Degree Of Comminution Research Articles

Clinical and functional outcomes of locked plating vs. cerclage compression wiring for AO type C patellar fractures– a retrospective single-center cohort study

Abstract Purpose Although “tension-band wiring” is still commonly used to stabilize patellar fractures, the technique has recently been scrutinized due to biomechanical insufficiency. Consequently, the AO Foundation renamed the principle to compression cerclage wiring (CCW). Several studies propose favorable outcomes when utilizing locked plating (LP). This study aims to compare outcome of CCW and LP for complex patellar fractures. Methods A retrospective, single-center cohort study was performed on patients who underwent operative treatment for (AO 34 C-Type) patellar fractures between April 2013 and March 2023. Patients with a 12 month follow up were included. We grouped and compared patients based on the applied treatment strategy: group LP vs. group CCW. Primary outcome parameters included implant-related complications and revision surgeries. Secondary outcomes were length of stay, return to work and 12 months functional outcome (Lysholm score). Odd ratios for complications and revisions were calculated using the conditional Maximum Likelihood Estimate. The threshold for statistical significance was set at p < 0.05. Results Of 145 patients, 63 could be included (group LP: n = 23 and group CCW: n = 40). Fractures in group LP were significantly more complex in regard to AO Classification (p < 0.001), number of fragments (p < 0.001) and degree of comminution (p < 0.001), yet odds of complications were significantly lower in group LP (OR: 0.147; 95%CI: 0.015–0.742; p = 0.009). K-wire migration was the most common complication in group CCW (20%). Odds of revision surgery were significantly lower in group LP (OR: 0.000; 95%CI: 0.000-1.120; p = 0.041). The average Lysholm score at one year was favorable in both groups (89.8; SD: 11.9 in group LP and 90.6; SD: 9.3 in group CCW; n.s.). Conclusion In our study cohort, LP was routinely chosen for more complex fracture morphologies; nevertheless the data implies that LP may be considered as the superior fixation technique in regard to complications and revision operations. Especially, K-wire migration occurs frequently after CCW. The one year functional outcome was comparable between the groups, with both demonstrating good results. Prospective randomized studies are indicated to validate our findings.

Transulnar basal coronoid fractures – Surgical tips and tricks

Transulnar basal coronoid fractures of the elbow are complex injuries in which there is a transulnar fracture dislocation of the elbow, and the coronoid is fractured and not attached to either the olecranon fragment or the metaphyseal segment. These fractures are difficult to manage and can lead to poor outcomes if not adequately addressed. This technical note aims to introduce an approach to their operative management. Due to the variety of fracture patterns and degree of comminution, the sequence of intraoperative management as well as fixation methods may vary. The utilization of this technical note will guide surgeons through the optimal management of these injuries to achieve stable fixation that will allow early range of motion.

Using Equipoise to Determine the Radiographic Characteristics Leading to Agreement on Best Treatment for Thoracolumbar Burst Fractures Without Neurologic Deficits.

Retrospective analysis of prospectively collected data. Our goal was to assess radiographic characteristics associated with agreement and disagreement in treatment recommendation in thoracolumbar (TL) burst fractures. A panel of 22 AO Spine Knowledge Forum Trauma experts reviewed 183 cases and were asked to: (1) classify the fracture; (2) assess degree of certainty of PLC disruption; (3) assess degree of comminution; and (4) make a treatment recommendation. Equipoise threshold used was 77% (77:23 distribution of uncertainty or 17 vs 5 experts). Two groups were created: consensus vs equipoise. Of the 183 cases reviewed, the experts reached full consensus in only 8 cases (4.4%). Eighty-one cases (44.3%) were included in the agreement group and 102 cases (55.7%) in the equipoise group. A3/A4 fractures were more common in the equipoise group (92.0% vs 83.7%, P < .001). The agreement group had higher degree of certainty of PLC disruption [35.8% (SD 34.2) vs 27.6 (SD 27.3), P < .001] and more common use of the M1 modifier (44.3% vs 38.3%, P < .001). Overall, the degree of comminution was slightly higher in the equipoise group [47.8 (SD 20.5) vs 45.7 (SD 23.4), P < .001]. The agreement group had a higher degree of certainty of PLC injury and more common use of M1 modifier (more type B fractures). The equipoise group had more A3/A4 type fractures. Future studies are required to identify the role of comminution in decision making as degree of comminution was slightly higher in the equipoise group.

Predictive Algorithm for Surgery Recommendation in Thoracolumbar Burst Fractures Without Neurological Deficits.

Predictive algorithm via decision tree. Artificial intelligence (AI) remain an emerging field and have not previously been used to guide therapeutic decision making in thoracolumbar burst fractures. Building such models may reduce the variability in treatment recommendations. The goal of this study was to build a mathematical prediction rule based upon radiographic variables to guide treatment decisions. Twenty-two surgeons from the AO Knowledge Forum Trauma reviewed 183 cases from the Spine TL A3/A4 prospective study (classification, degree of certainty of posterior ligamentous complex (PLC) injury, use of M1 modifier, degree of comminution, treatment recommendation). Reviewers' regions were classified as Europe, North/South America and Asia. Classification and regression trees were used to create models that would predict the treatment recommendation based upon radiographic variables. We applied the decision tree model which accounts for the possibility of non-normal distributions of data. Cross-validation technique as used to validate the multivariable analyses. The accuracy of the model was excellent at 82.4%. Variables included in the algorithm were certainty of PLC injury (%), degree of comminution (%), the use of M1 modifier and geographical regions. The algorithm showed that if a patient has a certainty of PLC injury over 57.5%, then there is a 97.0% chance of receiving surgery. If certainty of PLC injury was low and comminution was above 37.5%, a patient had 74.2% chance of receiving surgery in Europe and Asia vs 22.7% chance in North/South America. Throughout the algorithm, the use of the M1 modifier increased the probability of receiving surgery by 21.4% on average. This study presents a predictive analytic algorithm to guide decision-making in the treatment of thoracolumbar burst fractures without neurological deficits. PLC injury assessment over 57.5% was highly predictive of receiving surgery (97.0%). A high degree of comminution resulted in a higher chance of receiving surgery in Europe or Asia vs North/South America. Future studies could include clinical and other variables to enhance predictive ability or use machine learning for outcomes prediction in thoracolumbar burst fractures.

The Influence of Comminution and Posterior Ligamentous Complex Integrity on Treatment Decision Making in Thoracolumbar Burst Fractures Without Neurologic Deficit?

A prospective study. to evaluate the impact of vertebral body comminution and Posterior Ligamentous Complex (PLC) integrity on the treatment recommendations of thoracolumbar fractures among an expert panel of 22 spine surgeons. A review of 183 prospectively collected thoracolumbar burst fracture computed tomography (CT) scans by an expert panel of 22 trauma spine surgeons to assess vertebral body comminution and PLC integrity. This study is a sub-study of a prospective observational study of thoracolumbar burst fractures (Spine TL A3/A4). Each expert was asked to grade the degree of comminution and certainty about the PLC disruption from 0 to 100, with 0 representing the intact vertebral body or intact PLC and 100 representing complete comminution or complete PLC disruption, respectively. ≥45% comminution had a 74% chance of having surgery recommended, while <25% comminution had an 86.3% chance of non-surgical treatment. A comminution from 25 to 45% had a 57% chance of non-surgical management. ≥55% PLC injury certainity had a 97% chance of having surgery, and ≥45-55% PLC injury certainty had a 65%. <20% PLC injury had a 64% chance of having non-operative treatment. A 20 to 45% PLC injury certainity had a 56% chance of non-surgical management. There was fair inter-rater agreement on the degree of comminution (ICC .57 [95% CI 0.52-.63]) and the PLC integrity (ICC .42 [95% CI 0.37-.48]). The study concludes that vetebral comminution and PLC integrity are major dterminant in decision making of thoracolumbar fractures without neurological deficit. However, more objective, reliable, and accurate methods of assessment of these variables are warranted.

The AO Spine Thoracolumbar Injury Classification System and Treatment Algorithm in Decision Making for Thoracolumbar Burst Fractures Without Neurologic Deficit.

Prospective Observational Study. To determine the alignment of the AO Spine Thoracolumbar Injury Classification system and treatment algorithm with contemporary surgical decision making. 183 cases of thoracolumbar burst fractures were reviewed by 22 AO Spine Knowledge Forum Trauma experts. These experienced clinicians classified the fracture morphology, integrity of the posterior ligamentous complex and degree of comminution. Management recommendations were collected. There was a statistically significant stepwise increase in rates of operative management with escalating category of injury (P < .001). An excellent correlation existed between recommended expert management and the actual treatment of each injury category: A0/A1/A2 (OR 1.09, 95% CI 0.70-1.69, P = .71), A3/4 (OR 1.62, 95% CI 0.98-2.66, P = .58) and B1/B2/C (1.00, 95% CI 0.87-1.14, P = .99). Thoracolumbar A4 fractures were more likely to be surgically stabilized than A3 fractures (68.2% vs 30.9%, P < .001). A modifier indicating indeterminate ligamentous injury increased the rate of operative management when comparing type B and C injuries to type A3/A4 injuries (OR 39.19, 95% CI 20.84-73.69, P < .01 vs OR 27.72, 95% CI 14.68-52.33, P < .01). The AO Spine Thoracolumbar Injury Classification system introduces fracture morphology in a rational and hierarchical manner of escalating severity. Thoracolumbar A4 complete burst fractures were more likely to be operatively managed than A3 fractures. Flexion-distraction type B injuries and translational type C injuries were much more likely to have surgery recommended than type A fractures regardless of the M1 modifier. A suspected posterior ligamentous injury increased the likelihood of surgeons favoring surgical stabilization.

Functional Outcomes of Open Reduction and Internal Fixation in Proximal Humerus Fractures by Philos Plate

INTRODUCTION Proximal humerus fractures are one very common and usually occur in elderly people. These fractures are usually associated with some degree of comminution and deformity. Therefore, good anatomical reduction of fracture fragments and early mobilization are the main component for optimal outcomes of involved limb. This study was intended to evaluate the functional outcome of proximal humerus fracture in adults managed by open reduction and internal fixation (ORIF) by proximal humerus interlocking osteosynthesis (PHILOS) plate. MATERIAL AND METHODS This prospective and observational hospital based study was carried out in Orthopedics Department of Universal College of medical Sciences-Teaching Hospital (UCMS-TH) from October 2021 to September 2023. All patients with proximal humerus fractures who fulfilled the inclusion criteria and who underwent open reduction and internal fixation by PHILOS plate were enrolled in the study. Functional outcome was assessed according to Constant murley scoring system and Visual analogue score. Post-operatively patients were regularly followed at 6 weeks, 3 months and 6 months. RESULTS In this study of 60 cases, the mean age group was 55.38±11.40 years and male patients outnumbered female patients (39 males and 21 females). 36 cases (60%) were of right side and 24 (40%) were of left side. Majority of the fractures were due to fall injury (57%) followed by road traffic accident (35%). The mean Constant Murley Score was 78.15±5.620 and VAS (visual analogue score) was 1.88±0.865. CONCLUSION Open reduction and internal fixation by PHILOS plate is an effective procedure providing good anatomical restoration and early mobilization in proximal humerus fracture thus providing good functional outcome.

Functional Outcomes of Close Reduction and Percutaneous Pinning in Proximal Humerus Fractures

INTRODUCTION Proximal humerus fractures are usually sustained from trivial fall in elderly. These fractures are usually associated with severe degree of comminution and deformity. Therefore, anatomical reduction of fracture fragments, and early mobilization are key factors for optimal outcomes of involved limb. This study was intended to evaluate the functional outcomes of proximal humer- us fractures in adults managed by closed reduction and percutaneous pinning (CRPP). MATERIAL AND METHODS This prospective and observational hospital based study was carried out in Orthopedics Department, Universal College of medical Sciences-Teaching Hospital (UCMS-TH) from July 2021 to June 2023. All patients with proximal humerus fractures who fulfilled the inclusion criteria and who underwent closed reduction and percutaneous pinning were enrolled in the study and functional outcome was assessed according to Constant murley scoring system and Visual analogue score. Post-operatively patients were regularly followed at 6 weeks, 3 months and 6 months. RESULTS In this study of 60 cases, the mean age group was 53.08±13.10 years and male patients outnumbered female patients (37 males and 23 females). Forty one cases (68.3%) were of right side and 19 (31.7%) were of the left side. Majority of the fractures were due to fall injury (53.3%), followed by road traffic accident (40%). The mean Constant Murley Score was 76.95 ± 5.53 and VAS (visual analogue score) was 1.97 ± 0.97. CONCLUSION Closed reduction and percutaneous pinning is simple, less invasive and effective procedure for proximal humerus fracture providing good functional outcome.

Surgical Treatment of Tibial Plateau Fractures About 100 Cases

Tibial plateau fractures are articular fractures that must benefit from anatomical reduction to avoid the occurrence of complications, a source of serious functional sequelae. Their management has become largely surgical. We report a retrospective study of 100 tibial plateau fractures treated surgically between 2012 and 2018. The objectives were to study the epidemiological characteristics of tibial plateau fractures, to evaluate and compare the clinical and radiological results, in the short and long term, of different techniques for the surgical treatment of tibial plateau fractures. The average age of our patients was 45 years old. The male sex was affected in 66% with a sex ratio of 1.94. The etiologies were dominated by domestic accidents in 52% of cases, followed by public voting accidents (47%). The fracture was open in 3 cases. We adopted the classifications of DUPARC and FICAT and of SCHATZKER, thus the patients were classified: 30 cases of unituberosity fractures, 41 cases of spinotuberosity fractures and 29 cases of bituberosity fractures. Stabilization was provided by a screwed plate in 62 cases and by screwing in 32 cases, 26 of which were percutaneous. Only 1 patient had stabilization with a HOFFMAN-type external fixator for an open CAUCHOIX II fracture. 5 patients had an ILIZAROV type external fixator. Autologous corticocancellous bone grafting was performed in 12 cases. According to the criteria of HOLH AND LUCK, the anatomical results were satisfactory in 77% of cases. According to the criteria of MERLE AUBIGNE and MAZAS, the functional results were satisfactory in 82% of cases. In the light of our results and a review of the literature, it appears that the prognosis of these fractures depends on the type of fracture, the degree of comminution, the quality of the reduction, the patient's age, the time to treatment, meniscal and ligament lesions, type of surgical treatment and quality of rehabilitation.

Intra-articular distal humerus fracture – TRAP or olecranon osteotomy

: Intra-articular distal humeral fractures can be approached in a variety of ways. The purpose of this study is to evaluate and compare the functional outcomes of two approaches: one with olecranon osteotomy and other with triceps-lifting approach; for the treatment of intra-articular distal humeral fractures.: In this study, 10 patients in Group A were compared with 10 patients in Group B. Both the groups were comparable in terms of age, gender, duration of injury and degree of comminution of the fracture. Results were compared in terms of operative time, hospital stay, union, range of motion and complications. Functional evaluation was done using the Mayos’ elbow performance score (MEPS).: Patients were followed for a minimum of 12 months. Fracture union was seen at or before 4 months in all the patients of both the groups, except in 1 case of Group A where it was seen at 7 months. Average time to union was comparable in both the groups. In Group A, mean range of flexion was found to be 118 degrees (SD 7.33) and extension lag was found to be 11 degrees (SD 3.84). In Group B, mean degree of flexion was found to be 118.25 (SD 4.94) and extension loss of 12 degrees (SD 4.70). Average range of motion was comparable in both groups. There were no significant differences noted between the two groups in terms of mean MEPS (p= 0.573). The overall complication rate was 40% in the TRAP group and 30% in the olecranon osteotomy group.: Intra-articular distal humerus fractures mandate surgical fixation for best functional outcomes. Although technically demanding, TRAP exposure can prove to be as effective as olecranon osteotomy approach. Both approaches appear to yield no significant differences in clinical and functional results for intra-articular distal humerus fracture management.

D77. In-fracture and Out-fracture: Novel Conceptions of Nasoorbitoethmoid Injury

PURPOSE: Nasoorbitoethmoid (NOE) fractures are commonly categorized by the Markowitz-Manson classification system, which grades severity of injury by degree of comminution and involvement of the medial canthal tendon. However, this system does not account for directionality of bony injury, which may impact clinical findings. We propose these fractures may be conceived as either in-fractured, resulting in nasal airway obstruction, or out-fractured, resulting in traumatic telecanthus. METHODS: A retrospective review was conducted of all patients with NOE fractures referred to plastic surgery at a tertiary academic medical center from 2017—2022. Radiographic data (CT) were evaluated to assess for directionality of NOE segment involvement. Frequencies of in-fracture and out-fracture across NOE type were compared by chi-squared test. RESULTS: Among 57 adults, 73 NOE fractures were identified with 39.7% (29) as Type 0 (non-displaced), 43.8% (32) as Type I, 12.3% (9) as Type II, and 4.1% (3) as Type III. Type I fractures were significantly associated with in-fracture (p < 0.0001), whereas Type III fractures were more likely out-fractured (p = 0.02). Type II fractures were not significantly associated with either presentation (p = 0.32). CONCLUSION: We discover that Type I NOE fractures more frequently present with in-fracture, whereas comminuted injuries such as Type III are typically out-fractured. Further study will validate these findings in a larger cohort and correlate radiography with clinical symptoms.

Retrograde Intramedullary Interlocking Nailing in Fractures of the Distal Femur: A Review of 20 Cases with an Average Follow-Up of One Year

Objectives: In patients with distal femur fractures, we studied the role of retrograde locked intramedullary nails. Methods: Retrograde locked intramedullary nailing was used to treat the distal femur fractures of 20 patients (15 males, 5 females; mean age 47 years; range 25 to 69 years). Two patients had fracture of the distal femur and shaft. The fractures were classified as A1 (n=12), A2 (n=6), A3 (n=2), by the AO classification. There were two Grade I open fractures and 18 closed fractures. Three fractures were managed with percutaneous technique. At the mean first follow-up time of 18 months (range 15-48 months and mean second follow up at 27 months (range 12 to 68 months), the concluding functional results were assessed by using the modified Hospital for Special Surgery (HSS) knee assessment scale. Results: The average time to achieve union was 24.2 weeks (range 14 to 42 weeks). One patient had a delayed union (44 weeks). Five knees (25%) had normal joint range of motion, ten knees (50%) were having range of motion from 100° to 110°, three knees (15%) were having range of motion of 80°, and two knees (10%) were having range of motion below the 80°. According to the modified HSS knee scale, the results were excellent in eleven cases (55%), good in six (30%), moderate in two (10%), and poor in one case (5%). In two patients (10%), the postoperative radiographic examination revealed varus angulation (10°), healing took place with severe distortion in one subject. None of the patient had any deep infection or wound issues. Conclusion: Retrograde femoral nailing is an effective method for treating distal femoral shaft fractures. The healing rate of femoral shaft fractures fixed with a retrograde nail is the same regardless of fracture location, patient age, gender, or degree of comminution. For good results surgical treatment, post-surgery immediate knee mobilisation and avoiding nail tip prominence in the knee are essential.

Bridge Plating Versus Hybrid External Fixation in the Management of Proximal Tibia Metaphyseal Fractures.

Due to the surge in high-speed road traffic accidents during the past few years, extra-articular proximal tibia fractures have also risen in number. For the treatment of such fractures, various options are available like conservative treatment with casting, surgical treatment with plate osteosynthesis, or a hybrid external fixator. Exposure of the bone surface and extensive soft tissue dissection is needed in bridge plating, posing a risk of bleeding, infection, and soft-tissue healing issues, and the blood supply of the fractured area is also hampered as the periosteum is also destroyed. To avoid these complications, a hybrid external fixator can be used but it has its own risks of malunion, non-union, and pin-tract infections; another drawback is patient compliance. In this study, we compare the clinical and functional outcomes of two treatment modalities, i.e., bridge plating and hybrid external fixator, in the treatment of proximal tibia metaphyseal fractures. This prospective randomized study was conducted from February 2021 to June 2022 on 46 adult patients diagnosed with proximal tibia metaphyseal fracture and willing to participate. An odd number of patients were treated with a bridge plate and even with a hybrid external fixator. A total of 46 patients were included in the study, sustaining proximal tibia metaphyseal fracture, out of which23 patients underwent hybrid external fixation with an outcome of 69.43 ± 8.11 according to the Knee Society Score (KSS) and 23 for bridge plating which showed better results as their score at final follow-up was 75.00 ± 8.22. According to our study, we found that bridge plating is a better treatment modality than the hybrid external fixator as the former showed better postoperative knee range of motion and functional outcome and led to a smaller number of complications. But the clinical outcome would also be influenced by the type of fracture, degree of comminution, type of injury, i.e., open or closed, and quality of bone.

Surgical Treatment of Adams Type IV Anterolateral Fracture of the Ulna Coronoid Process.

Anterolateral coronal fractures are so rare that the mechanism of injury, the type of combined fracture and ligament injury, and the optimal treatment are unknown. To study the outcome of surgical treatments for anterolateral (AL) fracture of the ulna coronoid process (Adams Type IV) and summarize the characteristics of this type of fracture and to guide clinical applications. From February 2015 to April 2021, 32 patients were included in the study. All patients had standard radiography with anteroposterior and lateral views, computed tomography, and intraoperative fluoroscopy. All patients were treated surgically. Surgery-related information, including surgical approach, operation duration, blood loss, and repairing the lateral collateral ligament and the medial collateral ligament integrity, were recorded. The patient's clinical details, such as the final range of motion (ROM), the Broberg-Morrey scores and the visual analogue scale (VAS) at the last follow-up, were described. The chi-square test or Fisher's exact test was used for statistical analysis. We divided patients into two groups according to the anterolateral coronoid fracture morphology. In the intact group, 20 patients with an intact anterolateral coronoid fracture fragment. In the comminuted group, 12 patients with comminuted anterolateral coronoid fracture fragments extended the less sigmoid notch of the ulna. There was no difference in age, sex, total incision length, follow-up duration, and recovery with rehabilitation among the two groups (all Ps >0.05). The other follow-up outcomes, such as elbow ROM (Flexion, Extension, Posterior rotation, Anterior rotation), VAS score, or Broberg-Morrey scores, were not different between the two groups (all Ps >0.05). Both groups achieved relatively satisfactory clinical outcomes, and the Broberg-Morrey score and index excellence rate reached 84.38%. There is a statistical difference in the history of elbow dislocation (P=0.017), radial head fracture type (P=0.041), operation duration (P=0.014) and blood loss at operation (P=0.029) between the two groups. Cannulated screws, anchors, and sutures were used as point fixation in the coronoid process of the ulna. There was a statistical difference between the two groups in the choice of internal fixation (P=0.020). For anterolateral ulnar coronoid fractures with different degrees of comminution, effective and reliable surgical treatment can achieve better results and fewer complications.

Technical considerations of computer-aided planning in severe orbital trauma: A retrospective study

The aim of this study was to evaluate the clinical outcomes of linear and orbital volume measurements in severe orbital trauma. Patients with severe orbital trauma that involved more than two walls and entailed a marked degree of comminution were included in this retrospective analysis. However, patients with incomplete clinical records and a simple blowout or zygmatico-orbital fractures were excluded. All the cases underwent surgical correction guided by virtual surgical planning and 3D-printed templates. The measurement protocol depended on assessing orbital dimensions, orbital volumetry, and the zygomatic bone's position in the three-dimensional planes. All patients' preoperative 3D CT scans were obtained, and DICOM files were imported into a three-dimensional image processing software. Data were then converted for 3D reconstruction in the axial, coronal, and sagittal views. A total of 18 patients with a mean age was 39.28 ± 6.28 were included in this study. The results revealed a significant difference between the pre and postoperative differences in distances in relation to the FHP (Frankfurt Horizontal Plane) (P = 0.0014) and sagittal planes (P < 0.0001). The orbital width and height of the traumatized orbit were significantly decreased from 45.26 ± 6.72 mm and 45.30 ± 2.89 mm to 39.74 ± 3.91 mm (P = 0.0022), and 40.34 ± 0.86 mm (P < 0.0001), respectively. Clinically, there was a satisfactory degree of symmetry regarding the zygomatic bones' position and orbital dimensions postoperatively. Moreover, the mean orbital volume on the traumatized side decreased significantly from 23.16 ± 1.91 cm3 preoperatively to 20.7 ± 1.96 cm3 postoperatively (P < 0.0001). These findings were associated with a low incidence of complications. Within the limitations of the study it seems that the described methodology is a relevant addition to clinical treatment options. It incorporates all the latest technology to plan virtual reconstruction surgery in the treatment of complex orbital trauma and should be adapted accordingly in cases of severe displacement and comminution.

Novel External Fixation Device for the Treatment of Hallux Distal Phalanx Fractures

Category: Midfoot/Forefoot; Trauma Introduction/Purpose: The great toe plays a large role in activity, including maintenance of balance and substantial weight bearing capabilities. Fractures of the hallux distal phalanx, especially when displaced or unstable, can lead to significant dysfunction of the interphalangeal joint (IP) and pain and may need operative intervention. Surgical options include wire pinning, screw fixation, external fixation, arthrodesis, or amputation. For patients with significant comminution and shortening who would like to attempt toe salvage without fusion, external fixation can lead to great outcomes. Unfortunately, the use of these devices is hindered by cost, size, and availability. We recommend the use of a novel low cost external fixation device that can be made intraoperatively using common materials found in the operative room. Methods: A 27-year-old female, with a severely comminuted right distal phalanx fracture with interphalangeal (IP) joint dislocation, presented 4 days after a skiing accident. We discussed treatment may require IP joint arthrodesis or partial amputation, however, salvage fixation could be attempted initially. First, a transverse percutaneous wire was placed through the distal phalanx tip since the fragment was still mostly intact. The wire exited the skin medially. Two Kocher clamps to each side of the wire were applied for distraction of the fracture site while simultaneous manual manipulation of the more proximal fragments was performed. Once reduced, three more proximal transverse wires were placed through a 3cc syringe, which acted as a rail to hold the fracture length stable. The distal transverse wire was then impaled through the rail so that all four wires were within the rail providing two points of fixation in the distal phalanx and proximal phalanx. Results: The patient's weight-bearing status was non-weight bearing to the right lower extremity for 6 weeks. This was actually being dictated by the more proximal tibial plateau fracture for which she was non-weight bearing. With regard specifically to the hallux fracture, she could have been heel weight beared immediately. At her most recent post-operative visit at 6 weeks, she was doing well with minimal pain. The external fixation device was removed in clinic and she was transitioned to a post-op shoe and allowed to weight bear as tolerated. She was motor and sensate intact with the ability to actively range her IP joint. Radiographs at the most recent visit revealed excellent alignment of the toe with minimal articular step off. Conclusion: With severely unstable hallux distal phalanx fractures, operative intervention should be considered. For those with a significant degree of comminution who still would like to undergo salvage fixation, external fixation is an excellent option. Unfortunately, the use of these devices is hindered by cost, size, and availability. Hand surgeons solved this problem by introducing small, low cost external fixators composed of common materials such as needle sheaths, IV cannulas, and syringes. We adapted their model to the toes and were able to obtain great clinical outcomes with low cost, all the while maintaining the patient's expectations for cosmesis.

Factors Related to the Inconstancy of Sustentaculum Tali Fragments in Intra-Articular Calcaneus Fractures

Category: Trauma Introduction/Purpose: Since intra-articular fractures are common in calcaneus fractures, anatomical reduction is important. Several ligaments such as spring ligament and deltoid ligament are attached to the Sustentaculum tali (ST). It is known that ST fragment is constant in calcaneus fracture. However, few studies have been reported to prove this. Therefore, we studied to establish criteria for the inconstancy of ST fragments through the analysis of computed tomography (CT) of the unaffected calcaneus, to confirm the prevalence of ST fragment inconstancy by applying these criteria, and to analyze the factors related to the inconstancy of the ST fragment. Methods: From 2012 to 2020, CT scans of calcaneus fractures of 122 patients (101 men and 21 women) were taken, and angulation and diastasis of ST fragment were measured in the semi-coronal plane. As a control, angulation and diastasis were measured in 62 unaffected calcaneus. After establishing criteria for the inconstancy of ST fragments, we evaluated the prevalence of ST fragment inconstancy. After, we analyzed related factors. Patient factors included age, BMI, smoking, and diabetes. Radiographic factors included the degree of comminution of the posterior facet, location of the outermost fracture line of the posterior facet, presence of an intra-articular fracture of the ST, and width of the ST fragment. Results: The upper limit of the 95% CI of angulation and diastasis was 7.58° and 2.51 mm, respectively. Based on these criteria, the inconstancy of the ST fragment was observed in 34.5%. The width of the ST fragment was significantly smaller in the inconstant group. Severe comminution of the posterior facet, intra-articular fracture of the ST, and diabetes were significantly higher in the inconstant group. The inconstancy of the ST fragment was significantly associated with the width of the ST fragment (p &lt; 0.001) (Table 1). Cut-off values for the inconstancy of the ST fragment were 20.5 mm for the width of the ST fragment. Conclusion: In intra-articular calcaneal fractures, ST fragment inconstancy was observed in 34.5%. The width of the ST fragment was significantly associated with the inconstancy of the ST fragment.

A Study of Functional Outcome of Retrograde Intramedullary Interlocking Nailing in Treatment of Supracondylar Femoral Fracture

INTRODUCTIONFractures of the distal femur are usually sustained from high velocity trauma in adults and trivial fall in elderly. These fractures are usually associated with severe degree of comminution and intra-articular involvement. Therefore, anatomical reduction of fracture fragments, restoration of limb length, and early mobilization are key factors for optimal outcomes of involved limb. This longitudinal study was intended to evaluate the functional outcome of distal femoral fracture in adults managed surgically by Retrograde Nail. MATERIAL AND METHODSThis prospective and observational hospital based study was carried out in Orthopedics Department, Universal College of medical Sciences-Teaching Hospital (UCMS-TH) from July 2020 to June 2021. All patients with traumatic distal femoral fractures (AO/OTA type A) who fulfilled the inclusion criteria were enrolled in the study and were treated surgically by Retrograde Nail. Fracture was classified according to AO/OTA classification and functional outcome was assessed according to Neer’s scoring system. Post-operatively patients were regularly followed at 6 weeks, 3 months and 6 months. RESULTSIn this study of 30 cases, male to female ratio was 3:2 with mean age of 39.47 years. Road Traffic Accident (RTA) was most common mode of injury. The functional outcome evaluated according to Neer’s scoring system was found good result in 43.3%, excellent in 36.7%, fair in 16.7% and poor in 3.3%. The mean Neer’s score was 78.9. CONCLUSIONDistal femoral fractures (AO/OTA type A) when treated with retrograde nailing has good to excellent functional outcome in majority of cases with minimal manageable complication.

Comminution and amorphisation of Diaqua-bis(Omeprazolate)-Magnesium Dihydrate: An analysis of the energies involved

Size reduction of Diaqua-bis(Omeprazolate)-Magnesium Dihydrate (DABOMD) crystals, an active pharmaceutical ingredient (API) which inhibits gastric acid secretion and its related disorder in mammals, has been investigated using a planetary ball mill and a single ball mill. The outcome of milling shows that DABOMD undergoes prominent comminution and amorphisation processes that occur parallel to each other, with planetary ball mill causing higher amorphisation rate compared to the single ball mill. To establish a relationship between the degree of comminution and amorphisation, the energies of the planetary ball mill and the single ball mill were quantified using a collision model derived from the literature, and through tracking the milling jar with high speed-camera, respectively. In addition, energies were calculated using the Discrete Element Method (DEM) simulations of both mills. The energy obtained from the DEM simulation of the planetary ball mill is lower than the calculated energies from the literature collision model. This could be due to the fact that the collision model does not consider additional factors affecting the motion of balls, such as friction between the balls and balls and the wall. However, the energy calculated from the DEM simulation is higher than that generated from high speed video tracking of the milling jar for the single ball, since as shown by the DEM the movement pattern and the velocity magnitude of the ball is different to those of the jar, resulting in higher relative collision velocities than the jar velocity itself. Nevertheless, it was found that the planetary ball mill produces higher energy than the single ball mill which explains the difference in the amorphisation obtained in the two mills. This methodology enables quantification of the changes that arise with the milling of a solid (i.e. comminution and amorphisation) with respect to the energy level involved.

Arthroscopically Assisted Percutaneous Screw Fixation of Tibial Plateau Fractures.

This technique involves the use of both arthroscopy and fluoroscopy to facilitate reduction and fixation of the tibial plateau fracture. Through a minimally invasive technique, the depressed articular joint surface is targeted with use of preoperative computed tomography (CT) scans and intraoperative biplanar fluoroscopy. Reduction is then directly visualized with arthroscopy and fixation is performed with use of fluoroscopy. Lastly, restoration of the articular surface is confirmed with use of arthroscopy after definitive fixation. Modifications can be made as needed. The traditional method for fixation of displaced tibial plateau fractures is open reduction and internal fixation. Articular reduction can be visualized directly with an open submeniscal arthrotomy and an ipsilateral femoral distractor or indirectly with fluoroscopy. Visualization of the articular surface is essential to achieve anatomic reduction of the joint line. Inspection of the posterior plateau is difficult with an open surgical approach. Arthroscopically assisted percutaneous screw fixation of a tibial plateau fracture may allow for improved restoration of articular surfaces through enhanced visualization. Less soft-tissue dissection is associated with lower morbidity and may result in less damage to the blood supply, lower rates of infection and wound complications, faster healing, and better mobility for patients. In our experience, this technique has been successful in patients with severe osteoporosis and comminution of depressed fragments. If total knee arthroplasty is required, we have also observed less damage to the blood supply and fewer surgical scars with use of this surgical technique. Arthroscopically assisted percutaneous screw fixation of a tibial plateau fracture facilitates anatomical reduction through a less invasive approach. Patients undergoing this method of tibial plateau fracture fixation are able to engage earlier in rehabilitation2. Studies have shown early postoperative range of motion, excellent patient-reported outcomes, and minimal complications7,8. Arthroscopically assisted fixation can be applied to a variety of tibial plateau fractures; however, the minimally invasive approach is best suited for patients with isolated lateral tibial plateau fractures (Schatzker I to III) and a cortical envelope that can be easily restored. The cortical envelope refers to the outer rim of the tibial plateau. Fracture pattern and ligamentotaxis determine the cortical envelope, which can be evaluated on preoperative CT scans. In our experience, even depressed segments with a high degree of comminution may be treated with use of this technique with satisfactory results.Articular depression should be targeted with use of a preoperative CT scan and intraoperative fluoroscopy and arthroscopy.The surgeon should be careful not to "push up" in 1 small area; rather, a "joker" elevator or bone tamp should be utilized, moving anterior to posterior, which can be frequently assessed with arthroscopy.The intra-articular pressure of the arthroscopy irrigation fluid should be low (≤45 mm Hg or gravity flow), and the operative extremity should be monitored for compartment syndrome throughout the procedure. ACL = anterior cruciate ligamentK-wires = Kirschner wiresORIF = open reduction and internal fixationAP = anteroposteriorCR = computed radiography.