = 9), wound complications (n = 7), and tendon complications (n = 4). Neurologic reasons for return included carpal tunnel release (n = 13) and ulnar nerve decompression (n = 1). QuickDASH scores were higher for URTO compared with control cohort at the final follow-up (33 [range: 0-91] vs 14 [range: 0-100], P < .01). Conclusions: Mechanical hardware failure and neurologic symptoms were the most common reasons for URTO after distal fracture ORIF.

Background: It was aimed to compare conventional surgery and three-dimensional (3D) model-assisted surgery used in the treatment of calcaneal fractures. Materials & Methods: A total of 37 patients with unilateral calcaneal fractures were randomly divided into two groups as a conventional surgery group (n: 19) and a 3D model-assisted surgery group (n: 18). The preoperative, postoperative and last follow up angles of the Bohler and Gissane, calcaneal width and facet height were measured. The duration of the operation, blood loss volume, fluoroscopy usage, instrumentation time for both groups were recorded. Finally, the follow-up AOFAS scores were evaluated. A questionnaire was used to determine the perceptions of the resident doctors about the 3D model. Results: The duration of the operation, blood loss volume, fluoroscopy usage, instrumentation time for 3D model-assisted surgery group were 83.3 +/- 4.6 minutes, 83.6 +/- 4.6 ml, 6.8 +/- 1.4 times and 13.0 +/- 0.8 weeks, and as for conventional group they were 130.0 +/- 5.8 minutes, 105.1 +/- 5.6 minutes, 11.7 +/- 1.5 ml, 22.2 +/- 2.4 times and 13.3 +/- 0.8 weeks, respectively (p < 0.0001). The both groups significantly restored Bohler angle, Gissane angle, calcaneal width and calcaneal facet height after operation (p < 0.0 001). The 3D model-assisted group was significantly more succesful in restoration and protection of achieved correction of calcanel facet height (p < 0.0001). The difference was determined among the groups at the final follow-up examination with respect to the amount of change according the values achieved postop. were significant in Bohler angle (p < 0.001), calcaneal facet height (p < 0.0001) and calcaneal widht (p = 0.017). There was no significant difference between AOFAS scores of the two groups at last follow-up. Resident doctors exhibited high scores of overall satisfaction with the use of a 3D printing model. Conclusions: Compared to the conventional group, the 3D model-assisted group provide successful intervention and reduce operation, instrumentation time and the fluoroscopy usage with less blood loss. Performing 3D-assisted surgery helps the quality of reduction during the surgery and stability of internal fixation to protect achieved reduction at follow-up more succesfully. (C) 2020 Elsevier Ltd. All rights reserved., European Society of Tissue Regeneration in Orthopaedics and Traumatology (ESTROT), This paper is part of a Supplement supported by the European Society of Tissue Regeneration in Orthopaedics and Traumatology (ESTROT).

Intracapsular fractures of the proximal femur are one of the most common fractures of the lower limbs. Most cases require osteosynthesis with suitable implants, and intraoperative positioning of the patient on the fracture table is a prerequisite to facilitate fracture manipulation, traction, reduction and fluoroscopy assessment. However, positioning the limbs of bilateral above-knee amputees for internal fixation of related proximal femoral fractures is a difficult task, which require customized inventory for effective limb positioning and fracture manipulation. This study reported a rare case following a crush injury of bilateral lower limb in a road traffic accident, and described some technical tips of acute femoral neck fractures in bilateral above-knee amputation. The patient was managed with immediate guillotine amputation and later secondary wound closure followed by internal fixation of the right-sided femoral neck fracture with multiple cancellous cannulated screws.

Background The purpose of this study is to assess the incidence and clinical characteristics of adolescent tibial tubercle fractures (TTFs) during the COVID-19 pandemic by sharing our experiences. Methods Pediatric patients aged between 0 and 18 years old with confirmed diagnosis of TTFs who were treated at our center between April 2020 and May 2020 were included in the study. In addition to demographics, mechanism injury, treatment modalities, complications were also noted. Results Sixteen patients were included in the study. The mean age was 14.8 ± 0.9 years (range: 13–16 years). The mean BMI of patients was 26.3 ± 2.3 kg/m2 (range: 23.2–30.4 kg/m2). According to the BMI-for-age percentiles growth chart, eight patients (50%) were overweight, and eight patients (50%) were at a risk of being categorized as overweight. The most common cause for the injury was jumping due to basketball (50%). Twelve of 16 patients were treated operatively by open reduction and internal fixation. The remaining 4 patients were treated non-operatively with long leg cast. Conclusion The incidence of TTFs was 16 cases over about two months during the pandemic isolation period. Our results demonstrated that all adolescent TTFs occurred during periods when outdoor activities were permitted. This finding may be explained by sudden athletic activity after prolonged immobilization. We observed that all of our patients were male and either overweight or at risk of being overweight.

Background Indications for deltoid ligament repair in bimalleolar equivalent ankle fractures are unclear. This study compared radiographic outcomes in bimalleolar equivalent ankle fractures undergoing open reduction internal fixation (ORIF) +/− deltoid ligament repair. Methods A retrospective review of 1024 ankle fractures was performed. Bimalleolar equivalent injuries treated with ORIF +/− deltoid ligament repair were included. Radiographic assessment was performed preoperatively, and at three months postoperatively. Results One hundred and forty-seven ankle fractures met inclusion criteria with 46 undergoing deltoid ligament repairs. There was a significant decrease in medial clear space (1.93 ± 0.65 mm vs. 2.26 ± 0.64 mm, p = 0.01), and tibiofibular clear space (3.89 ± 1.20 mm vs. 4.87 ± 1.37 mm, p = 0.0001) at 3 months postoperative in the deltoid repair group compared to the no repair group. When syndesmotic fixation was performed, there were no differences between groups. Conclusion Deltoid ligament repair in bimalleolar equivalent ankle fractures resulted in reduced medial clear space, and tibiofibular clear space in the early postoperative period. These differences were small and remained within established normal limits. Level of clinical evidence Level III, retrospective cohort study.

Background: Surgeons are sometimes presented with patients with distal radius fractures who present in a delayed fashion or lose reduction after several weeks of attempted closed management. There are limited studies on delayed surgical treatment of distal radius fractures to assist providers in decision-making. Methods: We conducted a matched cohort study to compare radiographic outcomes and complications for patients with a distal radius fracture treated with delayed (3-5 weeks) or early (0-2 weeks) surgical fixation. Patients ages 18+ who underwent open reduction and internal fixation of distal radius fractures by a volar approach at 2 Level I trauma centers between 2003 and 2015 were eligible. We measured radiographic outcomes and reviewed medical records to determine operative approach and complications. Results: There were 25 cases and 50 controls matched for age (18-87), sex, and AO fracture type. The delayed group had surgery at a mean of 24.8 days from injury and the early group at 5.6 days. There was no statistically significant difference between the delayed and early cohorts in radiographic parameters on injury x-rays, in improvement in radiographic parameters on first postoperative x-rays, or in maintenance of radiographic parameters at union. Conclusion: We did not find significant differences in radiographic outcomes or complication rates between patients with delayed versus early surgical treatment for distal radius fracture. Providers treating patients with late presentation or late displacement have the option of surgical fixation beyond the first few weeks after injury. Level of Evidence: III (Retrospective matched cohort study)

A 57-year-old man with a history of hypertension was admitted to the emergency department with septic shock and was therefore intubated and transferred to our intensive care unit (ICU). The patient had a supracondylar knee fracture 4 months ago, and underwent open reduction, internal fixation with

Background Fixation and arthroplasty remain the mainstays of surgical treatment of degenerative and traumatic shoulder pathology. They also constitute an appreciable sum of Medicare expenditure. With continued concern for declines in Medicare reimbursement across orthopedic surgery, it is important to understand how trends in reimbursement correlate with relative procedure volumes. Our aims were to describe temporal changes in procedure volumes, physician payment, and patient charges for proximal humerus open reduction internal fixation (ORIF) and shoulder arthroplasty. Methods Using Medicare's Physician Fee Schedules from 2012 to 2017, we examined procedure volumes, number of unique surgeons performing, actual submitted patient charges, and surgeon payments from 2012 to 2017 for six shoulder procedures: proximal humerus ORIF (CPT-23615), traumatic hemiarthroplasty (HEMI) (CPT-23616), degenerative HEMI (CPT-23470), primary total shoulder arthroplasty (TSA) (CPT-23472), partial TSA revision (humeral or glenoid component, CPT-23473), and total TSA revision (CPT-23474). The reimbursement ratio was calculated by dividing surgeon payment by patient charges. Growth rates of charges and payment were adjusted for inflation using annual consumer price index inflation rates over the same time period. Results The total number of traumatic and degenerative HEMI cases fell over −60%. Similarly, the number of unique surgeons performing traumatic and degenerative HEMI fell over −53%. In contrast, the number of TSA procedures rose by +70%, whereas partial and total revision TSA rose by +62% and +88%, respectively. The number of unique surgeons rose +28% and over +73% for primary and revision TSA, respectively. There was a large gap (between 3.4 and 4.4 times) between submitted charges and surgeon payment for all years analyzed. After adjusting for inflation, Medicare payment to surgeons decreased for all types of surgery (−6% to −9%) other than ORIF, which increased +10%. Submitted patient charges during this period increased +14% and +9.7% for ORIF and revision TSA (total), respectively, but decreased by −6% for traumatic HEMI. The reimbursement ratio was ≤29% for all procedures analyzed across all years and fell the most for revision TSA (partial and total). Conclusion From 2012 to 2017, there was a sharp decline in the use of shoulder HEMI with a correspondingly high increase in TSA. After accounting for inflation, HEMI and TSA showed appreciable declines in surgeon payment over time, whereas ORIF was the only surgery with increased surgeon payment. Revision TSA saw the largest declines in the reimbursement rate. Physicians and health care policy makers must be aware of these trends to ensure both a sustainable payment infrastructure for surgeons as well as to maintain access to care for these procedures. Level of evidence Level III; Economic Study

Objectives To describe the trajectory of recovery following fixation of pilon fractures from baseline to 5 years follow-up. Design Prospective cohort study. Setting Level 1 trauma centre. Patients/participants Patients with pilon fractures (OTA/AO 43.C) treated with open reduction and internal fixation (ORIF). Intervention None. Main outcomes measurements Patient reported outcome measures (PROMs) were measured at baseline, 6 months, 1 year and 5 years using the Short-Form 36 Health Survey Physical and Mental Component Scores (SF-36; PCS, MCS), Short Musculoskeletal Functional Assessment (SMFA), and the Foot and Ankle Outcome Score (FAOS). Results 102 patients were enrolled: mean age was 42.6 years; 69% were males; 88% had an injury severity score (ISS) of 9; 74 patients (73%) completed 1 year follow-up; 40 patients (39%) completed 5 years follow-up. Trajectory of recovery of physical function showed a significant decline between baseline and 6 months, with significant improvement between 6 months and 1 year, and then ongoing but slower improvement between 1 year and 5 years. 64% of patients returned to baseline SF-36 PCS at 5 years. Pain was a persistent issue and remained significantly worse at 5 years when compared to baseline. Psychological wellbeing (SF-36 MCS) did not significantly change from baseline at 5 years. Conclusion Functional recovery following ORIF for pilon fractures was characterized by an initial decrease in function from baseline, followed by an increase between 6 months and 1 year, and then slower but continued increases from 1 year to 5 years. Function did not return to baseline levels, pain was a persistent issue, and mental wellbeing showed no change from baseline at 5 years. This information may be useful when counselling patients.Level of Evidence:Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background We aimed to evaluate the effect of a surgery technique-total arthroscopic internal fixation with adjustable double loop plate in treatment of patients with tibia avulsion fracture of posterior cruciate ligament (PCL). Methods From April 2018 to January 2020, 26 patients with tibia avulsion fracture of PCL treated in the joint surgery of our hospital were enrolled in this retrospective cohort study. According to the way of operation, the patients were divided into the experimental group (receiving total arthroscopic internal fixation with an adjustable double loop plate) and the control group (receiving traditional open surgery). The knee joint X-ray, CT or magnetic resonance imaging (MRI) were used to evaluate the injury or the fixation effect. Results There were no significant differences in baseline patient demographics between the two groups in terms of age, sex, the average time from injury to surgery, type of surgery, preoperative knee range of motion, Lysholm score, IKDC score and KT-1000 score (P>0.05). The average operation time in the experimental group (59.5 ± 10.6 minutes) was significantly shorter than that in the control group (96.8 ± 13.7 minutes) (P < 0.05). Postoperative re-examination of knee CT and X-ray showed that the fracture fragments were well fixed in all patients. The fracture was all healed 2 months after the operation. Post-operative posterior drawer tests were negative in all patients at final follow-up. All patients regained a satisfactory knee range of motion and the flexion and extension function and were satisfied with the results of surgery and rehabilitation. There was significant difference (P < 0.05) in the Lysholm scores, the IKDC scores, the KT1000 scores, and the ROM between preoperative and postoperative values in the control group and the experimental group. However, there were no significant differences in these values between the two groups (p>0.05).Conclusions Total arthroscopic internal fixation with adjustable double loop plate is relatively simple, safe, minimally invasive, and reliable. After taking this operation and rehabilitation training, patients with tibia avulsion fracture of PCL can regain a satisfactory knee range of motion and the flexion and extension function.

Objectives This study evaluated optimum stability of different screw techniques for condylar head fractures (CHF) (P close to an M fracture with the lateral pole preserved according to AO classification 2014) by finite element analysis (FEA) and provided a biomechanical basis for clinical treatment. Study Design Four CHF fixation models were evaluated: (A) single bicortical screw, (B) 2 bicortical screws, (C) 1 bicortical screw and 1 monocortical screw (used as a positional screw) inserted via a 2-hole titanium plate, and (D) 2 bicortical screws inserted via a titanium plate. Stresses were calculated (FEA) to measure mechanical properties. Results The displacement for A and C was larger than for B and D. The maximum stress on the screws for A and C exceeded their breaking limit but was safe for B and D. The stress on the titanium plate for C and D was safe. The stress on bone for A and C was larger than for B and D. Conclusions The 2 bicortical screw fixation reduced the stress on implanted materials and surrounding bone tissue. Titanium plates further alleviated the lever action. Two bicortical screw fixation was more reliable for CHF, and early postoperative loading and functional training can be expected.

OBJECTIVES To determine the prevalence of ulnar head subluxation/dislocation in distal radius fracture and to discuss management, surgical outcomes, and relevant anatomy. DESIGN Retrospective review of prospectively collected data. SETTING Urban tertiary care hospitalPatients/Participants: 271 patients with displaced distal radius fractures undergoing surgical management were reviewed to determine the incidence of ulnar head subluxation or dislocation using the criteria defined by Mino et al. MAIN OUTCOMES Post-operative CT and radiographs were assessed for sigmoid notch and DRUJ reduction and fracture healing. Range of motion, functional limitation, and pain were documented at final outcome. RESULTS Of the 271 cases, there were 8 cases of pre-reduction DRUJ subluxation/dislocation, including two frank dislocations and six subluxations (2.95%). All were treated with open reduction and internal fixation of the distal radius (ORIF) with a volar locked plate. Additionally, one patient underwent ORIF of an associated distal ulnar shaft fracture and another, who had a Grade 1 open fracture over the distal ulna, underwent open TFCC repair. The remaining six patients had closed reduction of the DRUJ without further stabilizing procedures. All had stable DRUJ joints following ORIF, both intra-operatively and at final follow-up. All ulnar heads were located within the DRUJ on post-op CT; using the more sensitive radioulnar ratio there was residual ulnar head subluxation in 5/8 patients. Range of motion and functional outcome were excellent at an average of 133 weeks post-operatively. The DRUJ was stable at long-term follow-up in all patients. CONCLUSIONS Ulnar head subluxation/dislocation is an uncommon injury in the setting of distal radius fracture. When present, it can usually be treated effectively with operative stabilization of the distal radius fracture without further stabilizing procedures. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Injury to Lisfranc's joint complex affects the longitudinal and transverse arches of the foot and can significantly alter its biomechanics. Some of the previous studies have suggested primary arthrodesis to be superior to open reduction and internal fixation for treating primarily ligamentous Lisfranc injuries. Additionally, arthrodesis is often used for treating chronic Lisfranc injuries, including those which previously underwent open reduction and internal fixation and subsequently developed arthrosis. The purpose of this study was to retrospectively evaluate the outcomes of arthrodesis at the level of Lisfranc's articulation for both acute and chronic injuries. Patients who underwent midfoot arthrodesis surgical procedures between years 2001 and 2017 were retrospectively reviewed. About 187 patients with an average age of 55.9 ± 13.2 years old and a minimum follow-up of 1 year were included in the study. Median time to return to preoperative activities was 11 weeks. Overall successful joint fusion rate was 81.4%. However, concomitantly fused joints of the midfoot and hindfoot, in addition to the tarsometatarsal joints (TMTJ), were included in the overall fusion rate. Fusion rate at the first TMTJ was 90.2% (101 out of 112), second TMTJ was 94.4% (67 out of 71), and third TMTJ was 97.8% (45 out of 46). The present study demonstrates that patients who undergo arthrodesis for both acute and chronic Lisfranc injuries typically can return to activity in under approximately 3 months postoperatively (acute patients significantly faster) with a high union rate at the TMTJs. However, the overall union rate is significantly lower when concomitant proximal midfoot and rearfoot arthrodesis procedures are performed.

Diabetes increases the risk of developing postoperative complications such as superficial and deep infection, wound dehiscence, and revisional surgery. Prolonged non-weightbearing and/or augmented fixation may reduce postoperative complications in complicated diabetic ankle fractures. This study's purpose was to compare the development of postoperative infection, wound dehiscence, and revisional surgery in complicated diabetic ankle fractures with respect to weightbearing status. We hypothesized that fewer complications would occur in patients with prolonged non-weightbearing. Medical records of 90 surgically treated complicated diabetic ankle fractures were retrospectively reviewed for postoperative radiographs, weightbearing status, and complications. Complicated diabetes was defined as HbA1c ≥ 8% within 1 year of surgery. Twenty-four out of 90 patients had prolonged non-weightbearing status, which was defined as ≥ 8 weeks of non-weightbearing postoperatively. Twelve out of 90 patients had augmented fixation, which was defined as standard open reduction and internal fixation plus ≥ 2 tetra-cortical or > 2 tri-cortical syndesmotic screws with medial plate, external fixation, or other combination. Thirty-three out of 90 patients (36.7%) patients developed complications postoperatively. Patients with prolonged non-weightbearing had less complications (29.2% vs 39.4%, p = .37) and larger HbA1c values compared with early weightbearing patients (10.0 vs 9.3, p = .04). A one-unit increase in creatinine value (mg/dL) revealed a 3.15-fold increase in development of complications (95% confidence interval 1.29-7.65, p = .01). Although not statistically significant, complicated diabetic ankle fractures treated with prolonged non-weightbearing had less complications postoperatively except for ankle Charcot. Creatinine can be utilized as an independent risk factor for postoperative complications in this population.

Surgical management of patients with comorbid long-term myasthenia gravis (MG) is particularly challenging and MG thus represents an independent risk factor for perioperative complications. However, few studies have reported on the perioperative assessment, prevention measures, and risks in MG patients undergoing major surgery, especially for anterior cervical spine surgery. We herein report the rare case of a 62-year-old man with a 20-year history of MG, who was admitted to our hospital with diagnosis of degenerative cervical spondylosis. He safely underwent anterior cervical corpectomy of C4, discectomy of C5-6, and fusion of C3-6. Intraoperative motor evoked potential was recorded to detect significant improvement after decompression. However, the patient suffered from progressive dysphagia, bucking, and hyperpyrexia 20 days after the initial operation. Imaging revealed titanium cage sliding and graft dislodgement. Secondary surgery was performed for posterior internal fixation from C2-7 and anterior revision from C3-6 after Halo-Vest traction, antibiotic treatment, and immunoglobulin therapy. He underwent a series of postoperative treatments, including cervicothoracolumbosacral orthosis, atomization inhalation, chest physiotherapy, antibiotics, and nutritional support. His condition improved markedly and he had no recurrence of symptoms during the 6-month follow-up. It is the rare reported case of anterior cervical spinal surgery in a patient with MG. This rare case indicates a relative contraindication to anterior-only approaches especially with multiple levels for MG patients with cervical spondylosis. Posterior approach, intraoperative monitoring, osteoporosis, postoperative strong brace protection, and supportive management should be considered for patients who were on large doses of steroids for long duration of time, given the lack of sufficient bone mineral density.

OBJECTIVES Appropriate visualization of the femoral neck is critical when performing open reduction and internal fixation (ORIF) of a femoral neck fracture. The purpose of this study was to objectively identify which surgical approach provided the most extensive visualization of the femoral neck during ORIF. Our hypothesis was that the Smith-Petersen approach with rectus release would provide the most extensive visualization. METHODS Ten cadaveric hips were utilized to compare 4 different surgical approaches to the femoral neck: Smith-Petersen (SP), Smith-Petersen with rectus release (SPwR), Watson-Jones (WJ), and Hueter approach. After surgical exposure, calibrated digital images were captured and analyzed using a computer software program to determine the percent-area visualized. Three trained investigators separately assessed each specimen to determine clinical visualization and ability of the surgeon to manually outline anatomic locations of the femoral neck: subcapital, trans-cervical, and basicervical. Data were analyzed for significant (p

OBJECTIVES To investigate patient demographics, injury characteristics, radiographic outcomes, and identify risk factors for developing post-traumatic arthritis in high energy transsyndesmotic ankle fracture dislocations, or "Logsplitter" injuries. DESIGN Retrospective cohort study. SETTING Academic level one trauma center. PATIENTS/PARTICIPANTS Twenty-seven adult patients with logsplitter injuries. INTERVENTION All patients were treated with open reduction internal fixation, with possible addition of syndesmosis screw(s) and deltoid repair. MAIN OUTCOME MEASUREMENTS Rate of post-traumatic arthritis at one year along with rate and reasons for reoperation. RESULTS Twenty-seven patients were included with mean follow up of 14.5+/-12.5 months. At one year postoperative, 14/20 patients (70%) demonstrated posttraumatic arthritis. Two patients (7.4%) went onto fusion. Reoperation rate was 51.9%. There was no significant difference in arthritis rate with the number of syndesmosis screws used, quality of reduction, or the addition of deltoid repair. CONCLUSIONS The logsplitter injury is one with devastating outcomes and high rates of arthritis; it should be considered separately from conventional ankle fractures. The role of deltoid repair remains unclear. Further study of this injury pattern is required. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES Assess outcomes of acetabular open-reduction and internal fixation (ORIF) in the elderly; 2) Investigate factors influencing outcome; 3) Compare outcomes following low and high energy mechanisms of injury. DESIGN Retrospective case series. SETTING Level 1 trauma center. PATIENTS Seventy-eight patients over 60 (age:70.1±7.4; 73.1% males). INTERVENTION ORIF for acetabular fractures. MAIN OUTCOME MEASUREMENTS Complications, re-operation rates, and Oxford Hip Score (OHS), joint preservation and development of symptomatic OA. Cases with OA and OHS

Purpose The purpose of this study was to determine how fellowship training influences the treatment of distal humerus fractures with either total elbow arthroplasty (TEA) or open reduction internal fixation (ORIF). Methods The American Board of Orthopaedic Surgery (ABOS) Part II Examination Database was queried for all orthopaedic surgeons who sat for the Part II examination between the years 2003-2019. Inclusion criteria were ORIF or TEA cases, selected by individual CPT codes for each procedure, and patients of at least age 65 years who sustained acute distal humerus fractures. Analysis was performed for each type of fellowship training completed, total number of procedures performed, the type of procedure performed, patient demographics, and any complications. Results There were 149 TEAs and 1306 ORIFs performed for distal humerus fractures between the exam years of 2003-2019. The proportion of TEA to ORIF increased from 7.6% to 11.0%. Partitioned by fellowship training, Hand and Upper Extremity surgeons performed 69 (17.4%) TEAs and 328 (82.6%) ORIFs, Shoulder and Elbow surgeons performed 34 (29.6%) TEAs and 81 (70.4%) ORIFs, Sports Medicine surgeons performed 14 (5.1%) TEAs and 263 (94.6%) ORIFs, and Trauma surgeons performed 16 (4.2%) TEAs and 366 (95.8%) ORIFs. Hand and Upper Extremity surgeons treated the most distal humerus fractures (397, 27.3%), followed by Trauma surgeons (382, 26.3%). Conclusion Our data suggests that fellowship training does influence the surgical decision-making process for treating distal humerus fractures in elderly populations. Hand and Upper Extremity surgeons performed the greatest number of TEA for acute distal humerus fractures, followed by Shoulder and Elbow surgeons. Conversely, trauma surgeons performed the lowest proportion of TEA to ORIF. Level of Evidence III.

Objectives The posterolateral approach to the distal tibia is commonly used for stabilisation of ankle fractures as it allows good visualisation and direct reduction of the posterior distal tibia and malleolar fragments. This approach can also be used for internal fixation of an associated lateral malleolus fracture. The aim of our study is to describe the surgical anatomy of the peroneal artery (PA) in relation to the tibial plafond and the distal fibula; thereby suggesting a safe zone during proximal dissection of posterolateral approach. Methods Using Computed Tomography Angiographic (CTA) study, the course of the PA in relation to the tibial plafond and distal fibula was analysed in 142 lower limbs (bilateral limbs of 71 adult patients; 43 males and 28 females). Axial, coronal, and sagittal CT sections were cross-linked to specify the position of the PA. The PA course was identified and the level of its distal bifurcation over the tibia was marked. Perpendicular measurements were made from this point to the tibial plafond and tip of distal fibula. Results The PA bifurcated distally at mean 58.3±24.2mm (SD) (range: 37.0–115.0mm) proximal to the right tibial plafond and mean 81.9±24.4mm (range: 54.0–137.0mm) from the right distal fibular tip. In the contralateral side, the PA bifurcated at mean 57.9±23.3mm (range: 36.0–125.0mm) proximal to the left tibial plafond and 81.8±23.9mm (range: 54.0–147.0mm) from the left distal fibular tip. The difference between the right and the left side of distal bifurcation point diameter of the same patient was assessed, range (0.0–58.0mm) with median 2.0mm and IQR 10.0mm. Three different PA vasculature patterns were identified. Conclusions It is important for surgeons to be aware of the surgical anatomy of PA to avoid inadvertent injury during posterolateral approach to distal tibia. The PA may bifurcate as close as 36mm from the tibial plafond with possible variation bilaterally. Therefore, special attention needs to be considered by the operating surgeon while dissecting in this region due to the wide anatomical variation in vasculature. However, once the PA is mobilised, any fixation modality including posterior buttress plate could be safely performed.

Despite the advantages of anterolateral thigh (ALT) flaps, many surgeons are hesitant to choose a thigh with ipsilateral femoral fracture and internal fixation as the flap donor site. To cover the right mid-upper leg wound, a free ALT flap was harvested from the left thigh of a 55-year-old man who initially underwent closed retrograde intramedullary fixation for a left distal third femoral shaft fracture. The flap was based on a musculocutaneous perforator located in the mid thigh, which was approximately 10 cm above the proximal fracture level. No adhesion or scar formation between the fascia and adipose tissue was noted when the flap was raised supra-fascially, and the adipose tissue surrounding the trunk of the descending branch of the lateral circumflex femoral artery was found to have mild oedema. The patient regained good aesthetic outcomes and a complete range of active motion in both lower extremities. Based on current evidence of the vascular anatomy of the ALT flap in the literature and our experience, an ipsilateral thigh with distal third femoral shaft fracture and closed retrograde intramedullary fixation should not be considered an absolute contraindication to ALT flap harvesting.

Background: A 72-year-old male developed a late-onset infection of an internal fixation device caused by Microbacterium oxydans. Although often considered contaminants, bacteria from the genus Micr...

Mandibular non-union occurs in 2-9% after open reduction and internal fixation of a mandibular fracture (trauma surgery, orthognathic cases, access osteotomy for oncological purposes). The medial femoral condyle (MFC) has emerged more recently as one of the most versatile donor sites in the treatment of challenging bone reconstruction. This is the first description of MFC for treatment of mandibular non-union. A retrospective chart review was conducted for all patients who underwent reconstruction with a microvascular MFC flap for bone defects of the head and neck area between January 2015 and December 2018 at Careggi Hospital of Florence. Inclusion criteria were patients where the FMC was used for mandibular defects arising due to non-union. Seven patients presented mandibular defects reconstructed by MFC flap and were included in this investigation (two cases of segmental mandible defect due to post-traumatic non-union; two patients of pathological mandibular fracture after prolonged bisphosphonate therapy for osteoporosis; three patients with mandibular continuity loss after failed orthognathic surgeries). At one-year follow-up, all patients had satisfactory occlusion. One-year postoperative CTs revealed full osteointegration of the flaps. In conclusion, the MFC free flap is an attractive option for mandibular reconstruction. Small defects (3-5 cm) in poorly vascularized beds are the ideal target.

Calcaneus fractures can be devastating injuries, and operative treatment is fraught with complications. We are unaware of any studies evaluating all calcaneus fractures, both open and closed, treated operatively in the military. The purpose of this study is to evaluate all calcaneus fractures that required open reduction internal fixation to determine soldiers' ability to return to work and the need for additional surgeries.All active-duty patients undergoing open reduction internal fixation of calcaneus fractures from 2010-2016 were identified utilizing the Military Health System Management Analysis and Reporting Tool (M2). Armed Forces Health Longitudinal Technology Application (AHLTA) was utilized to determine comorbid medical conditions, subsequent procedures, surgical outcomes, and duty status within the military.Three hundred seventy-five active-duty service members who met our inclusion/exclusion criteria were identified. One hundred fifty-one patients (55.1%) sustained their calcaneus fracture as a result of a blast injury. One hundred sixty (59.3%) patients required separation from the military as a result of their injury. Among patients who required a subsequent procedure, thirty-four patients (9.1%) required a subtalar arthrodesis, and thirty-two patients (8.5%) eventually required a below knee amputation. Blast as mechanism of injury was the single most predictive variable for patients requiring separation from the military (Odds Ratio 16.2, p.001), requiring a subsequent procedure (Odds Ratio 8.4, p.001), and for requiring a below knee amputation (Odds Ratio 47.3, p.001).Calcaneus fractures treated operatively in the military are often caused by blast injuries, and have a high rate of requiring subsequent procedures, amputation, and separation from the military.

Introduction Cephalomedullary nailing (CMN) is the standard treatment for internal fixation of trochanteric fractures. Complications related to CMN include intraoperative fracture (IF), which is difficult to detect using only plain radiographs. However, analyses of IFs using plain radiographs and computed tomography (CT) with a large sample size of clinical cases are lacking. Therefore, this study aimed to report the incidence of IFs diagnosed by CT, the risk factors for IFs, and a comparison of clinical outcomes between patients with and without IFs. Methods This multicenter retrospective cohort study included 638 patients who underwent CMN fixation for trochanteric fractures. We evaluated IF using pre-and postoperative plain radiographs and CT. The primary outcome was reoperation and the secondary outcome was the proportion of patients who regained independent mobility at 3 months postoperatively. Furthermore, we conducted multivariable logistic regression analyses to examine the association between risk factors and IFs. Results Seventy-five (11.8%) patients had IFs, including 53 patients with occult IFs (8.3%). The most common location of IF was at the interference with the lag screw entry (45.3%). The nail insertion procedure (17.3%) was the most common reason for IF. In the assessment of clinical outcomes, patients with IFs had no reoperations and independent mobility at postoperative 3 months was lower (69.6% vs. 79.1%). Regarding regaining independent walking in the IF group, IF distal to lag screw entry and obvious IF diagnosed with plain radiographs were poor factors. The multivariable analysis showed that only inadequate reduction on the anteroposterior view based on the plain radiograph was significantly associated with the incidence of IFs (odds ratio 3.91; 95% CI, 1.28–11.94; p = 0.017). Conclusions This multicenter study indicated that the incidence of IFs detected by CT in CMN treatment for trochanteric fractures was 11.8%. An inadequate reduction in the anteroposterior view based on plain radiographs was the only independent risk factor of IFs. In the assessment of clinical outcomes, patients with IF had no incidences of reoperation. However, patients with IFs tended not to regain independent mobility compared with those without IFs.

Introduction: Geriatric distal femur fractures are challenging to treat. The high mortality rate associated with a loss of mobility in this population has led some authors to compare distal femur fractures to femoral neck fractures with respect to the importance of rapidly regaining mobility in the geriatric population. Acute distal femur replacement has been advocated by some as a preferred treatment over internal fixation because arthroplasty may facilitate a more rapid return to a patient's baseline mobility level. The purpose of this study was to systematically review the literature on the costs and outcomes of fixation and arthroplasty in the geriatric distal femur fracture population and to employ decision modeling techniques to generate evidence-based treatment recommendations. Methods: A systematic literature review of clinical studies published since 2000 was conducted to synthesize the available data on outcomes, reoperation rates, and mortality rates after fixation or arthroplasty for distal femur fractures in patients with an average age greater than 70 years. A Markov decision analysis model was created. Costs, health state utilities, reoperation rates, and mortality rates were derived from the systematic literature review and publicly available data. The model was analyzed via probabilistic statistical analysis as well as sensitivity analyses with a willingness-to-pay threshold set at $100,000 per QALY and a 5-year time horizon. Results: From a US societal perspective, fixation was associated with a greater quality of life benefit (2.44 QALYs vs. 2.34 QALYs) and lower cost ($25,556 vs. $65,536) compared with distal femur replacement for geriatric distal femur fractures. Probabilistic analysis demonstrated that 82 in 100 model outcomes favored fixation over arthroplasty and 18 in 100 model outcomes favored distal femur replacement. Sensitivity analyses demonstrated that this result was robust to small deviations in the cost and functional outcome variables in the model. Conclusion: Compared to distal femur replacement, ORIF is likely to be a more cost-effective treatment for distal femur fractures in the geriatric patient population, though this recommendation is tempered by the relatively low quality of evidence available on the comparative functional outcomes of these treatments.

Study Design: A retrospective analysis of patients with subcondylar fractures treated via a transmasseteric anteroparotid approach by the Oral and Maxillofacial Department at the University of Oklahoma. Objective: The goal of this study was to evaluate complications, morbidity, and safety with the transmasseteric anteroparotid approach for treatment of subcondylar fractures, and compare it to other findings previously reported in the literature. Methods: A retrospective study was conducted that consisted of 23 surgically treated patients in the past 2 years for subcondylar fractures. Only patients with pre-operative malocclusion and who underwent open reduction with internal fixation with the transmasseteric anteroparotid (TMAP) approach were included. Exclusion criteria included 1) patients treated with closed reduction 2) patients who failed the minimum of 1, 3, and 6-week post-operative visits. The examined parameters were the degree of mouth opening, occlusal relationship, facial nerve function, incidence of salivary fistula and results of imaging studies. Results: 20 of the surgically treated patients met the inclusion criteria. Two patients were excluded due to poor post-operative follow up and 1 was a revision of an attempted closed reduction by an outside surgeon that presented with pre-existing complications. There were no cases of temporary or permanent facial nerve paralysis reported. There were 3 salivary fistulas and 2 sialoceles, which were managed conservatively and resolved within 2 weeks, and 2 cases of inadequate post-surgical maximal incisal opening (Conclusion: The transmasseteric anteroparotid approach is a safe approach for open reduction and internal fixation of low condylar neck and subcondylar fractures, and it has minimal complications.

Introduction. Damage to the musculoskeletal system in multiple traumas occurs in 80–90 % of cases, in 10–15 % of victims they are leading and define life prognosis [2]. Out of injuries of the locomotor system, hip fractures are one of the most significant and life-threatening, their treatment is difficult. The severity of these injuries, difficulties of using conservative methods of treatment for multiple and combined fractures, frequent development of complications when using standard methods of osteosynthesis often lead to unsatisfactory results [4]. In this regard, the search continues for the optimal treatment of bilateral hip fractures in patients with polytrauma. The aim of our study was to determine the optimal methods of surgical treatment of bilateral hip fractures in patients with multiple injuries. Materials and methods. To perform our study, we analyzed the data of 75 patients with bilateral fractures of the hip and polytrauma, who were treated at the Kyiv Municipal Clinical Emergency Hospital between 2006 and 2015. There were 59 men (78.7 %) and 26 women (21.3 %). The average age of victims was 38.2 ± 1.1 years. Results. On admission to the hospital, diagnosis of bilateral hip fractures was carried out, with subsequent stabilization of vital functions. Bilateral hip fractures were found in 48 (64.0 %) of the victims. One open and the other — closed fractures were observed in 16 (21.3 %) of patients. Both open fractures were diagnosed in 11 (14.7 %) of the victims. After stabilization of patient’s state, we have conducted replacement of external fixation device (EFD), plaster splints and skeletal extension by internal fixation in different ways depending on the type and location of fractures, as well as taking into account the general condition of patients. Reasons for changing the method were the development of contractures in adjacent joints, inappropriate position of fracture fragments in EFD, the risk of inflammation around the rods and the possibility of infection of bone or soft tissues. 13 (17.3 %) patients had two supracondylar or transcondylar fractures (33 А 1–3, С 1–3). These individuals underwent extramedullary minimally invasive osteosynthesis using plates with angular stability (locking compression plates — LCP). In 23 (30.7 %) patients, we have detected a combination of distal and diaphyseal femur fractures. For the treatment of these patients, a combination approach was used: at the first stage, diaphyseal fracture was fixed with the help of intramedullary nailing, and the second stage was the fixation of distal fracture using minimally invasive external osteosynthesis with LCP. Conclusions. At the early hospital stage, when treating bilateral hip fractures in polytrauma, it is necessary to stabilize fractures using EFD that makes it possible to anesthetize, to reduce the fracture and to mobilize the patient. At the hospital stage of treatment, there is a need to change the method by internal fixation according to indications, depending on the location and type of a fracture, with the aim of final reposition, stable fixation and mobilization of adjacent joints. Using an integrated differentiated approach to the treatment of bilateral hip fractures in patients with polytrauma made it possible to obtain positive outcomes in 94.6 % of cases.

Background. Pathological vertebral fracture is a major complication of tumor, which dramatically changes the quality of life. The most common cause of neurological disorders is spinal cord compression by bone-ligament structures of the spine in pathological fractures and spinal deformity or as a result of direct effects of tumor tissues on it. An important feature of the surgical phase of treatment is that its main tasks are: to eliminate compression of the spinal cord, to correction deformity and to restore the support ability of the spine and to radically remove the tumor. Sometimes, radical resection of the tumor is impossible. In most cases, the use of additional internal fixation with metal implants significantly improves outcomes and reduces the period of rehabilitation of patients by primary spine stabilization in the early postoperative period. The use of transpedicular device provides stable fixation and stability of the spine segment, even with the destruction of all three columns (i.e. its maximum degree of instability). Determining the optimal length of posterior spondylodesis in palliative and radical surgical treatment of tumors of the spine was the purpose of our study. Materials and methods. To explore stabilization possibilities of transpedicular fixation with resection of one-three vertebrae, experimental studies were conducted on pig spinal cord samples. We used samples of thoracic spine segments, from Th3 to Th12 vertebrae. We studied three groups of models: with 1 resected vertebra Th6, with 2 — Th5-Th6 and with 3 — Th5-Th7. In all three groups of models, we have used 4 ways of transpedicular fixation: one vertebra above and below the resected one, two vertebrae above and below resection, three vertebrae above and below the resected one, the first and third vertebrae above and below the zone of resection. In the experiment, the model firmly fixed on the body of lower Th12 vertebra. Vertical compressive load was applied to the Th3 vertebral body. The load was increased from 100 to 600 N, in increments of 100 N. In each of the load, the deflection of the lower vertebral edge above the resection area was measured. Deformation was measured using clock type micrometer. The load was measured using strain gauge sensor SBA-100L, the results were monitored by the CAS type CI-2001A registration device. Results. It was found that when one vertebra is resected in the thoracic spine, transpedicular fixation by the schemes 111x111, 101x101 and 011x110 have almost the same efficiency in terms of spinal motion segment displacement in the area of resection, as evidenced by the lack of statistically significant differences in the minimum and maximum load. The differences between these schemes obtained at intermediate load values may be the result of technical errors of the experiment. In resection of two vertebrae of the thoracic spine, the best stabilizing capabilities was demonstrated by transpedicular structure imposed by the scheme 111хх111. Schemes of transpedicular fixation 101хх101 and 011хх110 showed almost identical results of the tests, but statistically, they are behind 111хх111 scheme. The worst results according to the value of spinal motion segment displacement in the area of resection were obtained when using 001хх100 scheme. Models with ranspedicular fixation scheme 111ххx111 showed the stabilization during resection of three thoracic vertebrae, as well as the most stable fixation. The fixation scheme 001ххх100 turned out to be very unstable and dropped out of the experiment even at loads of 300 N. Conclusions. Experimental studies of transpedicular fixation in radical surgical treatment of tumors of the spine, which includes resection of one-three vertebrae, have shown that the design meets the requirements of fixation when attachment occurs not less than two vertebrae above and two vertebrae below (one can be through one); in resection of three vertebrae, the most stable is structure of the fixation of three vertebrae above and three vertebrae below (without gaps). This mounting system provides the greatest stability in vertebral resection of any length. The fixation system in one vertebra proved to be unsuccessful for almost all types of resection.

Purpose To evaluate rates of recurrent instability in adolescent patients with medial patellofemoral ligament (MPFL) reconstruction with allograft and associations of anatomic risk factors with complications. Methods A retrospective review identified patients of a single surgeon who underwent MPFL reconstruction with allograft for recurrent patellar instability with minimum 2-year follow-up. Surgical management was recommended after a minimum 6 weeks of nonoperative management and included MPFL reconstruction with gracilis allograft using a double-bundle technique. Preoperative radiographs were evaluated to assess physeal closure, lower-extremity alignment, trochlear morphology, and Insall-Salvati and Caton-Deschamps ratios. Magnetic resonance images were reviewed to evaluate the MPFL, trochlear morphology, and tibial tubercle trochlear groove distance (TT-TG). Descriptive statistics were used to characterize data. The primary outcome was recurrent instability. Results 20 patients (24 knees; 18 knees in 14 females and 6 knees in 6 males; average age 15.7 years; range 11.5 to 19.6) underwent MPFL reconstruction with allograft (mean ± standard deviation follow-up 5.2 ± 1.7 years; range 2.2 to 8.1). Physes were open in 9 knees. The Insall-Salvati ratio was 1.09 ± 0.16, and the Caton-Deschamps index was 1.17 ± 0.15. Preoperatively, 19 patients were noted to have trochlear dysplasia, and TT-TG was 15.3 ± 3.9 mm. Three of 4 knees (16.7%) with non–hardware-related complications had open physes: 3 (12.5%) had recurrent instability, 2 of which underwent subsequent operation, and 1 sustained a patella fracture after a fall, requiring open reduction and internal fixation. The average Insall-Salvati ratio of these 4 patients was 1.21 ± 0.20, Caton-Deschamps index was 1.18 ± 0.17, and TT-TG was 17.5 ± 3.3 mm, none of which were statistically different from the group without complications. There were no clinically noted growth disturbances postoperatively. Conclusions MPFL reconstruction using allograft tissue may be performed safely in the pediatric and adolescent population with good outcomes at midterm follow-up, few complications, and a low rate of recurrent instability. Level of Evidence IV, case series.

To assess the points of consideration when performing surgical procedures for proximal femoral bone metastasis.Fourty patients who underwent surgery for proximal femoral bone metastasis from 2009 to 2019 were included. Prognostic assessments were performed based on the Katagiri scoring system. The low-risk group underwent endoprosthetic replacement (EPR) following resection, while the high-risk group underwent internal fixation (IF). For the intermediate-risk group, one of the surgical procedures was chosen depending on general and local condition. Survival period, walking ability, and treatment failure were evaluated.Sixteen and 24 patients underwent EPR and IF, respectively. Although walking reacquisition rate was 94% (15 of 16 patients) for EPR and 75% (18 of 24 patients) for IF (p = 0.210), the median time to walking was shorter in IF compared to EPR (EPR, 29 days, interquartile range [IQR] 23-40; IF, 14 days, IQR 9-24; p = 0.014). Neither EPR nor IF resulted in treatment failure for those with survival periods of1 year. The treatment failure rate for those with survival periods of ≥1 year was significantly different between EPR (9%, 1 of 11 patients) and IF (50%, 5 of 10 patients) (p = 0.038). All five patients of treatment failure for IF were renal cancer with no bone formation in the intermediate-risk group. Of the 13 patients who underwent IF for the intermediate-risk group, treatment failure did not occur in 5 patients with bone formation.Although EPR is a more reliable treatment than IF, patients with life expectancy of1 year are sufficiently manageable with IF. For the intermediate-risk group, EPR should be selected for cases without expected bone formation, and IF can be considered for cases with expected bone formation due to the risk of treatment failure for IF at ≥ 1 year after surgery.

Background Coronal shear fractures of the capitellum and trochlea are relatively uncommon and can be challenging to treat because of variable articular comminution and poor bone stock. Classification is valuable to help guide surgical decision making and prognosis. The aim of this study was to present a large series of coronal shear fractures treated according to the Modified Dubberley Classification System (MDCS). Methods Forty-five patients with a coronal shear fracture were followed up (12-93 months, mean: 28 months) after surgical intervention. Fractures were classified according to the MDCS by 3 observers, and outcome data collected included Oxford elbow score (OES), visual analog pain score (VAS), range of motion, complications, and radiographic findings. Results There were 10 type 1, 12 type 2, 8 type 3, and 15 type 4 fractures. There were 26 subtype B fractures (posterior comminution). A total of 37 patients underwent open reduction and internal fixation (ORIF) and 8 primary arthroplasty. The median OES and VAS were 43(16-48) and 2 (0-9), respectively. Median flexion extension arc was 125° (range, 70°-140°). There was no significant difference in OES, VAS, or range of motion according to fracture type (types 1-4), subtype (type a or b), or treatment method (arthroplasty vs. ORIF). The overall complication and reoperation rates were 31% and 33%, respectively. A total of 75% of complications occurred in type 3 and 4 fractures, and there was a nonsignificant trend toward higher complication rate in type B fractures than type A fractures (34% vs. 16%, P = .19). Patients with a type B fracture who underwent screw-only fixation had a significantly lower OES and higher complication rate compared with when they had combined plating with screws (OES, P = .03; complications P = .04) and compared with when an arthroplasty was performed (OES, P = .05; complications P = .04). Conclusion Consistently good outcomes can be achieved by classification and management according to the MDCS. It is recommended that type B fractures undergo combined plate and screw fixation and that type 4 fractures should be considered for arthroplasty because of the higher risk of complications with ORIF.

We conducted a prospective randomized controlled trial to compare the radiological and clinical outcomes of Sanders type III calcaneal fractures treated with percutaneous prodding reduction and K-wire fixation via a sinus tarsi approach (PPRKF) versus open reduction and internal fixation (ORIF). Fifty-one patients with closed, unilateral, Sanders type III calcaneal fractures were randomly assigned to the PPRKF group (n = 26) or the ORIF group (n = 25). The clinical outcomes evaluated were time to surgery, blood loss, operative time, hospital stay, wound healing time, wound complications, and Maryland foot score. Radiological results were evaluated on lateral and axial X-rays and computed tomography images and included Böhler's angle, Gissane's angle, and calcaneal width. Compared with the ORIF group, the PPRKF group had shorter time to surgery, shorter operative time, less blood loss, shorter hospital stay, shorter wound healing time, and fewer wound complications (p.001). The postoperative Böhler's angle, Gissane's angle, and calcaneal width in both groups were significantly better than those measured preoperatively (p.001) and did not differ between the PPRKF group and ORIF group (p.05). Regarding clinical results, there was no significant difference in Maryland foot score between the two groups at 12 months after surgery (p.05). Both PPRKF and ORIF can result in satisfactory clinical function. PPRKF is superior to ORIF in reducing the time to surgery, operative time, blood loss, hospital stay, wound healing time, and wound complications.

Objectives To determine the effect of intramedullary screw-based fixation on early postoperative complications after olecranon fractures. We hypothesized that intramedullary screw-based fixation results in decreased need for reoperation compared to plate and screw and tension band-based fixation. Design: Retrospective cohort. Setting 2 academic level-1 trauma centers.Patients / Participants: 556 patients treated with a tension band, plate and screw, or intramedullary-based construct for an olecranon fracture over a 10-year period. Intervention: Open reduction and internal fixation. Main outcome measurement Unplanned reoperation. Demographic, injury type and severity, supplemental fixation, and length of follow up data were viewed as potential confounders and analyzed as such. Results We identified 556 relevant patients. 199 patients were treated with an intramedullary screw-based construct, 229 with a plate and screw-based construct, and 128 with a tension band-based construct. We observed significant differences in the age, fracture type, percentage of open fractures, use of supplemental fixation, and treating institution between the treatment groups. 95 patients (17.1%) had an unplanned reoperation. When we adjusted for confounders, intramedullary screw-based fixation reduced the odds of an unplanned reoperation by 54% compared to plate and screw-based treatment. In the adjusted analysis, we did not observe a difference between plate and screw-based treatment and tension band-based fixation. Conclusions Intramedullary screw-based fixation of olecranon fractures results in decreased need for early reoperation compared with more common olecranon fixation strategies. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Scaphoid bone fracture is one of the commonest carpal bone fractures. It is predominantly seen in young population. Unstable or displaced scaphoid fractures can be treated either by primary use of cast immobilization alone, by use of Open Reduction Internal Fixation (ORIF) technique or by percutaneous fixation with Herbert screw under direct C arm fluoroscopic guidance. This study aims to review clinical, radiological and function outcome following ORIF technique Vs Percutaneous Fixation Technique in scaphoid fractures.Cases of acute scaphoid fractures who came to our department and met inclusion and exclusion criterias were identified and included in this study. Clinical details of these patients were obtained and scaphoid radiographs were taken. Injuries were graded as per Herbert and Fisher Classification. All our cases underwent grip-strengthening exercises and relevant physiotherapy Clinico-radiological details of our cases were obtained at each follow-up. Final follow-up of our cases was performed using Modified Mayo Wrist Score (MMWS). Grip strength was graded as per Medical Research Council (MRC) scale and range of motion was assessed using goniometer.A total of 40 cases were enrolled in our study. 16 patients (40% cases) underwent percutaneous herbert screw fixation and rest of our cases underwent open reduction and internal fixation. Radiological union in cases treated with percutaneous fixation was faster as compared to cases treated by ORIF. Also patients treated with percutaneous method demonstrated higher mean range of motion score, mean grip strength score and activity score. In our study excellent results have been obtained in cases treated with percutaneous approach in terms of post-operative morbidity and this approach also allows earlier return to sports and work thereby necessitating importance of this approach over ORIF approach in a developing resource poor country like India.

Hypophosphatemic rickets is a hereditary disease of childhood that affects bone metabolism. Patients with this disease can have poor bony healing at growth centers due to impaired mineralization of the cartilaginous bone plates. The orthopedic literature has shown appropriate long bone healing in patients with rickets who are undergoing concurrent medical management. However, there has never been a report of successful osteotomy or fracture of the maxillomandibular skeleton in a patient with rickets with documented radiographic and clinical resolution. This report describes a case of successful Le Fort I osteotomy with bilateral mandibular sagittal split osteotomies with concurrent medical management in an 18-year-old female with hypophosphatemic rickets. Before surgery the patient was consented and understood that because there has never been a documented case such as this, she might especially risk complications including non-union, malunion, or unfavorable osteotomy splits. The intraoperative quality of the patient's bone was of normal caliber and allowed routine osteotomy creation and internal fixation with no complications. She was followed for over 3 years and showed uneventful healing. While this disease is especially rare, practitioners should be aware that acceptable healing alongside appropriate medical management has been documented.

Displaced bony avulsion of the hamstring origin is a rare condition that necessitates surgical treatment. This article describes the surgical treatment of acute apophyseal separation of the ischial tuberosity via open reduction and internal fixation with cortical screws., Technique Video Video 1 Technique of open reduction and internal fixation of bony avulsion of ischial tuberosity. Patient preparation may be considered the most important step of the operation. Under spinal anesthesia, the patient lies prone; the hip joint is in neutral position, and the knee is flexed. In this manner, traction forces on the fragment will be at a minimum, allowing an easier reduction. The orientation of the ischial tuberosity should be remembered for the future placement of the fixation material. The skin is marked to delineate the gluteal fold. One should note that it is usually more horizontal compared with the limit of the underwear. Use of a leg holder with a lateral extension permits the surgeon to keep the hip in an abducted position during sciatic nerve dissection and screw placement. Before draping, the placement of the patient on the table is verified with an image intensifier. After the skin incision, subcutaneous dissection is performed until the inferior border of the gluteus maximus muscle is reached. The muscle is elevated with blunt dissection, the ischial tuberosity is palpated, and a curved retractor is placed superior to the ischial tuberosity. Before deep dissection, the lower extremity is abducted to avoid nerve damage. The fragment is mobilized beginning from the medial side. Dissection of the lateral side is carried out longitudinally, with care, to the nerve fibers. As the fragment becomes more mobile, the bony fragment is handled with a sharp forceps to gain control of it. The interval between the sciatic nerve and the avulsed proximal hamstring origin may be dissected bluntly with a finger until all of the adhesions between the nerve and the fragment are removed. The ischium is cleaned of fibrotic tissues. A Hohmann retractor is placed on the ischial ramus and replaced by a glenoid retractor, which is more stable. This will provide a wider area of sight. The avulsed fragment is debrided to achieve good bone contact. When the fragment is well mobilized, the quality of reduction is checked. A Hohmann retractor is placed lateral to the ischial tuberosity to protect the sciatic nerve from the wires. One must pay attention to align the inferior border of the fragment with the ischium. Usually, it is needed to be fixed more proximally than it is presumed to be. Two provisional K-wires are applied. The quality of reduction is checked with the image intensifier. The orientation of the K-wires may be used to guide screw placement. The proximal screw is measured and inserted after drilling with a 3.5-mm drill bit. Screw tensioning must be performed gently and sequentially, preferably with 2 fingers, to avoid breakage of the fragment. The same procedure is repeated for the second screw, and the fixation is controlled with the image intensifier.

OBJECTIVES: Laser-assisted Indocyanine Green Angiography (LA-ICGA) is a novel method for objectively quantifying soft tissue perfusion. The primary aim of this study was to determine whether skin perfusion surrounding tibial plateau and pilon fractures is associated with the Tscherne classification for severity of soft tissue injury. The secondary aim was to determine if soft tissue perfusion improves from the time of injury to the time of definitive fracture fixation in fractures treated using a staged protocol. DESIGN: Prospective cohort study SETTING: Academic trauma centre PATIENTS: Eight pilon fracture patients and 19 tibial plateau fracture patients that underwent open reduction internal fixation MAIN OUTCOME MEASUREMENTS: Skin perfusion (fluorescence units) as measured by LA-ICGA RESULTS: Six patients were classified as Tscherne grade 0, nine as grade 1, ten as grade 2, and two as grade 3. Perfusion decreased by 14 fu (95% CI: −21, −6, p

SUMMARY Intra-articular fractures of the distal humerus present challenges to treating physician and patient alike. The olecranon osteotomy is accepted as the standard exposure for intra-articular distal humerus fractures; nevertheless, complications such as nonunion and implant prominence are common. In this article, we describe the clinical outcomes and anatomic features of the triceps tenotomy as an alternative method of exposure for internal fixation of intra-articular distal humerus fractures. The olecranon osteotomy approach affords greater exposure of the distal humerus articular surface; however, there was no difference in quality of fracture reduction, progression to fracture union, posttraumatic arthrosis, or implant failure between approaches in our series. The osteotomy approach resulted in a greater need for reoperation (15% vs. 46%, respectively); largely as a result of olecranon implant-related complications. In summary, the triceps tenotomy offers an alternative exposure for intra-articular distal humerus fracture fixation with comparable clinical outcomes to the olecranon osteotomy technique.

Category: Ankle; Other Introduction/Purpose: Open reduction and internal fixation (ORIF) of the ankle is a common procedure performed to correct ankle fractures in many different patient populations. Diabetes, peripheral vascular disease, and osteoporosis have been identified as risk factors for postoperative complications following surgery for ankle fractures. To date, there have not been any studies evaluating postoperative outcomes in patients with bleeding disorders undergoing operative treatment for ankle fractures. The aim of this study was to determine the postoperative complication rate following ORIF of the ankle in patients with a bleeding disorder versus those without a bleeding disorder. Methods: From 2006 to 2018, patients undergoing operative treatment for ankle fracture were identified in the National Surgical Quality Improvement Program database. Two patient cohorts were defined: patients with a bleeding disorder and patients without a bleeding disorder. Patients who underwent either inpatient or outpatient ORIF of the ankle were included in this study. In this analysis, demographics, medical comorbidities, and postoperative complications variables were assessed between the two cohorts. Bivariate and multivariate analyses were performed. Results: Of 10,306 patients undergoing operative treatment for ankle fracture, 9,909 patients (96.1%) had no bleeding disorder whereas 397 patients (3.9%) had a bleeding disorder. Following adjustment on multivariate analysis, compared to patients who did not have a bleeding disorder, those with a bleeding disorder had an increased risk of any postoperative complications (OR 1.479; p=0.024), requirement for postoperative blood transfusion (OR 2.863; p=0.001), and extended length of hospital stay greater than 5 days (OR 1.455; p=0.010) (Table 1). Conclusion: Patients with bleeding disorders are at an increased risk of postoperative complications following ORIF for ankle fractures. Our study found that patients with bleeding disorders had greater odds of postoperative complications following ORIF of the ankle. Determining patient risk factors and creating optimal preoperative and perioperative management plans in patients with bleeding disorders undergoing ORIF can be beneficial in reducing postoperative complications, improving patient outcomes, and reducing overall cost.

Osteochondral lesions of the talus (OLT) are often associated with ankle pain and dysfunction. They can occur after ankle trauma, such as sprains or fractures, but they usually present as a continued ankle pain after the initial injury has resolved. Chronic ankle ligament instability and subsequent microtrauma may lead to insidious development of an OLT. Medial-sided lesions are more common (67%) than lateral-sided lesions. For acute lesions that are nondisplaced, nonoperative management is initially performed, with a 4-6 week period of immobilization and protected weight bearing. Symptomatic improvement results in more than 50% of patients by 3 months. Acute osteochondral talus fractures, which have a bone fragment thickness greater than 3 mm with displacement will benefit from early surgical intervention. These injuries should undergo primary repair via internal fixation with bioabsorbable compression screws 3.0 mm or smaller using at least 2 points of fixation. Acute lesions that are too small for fixation can be treated with morselization and reimplantation of the cartilage fragments. If OLTs are persistently symptomatic following an appropriate course of nonoperative treatment, various reparative and restorative surgical options may be considered on the basis of diameter, surface area, depth, and location of the lesion. A small subset of symptomatic osteochondral lesions of the talus involve subchondral pathology with intact overlying articular cartilage; in these cases, retrograde drilling into the cystic lesion can be employed to induce underlying bony healing. Cancellous bone graft augmentation may be used for subchondral cysts with volume greater than 100 mm3 or with those with a depth of more than 10 mm. Debridement, curettage, and bone marrow stimulation is a reparative technique that may be considered in lesions demonstrating a diameter less than 10 mm, with surface area less than 100 mm2, and a depth less than 5 mm. This technique is commonly performed arthroscopically using curettes and an arthroscopic shaver to remove surrounding unstable cartilage. A microfracture awl of 1 mm or less is used to puncture the subchondral bone with 3-4 mm of spacing between to induce punctate bleeding. Initial ( Lesions greater than 1.29 cm2, cystic lesions, and lesions that have failed prior treatment are potential candidates for osteochondral autograft transplantation. The autograft is typically harvested from the lateral femoral condyle of the ipsilateral knee with an optimal plug depth and diameter of 12-15 mm. Transplantation often involves open technique and may even require malleolar osteotomy for perpendicular access to the defect, as well as visualization of a flush, congruent graft fit. Good to excellent outcomes have been reported in up 87.4% of cases with the most common complication being donor site morbidity in up to 15% of cases. Failure rates increased significantly in lesions larger than 225 mm2. Scaffold-based therapies, such as matrix-associated chondrocyte implantation, can be employed in primary or revision settings in lesions larger than 1 cm2, including uncontained shoulder lesions with or without cysts. Lesions with greater than 4 mm of bone loss following debridement may require bone grafting to augment with the scaffold. This technique requires an initial procedure for chondrocyte harvest and a secondary procedure for transplantation of the scaffold. Outcomes have been good to excellent in up to 93% of cases; however, this technique requires a two-stage procedure and can be cost-prohibitive. Particulated juvenile cartilage is a restorative technique that employs cartilage allograft from juvenile donors. The cartilage is placed into the defect and secured with fibrin glue in a single-stage procedure. Studies have shown favorable outcomes in 92% of cases, with lesions between 10 and 15 mm in diameter, but increased failure rates and poorer outcomes in lesions larger than 15 mm. This may be an alternative option for contained lesions between 10 and 15 mm in diameter. Osteochondral allograft plugs are an option for larger contained lesions (>1.5 cm in diameter) and in patients with knee osteoarthritis (OA) and concern for donor site morbidity. Furthermore, bulk osteochondral allograft from a size-matched talus can also be used for even larger, unstable/uncontained shoulder lesions. An anterior approach is often employed and fixation is achieved via placement of countersunk headless compression screws. Failure of the aforementioned options associated with persistent pain or progressive OA would then lend consideration to ankle arthroplasty versus ankle arthrodesis.

Objective To determine the rate of acute compartment syndrome (ACS) in a series of patients with Gustilo-Anderson type IIIB open tibial shaft fractures that were treated using a specific two-stage orthoplastic protocol. Design Consecutive cohort study.Patients/Participants: Ninety-three (n =93) consecutive patients with a type IIIB open tibial shaft fracture (OTA/AO-42) treated utilizing a two-stage orthoplastic approach, between August 2015 and January 2018. Following exclusions, eighty-three (n=83) were eligible for analysis. Intervention Colloid resuscitation and two-stage orthoplastic reconstruction of type IIIB open tibial shaft fracture. Stage one consists of "three-vessel view" early debridement and temporary internal fixation, with stage two consisting of a single-stage fix and flap. Main outcome measurements Rate of ACS. Secondary outcomes included early/late sequelae of missed ACS, deep infection, arterial injury, nonunion and flap failure. Results Eighty-three (n = 83) patients were included for analysis. Median age was 45.4 years (Interquartile range (IQR) 35) with a median follow up of 1.6 years (IQR 0.8). Median number of operations was 2.0 (IQR 4). For the primary outcome, there were a total of zero (0/83) patients who required fasciotomy or developed early/late clinical sequelae of missed ACS. Six (6/83, 7.2%) patients developed deep infection, eighteen patients (18/83, 21.7%) experienced non-ischaemic arterial injury, five patients (5/83, 6.0%) experienced nonunion, with four patients (4/83, 4.8%) experiencing flap failure. Diabetes was the only variable associated with deep infection (p=0.025) and nonunion (p Conclusions Patients with type IIIB open tibial shaft fractures treated with colloid resuscitation and a two-stage orthoplastic protocol, which includes early "three-vessel view" exposure and debridement, do not appear to develop ACS. Furthermore, no sequelae of missed compartment syndrome was observed at final follow up. Level of evidence Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.