What's New in Orthopaedic Trauma.

What's New in Orthopaedic Trauma.

What's New in Orthopaedic Trauma.

What's New in Foot and Ankle Surgery.

What’s New in Orthopaedic Trauma

To determine the minimum clinically significant difference in visual analog scale (VAS) pain scores for acute pain in the ED setting and to determine whether this difference varies with gender, age, or cause of pain. A prospective, descriptive study of 152 adult patients presenting to the ED with acute pain. At presentation and at 20-minute intervals to a maximum of three measurements, patients marked the level of their pain on a 100-mm, nonhatched VAS. At each follow-up they also gave a verbal rating of their pain as "a lot better," "much the same," "a little worse," or "much worse." The minimum clinically significant difference in VAS pain scores was defined as the mean difference between current and preceding scores when pain was reported as a little worse or a little better. Data were compared based on gender, age more than or less than 50 years, and traumatic vs nontraumatic causes of pain. The minimum clinically significant difference in VAS pain scores is 9 mm (95% CI, 6 to 13 mm). There is no statistically significant difference between the minimum clinically significant differences in VAS pain scores based on gender (p=0.172), age (p=0.782), or cause of pain (p=0.84). The minimum clinically significant difference in VAS pain scores was found to be 9 mm. Differences of less than this amount, even if statistically significant, are unlikely to be of clinical significance. No significant difference in minimum significant VAS scores was found between gender, age, and cause-of-pain groups.

Determining the minimum clinically significant difference in visual analog pain score for children

Aim To explore a more effective surgical procedure, the outcomes of closed manipulative reduction (CMR) combined with minimally invasive plate osteosynthesis (MIPO) and conventional open reduction and internal fixation (ORIF) for treating proximal humeral fractures were compared. Material and methods In a retrospective study of patients operated for humerus shaft fractures from April 2008 to July 2011, the outcomes of 33 patients treated with CMR/MIPO were compared with the outcomes of 42 patients treated with ORIF. The fractures were classified, and the incision length, blood transfusion, operating time, as well as the VAS (Visual Analog Scale) pain scores were analyzed. The neck–shaft angles of the proximal humerus were detected, and the postoperative function of the shoulder was evaluated. Results The mean values of incision length, blood transfusion, and VAS pain scores at the 1st and 3rd day after CMR/MIPO and operation time were lower than that of ORIF. The postoperative radiographs verified good position of all screws and satisfactory bone fracture reduction in both groups. Meanwhile, in the ORIF group, nonunion (three cases) and humeral head necrosis (four cases) were detected. Conclusions The MR/MIPO technique showed smaller incisions, easier operation, less blood transfusion and more effective recovery of shoulder joint function for treating proximal humeral fractures than ORIF.

Most pediatric tibial shaft fractures (75%)1 can be treated nonoperatively; however, unstable and open fractures require surgical intervention. Titanium elastic nails have become a popular technique for fixation of pediatric tibial shaft fractures. They act as internal splints that impart relative stability to the fracture, promoting callus formation at the fracture site2. After the patient is placed in the supine position, the proximal tibial physis is marked using fluoroscopy. An anteromedial and anterolateral incision are made distal to the physis. Entry holes are created in the proximal part of the tibia, and appropriately sized titanium nails are introduced into the bone. Nail size should be 40% of the width of the canal, yielding 80% canal fill when 2 nails are used. The nails are prebent into a gentle C-shape to increase cortical contact at the apex so that 3-point fixation is achieved. The nails are passed to the fracture site, and the fracture is then reduced. The nails are then passed across the fracture site and stopped proximal to the distal tibial physis. The nails are then cut and tamped distally until there is just a short portion of nail left out of the proximal part of the tibia so that the nails can be removed once the fracture is healed. The wounds are then closed, and postoperative immobilization is applied. Many pediatric tibial shaft fractures can be treated with closed reduction and cast immobilization. Open fractures, or fractures that fail nonoperative management, can be treated with external fixation, open reduction and internal fixation (ORIF), or intramedullary stabilization3. Anatomic reduction and fracture compression can be achieved with ORIF; however, a drawback to this technique is the lack of soft-tissue coverage in the diaphyseal area of the tibia, which can lead to infection and wound-healing problems4. External fixation has traditionally been the technique of choice for open tibial fractures; however, with the ability to use flexible tibial nails in both open and closed tibial fractures, external fixation is now reserved for open fractures with large soft-tissue defects or in fractures with segmental bone loss. Intramedullary flexible nailing can be used in both open and closed tibial fractures, provides excellent fracture fixation, and utilizes incisions that are more cosmetically appealing to patients5,6. Outcomes following flexible nailing for pediatric tibial fractures are excellent. In a study of 19 patients undergoing flexible nailing for tibial shaft fractures, 18 had excellent or satisfactory results7. Compared with patients who had external fixation, those treated with flexible nails had less pain, shorter time to union, and better functional outcomes2. Compared with patients treated with ORIF, those who underwent flexible intramedullary nailing spent less time in the operating room and had lower rates of wound complications4. In the immediate postoperative period, clinicians should be aware of the risk of compartment syndrome, particularly in patients with high-energy injuries, older patients (>14 years old), and heavier patients (>50 kg)8. There is also an increased risk of soft-tissue irritation and fracture malunion in heavier patients treated with flexible nails9,10. Nail size should be 80% of the canal diameter (e.g., two 4.0-mm nails should be chosen for a canal that measures 10 mm).Nails should be properly contoured to avoid corticotomy of the far cortex during insertion; apex of the bend should be positioned at the level of the fracture.During insertion, leave room to advance nails further after they are cut proximally.Do not bury the proximal nail tips beneath the cortex as extraction will be difficult.Ensure that the ends of the nails are not lying up against the proximal tibial physis as this may cause premature growth arrest.

What's New in Foot and Ankle Surgery.

Objective To compare minimally invasive plating via a small infero-fibular approach versus open reduction and internal fixation via an extended lateral approach in the treatment of intra-articular fractures of the calcaneus. Methods A retrospective study was conducted to analyze the 92 patients who had been treated in our department for calcaneal fracture of Sanders type Ⅲ form March 2010 to March 2011.They were treated either by minimally invasive plating via a small infero-fibular approach (MI group) or by open reduction and internal fixation via an extended lateral approach (ORIF group).Only 17 pairs of the patients were included in the present study who were matched in sex,age and fracture type.The operation time,intraoperative and postoperative bleeding volume,fracture healing time and local complications for the 2 groups were documented.The therapeutic outcomes were compared between the 2 groups according to the evaluation system of American Orthopaedic Foot and Ankle Society (AOFAS),Visual Analogue Scale (VAS) pain score,and short form 36(SF-36). Results The MI group and the ORIF group obtained a mean follow-up of 14.2 months and of 15.3 months respectively.The MI group and the ORIF group had a mean operation Time of 84.0 ± 6.1 minutes and of 90.8 ± 5.4 minutes, a mean intraoperative and postoperative bleeding volume of 97.4 ± 10.6 mL and of 181.2 ± 10.9 mL,and a mean SF36 score of 60.2 ± 5.9 points and of 49.8 ± 5.0 points,respectively.There were significant differences between the 2 groups regarding the above indexes ( P ＜ 0.05).On average,there were no significant differences between the 2 groups regarding fracture healing time (9.5 ± 1.2 weeks versus 9.8 ± 1.4 weeks),AOFAS score (91.2 ± 6.6 points versus 88.7 ± 12.3 points) and VAS pain score ( 1.8 ± 0.7 points versus 1.9 ± 0.7 points) ( P ＞ 0.05).The MI group had one case of achilles tendon pain and the ORIF group had one case of incision infection and one case of delayed incision healing.There was no significant difference in complications between the 2 groups(x2 =3.000,P =0.223). Conclusion Compared with ORIF in the treatment of intra-articular fractures of the calcaneus,the minimally invasive plating via a small infero-fibular approach can better improve the quality of life of the patient without significant compromises in functional recovery and complications. Key words: Calcaneus; Fractures, bone; Fracture fixation, internal; Surgical Procedures,minimally invasive

ObjectivesTo determine whether the minimum clinically significant difference (MCSD) in visual analogue scale (VAS) pain score varies with age, gender, education level and cause of pain (trauma versus non‐trauma) in Chinese patients.MethodsThis was a prospective descriptive study of local Chinese patients 15 years of age or older who presented with pain to the accident & emergency department. On presentation, patients were asked to indicate their current pain severity with a single mark through a standard 100–mm visual analogue scale. Then they would be offered an analgesic for pain‐relief. After 30–45 minutes, the patients were asked to give a verbal categorical rating of their pain as ‘a lot better’, ‘a little better’, ‘much the same’, ‘a little worse’, or ‘much worse’ and to mark the level of pain on a VAS of the same type as used previously. The MCSD in VAS pain score was defined as the mean difference between the current and preceding scores when the subject reported ‘a little worse’ or ‘a little better’ in pain. Data were compared based on gender, age, education level, and traumatic versus non‐traumatic causes of pain.Results186 patients were enrolled in the study, yielding 77 evaluable comparisons where pain was rated as ‘a little better’ or ‘a little worse’. Overall, the MCSD in VAS pain score in the group was 17 mm (95%CI 13.6 mm to 20.6 mm). There were statistically significant differences between the MCSD in VAS pain score between genders and causes of pain (trauma versus non‐trauma).ConclusionsThe MCSD in VAS pain scores was found to be 17 mm. There was significant differences in MCSD in VAS pain score in different genders and between trauma and non‐trauma cases.

Partial meniscectomy using needle arthroscopy associated with significantly less pain and improved patient reported outcomes at two weeks after surgery: A comparison to standard knee arthroscopy

Proximal humeral fractures (PHFs) are a significant healthcare burden, representing the third most common osteoporotic fracture in older adults. Although open reduction and internal fixation (ORIF) with the Proximal Humeral Internal Locking System (PHILOS) provides a reliable rate of osseous union, postoperative complications such as shoulder stiffness and residual pain remain prevalent. Current rehabilitation protocols are predominantly glenohumeral-centric and often overlook fracture-associated scapular dyskinesis. This randomized controlled trial (RCT) aims to evaluate whether incorporating a systematic scapular control and stabilization program into standard postoperative rehabilitation yields superior outcomes after PHILOS fixation. A single-centre, prospective RCT was conducted from June 1, 2023, to December 31, 2024. Sixty eligible patients (aged 18 to 80years) with severely displaced two- or three-part PHFs were randomized (1:1) to a scapular-focused rehabilitation (SFR) group (n = 30) or a standard rehabilitation (SR) group (n = 30). Both groups attended supervised physiotherapy twice weekly for 12weeks, with the SFR group receiving additional systematic scapular stabilization exercises. The primary outcome was the Constant-Murley score (CMS) at 12months. Secondary outcomes included the Disabilities of the Shoulder, Arm, and Hand (DASH) score, the American Shoulder and Elbow Surgeons (ASES) score, the Shoulder Pain and Disability Index (SPADI), and visual analog scale (VAS) pain scores assessed at one, three, six and 12months, along with EuroQol (EQ) scores, patient-reported satisfaction and radiographic evaluations (neck-shaft angle [NSA] and humeral head height [HHH]). Baseline characteristics were well balanced between the two cohorts. The SFR group had significantly higher adjusted mean CMS at 1month (46.1 ± 7.5 vs. 41.5 ± 8.4; P = 0.039) and threemonths (63.4 ± 9.6 vs. 57.2 ± 9.1; P = 0.018) postoperatively than the SR group. Similarly, the SFR cohort had significantly superior DASH, ASES, SPADI pain, and VAS pain scores at one and threemonths (all P < 0.05). Furthermore, health-related quality of life, comprehensively evaluated via EQ-5D and EQ-VAS indices (P < 0.05), as well as patient-reported satisfaction metrics (P < 0.001), were markedly higher in the experimental cohort during the initial threemonths of intensive rehabilitation. However, these functional differences attenuated over time, with no statistically significant differences in CMS (P = 0.325) or secondary clinical outcomes at the 12-month final follow-up. Radiographic analysis revealed no significant intergroup differences in NSA or HHH at any time point (P = 0.600 and P = 0.462 at 3months, respectively), indicating that the targeted intervention did not compromise construct stability. Incorporating systematic scapular-focused exercises into standard postoperative rehabilitation after PHILOS fixation for PHFs serves as a beneficial adjunct that significantly accelerates early functional recovery, reduces early postoperative pain, and improves patients' overall health utility and satisfaction in the early stages. These early gains are achieved without compromising fracture reduction or implant stability. Although long-term functional outcomes converge by 12months, this accelerated recovery trajectory provides substantial clinical value by effectively reducing the burden of early postoperative disability in a vulnerable demographic.

Comparison of warm and cold contrast media for hysterosalpingography: a prospective, randomized study

Distal tibial and fibular fractures are typically the result of high-energy trauma. Open reduction and internal fixation (ORIF) are often used to reconstruct and reduce displaced fractures, especially intra-articular ones. These fractures can be addressed either by a dual-incision approach (medial approach for the distal tibia and lateral approach for the fibula) or by a single-incision direct lateral approach to fix both the tibia and fibula. The direct lateral approach avoids injury to the medial soft tissues. This study was conducted to compare the postoperative clinico-radiological and functional outcomes of the single-incision direct lateral approach and the dual-incision approach for distal tibial and fibular fractures. A prospective comparative cohort study of 40 patients was conducted. The patients were classified into two cohorts of 20 each based on the surgical approach: those who underwent a single-incision direct lateral approach and those who underwent a dual-incision approach for distal tibial and fibular fractures (procedure: ORIF with plating). The study was conducted from September 2022 to March 2024. A follow-up period of at least 12 months was carried out, comparing operative time, discharge time, and postoperative outcomes using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, ankle range of motion (ROM), Southampton wound score for wound healing, visual analog scale (VAS) pain score, and periodic radiographs at each follow-up. Complications were also studied. The mean operative time was 95.06 ± 7.04 minutes for thesingle-incision approach and 109.89 ± 7.88 minutes for the dual-incision approach. The average blood loss was 202.41 ± 32.76 mL for thesingle-incision approach and 248.39 ± 28.18 mL for the dual-incision approach. The hospital stay was shorter in the direct lateral approach group, and the AOFAS score at 12 months was better in the direct lateral approach group (91.47 ± 2.55 for thesingle-incision approach vs. 83.33 ± 8.71 for the dual-incision approach). Postoperative wound healing was observed, and the Southampton wound score was compared. Overall, soft tissue complications were fewer in the direct lateral approach group. The postoperative VAS pain score was consistently lower in the single-incision direct lateral approach group, which also demonstrated better ankle ROM. The p-value was significant (<0.05) for these parameters. At the six-month follow-up, all patients exhibited clinical and radiographic healing and bone union, except for one case in the dual-incision group. A medial compound wound, treated by plastic surgery with flap cover intervention, was identified as one of the definitive indications for single-incision plating. The single-incision approach was associated with better soft tissue healing, fewer wound complications, and superior ankle functional outcomes compared to the dual-incision approach.