Arc Of Motion Research Articles

Autologous triceps tendon graft for LUCL reconstruction of the elbow: clinical outcome after 7.5years.

The objective of this study was to assess mid- to long-term functional outcomes in patients treated for symptomatic posterolateral instability of the elbow (PLRI) using an autologous ipsilateral triceps tendon as graft. A total of 196 patients were treated with autologous triceps tendon graft for symptomatic PLRI at single orthopedic institution from 2006 to 2013. The surgical treatment contained arthroscopic instability testing, reconstruction of the lateral ulnar collateral ligament (LUCL) and harvesting autologous ipsilateral triceps tendon as graft. The follow-up outcomes included range of motion (ROM), pain measured on a visual analogue scale (VAS), Mayo Elbow Performance Score (MEPS), Oxford Elbow Score (OES) and ultrasound to evaluate the integrity of the refixation of the common extensor. A total of 178 patients (female: 73; male: 105) were available for follow-up at a mean of 91months (range 48-144). No patient reported pain at rest; VAS during activity was 1.8 (range 0-5). The ROM decreased slightly compared to preoperative measurements. Flexion decreased significantly from 135.4 to 131.1, though still within the functional arc of motion. All but 13 patients (8.5%) were clinically stable. However, only two patients received a revision of the LUCL reconstruction due to subjective instability. The mean MEPS in the final follow-up was 91.3 (range 73-100). The mean OES was 46.5 (range 39-48). Three patients reported a pain-free clicking of the elbow. No patient complained about donor site morbidity of the ipsilateral triceps tendon. Ultrasound evaluation showed integrity of the common extensors in all patients. LUCL reconstruction using the ipsilateral triceps tendon as graft shows good to excellent mid- to long-term results in the treatment of symptomatic posterolateral elbow joint instability with a low re-instability and complication rate.

Biomechanical Comparison of Dart-Throw Motions after Partial Wrist Fusions.

Background Multiple partial wrist fusions exist for the management of arthritic disease. Limited information is available on their effect on wrist range of motion in the dart-throwing direction of wrist motion, even though it is used in most activities of daily living. Purpose The purpose of this study was to measure the retained motion for different orientations of dart-throwing motion for seven different partial wrist fusions and proximal row carpectomy (PRC). Methods Eight fresh frozen right cadavers were tested with the wrist intact and followed simulated fusions. Fusions were performed using an external fixation technique and included scaphocapitate, scapholunate (SL), capitolunate, radiolunate, radioscapholunate, scaphotrapeziotrapezoid, 4 corner fusion, and PRC. Results In the intact wrist, the average arc of wrist motion with the wrist oriented at 20 degrees away from the flexion-extension axis was significantly larger than at any other orientation of motion. All partial wrist fusions and the PRC had significantly smaller average dart-throw arc of motion compared with intact at an orientation 20 and 25 degrees away from flexion-extension. The SL fusion provided a significantly larger arc of motion than most of the other fusions at most orientations. Conclusion/Clinical Relevance This study provides a comprehensive compilation of the range of motion in a functional plane, "the dart-throw motion," for limited wrist fusions and PRC. These data provide the clinician with important information that can be used to educate patients regarding expectations after surgery.

English

Stiff elbow is a common problem associated with terrible triad injuries which if not managed properly can lead to significant functional limitations. Here we are describing a case of post-traumatic stiff elbow following terrible triad who presented to us after taking native treatment primarily. He was treated with open arthrolysis and prophylactic ulnar nerve decompression along with rigorous physiotherapy including dynamic splinting with hinge elbow bracing. The results were satisfactory in achieving a functional range of movement according to the patient's vocational need. This study aims to present the prompt management of post-traumatic stiff elbow case along with functional improvement postoperatively in a decisive way. Terrible triad injuries are a group of the rare and severely unstable fracturedislocations following which the chance of recurrent instability, elbow stiffness, and functional limitations increases coherently.1 To perform normal daily activities, painless motion at the elbow joint is very much necessary and critical. Following a traumatic insult, a cascade of events can lead to a decrease in the normal arc of motion and also cause stiffness of the elbow joint.2 Over the last two decades, there has been a lot of speculation revolving around the management of terrible triad injuries.3 Van Riet et al had documented that the majority of the terrible triad injuries need to be managed surgically whereas the non-operative treatment is reserved for a few selected cases. 4 The ones which were not managed adequately had higher chances of turning up into stiff elbow. Post-traumatic elbow stiffness is one of the dreaded complications following terrible triad injuries.3 The aim of managing the case of post-traumatic stiff elbow is to have a painless, near-normal range of motion which can help the patient to do daily activities by himself. We are presenting a case of post-traumatic type- 4 stiff elbow following native bandage treatment and how prompt management has led to satisfactory results.

Outcomes of Surface Replacement Arthroplasty in Metacarpophalangeal Joints Affected by Noninflammatory Arthritis.

The purpose of this study was to investigate the outcomes of surface replacement arthroplasty (SRA) for noninflammatory arthritis of the metacarpophalangeal (MCP) joint. Records from 20 SRAs performed between 1995 and 2017 in 17 patients with noninflammatory arthritis affecting the MCP joint were retrospectively reviewed. The mean follow up was 6.6 years. Three arthroplasties (15%) underwent 4 revision operations. The 2-, 5-, 10-, and 15-year rates of survival from surface replacement implant revision were 90%, 90%, 79%, and 79%, respectively. Major complications occurring in revised joints included arthrodesis (n = 1) and amputation (n = 1). The overall reoperation rate was 35%. The 2-, 5-, 10-, and 15-year rates of overall reoperation-free survival were 75%, 69%, 60%, and 60%, respectively. Pain ratings and MCP arc of motion significantly improved following arthroplasty. Metacarpophalangeal SRA for noninflammatory arthritis can improve arc of motion and pain. Revision is uncommon; however, 1 in 3 joints requires reoperation.

Classification-Based Management of Stiff/Ankylosed Knees.

Stiff knees are defined as those with an arc of motion <50°. They pose a considerable surgical challenge to the operating surgeon. Based on our experience to deal with these complex cases, we have developed a working classification that outlines a flowchart to manage the stiff/ankylosed knees. It was a retrospective study conducted in our department. Out of 570 TKA performed in last 5years, 57 had stiffness and four had bony ankyloses (total 61 knees). Patients were classified based on the fibrous or bony ankylosis and preoperative ROM. Patients were followed for an average 2.4years (1.8-5.5years). KSS pain scores improved from an av. 32 preop (18-64) to av. 76 postoperatively (61-90). The KSS function scores improved from a preoperative value of 36 (16-56) to an av. 78 (52-90) postoperatively. ROM improved from an average of 35.6° (0°-44°) preoperatively to an average of 95.6° (ROM 73°-118°) postoperatively. Extension lag was an av. 8° (3°-12°) and was seen in 13 patients postoperatively. Residual fixed flexion deformity was an av. 7° (3°-14°) and seen in 17 patients. The stiff knees (type 1 and type 2) fared better than ankylosed knees (type 3) in all aspects. Complication rate was high (24%) in our series. Our classification of stiff/ankylosed knees guides the surgeon to decide upon which approach to take, which implants to keep handy and has a predictive and prognostic value.

Effect of Forearm Position on Glenohumeral External Rotation Measurements in Baseball Players.

Alterations in glenohumeral internal rotation (GIR), glenohumeral external rotation (GER), and the total arc of motion (TAM) have been linked with increased injury risk in the shoulder and elbow. These motions have been routinely measured with the forearm in neutral rotation (GIRN, GERN, TAMN). GER capacity appears to be especially important. The throwing motion, however, requires forearm pronation as GER occurs to achieve optimal cocking (GERP). No previous studies have evaluated GERP to determine GER capacity or pronated TAM (TAMP) values. There would be significant differences between GERN and TAMN and between GERP and TAMP. Cross-sectional. Level 3. Sixty asymptomatic male Minor League Baseball players (32 pitchers, 28 position players) participated in the study and were tested on the first day of spring training. Passive range of motion measurements were recorded using a long-arm bubble goniometer for GIRN, GERN, and GERP on both arms. TAM was calculated separately as the sum of internal and external rotational measurements under neutral and pronated conditions. Within pitchers and position players, all measurements were statistically reduced for the throwing arm (P ≤ 0.03) except for GERN of the pitchers. GERP measures were significantly less than GERN for both arms of each group (P < 0.01): pitchers throwing arm +11.8°/nonthrowing arm +4.8°, position players throwing arm = +8.6°/nonthrowing arm +4.0°. The forearm position of pronation, which appears to be mediated by tightness of the biceps, decreases GER capacity and TAM. GER and TAM should be calculated in neutral and pronated positions, considering that 80% of the players have a demonstrated difference between 8° and 12°. Measurement of GERP more accurately reflects the GER required in throwing, allows better quantification of the motion capacity necessary to withstand the loads in throwing, and may suggest interventions for at risk athletes.

Outcomes of Arthroscopic Elbow Contracture Release: Improvement for Severe Prosupination and Flexion Contracture

The purpose of this study was to investigate outcomes following arthroscopic elbow contracture release to describe the use of arthroscopy for improvement in extension/flexion and pronation/supination arcs of motion at a single institution for degenerative and posttraumatic etiologies. Consecutive arthroscopic elbow arthrolysis performed between 2003 and 2015 were retrospectively reviewed. Basic patient demographics, indications for surgery, preoperative and postoperative elbow range of motion, postoperative patient outcome score, and all complications were recorded and analyzed. Fifty-two patients were included with an average follow-up of 5.1 years (range 1.4 to 9.4). Severe contractures made up 50% of cases, followed by 23% moderate, and 27% mild. Average extension/flexion for the post-traumatic group (n= 30) increased by 63° ± 31 and by 29° ± 24 for the degenerative group (n= 22). Average gain in pronosupination was 38° ± 62 in the post-traumatic group and 13°±23 in the degenerative group. Postoperative DASH scores were 17.5 ± 18.4 for post-traumatic cases and 12.8 ± 19.3 for degenerative cases. Arthroscopic elbow contracture release is an effective intervention for degenerative and post-traumatic elbow contracture for both flexion/extension and pronosupination contracture. Furthermore, a two-stage release should be considered when both flexion and pronosupinaton contractures are present. IV, case series, treatment study.

The Unsalvageable Radial Head in Patients Aged 30 Years and Younger

Concern exists regarding the use of radial head arthroplasty (RHA) in younger patients. This study assessed clinical, functional, and radiographic outcomes of RHA in patients aged 30 years and younger. A retrospective review identified 26 elbows that underwent a smooth stem modular RHA in patients aged 30 years and younger at a median follow-up of 3.3 years clinically and 2.9 years radiographically. The mean age was 24 ± 5 years. Indications were acute trauma in 13 patients and chronic pathologies in the remaining 13, and these 2groups were evaluated separately. Patients underwent clinical, functional, and radiographic evaluation. Average arc of motion was 137° ± 16° in the cohort with acute trauma and 120° ± 24° in the cohort with chronic pathologies. Mean Patient-Rated Elbow Evaluation scores were 23 ± 18 (acute) and 31 ± 19 (chronic). Mean Quick Disabilities of the Arm, Shoulder, and Hand scores were 18 ± 15 (acute) and 23 ± 20 (chronic). Average Mayo Elbow Performance Index scores were 90 ± 9 (acute) and 80 ± 13 (chronic). Severe capitellar erosion was present in 1 patient (4%) in the cohort with chronic pathologies. Radiographic stem lucency was seen in all cases with 10 of these (38%) graded as severe. Moderate-to-severe ulnohumeral arthritis developed in 4 patients (15%), 3 of whom were in the chronic reconstruction group. Two patients (8%) required reoperation, 1 for persistent instability and 1 for stiffness, both in the cohort with chronic pathologies. For acute trauma and challenging chronic conditions involving the radial head in patients aged 30 years and younger, a smooth stem modular RHA is an option. Although reoperation rates based on this series are low, osteoarthritis is common when used for posttraumatic conditions and severe radiographic stem lucency was seen in greater than one-third of patients. These concerning features warrant close follow-up, and further long-term outcomes are needed. Therapeutic IV.

A study on the management of non-union of fracture distal femur with locking plates

Background: US FDA defines non-union as fracture bone that has not completely healed in 9 months since injury and which has not shown any signs of healing over 3 consecutive months on serial x-rays. The operative treatment depends on the type of non-union. There are one-step or two-step procedures according to the principles of the ‘diamond concept’. This involves the improvement of the mechanical situation (in most cases with a re osteosynthesis) and vascularization, local application of osteoconductive carriers e.g. tricalcium phosphate, vial cells from autologous bone and osteoinductive substances like bone morphogenic proteins (BMP-2 or BMP-7). Aim: To study the principles and method of fixation of non-union of distal femur with lock plates. Material and Methods: It was a prospective study including patients with non-union of distal femur admitted and examined according to protocol after obtaining informed consent from the patient and permission from the institutional ethics committee. 40 cases satisfying the inclusion criteria admitted in tertiary healthcare centre of Navi Mumbai since May 2018 to March 2020 with minimum 1 year of follow up were included in the study.Results: Patients were also evaluated as per non-union scores. The average non-union score was 19 (range 11 to 27). All of the non-unions united, at an average of 19 weeks. The average arc of knee motion improved from 85° preoperatively to 114° postoperatively. The average Neer’s score improved from an average of 60.4 points (range 16 to 44 points) preoperatively to 89 points post operatively. The knee society score (Part 1) improved from an average of 51.87 points (range 36 to 68) preoperatively to 81.725 points (range 74 to 93) post-operatively. Conclusion: The operative technique respecting the biology and biomechanical principles has shown the influence of success of treating these fractures with locking plates.

A Study comparing Olecranon osteotomy with Triceps reflecting anconeus pedicle approach (TRAP) for internal fixation of supracondylar and intercondylar fractures of the humerus

Objective: To evaluate the outcome of the Olecranon osteotomy approach and TRAP (triceps reflecting anconeus pedicle) approach and comparing them, attributable to Mayo Elbow Performance Score, range of motion, duration of fracture union and duration of surgery. Studydoneat: Government Medical College, Ratlam, MP, India Method and Material: The study is a retrospective randomized control trial on patients with intercondylar and supracondylar fractures of humerus admitted and operated in Department of Orthopaedics, Government medical college and District Hospital, Ratlam from July 2019 to September 2020. Total of 30 patients was included in the study, 15 in each group viz. Group-A operated by TRAP approach and Group-B operated by olecranon osteotomy approach. Results: The difference in Mean duration for fracture union was not statistically significant, in group-A was 12.21 ± 1.621 weeks, while it was 13.46 ± 2.307 weeks in group-B. Duration of surgery was statistically significantly different, more in group B (1.42 ± 0.14 hours) compare to group-A (1.21 ± 0.21 hours). Comparison between ranges of motion of both groups was assessed by Average of extension lag, the mean elbow arc of motion and average of flexion. No significant difference was found between the parameters. The average of extension lag was 11.96 ± 9.26 degree in group-A and it was 16.77 ± 10.31 degree in group-B. The mean elbow arc of motion in group A was 98.34 ± 24.17degrees and in group B was 91.25 ± 21.84 degrees. Average flexion was 109.71 ± 16.65 degrees and 111.47 ± 20.37degrees in group-A and group-B respectively. The average Mayo Elbow Performance Score in group-A was 86.93 ± 12.42 and in group-B was 83.48 ± 15.93. P-value was >.05 show that there was no statistically significant difference between two groups Mayo elbow score. Finally, 25 patients (83.33%) out of 30 showed good and excellent results and hence concluding that there is no statistically significant difference between these two modalities when it comes to outcome. Conclusion: TRAP approach is comparatively better than osteotomy approach in terms of stable fracture fixation and better outcome, with the advantage of intact olecranon. However the approach demands fast rehabilitation. Design: Prospective randomized control trial

Surgical outcome of proximal tibial fractures treated with locking compression plate: A prospective study

Background: The knee joint is one of the major weight bearing joints in the lower extremity. Generally, these injuries fall into two broad categories, high energy fractures and low energy fractures. Fractures of the proximal tibia are the result of high energy injuries and because of lack of soft tissue coverage in this region. The majority of tibial plateau fractures are secondary to high speed velocity accidents and fall from height. Fractures result from direct axial compression usually with a valgus or varus moment and indirect shear forces. Materials and Methods: The study was conducted between the period of November 2017 to April 2019 includes at Department of Orthopaedics, Bowring hospital,Bangalore.20 patients with diagnosis of proximal tibial fractures were treated with locking compression plate. All Schatzker’s classification type 1-6 proximal tibial fractures in adults aged 18 years and above of either sex were included in the study. All patients were followed up. With each follow up, clinical and radiological examinations were performed at 6 weeks, 3 months and 6 months. Results: The study included 20 patients, 18 males and 2 female aged from 21-80 years with mean age of 40.02 years. The average time for fracture union in our series was 15.52 weeks. In present study, knee stiffness was observed in 2 patients. Our study yielded excellent to good results in 80% of cases. Conclusion: Displaced tibial plateau fractures are best managed operatively. Optimal knee function is achieved by accurate anatomical reduction and secure fixation followed by early mobilization to attain functional arc of motion. For minimally-displaced fractures with minimal bone defects percutaneous fixation suffices, whereas for comminuted fractures, open reduction and internal fixation is mandatory. In our study, we found that proximal tibial locking plate provides complete union and early mobilization to attain better functional outcome.

The posterolateral corner of tibial plateau: When and how to fix?

Introduction: The posterolateral tibial plateau fractures remain a challenge and usually a tough nut to crack even for experienced surgeons. The proximity of the neurovascular structures and difficulty owing to the presence of the fibular head demands surgical skills and expertise. The purpose of this study is to understand the technical difficulties such as difficult exposure, limitation of distal extension of approach, limited implant choices. Material and Methods: 14 consecutive cases of isolated posterior fractures of the posterolateral tibial plateau were operated with a modified posterolateral approach without exposing the CPN between September 2016 and September 2019. Articular reduction quality was assessed according to the intraoperative fluoroscopy and immediate postoperative radiographs. Patients were followed up at 2 weeks, 4 weeks, 2 months, 4 months and 6 months. International knee score was assessed online, at the end of 6 months. Results: All patients were followed up, with a mean period of 8 months (range 25–40 weeks). Bony union was achieved in all patients. The average range of motion arc was 126° (range 110°–135°) and the mean postoperative IKS was 94.2 (range 81–97) at 6 months follow-up. None of the patients sustained neurovascular complications. Conclusions: The modified posterolateral approach could help to expand the surgical options for optimal treatment of this kind of fracture, and plating of posterolateral tibial plateau fractures would result in restoration and maintenance of alignment. This approach demands precise knowledge of the anatomic structures of this region but the results are gratifying.

Novel Approach to Improving Knee Range of Motion in Arthrogryposis with a New Working Classification.

Arthrogryposis multiplex congenita (AMC) is a rare condition defined as contrac-tures in multiple joints. Surgical interventions for severe knee flexion contractures have included posterior release, distraction and extension with external fixation and distal femoral extension osteotomies. These operations have been able to achieve knee extension, but not increase the range of motion. The purpose of this study was to review our experience with peroneal nerve decompression, posterior knee release and proximal femoral shortening. We retrospectively reviewed the medical charts and radiographs of all patients with a diagnosis of arthrogryposis who underwent aforementioned procedure. There were 39 patients with 73 knees included in the analysis with a mean follow-up of 21 months. The mean preoperative arc of motion was 45° and last followup arc of motion was 79° (p < 0.0001). The mean last followup flexion contracture was 8° (p < 0.0001). Additional subanalyses were performed on those with followup greater than 24 months and those with flexion contractures >60°; there were no differences found in these groups. This study demonstrates that it is possible to achieve a functional range of motion of the knees in patients with AMC while improving ambulatory function.

Tratamiento de la inestabilidad aguda compleja de codo con fijador interno IJS-E System

IntroductionTreatment of acute complex fracture-dislocation of the elbow has been associated with a high rate of complications. Internal Joint Stabilizer of the Elbow (IJSE) device appears as a valid option to optimize and improve our results. Material and methodsWe present a retrospective case series of five patients treated at our institution with IJS-E System (Skeletal DynamicsR) from February 2019 to 2020. Our inclusion criteria was: patients over 18 years old surgically treated with IJS-E due to persistent elbow instability despite of a suitable osteoligamentous surgical repair. ResultsWe obtained a total of five patients (4 males and 1 female) with an average age of 37.4 years old (24-71). The Injury pattern was posterolateral instability, TTIE in all cases. The mean final postoperative MEP score was 94 points (85-100) and the postoperative DASH score was 11.78 points (4.2-20.6) with an average follow-up of 9.8 months (6-12). We described a final arc of motion of 134° with a range of flexionbetween 120° and 140° and a mean lack of extension of 12° (5°-20°), with a complete arc of pronosupination. As complications we found one case of heterotopic ossfication and one case of elbow stiffnes. However, no complications device-related or articular incongruence were reported during follow-up. ConclusionsThe IJS-E device appears as an effective alternative instead of external fixation. Nevertheless, a high rate of reoperation up to 100% is associated with IJS-E. A larger series, longer follow-up and prospective studies are needed to define properly his role in the surgical treatment of acute elbow instability.

Functional Outcome of Intercondylar Distal Humerus Fractures Surgically Treated with Open Reduction and Internal Fixation with a Principle Based on Orthogonal Plating Technique

Introduction: Owing to the complex articular structure, paucity of metaphyseal bone and thin soft tissue covering, treatment of intra-articular distal humerus fractures still pose challenge to surgeons. Although it comprises 2% of all fractures the massive complication rate to the treatment is worrisome. This study aims to evaluate the outcome of surgical treatment of these fractures by open reduction and internal fixation by dual orthogonal plates.&#x0D; Objectives: The objective of the study is to evaluate the functional outcome of intercondylar humerus fractures managed with open reduction and internal fixation with orthogonal dual plating technique.&#x0D; Methodology: Eighteen patients (19 – 68 years old) with AO/OTA type 13C fractures were evaluated after surgery for one year with MEPS and range of motion. Complications were categorized as major or minor complications. Functional comparisons were made between simple articular type C1/C2 and complex articular type C3 fractures at one year.&#x0D; Result: There were 2 (11.11%) type C1 fracture and 8 (44.44%) each in type C2 and C3 fractures. Eight (44.44%) patients obtained excellent, 7 (38.89%) obtained good and 3 (16.7%) obtained fair results. There was no poor outcome. Average MEPS score was 83.33 and there was no significant between the subgroups (p = 0.07). The average flexion was 118.06° and it was significantly impaired in type C3 fractures (p = 0.03). Three patients obtained full extension, and remaining patients had mean extension deficit of 12°. Average arch of motion was 108.06° with significant difference between two subgroups (p = 0.008). The mean arc of motion for supination-pronation was 154.44°. There was 5 minor and 2 major complications (total - 38.9%).&#x0D; Conclusion: The surgical management with open reduction and internal fixation by dual plates in orthogonal configuration for the intercondylar distal humeral AO type C fractures has good or excellent functional outcome in majority of the patients.

Is postoperative non-weight-bearing necessary? INWN Study protocol for a pragmatic randomised multicentre trial of operatively treated ankle fracture

BackgroundPostoperative management regimes vary following open reduction and internal fixation (ORIF) of unstable ankle fractures. There is an evolving understanding that extended periods of immobilisation and weight-bearing limitation may lead to poorer clinical outcomes. Traditional non-weight-bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The purpose of this trial is to investigate the safety and efficacy of immediate weight-bearing (IWB) and range of motion (ROM) exercise regimes following ORIF of unstable ankle fractures with a particular focus on functional outcomes and complication rates.MethodsA pragmatic randomised controlled multicentre trial, comparing IWB in a walking boot and ROM within 24 h versus non-weight-bearing (NWB) and immobilisation in a cast for 6 weeks, following ORIF of all types of unstable adult ankle fractures (lateral malleolar, bimalleolar, trimalleolar with or without syndesmotic injury) is proposed. All patients presenting to three trauma units will be included. The exclusion criteria will be skeletal immaturity and tibial plafond fractures. The three institutional review boards have granted ethical approval. The primary outcome measure will be the functional Olerud-Molander Ankle Score (OMAS). Secondary outcomes include wound infection (deep and superficial), displacement of osteosynthesis, the full arc of ankle motion (plantar flexion and dorsal flection), RAND-36 Item Short Form Survey (SF-36) scoring, time to return to work and postoperative hospital length of stay. The trial will be reported in accordance with the CONSORT statement for reporting a pragmatic trial, and this protocol will follow the SPIRIT guidance.DiscussionTraditional management of operatively treated ankle fractures includes an extended period of non-weight-bearing. There is emerging evidence that earlier weight-bearing may have equivocal outcomes and favourable patient satisfaction but higher wound-related complications. These studies often preclude more complicated fracture patterns or patient-related factors. To our knowledge, immediate weight-bearing (IWB) following ORIF of all types of unstable ankle fractures has not been investigated in a controlled prospective manner in recent decades. This pragmatic randomised-controlled multicentre trial will investigate immediate weight-bearing following ORIF of all ankle fracture patterns in the usual care condition. It is hoped that these results will contribute to the modern management of ankle fractures.Trial registrationISRCTN Registry ISRCTN76410775. Retrospectively registered on 30 June 2019.

Direct End-to-End Neurorrhaphy for Wrist-Level Long Nerve Defect with Fixation of the Wrist in Flexion: Technique Note.

Background For a nerve gap, end-to-end neurorrhaphy would either be difficult or would include tension. The use of a nerve graft or conduit could be a solution, but it might compromise the reinnervation. We describe a method for wrist-level ulnar and/or median long nerve injury by fixing the wrist in the flexion position with K-wire (s) to make possible an end-to-end and tension-free neurorrhaphy. Patients and Methods Two patients had wrist-level ulnar nerve injury for 2 and 3 months and nerve gaps of 2.5 cm and 3.5 cm, respectively, after the neuroma excision. K-wires were used to transfix from the radius to carpal bones, in order to keep their wrists in flexion of 45 and 65 degrees, respectively, with which the tension-free end-to-end neurorrhaphy could be achieved. The K-wires were removed in 6 weeks after surgery, and their wrists were kept in the splint for a progressive extension program. Results Both patients were noted to have an improved claw hand deformity 4 months after the surgery. The ulnar nerve motor and sensory function could be recovered mostly in the 12-month follow-up. The wrist flexion and extension motion arc both achieved, at least, 150 degree in the 12-month follow-up. There were no complications related to the K-wire fixation. Conclusion With the wrist fixed in a flexed position, maintaining a longer nerve gap to achieve a direct end-to-end and tension-free neurorrhaphy would be more likely and safer. Without the use of nerve graft, innervation of the injured nerve would be faster.

Intra-articular Distal Humerus Fractures: Parallel Versus Orthogonal Plating.

Background: Dual-plating osteosynthesis is the standard treatment for Orthopedic Trauma Association (OTA)-type 13-C distal humerus fractures. However, optimal plate position is debated. Purpose: The purpose of this study was to evaluate dual-plate positioning following intra-articular distal humerus fracture repair by comparing outcomes between patients plated in parallel and those plated orthogonally following open-reduction, internal-fixation (ORIF) of intra-articular distal humerus fractures. Methods: All OTA-type 13-C intra-articular distal humerus fractures treated operatively at our institution over a 10-year period were reviewed. Clinical outcomes and complications were compared between those plated in parallel and those plated orthogonally. Data were analyzed using independent-samples t-tests, Mann-Whitney U tests, chi-square tests, and Fisher's exact tests. Results: A total of 69 patients met inclusion criteria. Mean follow-up among this cohort was 19.3 months; 45 (64.8%) patients had orthogonal dual plating, and 24 (35.2%) had parallel plating. Groups did not differ with respect to demographics or duration of follow-up. Clinically, there were no significant differences in time to union, elbow arc of motion at any time point, or patient Mayo Elbow Performance Index (MEPI) scores at final follow-up. Furthermore, there were no differences in complications. Conclusion: Parallel and orthogonal plating following ORIF of distal humerus fractures with modern, contoured locking compression plates had similar outcomes in this study. This study represents the largest comparative series in the literature at the time of its writing. Both techniques may be considered when deciding on dual-plating technique for treating intra-articular distal humerus fractures.

Outcomes of Osteochondral Autograft Transplantation in Pediatric Patients With Osteochondritis Dissecans of the Capitellum

To assess the outcomes of osteochondral autograft transplantations in the treatment of osteochondritis dissecans of the capitellum in the pediatric population. Between 2011 and 2016, 15 patients who had undergone osteochondral autograft transplantation at a mean age of 13.7 years at surgery were identified. The donor site was from the superolateral, non-weight-bearing surface of the lateral femoral condyle of the ipsilateral knee. Mean follow-up was 29.5 months, with no patients lost to follow-up. Mean arc of motion increased significantly from 121.9° preoperatively to 139.1° postoperatively. All 9 elite athletes returned to sports at an elite level: 7 returned to the same level of competition in the same sport, 1 retired from gymnastics due to multiple injuries but began diving at an elite level, and 1 retired from baseball unrelated to elbow symptoms but continued hockey at the same level. Of the 4 recreational athletes, all returned to sport. There were no intraoperative complications. The symptoms resolved completely in all but 2 patients, who improved over their preoperative condition. The donor site knee pain resolved in all patients at an average of 2.3 months. Postoperative imaging demonstrated the healing and incorporation of the plug in all patients. In the treatment of osteochondritis dissecans of the capitellum, osteochondral autograft transplantation demonstrates excellent clinical and radiographic outcomes, with minimal short-term donor site morbidity and a high level of return to the sport. Therapeutic IV.

Type III open complete articular fractures of the distal humerus: case series outcomes after orthoplastic reconstruction

Open complete articular injuries of this distal humerus are rare injuries which are challenging to manage. The study unit aims to present a small case series of Gustilo-Anderson type III open complete articular fractures which have undergone a single-stage definitive fixation and soft-tissue coverage, presenting their functional outcomes. Retrospective case series identifying all type IIIB AO 13-C3 distal humeral fractures from the unit trauma database. The primary outcome was the Oxford Elbow Score. Secondary outcomes included deep infection, nonunion, and reoperation. A total of six patients were identified, (four open type IIIA, 2 type IIIB). All patients underwent single-sitting definitive fixation and soft-tissue coverage. Mean range of motion arc was 90 degrees. The median Oxford Elbow Score was 35 (range 21-43), representative of mild to moderate arthritis. One patient (n= 1) developed deep infection at 24 months and required reoperation. All patients (n= 6) proceeded to union at the latest follow-up. We present a case report of a 59-years-old patient who sustained a type IIIB, AO 13-C3 distal humeral fracture who underwent single-sitting definitive fixation and flap coverage. This case series reports that positive functional outcomes representative of mild/moderate arthritis at short to midterm follow-up can be achieved after definitive fixation and soft-tissue coverage in a single sitting, including when the soft tissue is deficient. This is a rare injury which is under-reported in the literature.