Anatomical Fixation Research Articles

Unusual Combination of Postero-Lateral Elbow Dislocation and Ipsilateral Diaphyseal Radial Fracture: A Case Report and Review of Literature

The combination of a radial diaphysis fracture and ipsilateral elbow dislocation is a rare lesion. Only a few similar cases have been reported in the literature. Such injuries need a concentric reduction of the dislocation and an anatomical fixation of the radius for optimal functional outcomes. The radial fracture and ipsilateral dislocation of the elbow were probably caused by forearm hypersupination with extension of the elbow. Closed reduction of the elbow and operative stabilization of radial fracture were done with good clinical, radiological and functional outcomes in 8 months follow-up period. We discuss through a clinical case of a radial shaft fracture unusually associated with postero-lateral elbow dislocation and through a review of the literature the clinical aspects, the mechanism, treatment and the evolving profile of this particular lesion.

L’ajout d’un cerclage n’augmente pas la stabilité de la fixation des fractures inter-trochantériennes comminutives. Une étude biomécanique

BackgroundIntertrochanteric fractures with a posteromedial intermediate fragment are unstable because of the loss of medial support. Additional fixation with a cerclage is used in subtrochanteric fractures, but not in intertrochanteric fractures. The aim of this biomechanical study is to evaluate whether cerclage fixation improves stability of intertrochanteric fractures.Hypothesis Our hypothesis is that the cerclage fixation of the intermediate fragment increases fixation stability of intertrochanteric fractures. Materials and methodsSynthetic femora with intertrochanteric fractures (AO 31.A1.3) with a posteromedial fragment were fixed with a long gamma nail. The intermediate fragment was fixed with a cerclage cable. Four groups were compared: 1: no cable fixation, 2: anatomic reduction and cable fixation, 3: anatomic reduction and fixation of a fragment where its proximal part was removed simulating comminution, 4: non-anatomic reduction and cable fixation. The specimens were loaded axially in a testing machine. The preload was 100N, followed by ten conditioning cycles from 100N to 500N. The test phase consisted of the cyclic loading between 100N and the maximum force that increased at a rate of 50N at each cycle until failure. The stiffness was calculated from the load/displacement curve of the last three conditioning cycles. ResultsThere were no statistically significant differences between force to failure (group 1: 681N; group 2: 846N; group 3: 699N; group 4: 806N; ANOVA p=0.23) and stiffness (group 1: 769N/mm; group 2: 819N/mm; group 3: 815N/mm; group 4: 810N/mm; ANOVA p=0.84) between groups. There were significant differences in the widening of the lag screw canal (group 1: 2.16mm; group 2: 4.5mm; group 3: 3mm; group 4: 2.5mm; ANOVA p=0.017). In individual comparison, the differences were significant only between the anatomical reduction group and the non–anatomical reduction (p=0.04) and the no cable group (p=0.02). DiscussionThere is a controversy in clinical literature whether cable fixation improves treatment outcome of proximal femoral fractures. This study suggests that medial wall reconstruction with a cerclage cable does not improve axial stability of the fixation. Level of evidenceNot applicable; a biomechanical study.

Anatomical fixation of tibial intercondylar eminence fractures in children using a threaded pin with an adjustable lock

IntroductionTibial intercondylar eminence fractures are a rare pathology causing anterior laxity of the knee, which requires anatomical reduction and a stable osteosynthesis. The aim of this study was to present the clinical results of reinsertion in anatomical position of these fractures, in the paediatric population, using a threaded pin with an adjustable lock. HypothesisOur hypothesis was that the clinical results would be satisfactory and comparable to the literature. MethodThis retrospective, monocentric study involved 34 consecutive patients with tibial intercondylar eminence fractures, divided into 55.9% with type 2, 35.2% with type 3, 8.8% with type 4 according to Meyers & McKeever, operated on between March 1999 and March 2018. Assessments were performed at a minimum follow-up of 1-year and included the Lysholm, subjective International Knee Documentation Committee (IKDC) and Tegner activity scores, and the measurement of anterior knee laxity by the KT1000. ResultsAt the average follow-up of 8.8 years, 7 patients were lost to follow-up, 2 required anterior cruciate ligament reconstruction. Pathological residual laxity was present in 25% of cases and instability in 16%. The average Lysholm score was 93.1±9.8, the average subjective IKDC was 93.8±6.4 and the average Tegner score was 5.6±1.5. The average anterior laxity of the knee was 0.7±2.0mm. ConclusionThe anatomical reinsertion using a threaded pin with an adjustable lock for tibial intercondylar eminence fractures in a paediatric population provides good functional results and is comparable to the data in the literature. Level of evidenceIV; retrospective.

Two Decades of Abdominal Aortic Endovascular Repair With the Anatomical FiXation at the Aortic Bifurcation in a Large Single-Center Experience

Objective: The introduction of new endograft models improved long-term results of abdominal aortic aneurysm (AAA) endovascular repair (EVAR), but most of them maintained an old and unchanged design: a short body and long legs shifting up the flow divider. This study assessed the long-term results of EVAR with unimodular endoprosthesis fixed at the aorto-iliac bifurcation (Anatomical FiXation), in a large, unselected cohort. Materials and Methods: In a single-center, retrospective cohort study, 623 patients selectively treated between 1999 and 2016, were analyzed. Follow-up protocol included at least a computed tomography angiography within 3 months and a duplex ultrasound and clinical exam yearly. All enrolled patients were analyzed by 2020. The primary outcomes were technical success, clinical success, and survival. Secondary outcomes included survival-free from late-open-conversion (LOC), reintervention, and endoleaks. Results: Median age was 74±11 years and the follow-up 93±54 months. The technical success was achieved in 99.4% and the 30-day clinical success was 98.4%. A 5-year clinical success of 97.7% was registered and at 10 years success was 96.7%. The overall survival at 1, 5, 10, and 15 years was 92.4%, 79.5%, 64.9%, and 45.5%, respectively. Six (0.98%) AAA-related death were registered, 3 caused by infection of the endograft and 3 for secondary rupture. LOCs were 9 (1.47%) and reintervention-free survival at 1, 5, 10, and 15 years were 88.4%, 78.0%, 76.2%, and 74.6%, respectively. Freedom from endoleaks was 88.8% at 1 year and 72.7% at 15 years. A total of 63 high-flow endoleaks were registered (43 type I, 7 type IIIa, 12 type IIIb, and 1 type Ib+IIIb). No migrations were recorded, and the graft limb thrombosis rate was 1.14%. From a multivariate analysis resulted that long-term clinical success appeared to be reduced in patients affected by diabetes [odds ratio (OR) 0.24; p=0.04] and in presence of calcified and thrombotic iliac accesses (OR 0.16; p=0.006). Conclusion: EVAR with the Anatomical FiXation was confirmed to be safe, feasible, and effective to prevent AAA rupture in the long term as well. However, the overall survival remains afflicted by cardiovascular accident. The original concept of unibody bifurcated design allowed a very low rate of graft thrombosis and zeroed the risk of migration and related reintervention.

Tricortical iliac crest graft as a salvageable option in the reconstruction of comminuted posterior wall acetabular fractures: our experience from a level 1 trauma centre.

Comminuted fractures of the posterior acetabular wall, pose a significant challengein the reduction and fixation of the fracture fragments and usually result in dubious functional outcomes. Primary reconstruction of the severely comminuted posterior wall using the autologous tricortical iliac crest graft has shown promising results, especially in fractures not amenable for anatomical reduction and fixation. Thus, the present study analyses the functional and radiological outcomes of severely comminuted posterior wall acetabular fractures, primarily reconstructed with an autologous tricortical iliac crest graft. This is a retrospective study, where all cases of comminuted posterior wall acetabulum fractures treated primarily with reconstruction using ipsilateral autologous tricortical iliac crest graft between January 2011 and November 2018 were included. The data of patients were retrieved from the hospital records and all the patients were assessed clinically and radiologically at the final follow-up. Fourteen patients (ten males and four females) were operated on with a mean operative time of 160min (range 125 to 190min) and a mean blood loss of 410ml (range 320ml to 830ml). At 2years of follow-up, 11 patients (78.57%) had good to excellent functional outcomes based on the modified Merle d'Aubigneand Postel scoring system. The radiological assessment using Matta's criteria indicated excellent outcomes in two patients (14.48%), good in six patients (42.85%), fair in six patients (42.85%). Primary reconstruction of the comminuted posterior wall acetabulum fractures is a potential alternative and salvageable option with favourable outcomes. However, it ought to be considered in severely comminuted fractures where anatomical reduction and internal fixation is not feasible.

Syndesmotic diastasis and it’s relation to the functional outcome in ankle fractures

Ankle fractures are among the most common injury treated by orthopaedic surgeons. Syndesmotic injuries represent the severity of the ankle injuries. However, they are difficult to evaluate, have a lengthy recovery period, and may disrupt normal joint functioning if not appropriately treated. These ankle injuries are disastrous if not appropriately treated specially to athletes and those engaged in heavy work on irregular surfaces. Hence treating these ankle injuries are of utmost importance. The aim of this study was to assess the functional outcome in ankle fractures with syndesmotic diastasis and without syndesmotic diastasis. To provide guidelines for intra-operative assessment of syndesmotic stability. To find out the complications occurring in each group. This was a prospective observational study conducted in yenepoya medical college hospital from October 2017 to October 2020. In this study 42 patients were treated and each equally were divided into two groups with syndesmotic injury and without syndesmotic injury. Open reduction and internal fixation with locking / one third tubular plate with 3.5 system for lateral malleolus and 4 mm CC screws for medial malleolus for fractures without syndesmotic injury and fracture with syndesmotic injury additional 4mm screw was put, which was evaluated. Diagnosing the syndesmotic instability preoperatively wasn’t adequate. However when combined with intraoperative assessment by checking for translational movements and cottons test; it was found to be more reliable. Open reduction and anatomical fixation is required to obtain good results. A simple syndesmotic screw will suffice the job and the screw needs to be removed before weight-bearing in order to avoid screw breakage. To conclude, the functional outcome scores were lower in syndesmotic group. However, we need to assess the functional outcomes in a longer time frame to see if any statistically significant difference actually exists or not.

Cerclage cable augmentation does not increase stability of the fixation of intertrochanteric fractures. A biomechanical study

BackgroundIntertrochanteric fractures with a posteromedial intermediate fragment are unstable because of the loss of medial support. Additional fixation with a cerclage is used in subtrochanteric fractures, but not in intertrochanteric fractures. The aim of this biomechanical study is to evaluate whether cerclage fixation improves stability of intertrochanteric fractures. HypothesisOur hypothesis is that the cerclage fixation of the intermediate fragment increases fixation stability of intertrochanteric fractures. Materials and methodsSynthetic femora with intertrochanteric fractures (AO 31.A1.3) with a posteromedial fragment were fixed with a long gamma nail. The intermediate fragment was fixed with a cerclage cable. Four groups were compared: 1: no cable fixation; 2: anatomic reduction and cable fixation; 3: anatomic reduction and fixation of a fragment where its proximal part was removed simulating comminution; 4: non-anatomic reduction and cable fixation. The specimens were loaded axially in a testing machine. The preload was 100N, followed by ten conditioning cycles from 100N to 500N. The test phase consisted of the cyclic loading between 100N and the maximum force that increased at a rate of 50N at each cycle until failure. The stiffness was calculated from the load/displacement curve of the last three conditioning cycles. ResultsThere were no statistically significant differences between force to failure (group 1: 681N; group 2: 846N; group 3: 699N; group 4: 806N; ANOVA p=0.23) and stiffness (group 1: 769N/mm; group 2: 819N/mm; group 3: 815N/mm; group 4: 810N/mm; ANOVA p=0.84) between groups. There were significant differences in the widening of the lag screw canal (group 1: 2.16mm; group 2: 4.5mm; group 3: 3mm; group 4: 2.5mm; ANOVA p=0.017). In individual comparison, the differences were significant only between the anatomical reduction group and the non-anatomical reduction (p=0.04) and the no cable group (p=0.02). DiscussionThere is a controversy in clinical literature whether cable fixation improves treatment outcome of proximal femoral fractures. This study suggests that medial wall reconstruction with a cerclage cable does not improve axial stability of the fixation. Level of evidenceNot applicable; a biomechanical study.

A prospective study of clinical and radiological outcome of fractures of distal end radius treated using volar rim plate

Aim: This study has been undertaken to study clinical and radiological outcome of fractures of distal end radius treated using volar rim plate. Materials and Methods: This review the results of 25 cases of distal end radius fracture treated with volar rim plate from October 2019 to march 2021 in Bapuji hospital and Chigateri general hospital attached to J J M Medical College Davanagere. Results: Results were evaluated using Modified Cooney green and O Brien functional score. In present study we have 20 patients with excellent results 4 patients with good results and 1 patient as fair and 0 patients as poor .None of patients developed non union plate prominence tendon irritation and implant failure. Conclusion: The implant provides anatomic reduction stable fixation preservation of blood supply early and active mobilization.

Assessment of factors resulting to functional outcome of intertrochanteric fracture of femur managed by proximal femoral nail: Antirotation 2 (PFNA 2)

Background: Intertrochanteric femur fracture management in elderly needs more attention to reduce malunion and increase early mobilisation to reduce mortality and morbidity. Ideal choice of treatment is internal fixation by intramedullary or extramedullary devices. Intramedullary devices provide more stable proximal femoral anatomical fixation. Between PFN and PFNA; helical blade in PFAN provides more stability, better compression and rotational control with lower cut-out rate. Aim: a) To assess the factors for functional outcome of PFNA2. b) Evaluation of effectiveness and stability of PFNA 2. Material and Methods: 30 patients with unstable Intertrochanteric femur fracture between Nov 2020 to July 2021 fulfilling inclusion and exclusion criteria were included in this study and underwent closed reduction and intermal fixation by PFNA(n=30). Assessment was done in terms of demography, preoperative and intraoperative variables, postoperative parameters mainly functional outcome till 1 year postoperative. Results: Preoperative variables, AO fracture type were assessed preoperatively. Duration of surgery, blood loss and fluoroscopy imaging were significantly lower in PFNA as compared to PFN. Postoperative complications like cut-out rate, shortening, varus malalignment, return to pre-fracture state were also lower in PFNA group than PFN. Postoperative functional assessment done by Harris Hip Score shows better outcome in PFNA than other fixation devices. Conclusion: PFNA reduces duration of surgery, blood loss, fluoroscopy imaging as compared to other implants. PFNA also offers better postoperative functional outcome.

Proximal fixation of endovascular aortic device may not be associated with renal function decline after abdominal aortic aneurysm repair

ObjectiveSignificant debate exists among providers who perform endovascular abdominal aortic aneurysm repair (EVAR) regarding the renal function change between suprarenal (SuF) and infrarenal (InF) fixation devices. The purpose of this study is to review our institution's experience using these devices in terms of renal function. MethodsThis is a retrospective review of all elective EVARs performed within a three-site health system (Florida, Minnesota, and Arizona) during the period of 2000 to 2018. The primary outcome was renal function decline on long-term follow-up depending on the anatomical fixation of the device (SuF vs InF). Secondary outcomes were length of hospitalization (LOH) and progression to hemodialysis. Multivariable regression analysis was performed to test for associations affecting LOH. ResultsThere were 1130 elective EVARs included in our review. Of those, 670 (59.3%) had SuF and 460 (40.7%) InF. Long-term follow-up was 4.8 ± 3.7 years, and the rate of change in creatinine and estimated glomerular filtration rate (eGFR) were not statistically significant among groups (SuF vs InF). LOH was higher in those individuals with a SuF device (3.4 ± 2.2 vs 2.3 ± 1.0 days; P < .001). Ten patients with chronic kidney disease progressed to hemodialysis at 6.7 ± 3.8 years from EVAR. On Kaplan-Meier analysis, patients with chronic kidney disease with SuF were more likely to progress to hemodialysis (P = .039). On multivariable regression, female sex (Coef, 2.4; 95% confidence interval [CI], 0.17-0.41; P = .02), SuF (Coef, 9.5; 95% CI, 0.11-1.11; P < .0001), and intraoperative blood loss of greater than 150 mL (Coef, 15.4; 95% CI, 0.11-1.76; P < .0001) were predictors of prolonged LOH. ConclusionsOur three-site, single-institution data indicate that, although the starting eGFR was statistically lower in those individuals undergoing elective EVAR with InF, device fixation type did not affect the creatinine and eGFR on long-term follow-up. However, caution should be exercised at the time of abdominal aortic aneurysm repair in those individuals who already presented with renal dysfunction.

Suture Anchor Augmentation for Acute Unstable Isolated Ankle Syndesmosis Disruption in Athletes.

Isolated ankle syndesmosis disruption (without fibula fracture) causes acute pain and may cause chronic instability and pain. The aim of the present study was to evaluate the outcomes after anterior inferior tibiofibular ligament (AITFL) anatomical fixation using anchor sutures for unstable isolated syndesmosis disruption without fibular fractures. This study assessed 22 athletes who were diagnosed with unstable isolated syndesmosis disruption with a positive external rotation test, had more than 2-mm diastasis on ultrasound, and had complete AITFL rupture on magnetic resonance imaging between 2004 and 2020. Eighteen patients (82%) were elite-level athletes, and the remaining 4 were recreational athletes. Twelve patients (55%) were injured by an external rotation force. The athletes underwent open anatomical suture anchor fixation between the AITFL attachment sites, the fibula and tibia. The mechanism of injury, return-to-play time, and Foot and Ankle Outcome Score (FAOS) were evaluated. All athletes returned to previous play except 1 retired elite athlete. Twenty-two athletes returned to jogging, team training, and official game play at an average of 62, 89, and 102 days, respectively. The final average follow-up FAOS symptom, pain, daily activity, sports activity, and quality of life scores were 98, 97, 100, 99, and 97, respectively. Two athletes were reinjured, and 1 required reoperation in the follow-up period. Athletes with isolated syndesmosis disruption had a high likelihood to return to their previous activity level after suture anchor augmentation. Level IV, case series.

Locked plating of geriatric olecranon fractures leads to low fixation failure and acceptable complication rates.

HypothesisThe purpose of this study was to report the rate of major complications in patients with geriatric olecranon fractures managed operatively with a locking plate. Secondary objectives included minor complications, as well as pain and range of motion at the final follow-up. We hypothesized that these patients have a low rate of complications as well as low pain and satisfactory elbow range of motion at the final follow-up.Materials and MethodsA retrospective review of isolated geriatric olecranon fractures presenting from 2006 to 2019 was performed at a single level I trauma center. Inclusion criteria were ≥75 years of age, operative management with a locking plate, and clinic follow-up at least until evidence of radiographic union or a major complication. Exclusion criteria included nonoperative management, insufficient follow-up, and absence of locking plate in surgical technique. Variables examined included demographic information, Charleston comorbidity index, American Society of Anesthesiologists score, living independence, gait assistance, mechanism of injury, open vs. closed fracture, Mayo radiographic classification, Arbeitsgemeinschaft für Osteosynthesefragen classification, time to surgery, implant type, presence of triceps offloading suture, length of postoperative immobilization, date of radiographic union, range of motion at the final follow-up, pain visual analog scale score at the final follow-up, major and minor complications, and return to the operative room. A major complication was defined as a return to the operative room for deep infection or loss of fixation (displacement of fracture >5 mm). A minor complication was defined as any other complication.ResultsA total of 65 patients ≥75 years of age with olecranon fractures were identified. Of these, 36 patients met inclusion criteria with an average follow-up of 23 weeks (range 5-207). The mean length of immobilization was 13 days (range 0-29 days). Thirty-two of 36 (88.8%) patients achieved radiographic evidence of union at an average of 8.9 weeks (range 5.3-24.1 weeks). There were 4 remaining patients who underwent secondary intervention before primary union representing an 11.1% major complication rate including 2 deep infections (5.6%) and 3 failures of fixation (8.3%). There were 7 minor complications in 5 of 36 (13.9%) patients. At the final follow-up, the average visual analog scale score was 2.6 (range 0-6), the average elbow arc of motion was 120° (range 70-147°), and mean pronation/supination was 85°/84° (range 45-90°/45-90°).ConclusionGeriatric olecranon fractures are a challenging orthopedic problem with remaining controversy regarding ideal treatment. Despite advancement in geriatric fracture care, there is scant literature on the outcomes of locked plating technology in geriatric olecranon fractures. This study supports use of operative anatomic fixation with precontoured locked plates and early mobilization with an acceptable failure rate.

Precontoured Locking Compression Plate with Titanium Alloy Cable System: In Treatment of Neer Type IIb Distal Clavicle Fracture.

ObjectiveTo describe a new method which involves anatomical distal clavicle plate fixation and titanium alloy cable system‐augmented coracoclavicular ligament reconstruction to manage Neer type IIb distal clavicle fracture.MethodsBetween January 2013 and June 2018, 28 patients with acute Neer type IIb lateral clavicle fracture were treated by a new method – precontoured locking compressive distal clavicular plate fixation of the fracture combined with titanium alloy cable system‐augmented reconstruction of the coracoclavicular ligament. There were 11 females and 17 males treated in this way. There were 15 cases of the right side and 13 of the left. The mean age of the patients was 48.5 years (range, 18–78 years). The mean time from injury to surgery was 3.9 days (range, 1–7 days). After completing the preoperative examinations and evaluations, surgeries were performed for all these patients, anatomical distal clavicle plates were used for fractures, and titanium alloy cables were implanted for the augmented reconstruction of coracoclavicular ligaments. Postoperative protocols, including arm sling management and rehabilitative activities, were unified and recommended to all the patients. These patients were followed up for at least 1 year. The mean duration of postoperative follow‐up was 23.3 months (range, 12–52 months). At the last follow‐up, the coracoclavicular distances were recorded and shoulder functional outcomes were assessed by the Constant scores and the Fudan University Shoulder Scores (FUSSs) questionnaires.ResultsRadiographic bony unions were achieved in all patients within 20 weeks. Functional and radiographic outcomes were retrospectively evaluated. The mean coracoclavicular distance was 9.61 ± 0.61 mm on the injured side vs 9.62 ± 0.57 mm on the contralateral uninjured side. The mean Constant score and mean FUSS were 90.1 ± 6.6 (range, 68–98) and 86.1 ± 7.2 (range, 64–95) respectively, which indicating good restoration of function and high level of satisfaction for both the patients and their physical therapists. There were a few major complications, including one delayed healing of the skin, one severe shoulder stiffness, three incidences of moderate shoulder stiffness, and five incidences of symptomatic hardware. There is no deep infections, neurovascular injuried, delayed union or nonunion, peri‐implant fracture, loss of reduction, implant malposition or failure, or other severe complications.ConclusionThis combined method for the treatment of Neer type IIb distal clavicle fracture could yield high bony union rate, good functional outcome, and low complication rate. Further prospective randomized controlled studies are needed to confirm the benefits of this method of treatment.

Recognition, Treatment, and Outcome of Calcaneal Fracture-Dislocation.

Calcaneal fracture-dislocations are rare but potentially disabling injuries that are regularly overlooked at first presentation. To date, only about 50 cases have been reported in the literature. Over a period of 8 years, 10 patients (average age 61.7 years) with acute fracture-dislocations of the calcaneus were treated at 2 level 1 trauma centers. The calcaneocuboid joint was involved in 9 patients. There was a concomitant fracture of the lateral talar process and of the tip of the distal fibula in 7 patients each. Open reduction and internal fixation was performed in 9 of 10 patients via an oblique lateral dislocation approach. One patient underwent primary subtalar fusion. All patients were seen for clinical and radiographic follow-up at an average of 3 years using patient-reported outcome scores. Anatomic fixation was achieved in all patients as judged by postoperative computed tomographic imaging. In the 9 patients treated with internal fixation, the Foot Function Index averaged 12.8, the EuroQol 5D score averaged 0.89 and the visual analog scale score for patient satisfaction averaged 79.3 at final follow-up. Signs of mild subtalar arthritis were seen in 6 patients. No secondary subtalar fusions were needed. When recognized and treated early, prognosis of calcaneal fracture-dislocation was favorable. A dislocation approach starting over the distal fibula, continuing over the sinus tarsi, and extending toward the calcaneocuboid joint allowed for adequate visualization of the subtalar joint and treatment of all components of the injury. Level IV, retrospective case series.

Dilemma for Fracture Fixation of Paediatric Ipsilateral Neck with Shaft Femur Fracture.

Ipsilateral femoral neck with shaft fracture (IFNSF) in the paediatric population is a rare injury. This high-impact trauma is often associated with other orthopaedic and systemic injuries. Prognosis is usually guarded as both these osseous injuries are serious and exist together. We report two such patients of IFNSF. Two children with IFNSF were admitted at our hospital in 2018. The first patient had an associated head injury, while in the second patient, the shaft femur fracture was open. We report on the treatment and results in these two patients. Both the patients were serially assessed and followed 2years after the injury. Union was achieved in neck and shaft femur fractures in both the patients by 3months. Complications like avascular necrosis (AVN) of the femoral head, coxa vara, non-union or malunion of fractures, limb length discrepancy, knee and hip stiffness were not seen in either of the patients. IFNSF is a rare injury pattern seen in children, usually associated with concomitant orthopedic and other systemic injuries. Early operative stabilization is the preferred modality of treatment. For an undisplaced neck fracture, a provisional temporary fixation of a relatively less displaced neck fracture, definitively stabilizing the shaft fracture, and thereby returning to fix neck fracture is advocated. For displaced neck fractures, a direct open reduction is advocated. Anatomical fixation with separate implants and a relatively longer immobilization can provide the best-expected results. Long-term follow-up is needed to foresee any complications. V (case series). Therapeutic. The online version contains supplementary material available at 10.1007/s43465-020-00315-z.

Patella Fractures: Approach to Treatment.

Patellar fracture morphology varies based on the mechanism of injury. Most fractures are either a result of direct impact or through an indirect eccentric extensor contraction injury. Each fracture pattern requires appropriate preoperative planning and individualization of the fixation method. Displaced fractures affect the extension apparatus, and often require surgical fixation. Surgical treatment is recommended in fractures with any of the following features: articular step-off > 2 mm, > 3 mm of fracture displacement, open fractures, and displaced fractures affecting the extensor mechanism. Meticulous handling of the soft-tissue envelope is of the utmost importance, given the patella's tenuous blood supply and limited soft-tissue envelope. Incongruent articular surface can result in detrimental long-term effects; therefore, surgical treatment is directed toward anatomic reduction and fixation. The evolution of patellar fracture fixation continues to maximize options to balance rigid fixation with low-profile fixation constructs. Improving functional outcomes, minimizing soft-tissue irritation, and limiting postoperative complications are possible by using the therapeutic principles of rigid anatomical fixation and meticulous soft-tissue handling.

Periangular transmasseteric infraparotid approach in the treatment of condylar-base and low condylar‑neck fractures

Mandibular condylar fractures account for 25 to 52 % of all mandibular fractures. Though current literature favors open reduction and internal fixation (ORIF) of condylar‑base and low condylar‑neck fractures, extraoral approaches are usually considered to be complicated by the risk of facial nerve injury and other possible complications. This study was undertaken to demonstrate that the periangular transmasseteric infraparotid surgical approach (TMIP) to condylar‑base and low condylar‑neck fractures provides excellent access to the bony fragments with minimal risk of complications such as facial nerve and parotid gland injury. In the period from January 2010 to December 2018, 81patients (96 fractures) with condylar‑base and low condylar‑neck fractures underwent ORIF via periangular transmasseteric infraparotid surgical approach. The results of this retrospective study showed minimal postoperative complications. The periangular transmasseteric infraparotid surgical approach allowed precise anatomic repositioning and fixation of the bony fragments in almost all cases except for two juvenile cases with noticeable scars and one case with plate fracture. There were no transient or permanent facial nerve palsies, parotid gland or salivary fistulae complications during a 12‑month follow‑up period. The periangular infraparotid transmasseteric approach to ORIF of condylar‑base and low condylar‑neck fractures is an effective and safe approach allowing accurate anatomic reposition and fixation of the fragments with minimum surgical complications (Tab. 1, Fig. 12, Ref. 21).

Use of custom fabricated surgical jig to improve surgical outcomes in open reduction internal fixation of unilateral orbital fractures: A prospective clinical study.

PURPOSE:The aim of the study was to assess the efficacy of virtual planning and surgical guide jig to improve surgical outcomes of open reduction and internal fixation with restoration and correction of orbital volume (OV) in unilateral orbital wall fractures.METHODS:Fifteen patients with unilateral orbital fractures were assessed with ophthalmologic and radiographic parameters. The orbit was divided into three zones on computed tomography to localize defects. Fractures were coded into Fx Mx Rx Lx (F = Orbital Floor, M = Medial Wall, L = Lateral wall, R = Orbital Roof) based on pattern and specific wall involved. 1-mm sections were used to make stereolithographic models, design the custom fabricated surgical jig for intraoperative use as a guide.RESULTS:Pre- and postoperative ophthalmological parameters, OV, were compared with the contralateral normal orbit serving as the reference. Postoperative ophthalmological parameters showed significant improvement in terms of visual acuity, enophthalmos, dystopia, and traumatic optic neuropathy. OV changes were concentrated in Zones 2 and 3. OV showed adequate restoration postoperatively.CONCLUSION:The surgical jig served as an efficient guide to improve surgical outcomes of open reduction internal fixation. Preplanned intraoperative positioning helped achieve adequate anatomical reduction and fixation with an adequate reconstruction of OV aiding the effective transfer of virtual surgical plan on the table with improved surgical outcomes in clinical performance and functional restitution.Clinical trial registration: The Clinical Trials Registry of India (CTRI) Registration No.: CTRI/2019/11/021929.

Functional outcome of surgical management of ankle fractures with syndesmotic injury

Background: Ankle fractures with Syndesmotic injury are common in Orthopaedic practice. Ankle fractures are the second most common significant lower extremity fractures. Syndesmotic ankle injuries disrupt normal joint functioning, hence need meticulous diagnosis and surgical management to prevent crippling disabilities. Objective: To evaluate the functional outcome of surgically managed ankle fractures with Syndesmotic injury using AOFAS score. Materials and Methods: In this study, 40 patients diagnosed as ankle fractures with Syndesmotic injury, underwent Syndesmotic screw fixation using 3.5mm cortical screws in addition to anatomical fixation of medial and lateral malleolus. Functional outcome was analyzed at 6 months using AOFAS score. Results: In this study, 42.5% (17 patients) of patients had excellent outcome, 45% (18 patients) patients had good outcome, 7.5% (3 patients) had fair outcome, while 5% (2 patients) had poor outcome. 2 patients developed superficial wound infection, treated with IV antibiotics. One patient developed non union and one patient with ankle stiffness. Conclusion: For all cases of Ankle fractures with Syndesmotic injury, open reduction and internal fixation of ankle fracture with Syndesmotic screw fixation helped to achieve good union of fractures and pain free, stable ankle joint.

Injury mechanism affects the stability of suture-button syndesmosis fixation

BackgroundAnkle syndesmosis injury is a common condition, and the injury mechanism can be sorted into pure syndesmosis injury, Weber-B, and Weber-C type fractures. This study aims to evaluate the treatment outcomes and stability of suture-button fixation for syndesmosis injury with different injury mechanisms. We hypothesized that injury mechanisms would alter the stability of suture-button fixation.MethodsWe retrospectively reviewed 63 patients with ankle syndesmosis injury who underwent surgery with TightRope (Arthrex, Naples, FL, USA) from April 2014 to February 2019. The stability of suture-button fixation with TightRope was evaluated by comparing the preoperative, postoperative, and final follow-up measurements of tibiofibular clear space (TFCS), tibiofibular overlap (TFO), and medial clear space (MCS). A subgroup analysis for each demographic group and injury type including pure syndesmosis injury, Weber-B, and Weber-C type fractures were performed.ResultsSyndesmosis was effectively reduced using TightRope. After the index surgery, the tibiofibular clear space was reduced from 7.73 to 4.04 mm, the tibiofibular overlap was increased from 3.05 to 6.44 mm, and the medial clear space was reduced from 8.12 to 3.54 mm. However, syndesmosis widening was noted at the final follow-up, especially in Weber-C type fractures (TFCS 3.82 to 4.45 mm, p < 0.01 and TFO 6.86 to 6.29 mm, p = 0.04). Though widened, the final follow-up values of tibiofibular clear space and tibiofibular overlap were in the acceptable range. Postoperatively and at the final follow-up, medial clear space was found to be significantly larger in the Weber-C group than in the pure syndesmosis and Weber-B groups (p < 0.05).ConclusionsSuture-button fixation can offer anatomic reduction and dynamic fixation in syndesmosis injuries. However, when using this modality for Weber-C type fractures, more attention should be focused on the accuracy of reduction, especially of medial clear space, and rediastasis should be carefully monitored.Trial registrationThis trial was retrospectively approved by TMU-JIRB. Registration number N202004122, and the date of approval was May 06, 2020.Level of evidenceIII