Need For Hardware Removal Research Articles

Comparison of Clinical and Radiographic Outcomes Between Solid Headless and Headed Screws in the Treatment of Zone II and III Fifth Metatarsal Fractures in Elite Athletes

Background: Zone II and III fifth metatarsal (5-MT) fractures among athletes are typically managed with percutaneous fixation following anatomic reduction. However, screw head discomfort and refracture after bone union can occur because of the loads placed on the foot during play. Several hardware systems that use a smaller screw head compared to traditional hardware systems have been developed to minimize the rate of postoperative hardware complications. This study compares clinical and radiographic outcomes of 5-MT fractures in elite athletes treated with a solid headless screw vs a solid headed screw. We hypothesized that the headless screw would be associated with faster union rates, faster clearance times, and lower incidence of symptomatic hardware compared to the headed screw. Methods: Athletes competing at a collegiate level or higher treated for a zone II or III 5-MT fracture between 2016 and 2022 by 2 surgeons fellowship-trained in foot and ankle orthopaedics were screened. Operative notes were reviewed to determine the hardware system used. Subjects were divided based on the hardware system used during operation: headed screw and headless screw. Time to radiographic union, time to full clearance, and return to competition were determined. Postoperative complications, including nonunions, need for revision, need for hardware removal, and refractures were also noted. Results: Forty eligible patients (44 feet) were identified. The solid headed screw group included 20 patients (21 fractures), and the solid headless screw group included 20 patients (23 fractures). Average time to union for the headed screw group was 11.78 (range, 5.86-19.00) weeks; average time to union for the headless screw group was 11.65 (range, 6.00-22.57) weeks ( P = .93). Nineteen out of twenty (95%) patients were able to return to competition in both groups. Average time to return to competition for the headed screw group was 26.9 (range, 10.00-47.86) weeks, while average time for the headless screw group was 21.2 (range, 6.86-55.00) weeks ( P = .55). The overall complication rate for the headed screw was 23.8%, which was not statistically different from the overall complication rate for the headless screw of 13.0% ( P = .35). Conclusion: In this relatively small sample of elite athletes undergoing operative fixation of a 5-MT fracture, fixation using either a headless or headed screw system had similar good outcomes in regard to times to union, return to competition, and complication rate regardless of solid screw head type used. Level of Evidence: Level III, retrospective cohort study.

Superior versus anterior plating of midshaft clavicle fractures: 6 months follow up (union rates, risks, and complications: hardware irritation and need for removal)

Background Operative management of midshaft clavicle fractures is gaining popularity. The clavicle is a tubular bone with a flat lateral end. Open reduction and internal fixation could be achieved by the application of plates and screws either to the superior or anterior surface of the clavicle. However, there is no consensus in the literature to support one technique over the other. This study aims to compare the early functional and radiographic outcomes of anterior versus superior plating for the treatment of midshaft clavicle fractures. Patients and methods From March 2021 to November 2022, a prospective randomized clinical trial was conducted at our institute. We included all patients with isolated midshaft clavicle fractures. Thirty-six patients were randomized by the closed envelope technique, 18 were managed with superior plating (superior group), and the other 18 patients were managed using anterior plating (anterior group). All patients were followed up for 6 months. All patients were assessed clinically for union, range of motion, and functional scores. The secondary outcome measures included operative time, complications, hardware irritation, and the need for hardware removal or secondary procedure. Results The mean time to full union was 11.28 weeks in the anterior group and 11.72 weeks in the superior group. Mean constant shoulder score for the anterior group was 84.11 while for the superior group it was 82.67. No patients had skin and wound complications in the anterior group versus one patient in the superior group that got superficial infection successfully managed by repeated dressing and antibiotics. There was no statistically significant difference between superior and anterior plating regarding union, functional scores, return to ADLs, hardware problems, or complications. Conclusion Both superior and anterior plating of the clavicle fractures are safe treatment options for displaced midshaft clavicle fractures, and they lead to similar functional outcomes, functional scores, and complication rates. Moreover, the selection of the technique of plating depends on surgeon preferences.

Crucial Insights: Post-Op Spinal Infections in Lumbar Fusion

Postoperative spinal infections following lumbar fusion with posterior lumbar interbody fusion (PLIF) are a concerning complication, particularly in cases of degenerative spinal disease. However, factors contributing to infection risk remain unclear. This retrospective study analyzed data from 124 adults who underwent instrumented fusion for degenerative spinal conditions between 2015 and 2020. Multivariate proportional hazards regression identified risk factors associated with surgical site infections (SSI). Results revealed a 16.9% incidence of SSI, with 92.4% of cases showing positive microbiological cultures. Prolonged hospital stay, prior surgeries, advanced age, diabetes, and obesity were correlated with infection risk. Notably, 95% of infected patients were successfully treated with surgical intervention or antibiotics without hardware removal. This underscores the importance of early identification and intervention in managing postoperative spinal infections, mitigating the need for hardware removal and improving patient outcomes.

A novel flexible fixation technique for Lisfranc injuries: clinical outcomes and radiographic follow-up

Objectives: The purpose of this investigation is to present the follow-up results and patient-reported outcome measures (PROMs) of a continuous series of surgically managed Lisfranc injuries whose constructs included a novel technique. Methods: Our billing database was retrospectively queried by Current Procedural Terminology (CPT) codes to identify all Lisfranc injuries managed operatively between 2018 and 2021. Basic demographic data were collected. Clinical notes and radiographs were reviewed. Patients were contacted prospectively to complete the Foot and Ankle Ability Measurement – Activities of Daily Living (FAAM-ADL), Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Intensity, PROMIS Pain Interference, and PROMIS Depression surveys. Descriptive statistics were calculated. Results: Sixteen patients were included. While all patients underwent flexible fixation (FF), nine of them underwent concomitant open reduction internal fixation (ORIF) and seven, concomitant primary arthrodesis. Median radiographic and PROMs follow-up time was 7.3 months (IQR 4.4–11.6) and 25.8 (IQR 9.5–32.4), respectively. All fusion patients had evidence of joint fusion, and 8/9 of ORIF patients maintained articular congruity without evidence of arthritis at final follow-up. Median PROMs were 85 (64.75–93.5), 53.1 (49.7–57.75), 45.7 (37.7–51.3), and 46 (43.3–52.28) for the FAAM-ADL, PROMIS Pain Interference, PROMIS Pain Intensity, and PROMIS Depression scores, respectively. Conclusion: The novel FF technique proposed for residual tarsometatarsal subluxation in Lisfranc injuries appears to be safe and effective, with good PROMs at two-year follow-up and low complication rates, obviating the need for hardware removal. Level of Evidence IV; Therapeutics Studies; Cases Series.

Proximal ROw carpectOmy versus four-corner Fusion (PROOF-trial) for osteoarthritis of the wrist: study protocol for multi-institutional double-blinded randomized controlled trial

BackgroundScapholunate advanced collapse (SLAC) and scaphoid non-union advanced collapse (SNAC) are common types of wrist osteoarthritis (OA). Non-operative treatment consists of pain medication, splinting, and avoiding activities that induce pain. However, in case a course of conservative treatment is unsuccessful, operative treatment is needed. The two most conventional operative approaches for SLAC/SNAC OA are four-corner arthrodesis (FCA) and proximal row carpectomy (PRC). Although FCA is the gold-standard operative technique and may lead to superior grip strength, the evident benefit of PRC is that it obviates any need for hardware removal and controlling for bony union. To date, no high-quality randomized controlled trial comparing FCA and PRC exists. As clinical outcomes seem comparable, a trial that assesses patient-reported outcomes, adverse events, and secondary operations may guide clinical decision making between these two procedures. Thus, the aim of this multi-institutional double-blind randomized controlled trial is to study whether PRC is non-inferior to FCA in treating SLAC/SNAC OA. We hypothesize that PRC is non-inferior to FCA with lower economic expanses.MethodsThe trial is designed as a randomized, controlled, patient- and outcome-assessor blinded multicenter, two-armed 1:1 non-inferiority trial. Patients with SLAC/SNAC-induced wrist pain meeting trial inclusion criteria will undergo wrist arthroscopy to further assess eligibility. Each patient eligible for the trial will be randomly assigned to undergo either FCA or PRC. The primary endpoint of this study is the Patient Rated Wrist Evaluation (PRWE) at 1-year after FCA versus PRC. Secondary outcomes include Quick-Disabilities of the Arm, Shoulder and Hand, EQ-5D-5L, pain, grip strength, wrist active range of motion, radiographic evaluation, and adverse events. Trial design, methods, and statistical analysis plan will be presented here.DiscussionWe present an RCT design comparing FCA vs PRC for SLAC/SNAC-induced OA. The results of this trial will assist in decision making when planning surgery for SLAC/SNAC.Trial registrationClinicalTrials.gov NCT04260165. Registered February 7, 2020.

Distal femoral osteotomy for the valgus knee: indications, complications, clinical and radiological outcome

IntroductionThe aim of this study was to describe the indications and technical aspects of medial closing and lateral opening distal femoral osteotomy (MCDFO and LODFO) for patients with a valgus knee and to report clinical and radiological outcomes and complications.MethodsOver 6 years, 28 DFOs (22 MCDFO, 6 LODFO) were performed in 22 Patients. In this cohort study, we retrospectively analyzed clinical and radiological outcome measures as well as complications.ResultsThe median (range) age was 47 (17–63) years, height 1.68 (1.56–1.98) m, body mass 80 (49–105) kg, and body mass index (BMI) 27.4 (18.6–37.0) kg/m2. The clinical follow-up was 21 (7–81) months, the need for total or unicompartmental knee arthroplasty (TKA/UKA) and hardware removal was followed up for 59 (7–108) months postoperatively. Preoperatively, hip-knee-ankle angle (HKA, negative values denote varus) was 7.0 (2.0–13.0)°, mechanical lateral distal femoral angle (mLDFA) was 83.7 (79.9–88.2)°, and mechanical proximal tibial angle (MPTA) was 89.0 (86.6–94.5)°. Postoperatively, HKA was −1.3 (−9.0–1.2)° and mLDFA was 90.8 (87.3–97.3)°. The incidence of minor and major complications was 25% and 14%, the incidence of delayed and nonunion was 18% and 4%, respectively. At the last follow-up, 18% of the patients had pain at rest, 25% during activities of daily living, and 39% during physical activity, and 71% were satisfied with the outcome. 7% of the cases received a TKA/UKA, 71% received a hardware removal.ConclusionDFO is a reasonable treatment for lateral osteoarthritis in younger patients to avoid disease progression and the need for an UKA/TKA. However, there is a long rehabilitation time, a considerable risk for complications, and a high need for hardware removal. While many patients experienced symptoms at the long-term follow-up, most were satisfied with the outcome. Appropriate patient information is essential.Level of evidence Level IV, Case Series.Trial registration number NCT04382118, clinicaltrials.gov, May 11, 2020.

Treatment of scaphoid fractures and pseudarthroses with the human allogeneic cortical bone screw. A multicentric retrospective study

BackgroundAllograft bone screws are rarely described for the fixation of the scaphoid. When fresh fractures are treated, metal screws are mainly used; when pseudarthrosis is the indication, plates in combination with vascularized or non-vascularized bone grafts are mainly used. The necessity of metallic screw removal is under debate, but it is mandatory for plates because of movement restrictions due to the plate. The use of biomaterials in scaphoid fracture fixation was described as leading to union rates of between 64 and 100%. Brcic showed the incorporation of an allogeneic cortical bone screw at 10 weeks postoperative, along with revascularization and stable osteosynthesis with primary bone healing, without any signs of immunological rejection. The purpose of this retrospective study was to explore the results obtained using an allogenic cortical bone screw (Shark Screw®) in patients with fresh scaphoid fracture fixation and pseudarthroses with respect to union rates and time to union.Patients and methodsWe retrospectively analyzed 75 patients: 31 with fresh fractures and 44 pseudarthrosis patients. The Shark Screw® was used for the fixation of the scaphoid in the fresh-fracture and pseudarthrosis patients. We evaluated the union rate, complication rate and time to union.ResultsUsing the human allogeneic cortical bone screw for scaphoid fracture fixation led to a high union rate (94–96%). There were two nonunions in the fresh fracture group and two nonunions in the pseudarthrosis group. The complication rate was 1.3% (1 patient). Median time to union was 16, 18 and 29 weeks for the fresh-fracture, pseudarthrosis and delayed-union patients, respectively. The treatment of fresh scaphoid fractures and pseudarthroses showed similar union rates to those described in the literature, uses a shorter and less invasive surgical method with no need for hardware removal, and has a low complication rate.ConclusionUsing the human allogenic cortical bone screw (Shark Screw®) led to similar union rates in fresh fractures—but better union rates in pseudarthrosis patients—compared to those presented in the literature for other scaphoid fracture fixation techniques, and it enabled a short and low-invasive procedure without any donor site morbidity and without the necessity to remove the hardware in a second surgery. The pseudarthrosis patient group showed a particularly strong benefit from this new procedure. The physiological bone metabolism remodels the cortical bone screw without scars.Level of evidence: III: retrospective cohort study, therapeutic investigation of a treatment.

Total Wrist Arthrodesis: An Update on Indications, Technique and Outcomes.

Painful end-stage wrist osteoarthritis (OA) unresponsive to conservative treatment is frequently managed with total wrist arthrodesis (TWA), which might render pain alleviation and ameliorate function, pain, and grip strength. Usual indications for TWA include inflammatory arthritis, idiopathic degenerative OA and posttraumatic OA, Kienböck's illness, brachial plexus palsy, cerebral paralysis, infraclavicular brachial plexus blocks and other spastic and contracture base illnesses, scapholunate advanced collapse, scaphoid nonunion advanced collapse, and failure of other surgical techniques such as after failed total wrist arthroplasty, four-corner fusion, proximal row carpectomy and severe ligament injuries (this procedure iscarried out when all other treatment alternatives have failed to control the individual's symptoms). TWA is commonly carried out with a dorsal plate fixed from the distal radius to the third metacarpal. However, other surgical procedures have been reported, including intramedullary fixation and new implants that do not cross the third carpometacarpal joint or some procedures without utilizing hardware for example using a vascularized fibular grafting In individuals with rheumatoid arthritis. TWA has been shown to give persistent and painless stability for 20 years or more. The rate of adverse events for TWA ranges from 0.1% to 6.1%, though some authors have published that it can be as high as 27%. The most common adverse events are tendon ruptures, peri-implant fractures of the third metacarpal, the need for hardware removal, and constant pain at the third carpometacarpal joint. In idiopathic degenerative OA, the reoperation rate following TWA has been reported as high as 63%. While TWA can render foreseeable pain alleviation and ameliorate function, orthopedic surgeons should remember that this surgical technique is not without its risks and that the accessibility of many surgical procedures requires orthopedic surgeons to scrupulously contemplate the risks and benefits of each alternative for the individual in front of them.

Treating Inferior Pole Fracture of Patella with Hand Plating System: First Clinical Results.

Inferior pole fractures of patella are notorious fractures where it is difficult to obtain rigid internal fixation by conventional methods. The objective of the study was to introduce the Hand Plating System (HPS), which was a novel surgical technique for inferior pole fractures of patella, and to report the radiological and clinical outcomes following the application of the surgical technique. The study was designed as a retrospective cohort study. Between July 2017 and December 2018, 30 patients who were diagnosed with inferior pole fracture of the patella without additional orthopaedic injuries were enrolled in this case series. After X-ray and 3D-CT examinations, all patients underwent open reduction and internal fixation by HPS with or without supplementary cannulated screw and lag screw stabilization. The bony union time, final range of motion (ROM), Bostman score, visual analog scale (VAS), and complications were measured as the clinical outcomes under a minimum of 12months of follow-up. All of the operations went well with the mean operative time of 76.2 ± 15.3 min. Bony union achieved in all the cases at an average of 9.5 ± 1.4 weeks after surgery. There was no loss of reduction, fixative failure, or surgical implant removal during follow-up. The average range of motion 1 year postoperatively was 0°-123.3°. The mean Bostman Score at the last follow-up was 26.8 ± 2.1 with the satisfactory rate of 100%. The pain feeling during walking as measured by VAS averaged at 0.9 ± 1.3. No complications developed except for one case of poor incision healing, which healed eventually after surgical debridement. HPS was demonstrated as a secure fixation and as a kind of tension band for inferior pole fractures of the patella. Satisfactory recovery of knee function and low complication rate, including no need for hardware removal, could be expected.

Use of iodine tincture in the management of wound dehiscence in operated mandibular fracture along with hardware salvage: a case report

Mandibular fractures are one of the most common facial fractures. Depending on the severity, they are treated either by closed reduction or open reduction and internal fixation. Hardware exposure is one of the postoperative complications associated with the latter. Data involving decision regarding removal or salvage of hardware in such cases is lacking. We present a case of wound dehiscence with hardware exposure in an operated mandibular fracture, which was managed by placing tincture iodine dressing, thus obviating the need for hardware removal.

Resumption of complete weight bearing after osteosynthesis of bimalleolar fractures using locking plates

IntroductionBimalleolar fractures represent 9% of fractures and affect 187/100,000 people per year. The gold standard for osteosynthesis is a one-third tubular or lateral locking plate and compression screwing or use of tension band wiring, with complete weight bearing planned around the 6th week. The development of locking plates seems to allow earlier resumption of weight bearing. The objective of our study was to evaluate the clinical and radiological results after internal fixation of bimalleolar fractures using locking plates with complete weight bearing authorized from the outset. The hypothesis was that this does not predispose to cutaneous or mechanical complications. Hardware and methodA continuous multi-operator retrospective study was performed. The clinical and radiological data of 55 patients operated on for bimalleolar fractures were collected. All underwent osteosynthesis with medial and lateral locking plates with authorization for weight bearing from the outset. ResultsComplete weight bearing was resumed at 27.4 days 14.7 [7–60] postoperatively. No non-union or malunion was found. Two patients presented with delayed medial healing without the need for hardware removal. Two patients required removal of the lateral Plate 1 month postoperatively due to infection. Seven patients presented with discomfort related to hardware, justifying its removal at 1 year. The Kitaoka score at 1 year was 94.6 7.7 [71-100]. ConclusionThe use of medial and lateral locking plates in bimalleolar fractures associated with complete weight bearing authorized from the outset allows complete consolidation. There was no increase in cutaneous or mechanical complications. Level of evidenceIV, retrospective study.

Metal Tension-Band Wires vs Tension-Band Sutures in the Fixation of Olecranon Fractures: A Systematic Review

Background: Tension-Band Wiring (TBW) is the treatment of choice for displaced, non-comminuted olecranon fractures. Due to the high complication rate involved with TBW, particularly the need for re-operative hardware removal, an alternate method using a high-strength, non-metallic Tension-Band Suture (TBS) construct has been precipitated. There is currently no literature comparing and evaluating these 2 particular techniques, therefore, this systematic review aims to address this. Methods: 6 databases were searched (MEDLINE, Embase, Web of Science, Cochrane Library, The CRD and Clinicaltrials.gov). Titles, abstracts and full articles were then systematically screened against the eligibility criteria. The primary outcomes studied were reported postoperative functional outcomes, and complication rates. Results: From 2538 identified abstracts, 5 studies met our eligibility criteria. Only one study compared TBW with TBS and concluded that in paediatric patients, there is a lack of benefit from TBS due to a similar rate of reoperation for hardware removal. 4 studies solely analysed TBW. In TBW, the rate of reoperation reached as high as 76.5% with the need for hardware removal being the most common indication. Conclusion: This review was required to highlight the alarming paucity of studies analysing TBS fixation in the treatment of non-comminuted olecranon fractures. Based on the included studies, it is difficult to conclude an advantage for either TBW or TBS due to the lack of standardised measuring of functional outcomes and comparative studies. There is potential for a reduced rate of reoperation in TBS, however, there is a great need for more robust studies analysing this technique.

Paper 61: Surgical Management of Distal Clavicle Fractures in Skeletally Immature Athletes

Objectives:The objective of this study was to characterize distal clavicle fractures in a cohort of pediatric and adolescent athletes who underwent operative treatment at a single, tertiary-care pediatric center, including surgical techniques used and resultant clinical outcomes.Methods:A retrospective review was performed of all clavicle fractures extending to the level of the corococlavicular ligaments or more lateral, which were treated operatively at a single tertiary-care pediatric hospital between the years of 2005-2020. Patients >19 years-old or those with pathological fractures were excluded. Radiographic fracture characteristics, surgical techniques, time to radiographic healing, return to sports, and complications were analyzed.Results:Fifty-two patients were identified, with mean age 13.8 ± 2.2 years. The majority of fractures were classified as Nenopoulus type IIB (transverse, displaced; 42.3%) or type IIIB (oblique, displaced; 26.9%), though type IIA (transverse, minor displacement; 3.8%), IV (comminuted; 11.6%) , and V (AC dislocation; 15.4%) patterns were also observed. Primary direction of displacement was posterior in 90% of cases and superior in 10%. Plate fixation was performed in 53.8% of surgeries, with locking plate (26.9%) and hook plate (17.3%) most frequent. Suture-based fixation was performed in 32.7% of cases (Figure 1). Rate of implant removal was 66% after plate fixation, the majority of which (72.2%) were planned at the time of primary fixation. Total complication rate, including unplanned removal of implant, was higher in the plate fixation group (25%) than in the suture-based fixation group (11.2%). Time to radiographic healing was not significantly different between plate and suture-based constructs (2.9 vs. 2.9 months, p = 0.96) though patients with suture-based constructs returned to sport faster (2.5 vs. 3.6 months, p = 0.014).Conclusions:Posteriorly displaced fractures comprised the vast majority of surgically-treated distal clavicle fractures in pediatric and adolescent athletes. When chosen in the appropriate patient, based on age and fracture pattern, suture-only constructs can lead to similar time to radiographic healing and faster return to sports compared to plate-based constructs, with significantly reduced need for removal of hardware. These data provide a foundation for future comparative research to further elucidate precise surgical indications and optimal treatment approaches in this population.Table 1.Fixation Methods for Distal Clavicle Fractures

A new all-suture tension band tape fixation technique for simple olecranon fractures versus conventional tension band wire fixation: a comparative biomechanics study.

Simple transverse or short oblique olecranon fractures without articular comminution are classified as Mayo type IIA fractures and are typically treated with a tension band wire construct. Because of the high reoperation rates, frequently because of prominent hardware, all-suture tension band constructs have been introduced. It was the purpose to compare the biomechanical performance of conventional tension band wire fixation with a new all-suture tension band tape fixation for simple olecranon fractures. Mayo type IIA olecranon fractures were created in 20 cadaveric elbows from 10 donors. One elbow of each donor was randomly assigned to the tension band wire technique (group TBW) or tension band tape (Arthrex, 1.3-mm SutureTape) technique (group TBT). Both groups were cyclically loaded with 500 N over 500 cycles, after which a uniaxial displacement was performed to evaluate load to failure. Data were analyzed for gap formation after cyclic loading, construct stiffness, and ultimate load to failure, where failure was defined as fracture gap formation greater than 4.0 mm. There was no significant difference in gap formation after 500 cycles between the TBW (1.8 mm±1.3 mm) and the TBT (1.9 mm±1.1 mm) groups (P=.854). The TBT showed a tendency toward greater construct stiffness compared with the TBW construct (mean difference: 142 N/mm; P=.053). Ultimate load to failure was not significantly different comparing both groups (TBW: 1138 N±286 N vs. TBT: 1126 N±272 N; P=.928). In both groups, all repairs failed because of >4.0-mm gap formation at the fracture site and none because of tension band construct breakage. Our study shows that the TBT technique produces equivalent or superior biomechanical performance to the TBW for simple olecranon fractures. The TBT approach reduces the risk of hardware prominence and as a result mitigates against the need for hardware removal. The TBT technique offers a clinically viable alternative to TBW.

Surgical Management of Distal Clavicle Fractures in Skeletally Immature Athletes

Background:Distal clavicle fractures account for a significant proportion of clavicle fractures in the pediatric and adolescent age groups, but clinical decision making to date has largely been informed by adult studies. However, surgical treatment in this younger population may have unique technical and clinical considerations, due to distinct fracture patterns, increased healing potential and periosteal thickness.Hypothesis/Purpose:The objective of this study was to characterize distal clavicle fractures in a cohort of pediatric and adolescent athletes who underwent operative treatment at a single, tertiary-care pediatric center, including surgical techniques used and resultant clinical outcomes.Methods:A retrospective review was performed of all operatively-treated clavicle fractures extending to the coracoclavicular ligaments or lateral, between 2005-2020. Patients >19 years-old or those with pathological fractures were excluded. Radiographic characteristics, surgical fixation construct, time to radiographic healing, return to sports, and complications were analyzed.Results:Fifty-two patients were identified, with mean age 13.8 ± 2.2 years. The majority of fractures were classified as Nenopoulus type IIB (transverse, displaced; 42.3%) or type IIIB (oblique, displaced; 26.9%), with type IIA (transverse, minor displacement; 3.8%), IV (comminuted; 11.6%) , and V (AC dislocation; 15.4%) patterns also observed. Primary direction of displacement was posterior in 90% of cases and superior in 10%. Plate fixation was performed in 53.8% of surgeries, with locking plate (26.9%) and hook plate (17.3%) most frequent. Suture-based fixation was performed in 32.7% of cases (Figure 1). Rate of removal of implants was 66% after plate fixation, the majority of which (72.2%) were planned at the time of primary fixation. Patient age was comparable in suture and plate cohorts (12.9 vs. 13.5, p = 0.19). Total complication rate, including unplanned removal of implants, was higher in the plate fixation group (25%) than in the suture-based fixation group (11.2%). Time to radiographic healing was not significantly different between plate and suture-based constructs (2.9 vs. 2.9 months, p = 0.96) though patients with suture-based constructs returned to sport faster (2.5 vs. 3.6 months, p = 0.014).Conclusion:The vast majority of distal clavicle fractures treated operatively in pediatric and adolescent athletes are posteriorly displaced fractures. When chosen in the appropriate patient, suture-only constructs can lead to similar healing and faster return to sports compared to plate-based constructs, with greatly reduced need for removal of hardware. These data provide a foundation for future comparative research further elucidating precise surgical indications and optimal treatment approaches.Table 1.Fixation Methods for Distal Clavicle Fractures

Hallux Arthrodesis

Hallux arthrodesis is a prominent technique, both in primary surgery and in reoperations. New devices and instruments have significantly improved outcomes, minimizing complications, although it is a demanding intervention from the technical point of viewand not exempt from complications. Arthrodesis is indicated in cases of primary or secondary hallux rigidus, and also as a salvage surgery for previous failed treatments such as joint sparing osteotomies or arthroplasty. Proper arthrodesis positioning is important, maintaining a dorsiflexion of 10-15º with a hallux valgus angle of nearly 10º and neutral rotation, in order to prevent complications such as hallux varus or interphalangeal joint arthritis. Arthrodesis outcomes are excellent from the clinical-functional and radiological point of view, with a union rate of 93.5%; however, this technique is not exempt from complications such as nonunion, malunion, need for hardware removal, and skin and healing problems. Nonetheless, this technique provides excellent outcomes. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Surgical treatment of a symptomatic os acromiale by arthroscopy-assisted double-button fixation: a case report

CaseWe present the case of a symptomatic os acromiale in a 51-year-old female patient. Arthroscopy-assisted treatment was performed using a double-button fixation system and additional suture cerclage. The patient presented with complete radiographic bone union, pain relief, improved range of motion and did not require hardware removal at the 12-month follow-up.ConclusionThe achievement of persistent consolidation between the two fragmented bone surfaces, without further need for hardware removal and improved clinical outcome, suggests that our minimally invasive technique is appropriate for this specific indication. To our knowledge, this technique has not been described in the literature yet.

Simple Osteotomy Site Repair Method for the Trans-Olecranon Approach: Tension Band Wiring with Ring Pins.

Background: The trans-olecranon approach is commonly used to treat intra-articular distal humeral fractures (DHFs). We describe an osteotomy site repair technique that is both simple and safe. Methods: We retrospectively reviewed 30 patients with intra-articular DHFs who were treated via olecranon osteotomies repaired by tension band wiring (TBW) with ring pins. Medical records and radiographs were retrospectively assessed in terms of injuries, operative characteristics, clinical outcomes, and complications, as well as any need for hardware removal. Clinical outcomes were evaluated by deriving the range-of-motion and the Mayo elbow performance score. Results: Thirty patients (nine men, 21 women; mean age, 49.7 years) with Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 13-B and 13-C DHFs were included; the mean follow-up time was 49.9 months (range, 12-145 months). Anatomical reduction and bony union were achieved at all osteotomy sites. The mean elbow flexion was 121.7° (range, 100-135°) and the mean elbow extension was 11.3° (range, 0-30°). The mean Mayo elbow performance score was 90 points (range, 55-100 points); outcomes were excellent in 15 patients, good in 12 patients, fair in two patients, and poor in one patient. Olecranon implant removal was performed for 10 patients (33.3%; total removal in nine and isolated olecranon implant removal in one). Four of these patients (13.3%) complained of olecranon implant discomfort. Implants were removed during other surgical procedures from the remaining six patients (20%). No implant migration/breakage or wound complications were encountered. Conclusions: TBW with ring pins is a simple and safe method for olecranon osteotomy site repair.

Outcomes of Posterior Arthroscopic Subtalar Arthrodesis for Medial Facet Talocalcaneal Coalition.

Medial facet talocalcaneal coalition can be a painful condition. This study aimed to determine clinical and radiographic outcomes of posterior arthroscopic subtalar arthrodesis (PASTA) for adult patients presenting with symptomatic medial facet talocalcaneal coalition and normal hindfoot alignment, with a minimal follow-up of 18 months. Between June 2017 and July 2019, this procedure was performed on 8 feet (8 patients; mean age, 55 [42-70] years; mean BMI, 29.8 [24.4-45.0] kg/m2). Clinical assessment was performed using Visual Analog Scale for Pain (VAS-P), Foot and Ankle Outcome Score (FAOS) and the 36-Item Short-Form Health Survey (SF-36). Patient satisfaction was assessed at the last available follow-up as "very satisfied", "satisfied" or "unsatisfied". Radiographic analysis was performed using plain radiography, computed tomography (CT) scan and magnetic resonance imaging (MRI). The primary outcome was to determine both clinical and radiographic outcomes. The mean follow-up was 25.1 (18.2-34.2) months. The authors found statistically significant improvement on all clinical scores (VASP-P, FAOS and SF-36). They registered 6 "very satisfied" patients, 2 "satisfied" patients and no "unsatisfied" patient. Fusion of the subtalar joint was observed in all patients by 12 weeks and in 5 of them as soon as 8 weeks postoperatively (mean, 9.5 [8-12] weeks). There were no cases of delayed fusion or nonunion of the subtalar joint, superficial or deep infection, neurovascular damage, thromboembolic event, screw breakage, need for hardware removal or revision surgery. This study found that PASTA is a safe and reliable technique for adult patients presenting with symptomatic medial facet talocalcaneal coalition and normal hindfoot alignment, demonstrating and maintaining clinical improvement at an average follow-up of 2 years. Level IV, case series.

Operative time and learning curve between fluoroscopy-based instrument tracking and robot-assisted instrumentation for patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF)

IntroductionInstrument-navigation modalities including CT-guided and robot-assisted methods claim both efficacy and accuracy when applied to spine surgery, yet often increase setup and operating times which can translate to increased costs. To see the impact of different technologies on surgical efficiency, we studied the impact of a single surgeon’s experience with a multitude of instrument navigational technologies. MethodsConsecutive patients undergoing minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) were analyzed. Consecutive cases were done with assistance of a robot (Mazor, Medtronic, Minneapolis, MN), with the assistance of fluoroscopic instrument-tracking (TrackX, North Carolina, USA), or fluoroscopy alone without adjunctive navigation in consecutive blocks of time. The cases done without assistance were used to normalize for number of interbody implants and decompressions performed as well as hardware removal if needed. Age, body mass index (BMI), sex, operative levels, laminectomy, need for hardware removal, and total operative time were recorded. ResultsA total of 119 cases (74 conventional, 13 robot-assisted, 32 instrument-tracking) were included in analysis. There were no significant differences in age, sex, or BMI between modalities. Average total operative time for robot-assisted, and instrument-tracking-assisted cases was 175.46 ± 46.86 min 119.63 ± 34.33 min, respectively, for each level (p < 0.05 across each group). After normalization against operative times from similar cases performed with conventional fluoroscopy, robotic-navigation added an average of 42.25 ± 28.35 min while use of instrument-tracking saved an average of 13.88 ± 38.69 min. There was no learning curve seen using robotic navigation, as operative times remained consistently longer than similar cases using conventional fluoroscopy and showed no sign of improvement over time. Cases using instrument-tracking were initially slower but trended downwards through approximately 11 patients, at which point operative times were consistently quicker (R2 = 0.39). None of the assisted cases were abandoned in favor of standard fluoroscopy or required hardware revision. ConclusionEnabling technology can have a significant impact on surgical efficiency. Compared to MIS-TLIFs performed with standard fluoroscopy, those done with robotic-assistance consistently negatively impacted operative times while instrument-tracking was associated with a short learning curve and in the majority of cases studied showed improved operative times.