Articular Step-off Research Articles

Variation in Treatment of Young Adult Distal Radius Fractures by Pediatric and Adult Orthopaedic Surgeons.

There remains a lack of consensus on the optimal treatment of isolated distal radius fractures in young adults. The primary aim of this study was to identify differences in treatment of isolated distal radius fractures in patients aged 17 to 21 years treated by adult versus pediatric orthopaedic surgeons. The secondary aim was to identify whether there is a variation in utilization of open reduction and internal fixation (ORIF) versus closed reduction and percutaneous pinning when treated surgically by adult versus pediatric orthopaedic surgeons. Patients aged 17 to 21 years with isolated distal radius fractures who were treated by adult or pediatric orthopaedic surgeons at 1 of 3 hospitals were identified through retrospective chart review. 72 patients in the pediatric surgeon cohort and 64 patients in the adult surgeon cohort were included. Demographic details were recorded, and radiographs from the initial clinic visit and final follow-up were obtained. Bivariate analysis was used to evaluate for primary and secondary aims. 40 of 136 patients were treated surgically. Bivariate analysis showed that factors associated with surgical treatment were treatment by an adult orthopaedic surgeon, higher body mass index, radiographic severity, AO classification, intraarticular involvement, distal radial-ulnar joint involvement, and meeting AAOS clinical practice guideline surgical criteria. Factors associated with ORIF compared with closed reduction and percutaneous pinning included treatment by an adult orthopaedic surgeon, older age, higher body mass index, and greater articular step-off. In comparable cohorts of young adult patients with distal radius fractures with similar fracture characteristics, there was notable variation in treatment between adult and pediatric orthopaedic surgeons. Surgical treatment was used more by adult surgeons, and when treated surgically, ORIF was used more by adult surgeons. Variation among surgeons illustrates the persistent lack of consensus on the optimal treatment in this population and highlights the need for additional research on this topic to guide management. Level IV.

The Role of Early Mobilization in Outcome of Proximal Tibia Fractures Treated with Dual Plating

The management of bicondylar fracture of the proximal tibia is a challenging task and the aim of management is to achieve stable, painless and mobile joint and also to prevent the secondary degeneration of the joint. Open reduction and internal fixation with dual plating in such fractures is beneficial to address fracture fragments in different planes and also to achieve anatomical reduction under direct vision. It also allows stabilizing the fracture which helps in early mobilization of the patient. Early post-op rehabilitation is one the most important factor that play a vital role in outcome of the operated knees by preventing the post- operative stiffness and achieving good range of motion. This is a retrospective study conducted in Department of Orthopedic Surgery, Kurmitola General Hospital, Dhaka, Bangladesh from July to December 2022. Total 100 patients were included in the study. The functional outcome was evaluated according to Rasmussen scoring system. Mal-reduction of the articular surface was defined as an intra- articular step-off of at least 2 mm measured on scaled radiographs. Oldest patient was 71 years and youngest patient was 20 years old. Male were 79% and female were 21%. All the patients with bicondylar fracture treated with dual plating. Data was obtained from the Medical record department, indoor ward records, OPD registers and Operation theatre records. This study analyses the outcome of bicondylar proximal tibia fracture treated with dual plating in 100 patients. In our series we found 63 % excellent results and 28 % good results, while 7 % and 2% fair and poor outcome respectively. Fractures of proximal tibia are increasing with the increase in mechanization and increased road traffic in current world today. These fractures are more in men and those who use automobiles frequently for their outdoor ventures. Better preoperative planning in selection of approach can minimize the soft tissue injury and unnecessary periosteal stripping. ......

Poster 300: Patellar Cartilage Width and Facet Measurements Associated With Improved Patellar Osteochondral Allograft Matching

Objectives: Few studies have investigated how to best select a donor patella for ideal surface matching when performing a patellar osteochondral allograft (OCA) transplantation. Prior studies have suggested that certain anatomic factors, such as degree of donor patellar dysplasia may play a role. Patella OCA sizing is currently based on tibial width, but other anatomic factors may improve OCA topography matching. The purpose was to investigate how donor and recipient anatomical variables influence patella OCA topography mismatch and articular step-off. Methods: In silico point-cloud models were generated from CT images of 16 patella specimens. Virtual donor allografts were implanted (diameter of 18.0 mm or 22.5 mm) in virtual defects on medial, central, and lateral articular surfaces (Figure 1). Topographical mismatch and step-off were calculated. Linear regression analysis was used to identify anatomic variables influencing these factors. Results: Overall, surface incongruity was largely unaffected by anatomic variables. For 22.5mm medial defects, medial facet length, cartilage width, and medial facet percent were significantly associated with step-off (p < 0.05). For lateral defects (both 22.5 mm and 18.0 mm), lateral facet length, cartilage width, and lateral facet percent had greater effects on articular step-off than tibial width. For 18.0mm medial defects and central defects, tibial width demonstrated a small effect on step-off (Table 1). Cartilage width and tibial width, as well as lateral length and lateral percent were significantly correlated with each other (p = 0.019) (Figure 2). Conclusions: For noncentral defects, articular step-off was strongly influenced by differences in medial or lateral facet length and percent and cartilage width. Tibial width, the current standard for allograft matching, only modestly influenced step-off for central, 18.0 mm medial, and 22.5mm lateral lesions. Since tibial width highly correlated with cartilage width, using cartilage width as a surrogate for tibial width may improve patellar osteochondral surface topography matching as it is a strong predictor of articular step off for non-central lesions. Medial and lateral facet length should also be considered for topography matching of lateral lesions and 22.5 mm medial lesions as they were the strongest overall correlates with articular step-off.

Advancing treatment strategies for posterior malleolar malunion: The ankle dislocation method

BackgroundThis study aimed to assess the radiological and clinical outcomes of treatment using the ankle dislocation method for posterior malleolar malunion. MethodThirty-one patients with posterior malleolar malunion who underwent treatment using the ankle dislocation method from May 2015 to October 2021 were retrospectively analyzed. Key outcome measures were radiographic parameters (articular step-off, tibiofibular clear space, fibular length, tibial lateral surface angle, and ankle osteoarthritis), clinical scores (American Orthopaedic Foot and Ankle Society ankle-hindfoot scale and Visual Analogue Scale), and patient satisfaction rate. ResultPreoperative computed tomography revealed that Bartoní ček types 3 and 4 accounted for 64.5 % (n = 20) of total cases. Most posterior malleolar malunions were accompanied by depressed intercalary fragments (61.2 % [n = 19]). At the final follow-up, radiographic parameters and clinical scores showed significant improvements postoperatively (P < 0.05), with a high patient satisfaction rate of 77.4 %. Subgroup analysis revealed that the posterior malleolar fracture morphology significantly affected postoperative pain, particularly in more complex fractures (P < 0.001). ConclusionThe ankle dislocation method effectively exposes the distal tibial articular surface and facilitates the anatomical restoration of joint congruity under direct vision. This approach substantially improves the clinical and imaging outcomes in patients with complex posterior malleolar malunion. Levels of EvidenceLevel IV, retrospective case series.

Dorsal wrist plating for the management of intra-articular distal radius fractures.

The aim of the study was to evaluate the results of Dorsal Wrist Plating in intra-articular distal radius fractures with a dorsal displacement. In this prospective study, a single surgeon treated 20 patients with a (partially) intra-articular distal radius fracture with a dorsal rim avulsion or a dorsal Barton's type fragment. They all underwent an open reduction and internal fixation by Dorsal Wrist Plating. A total of 17 patients had a follow-up period of at least 12 months (mean follow- up of 17 months) and these patients were included in the study. Both functional and radiological outcome parameters were measured. The total range of motion was 92 % of the contralateral side. The mean grip strength and key pinch were 24.6 kg and 6.9kg respectively compared to 29.5 kg and 7.4 kg on the non-operated side. The average Mayo Wrist Score was 89.7 (range 80-100) and the mean Disability of the Arm, Shoulder and Hand score was 4.5 (range 0-9.2). An articular step-off was only noted in 2 patients (1 and 2 mm respectively). Radial inclination was restored in all patients. Palmar tilt was anatomically restored in five patients. In all other patients, the palmar tilt was acceptably restored. There was no significant radial shortening in any of the patients. No infections, no tendon ruptures, no Complex Regional Pain Syndrome, or union problems were observed. Dorsal wrist plating seems to be a safe and reliable procedure in the treatment of intra-articular distal radius fractures with dorsal displacement.

Articular Fragment Detachment and Separate Fixation for the Treatment of Comminuted Patellar Fractures with Coronal Split Articular Fragments: Articular Detachment Technique.

Treatment of comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments is a challenge. To treat this difficult fracture, we perform articular fragment detachment and separate fixation for coronal split articular and inferior pole fragments. We aimed to evaluate the radiological and clinical outcomes of our technique in comminuted patellar fractures at least 1 year after surgery. Between January 2019 and June 2022, 15 patients diagnosed with comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments based on preoperative computed tomography underwent surgery using the articular detachment technique. The key point of this technique was anatomical reduction and subchondral fixation of the coronal split articular fragment to the superior main fragment after complete detachment of the coronal split fragment from the inferior pole. The remaining inferior pole was fixed using a separate construct. Postoperative articular gap, articular step-off, and complications, including resorption, reduction loss, and avascular necrosis of fixed articular fragments, were evaluated as radiological outcomes. Range of motion and the Lysholm scores were used to evaluate clinical outcomes. Among the 15 patients, the coronal split articular fragments were fixed using Kirschner wires in 13 patients and headless screws in 2 patients. The inferior poles were fixed using separate vertical wiring in 13 patients and tension-band wiring in 2 patients. A postoperative articular gap was noted in 7 patients, with an average articular gap of 1.0 mm (range, 0.7-1.6 mm). No articular step-off was observed. Bone union and normal range of motion were achieved in all patients. On the 1-year postoperative lateral radiograph, resorption of the articular fracture site was seen in 5 patients. There was no loss of reduction or avascular necrosis of the coronal split articular fragments. The average postoperative Lysholm score at 1 year was 89.3 ± 4.1 (range, 82-95). The technique would be a reliable and safe option for the surgical treatment of comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments in terms of anatomical reduction and stable fixation of articular fragments without risk of avascular necrosis.

Clinical and Radiographic Outcomes Following Volar-Locked Plating Versus Dorsal Bridge Plating for Distal Radius Factures

PurposeDistal radius fractures indicated for operative intervention are most commonly treated with volar locked plating (VLP), however dorsal bridge plating (DBP) has been utilized as an alternative fixation method. The purpose of this study was to utilize a propensity score to match and compare the radiographic and clinical outcomes of patients undergoing isolated VLP or DBP for distal radius fractures. MethodsWe performed a retrospective, propensity score-matched analysis of patients undergoing isolated VLP or DBP treatment for isolated distal radius fractures from 2015 to 2022 at a single level-1 trauma center. Patients were propensity score matched by a total of 8 demographic and comorbidity factors, AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification, and preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores. Our primary outcomes included postoperative complications, wrist and forearm range of motion, grip strength, and radiographic measurements, including radial height, radial inclination, volar tilt, and articular step-off. ResultsOverall, 415 DBP and 2075 VLP were successfully propensity score matched and included in this study. Grip strength and range of motion measurements at 6-month follow-up, including wrist flexion, wrist extension, forearm pronation, forearm supination, radial deviation, and ulnar deviation, were increased in the VLP compared to DBP (p<0.05). Complication rates among both groups were relatively low, however, the rate of malunion and nonunion was significantly higher among the DBP group (p<0.05). Radial height, radial inclination, and articular step-off were improved in the VLP group compared to the DBP group (p<0.05), however, volar tilt was similar between groups. PROMIS Upper Extremity (UE) and Physical Function (PF) were significantly higher among the VLP group (p<0.05). There was no significant difference in PROMIS PI between groups. ConclusionsWhen compared to DBP, patients undergoing VLP are more likely to have improved clinical and radiographic outcomes. While improvement in wrist and forearm range of motion and radiographic parameters is statistically significant, it may not be clinically relevant.

Arthroscopic-Assisted Treatment of Bennett Fractures: A Potentially Advantageous Operative Procedure?

Articular fractures of the base of the first metacarpal (Bennett fractures) have been studied for years to determine the best method of reduction and fixation. This study aims to show the application of the percutaneous reduction and internal fixation technique with cannulated screws and arthroscopic assistance in articular fractures of the base of the first metacarpal. Descriptive cohort study in a series of 30 patients, the first cohort in our country and the largest series published so far, in which 8 patients presented with type 2A fracture and 19 patients with type 2B of the Torres-Becerra classification underwent the mentioned technique under direct vision and control of the articular reduction by arthroscopy evaluating the intraoperative characteristics of the articular surface, stability of de reduction and fixation. Assessment of functional and rehabilitation results with a minimum postoperative follow-up of 6 to 12 months. The senior author has used this technique with consistent clinical outcomes to improve reduction and fixation of intra-articular base fractures of first metacarpal bone (Bennett), reducing the articular step-off and gapping permitting an early rehabilitation progress with satisfactory functional results. We can suggest that this surgical method for the treatment of Bennett fractures may offer multiple advantages: adequate debridement of the trapeziometacarpal joint, direct visualization of the articular surface during reduction, achieving greater precision in fixation with minimum morbidity, imperceptible incisions and scars, shorter surgical time, and fewer associated complications.

A study of complications and their associated factors in the management of high-energy tibial plateau fractures treated by open reduction and internal fixation

Background: Tibial plateau fractures are one of the leading causes of joint dysfunction in major weight-bearing joints. Maintained articular surface, uniform plateau level, and a near-normal range of knee joint motion can all be preserved following the appropriate surgical guidelines. Aims and Objectives: The objectives of the study are as follows: (1) To study the complications and their associated factors in the management of high-energy tibial plateau fractures treated by open reduction and internal fixation. (2) To assess radiological parameters pre-operative and post-operative and their relation to fracture pattern. (3) To assess factors, such as fracture patterns, those influence the loss of reduction. Materials and Methods: Statistical analysis was done by expressing the data in frequency, percentage, mean, and standard deviation. Repeated measures ANOVA test or Friedman test or Wilcoxon signed-rank test will be used to compare radiological parameters from pre-operative to opposite side of the limb, and immediate post-operative to 6 weeks and 3 months. Results: Thirty-one cases of proximal tibial plateau fractures were studied between January 2021 and September 2022. The joint width has reduced in the immediate post-operative and has almost remained the same at 45 days and 3 months. The articular step off was noted to have a reduction of 0.3 mm in particular depression which is not significant. In the comparison of tibial offset preoperatively to the immediate post-operative and the 45-day and 12-week follow-up values, there was decrease in the values from the pre-operative to immediate post-operative radiographs and the reduction in the values noted in the further follow-ups is not significant. Conclusion: There was statistical significant difference noted between the pre-operative and immediate post-operative radiological parameters such as joint space width, tibial offset, and medial tibial plateau angle. Further radiological assessment done at 6-week and 3-month post-operative, there was no statistically significant loss of reduction.

Open Reduction Maneuver for Distal Radius Fracture Involving an Intra-articular Sagittal Split

Open Reduction Maneuver for Distal Radius Fracture Involving an Intra-articular Sagittal Split

Metaphyseal Fracture Displacement is Predictive of Intra-articular Diastasis in Adolescent Triplane Ankle Fractures.

Triplane fractures are rare enough that large homogeneous series to support management decisions are lacking. During initial evaluation, the addition of computed tomography (CT) to conventional X-rays (XR) does not always alter the patient's clinical course. Therefore, routine use of CT is controversial. This study aims to: (1) clarify quantitative relationships between articular displacement measured on XR versus CT and (2) identify whether metaphyseal displacement on the lateral XR predicts clinically relevant articular displacement on a CT scan. A 10-year retrospective review of consecutive triplane fractures was performed at a level 1 pediatric trauma center. Maximum articular and metaphyseal displacement were recorded from XR and CT. Quantitative relationships between XR and CT measurements were compared among imaging modalities and radiographically operative versus nonoperative fractures. Eighty-seven patients met the inclusion criteria. XR underestimated articular displacement by 229% in the sagittal plane (1 mm on XR vs 3.3 mm on CT; P < 0.05) and 17% in the coronal plane (2.3 mm on XR vs 2.7 mm on CT; P < 0.05). XR underestimated articular step-off by 184% in the coronal plane and 177% in the sagittal plane ( P < 0.05). CT measurements more often differentiated patients who did or did not undergo surgery at our institution. Metaphyseal displacement was significantly higher in patients with traditionally operative articular displacement (≥2.5 mm on CT) versus those with articular displacement below traditionally operative thresholds (2.4 vs 0.9 mm, P = 0.001). Sixty patients had metaphyseal displacement >1 mm on the lateral XR, of whom 56 had surgical-magnitude articular displacement (≥2.5 mm) on CT (positive predictive value = 94%). Conventional radiographs underestimate the true articular displacement of triplane fractures. Surgical-magnitude articular step-off is rare, and the largest articular gap is usually visualized on the axial CT image. Metaphyseal displacement >1 mm, which is easily measured on a lateral XR, is strongly predictive of clinically relevant articular displacement on CT. This radiographic finding should prompt advanced imaging before proceeding with nonoperative management. Level III.

Surface morphology of osteochondral grafts harvested from femoral condyles with free-hand technique: a cadaveric study.

The purpose of this cadaver study was to examine the surface morphology of the osteochondral grafts harvested from the femoral condyles using the free-hand graft harvesting technique. One hundred osteochondral grafts were harvested with 6.5mm chisels at ten different donor sites using the free-hand technique in five paired knee specimens (Mean age: 56.4years). The cartilage and subchondral bone surface angles were measured through multiplanar reconstruction computerized tomography examination. The cartilage thickness was measured with a MicroScribe G2X digitizer with an accuracy of 0.02mm. An acceptable congruity could be obtained when these plugs were transferred to a perpendicular socket (articular step-off of less than 1mm and 0.5mm) was evaluated. Four plugs were damaged or broken during harvesting due to technical difficulties; thus remaining 96 plugs were analyzed. The cartilage thickness varied between 1.36mm and 3.26mm across the donor sites. The cartilage was the thinnest in the medial intercondylar notch and thickest in the lateral supracondylar notch. Twenty of ninety-six plugs (20.8%) had unacceptable cartilage surface inclination according to the > 0.5mm protrusion criteria. Of these plugs, 14 were harvested from the lateral intercondylar notch, whereas five of 96 plugs (5.2%) had unacceptable cartilage surface inclination according to the > 1mm protrusion criteria. Of these plugs, all were harvested from the lateral intercondylar notch. High rates of unacceptable plugs (up to 100%) might be harvested from the lateral intercondylar notch. In large chondral lesions that require multiple plugs, lateral and medial supracondylar ridges were the best donor sites for perpendicular plug harvesting, whereas lateral intercondylar notch should be avoided.

Cadaveric Biomechanical Study of Partial Glenoid Arthroplasty Versus the Latarjet Procedure for Anterior Glenoid Bone Loss

Background: For severe anterior glenoid bone loss due to recurrent shoulder instability, the Latarjet procedure offers a dynamic sling effect in addition to bone augmentation. Yet, it heavily alters the surrounding anatomy, while fixation and graft union issues are also common. Purpose/Hypothesis: The purpose of this study was to compare a novel printed 3-dimensional (3D) partial glenoid arthroplasty (PGA) implant with the classic Latarjet procedure. It was hypothesized that by replicating the original glenoid geometry and preserving soft tissue anatomy, PGA may better reproduce normal joint kinematics. In addition, the locking screw construct may offer stronger fixation. Study Design: Controlled laboratory study. Methods: A total of 14 matched cadaveric shoulders were tested. The PGA implant was 3D printed in titanium based on preoperative computed tomography. The intact, 25% anterior glenoid bone loss, and postoperative states were tested in the scapular and coronal planes. The following parameters were measured: articular surface area and stepoff, rotational range of motion and the humeral head apex position during rotation, and load and linear stiffness at 25% anterior translation and at 2-mm construct displacement. Results: The baseline dimensions of the glenoid articular surface were comparable between the groups. The articular surface area after PGA was significantly larger (P = .006) with less articular stepoff (P = .030). PGA better approximated the intact state’s external (P = .006) and total (P = .019) rotational range of motion in the scapular plane. The course of the humeral head apex after PGA better followed that of the intact state (P < .001). Resistance against anterior translation after PGA was not significantly different compared with after the Latarjet procedure. Greater linear stiffness (P = .031) and loading (P = .002) at 2-mm construct displacement were demonstrated in the PGA group. Conclusion: In addressing anterior glenoid bone loss, PGA better approximated intact glenohumeral joint kinematics compared with the Latarjet procedure with less articular stepoff in a cadaveric model. PGA was comparable in resisting anterior translation while being significantly stronger against loading at 2-mm construct displacement. Further clinical studies are warranted to validate this novel procedure. Clinical Relevance: A 3D-printed PGA implant may offer an alternative treatment option for severe glenoid bone loss due to shoulder instability, overcoming the previous drawbacks of the Latarjet procedure, including altered kinematics, fixation failure, and hardware issues.

Poster 130: Accuracy of Distal Femoral Condyle Osteochondral Allograft Transplantation Using Patient Specific Instrumentation

Objectives: As a surgical treatment option for cartilage defects in the knee, osteochondral allograft (OCA) transplantation reconstructs the damaged area with a fully formed articular hyaline cartilage/osseous unit. For patients undergoing this procedure, topography matching between the donor and recipient sites is essential to limit premature wear of the OCA. To help prevent graft failure, the surgeon must precisely reconstruct the original anatomic curvature of the articular surface. For this to be successful, the graft needs to be chosen and harvested from the correct location on the donor femoral condyle, and then placed correctly on the recipient condyle during surgery to minimize step-off relative to the surrounding cartilage. Currently, the process of donor and recipient graft matching as well as intra-operative techniques to match these surfaces are fairly rudimentary and require significant experience from the treating surgeon. The purpose of this study is to evaluate a novel topography matching technique for distal femoral condyle OCA transplantation using three-dimensional (3D) laser scanning to create 3D printed patient-specific instrumentation in a human cadaveric model. Methods: Twelve cadaveric knees were dissected to isolate the distal femoral condyles (DFC) with cartilage intact and then 3D laser scanned. An 18-mm circular osteochondral recipient defect was virtually created on the medial femoral condyle (MFC) and the position and orientation of the best topography matched osteochondral graft from a paired donor lateral femoral condyle (LFC) was determined using an in-silico analysis algorithm minimizing articular step-off (Figure 1). Donor (LFC) and recipient (MFC) 3D-printed patient-specific guides were created based on 3D reconstructions of the scanned condyles. Using the guides, OCAs were harvested from the previously defined best-match position on the LFC and transplanted to the reamed recipient defect site (MFC) (Figure 2). The post-OCA recipient condyles were laser scanned. The 360-degree articular step-off and cartilage mismatch topography were calculated by a point-to-surface distance calculation algorithm and compared to the in-silico result. Results: The in-silico cartilage step-off and graft perimeter mismatch for the virtual OCA transplant was 0.073 ± 0.029 mm (range: 0.005-0.113 mm) and 0.166 ± 0.039 mm (range: 0.120-0.243 mm), respectively. Comparatively, our cadaveric specimens post-implant had significantly larger step-off differences (0.173 ± 0.085 mm, range: 0.082-0.399 mm, P = 0.001) but equivalent surface topography matching (0.181 ± 0.080 mm, range: 0.087-0.396 mm, P = 0.678). Conclusions: This novel technique for OCA articular step-off and topography matching demonstrated the ability to optimize cartilage topography matching for LFC to MFC transplantation. Despite a larger mean step-off in the cadaveric specimens compared to the ideal in-silico model, our study demonstrated substantially lower mismatch values compared to previous orthopedic literature evaluating LFC to MFC transplantation that reported means of 0.48 mm for articular step-off (range: 0.335-0.738 mm) and 0.63 mm for surface area mismatch (range: 0.349-1.461 mm). It should be noted that clinically, surgeons performing OCA for the femoral condyles will preferentially select the ipsilateral condyle from the donor to take a plug for the recipient, as this will generally allow for optimal surface matching. Our results show better mismatch values than prior work using this contralateral technique, and even the maximum step-off distance in our cadaveric model fell well below the 0.5 cm –1.0 cm maximum step-off values assigned to be clinically significant by prior studies evaluating ipsilateral OCA transplantations. Using this novel technique in a model performing MFC to MFC transplantation would likely yield further enhanced results due to improved radii of curvature matching. Improving upon topography matched graft implantation for focal chondral defects of the knee in young patients will improve surface matching and associated long-term outcomes. Additionally, efficient selection of the allograft using patient-specific guides would also improve availability of the limited allograft sources and reduce surgical time.

A retrospective epidemiological cohort study of ankle fractures in children and teenagers.

Ankle fracture is one of the most frequent pediatric lower-limb fractures and may result in serious complications. This study aimed to determine the epidemiology of ankle fractures, defining fracture types, treatments, and complications in a pediatric population below 16 years old. Medical records of all the ankle fracture patients treated in our hospital during 2004-2020 were retrospectively reviewed. Data regarding age, sex, mechanism of injury, fracture type, treatment modalities, and complications were collected. We examined records involving 328 children with 331 ankle fractures, with a ratio of 1:2 male per female. Mean annual prevalence was 24.3 per 100,000 children. Mean patient age was 11.2 ± 4.2 years, with 75.3% of them aged over 10 years. Sports activities accounted for the largest percentage of fractures (162 cases; 49.4%), followed by falls (67; 20.4%) and road traffic accidents (37; 11.3%). Physeal fractures were the most frequent type of lesion (223 cases). Most ankle fractures (60%) were managed using closed reduction and casting; for the remaining 40% of cases, fracture fixation was performed after closed or open reduction to correct the articular step-off and ensure the anatomical restoration of the physis. The main ankle fracture complication was premature growth arrest (12.1% of all physeal fractures). Pediatric ankle fractures primarily affect children older than 10 years. Most of these fractures were caused by sports injuries or low-energy trauma. The majority of these fractures are physeal, and the distal tibial physis is affected 10 times more frequently than the distal fibular physis. Level III.

Differences in Inflammation, Radiological and Clinical Outcomes between Short Arm Cast and Long Arm Cast in Intraarticular Distal Radius Fractures

BACKGROUND: Distal radius fractures are the most common upper extremity fractures with a prevalence of 20% of all limb fractures. According to the distal radius fracture guidelines by the American Academy of orthopedic surgeons, conservative therapy can be used in the management of distal radius fractures that are well reduced. AIM: The purpose of this study was to compare conservative therapy of short arm cast (SAC) and long arm cast (LAC) in the management of intraarticular distal radius fractures. METHODS: A prospective cohort observational study with consecutive sampling was conducted on 24 intraarticular distal fracture patients who underwent SAC and LAC procedures. The parameters measured were Interleukin-6 (IL-6) score, ulnar variance (UV), dorsal tilt (DT), articular step-off (SO), radiological union score system (RUSS), and patient-rated wrist evaluation (PRWE) score. RESULTS: The dominance of patients was males aged 46 years, with an average IL-6 levels at 0–24 was 1139.23 ± 266.82 SAC and 1082.64 ± 255.85 LAC, and IL-6 levels at 48 h was 102.98 ± 39.31 SAC and 118.38 ± 39.15 LAC; 2 patients with SAC and 1 patient with LAC obtained unacceptable reduction at week 2 based on UV, DT, SO which did not differ significantly from each follow-up; RUSS 6.08 ± 0.76 SAC and 5.71 ± 0.61 LAC; and PRWE 73.23 ± 4.42 SAC and 71.86 ± 4.07 LAC. Based on statistical analysis, there were insignificant differences in IL-6, UV, DT, SO, RUSS, and PRWE levels between the SAC and LAC groups (p &gt; 0.05). CONCLUSION: Conservative therapy with SAC may be an option for immobilization of distal radius fracture similar to LAC.

Middle-sized posterior malleolus fractures: Fixed versus non-fixed – A prospective randomized study

PurposeThis study aimed to assess the impact of fixation on functional and radiological outcomes of ankle fractures involving the posterior malleolus. We hypothesized that fixation of the posterior malleolus would be associated with improved radiological and functional outcome. MethodsA prospective randomized controlled study was planned and 40 consecutive ankle fractures involving middle-sized (10–25%) posterior fragment were included. Posterior fragments in Group 1 were not fixated while Group 2 underwent posterior malleolus fixation. The patients were evaluated both functionally and radiologically at minimum 2-years. ResultsDemographics and fracture type distributions were similar between the groups. Despite the slightly better functional outcome in Group 2, no significant functional or radiological outcome difference could be detected. Articular step-off> 1 mm was more common in Group 1 (p = 0.04) and the patients with articular step-off showed significantly worse functional outcome in all functional parameters (p < 0.05). Radiological and functional outcome parameters were positively correlated when all patients were evaluated together. Lateral radiographs caused an overestimation in the size of posterior fragment compared to CT (p < 0.001). ConclusionAlthough there was a slightly better clinical outcome in patients with fixed posterior fragments, it was not significant at short to mid-term follow-up. However, posterior fragment fixation contributed to functional outcomes by decreasing the incidence of articular step-off> 1 mm, which was found to be a negative prognostic factor. Level of evidenceLevel I; prospective randomized controlled study.

Arthroscopic double-row bridge fixation provided satisfactory shoulder functional restoration with high union rate for acute anterior glenoid fracture.

To introduce a novel surgical technique for arthroscopic reduction and double-row bridge fixation using trans-subscapularis tendon portal for anterior glenoid fracture and to evaluate the clinical and radiological outcomes. A total of 22 patients who underwent arthroscopic reduction and double-row bridge fixation for an acute anterior glenoid fracture were retrospectively evaluated. Arthroscopic surgery was performed using four portals including a trans-subscapularis tendon portal. All patients underwent 3D-CT preoperatively and one day and one year postoperatively to evaluate the fracture fragment size, reduction status, and presence of fracture union. To evaluate the degree of fragment displacement, articular step-off and medial fracture gap were measured using 3D-CT. Clinical outcomes were assessed based on the ASES and Constant scores. Postoperative glenohumeral joint arthritis was evaluated using plain radiographs with the Samilson and Prieto classification. The average preoperative fracture fragment size was 25.9 ± 5.6%. Articular step-off (preoperative: 6.0 ± 3.3mm, postoperative one day: 1.1 ± 1.6mm, P < 0.001) and medial fracture gap (preoperative: 5.2 ± 2.6mm, postoperative one day: 1.9 ± 2.3mm, P < 0.001) were improved after surgery. On the postoperative one year 3D-CT, 20 patients achieved complete fracture union, and two patients showed partial union. Postoperative glenohumeral joint arthritis was observed in four patients. At the last visit, the ASES score was 91.8 ± 7.0 and the Constant score was 91.6 ± 7.0. Arthroscopic reduction and double-row bridge fixation using a trans-subscapularis tendon portal for acute anterior glenoid fracture achieved satisfactory clinical outcomes and anatomical reduction as demonstrated by a low degree of articular step-off and medial fracture gap. Level IV.

Influence of articular step-off on contact mechanics in fractures of the posterolateral-central tibial plateau - a biomechanical study

BackgroundThe posterior quadrants of the tibial plateau are frequently involved in OTA type C tibial plateau fractures. The biomechanical influence of a residual articular step-off of the posterolateral-central (PLC) segment, which is difficult to visualize intraoperatively, remains unclear.Therefore, aim of this study was to investigate the contact area and stress of the tibial plateau in cases of different articular step-offs of the PLC segment. MethodsSeven human cadaveric knees were used to simulate articular impressions of the PLC segment with step-offs of 1 mm, 3 mm, and 5 mm. The knees were axially loaded up to 150 N during a total of 25 dynamic cycles of knee flexion up to 90°. Pressure mapping sensors were inserted into the medial and lateral joint compartments beneath the menisci to measure articular contact area and stress. ResultsBetween 60° and 90° of knee flexion, increasing PLC segment impressions of the tibial plateau led to increasing contact stress and a significantly reduced contact area. The largest decrease in the contact area was 30 %, with an articular step-off of 5 mm (0.003). An increase in contact stress, especially from a 3-mm step-off, was measured, with a doubling of the mean contact stress at 3-mm and 5-mm step-offs and 90° knee flexion (p = 0.06/0.05). ConclusionFrom a biomechanical point of view, posterior impressions of the PLC segment greater than a 1-mm step-off should be addressed as anatomically as possible, especially in active patients with the need for higher knee flexion angles.

Radiographic Outcomes for Comminuted, Intra-articular Distal Radius Fractures Treated with Primary Distraction Bridge Plate Fixation.

To determine if distraction bridge plate (DBP) fixation as the primary method of stabilization can effectively correct and maintain acceptable radiographic parameters in the treatment of comminuted, intra-articular distal radius fractures while allowing early load-bearing. A retrospective review was performed of all consecutive intra-articular distal radius fractures that underwent DBP fixation with or without supplemental fixation methods (fragment-specific implants or K-wires). Patients treated with a volar locked plate in addition to DBP were excluded. Radiographic outcomes measures included volar tilt (°), radial height (mm), radial inclination (°), articular step-off (mm), lunate-lunate facet ratio (LLFR), and teardrop angle (°) measured on post-reduction, immediately post-operative, prior to and after DBP removal. Twenty-three comminuted, intra-articular distal radius fractures were treated with primary DBP fixation. Supplemental fixation was utilized in 10 fractures and included fragment-specific implants (n = 6) and/or K-wires (n = 5). Distraction bridge plates were removed after a mean of 13.6weeks. At a mean radiographic follow-up of 11.4weeks (range: 2-45weeks) following DBP removal, all fractures had united with a mean volar tilt of 6.3° ± 5.8°, radial height of 11.3 ± 2.3mm, radial inclination of 20.2° ± 4.5°, articular step-off of 0.6mm ± 0.8, and LLFR of 1.05 ± 0.06. However, the teardrop angle could not be restored to a normal value with DBP fixation. Complications included 1 plate breakage and 1 peri-hardware radial shaft fracture. Distraction bridge plate fixation is a reliable method to stabilize highly comminuted, intra-articular distal radius fractures in patients with a well-aligned volar rim fragment of the lunate facet.