Open Reduction Of Fractures Research Articles

Weight-bearing Allowed Following Internal Fixation of Ankle Fractures, a Systematic Literature Review and Meta-Analysis.

Postoperative management regimes vary following open reduction and internal fixation of unstable ankle fractures. Traditional postoperative nonweightbearing cast immobilization may prevent loss of fixation and protect the soft tissue envelope but may also be associated with poorer functional outcomes. This systematic review and meta-analysis aimed to compare the complication rate and functional outcomes of early weightbearing (EWB) vs late weightbearing (LWB) following open reduction and internal fixation of ankle fractures. We performed a systematic review with a meta-analysis of controlled trials and comparative cohort studies using 3 databases. We included all studies that investigated the effect of weightbearing following internal fixation of ankle fractures in adult patients by any means. Studies that investigated mobilization but not weightbearing, non-English-language publications, and tibial Plafond fractures were excluded from this systematic review. We assessed the risk of bias using ROB 2 tools for randomized controlled trials and ROBINS-1 for cohort studies. Data extraction was performed using Covidence online software and meta-analysis by using RevMan 5.3. This systematic review included 10 randomized controlled trials and 4 comparative cohort studies. Most of the included studies were rated as having some concern with regard to the risk of bias. There was no significant difference in the complication rate between the protected EWB and LWB groups (the risk ratio [RR] for infection was 1.30, 95% CI 0.74, 2.30; I² = 0%; P = .36), but better functional outcome scores were detected in the EWB group only at 6 weeks postoperatively (MD =10.08, 95% CI 5.13, 15.02; I² = 0%; P ≤ .0001), with no significant difference seen at 6 or 12 months postoperatively. Based on the studies reviewed, it appears that early protected weightbearing following open reduction and internal fixation of ankle fractures does not affect surgical incision or fracture healing and is associated with better early functional outcomes at 6 weeks, but not 6 or 12 months, postoperatively.

Functional Outcomes of Close Reduction With K-wires Vs Open Reduction and Internal Fixation in Distal Radius Fractures

Functional Outcomes of Close Reduction With K-wires Vs Open Reduction and Internal Fixation in Distal Radius Fractures

The Study Intends to Compare the Efficiency of the Modified Tragus Edge Approach and the Retromandibular Transparotid Approach in Patients Who Underwent Open Reduction and Internal Fixation of Low-Level Condylar Fractures

The Study Intends to Compare the Efficiency of the Modified Tragus Edge Approach and the Retromandibular Transparotid Approach in Patients Who Underwent Open Reduction and Internal Fixation of Low-Level Condylar Fractures

Simultaneous Open Reduction and Corrective Osteotomy for a Child With Lateral Condylar Fracture and Cubitus Varus Deformity Following Supracondylar Fracture: A Case Report

Posttraumatic cubitus varus deformity in pediatric patients may cause second fractures of the distal humerus. Corrective osteotomy is used to obtain good alignment and is generally performed for patients with prolonged deformity or bony union after fracture. We report the case of a 10-year-old boy who presented with elbow pain after falling. Plain radiography showed lateral condylar fracture and cubitus varus deformity. This injury was the fourth fracture of the same distal humerus. Open reduction and internal fixation for lateral condylar fracture and lateral closing wedge osteotomy for cubitus varus deformity were performed simultaneously. At the last follow-up, one and a half years after operation, plain radiography showed closure of the physis of the distal humerus, and coronal alignment was maintained. The patient was asymptomatic and satisfied with cosmetic issues. There was no fracture after two surgical procedures simultaneously.

Is there any clinical significance of axillary nerve electrophysiological changes in the deltoid split approach?

PurposeThe clinical effects of axillary nerve injury in the deltoid splitting approach are controversial. This study investigated the axillary nerve function with clinical and electrophysiologically in proximal humeral fracture patients with internal fixation using the deltoid split approach. We also aimed to investigate the effects of this damage on deltoid muscle volume and discuss the effects of volumetric changes and nerve damage on patients' clinical outcomes. Methodsstudy designed prospectively with 25 consecutive patients who received open reduction and internal fixation of proximal humerus fracture through a deltoid splitting approach. We performed clinical, electrophysiological, and radiological examinations during minimum follow-up time of 24 months. Electrophysiological examination comprised electromyoneurography (EMNG). Functional results followed by Constant-Murley and Disabilities of the Arm, Shoulder, and Hand scores. Deltoid volumes were evaluated with magnetic resonance imaging. ResultsTwenty-five patients operated on with open reduction internal fixation were prospectively observed. In the EMNG measurements of the patients on the 45th postoperative day, partial degeneration was observed in the anterior part of the axillary nerve in all cases (100%). In the control EMNG measurements performed at the 12th month, normal values were obtained for 15 (60%) of the patients, while findings of ongoing regeneration were detected for 10 (40%) of the patients and normal values at all patients at the 24th month. The difference between abnormal and normal EMNG groups' on 12th month Constant-Murley scores was not statistically significant in any period. Only anterior muscle thickness was statistically higher in the normal patient group than with abnormal EMNG results. ConclusionsIn proximal humeral fractures treated with the deltoid split approach, there may be iatrogenic damage of the anterior branch of the axillary nerve. Axillary nerve damage does not affect the patients' clinical scores in the early and mid-terms. Level of evidenceLEVEL III.

The minimal clinically important difference (MCID) of the Olerud Molander Ankle Score (OMAS) in patients with unstable ankle fracture

IntroductionThe Olerud Molander Ankle Score (OMAS) is a widely used validated Patient Reported Outcome Measure (PROM). For clinical research, it is important to determine the Minimal Clinically Important Difference (MCID). The objective of this study was to determine the MCID of the OMAS at several moments in the follow-up, in a cohort of patients that underwent open reduction and internal fixation of unstable ankle fractures with syndesmotic injury.Materials and methodsData for this descriptive study were extracted from a prospective randomized controlled trial, the RODEO trial. The Dutch version of the OMAS was completed at 3, 6 and 12-month follow-up and estimated at baseline. The used anchor-based methods were: mean change and ROC curve. The distribution-based methods were: 0.5SD and minimal detectable change (MDC).ResultsThis cohort included 148 patients. The mean OMAS score in the group with minimal improvement between 3 and 6 months was 15.0 (SD 17.5, 95%CI 9.4–20.6) and between 6 and 12 months 9.5 (SD 17.1, 95% CI 3.1–15.9). The ROC curve between 3 and 6 months resulted in a MCID of 12.5 (AUC 0.72) and between 6 and 12 months, the MCID was 7.5 (AUC 0.78). Using 0.5 SD, the MCID was 10.52 (SD 21.04) at 3 months, 11.37 (SD 22.73) at 6 months and 10.47 (SD 20.94) at 12 months. The MDC was 4.72 at 3 months, 5.20 at 6 months and 4.71 at 12 months.ConclusionsThe calculated MCID in patients following surgery for unstable ankle fractures ranges from 10.5 to 15.0 at 3–6-month follow-up and from 7.5 to 11.4 at 6–12-month follow-up, depending on moment and method.

P-67613701-73 - Load-bearing ORIF of mandibular fracture caused by firearms projectiles: Case series.

Purpose The main challenge in mandibular fractures caused by firearms is restore the anatomy in the fracture areas, due to the severe destruction of the bone and tooth borne structures. To reestablish these areas, load sharing devices usually lacks support, leading to non-union and infections. Strong systems, with load-bearing pattern are the gold-standard for the treatment of complex mandibular fractures. Methods A series of patients with mandibular fracture caused by firearms injuries was treated with load-bearing devices and followed to observe the complications and outcomes. Results A total of 22 patients were enrolled by this study, 19 male and 3 females. All the patients were treated with transcutaneous approach and rigid fixation with a 2.4 mm titanium plate, a total load-bearing device. The complication rate was considered low, with infection of the surgical site (13%) and material fatigue (9%) the most prevalent. Conclusion Open reduction and internal fixation of mandibular fractures with load-bearing devices is a reliable procedure. The use of these materials in cases of caused by firearms projectiles is fundamental to promote the correct for bone support in long term. The main challenge in mandibular fractures caused by firearms is restore the anatomy in the fracture areas, due to the severe destruction of the bone and tooth borne structures. To reestablish these areas, load sharing devices usually lacks support, leading to non-union and infections. Strong systems, with load-bearing pattern are the gold-standard for the treatment of complex mandibular fractures. A series of patients with mandibular fracture caused by firearms injuries was treated with load-bearing devices and followed to observe the complications and outcomes. A total of 22 patients were enrolled by this study, 19 male and 3 females. All the patients were treated with transcutaneous approach and rigid fixation with a 2.4 mm titanium plate, a total load-bearing device. The complication rate was considered low, with infection of the surgical site (13%) and material fatigue (9%) the most prevalent. Open reduction and internal fixation of mandibular fractures with load-bearing devices is a reliable procedure. The use of these materials in cases of caused by firearms projectiles is fundamental to promote the correct for bone support in long term.

An Objective Tool for the Assessment of Masticatory Forces Following the Open Reduction and Internal Fixation of Posterior Mandibular Fracture

An Objective Tool for the Assessment of Masticatory Forces Following the Open Reduction and Internal Fixation of Posterior Mandibular Fracture

Outcomes and experience after open reduction for chronic Monteggia fracture in children.

BackgroundThe treatment of chronic Monteggia fracture-dislocation (CMF) remains controversial and challenging for surgeons. We describe our initial experience with ulnar osteotomy and angulation on correction with modified open surgery and evaluate outcomes from clinical and radiographic findings.MethodsWe retrospectively reviewed 18 children with a mean age of 6.78±2.67 years old who underwent surgical treatment because of CMF. Electronic medical records of Bado type, complaints, Kim scores, and complications were recorded. Radiographic parameters of maximum interosseous distance (MID), proportional ulnar length (PUL), lengthening, and bending angle of the ulna were summarized. The final reduction statuses of the radial head were reviewed. Parameters were compared at the time of pre-operation and the last follow-up. The relationship between the lengthening and angulation of ulna and the interval was calculated.ResultsThe mean interval was 11.1 [1–48] months and the follow-up time was 46.6 [24–96] months. A good reduction was observed in 15 (83.33%) patients, while 3 (16.67%) patients were fair. Postoperatively, the Kim scores were improved, from 59.17±18.17 to 90±6.64 (P=0.000). The mean posterior bending angle was 12.88° (range, 3 to 25°), and the mean amount of elongation of the ulna was 8.78 mm (range, 3.61 to 17.52 mm). The lengthening of the ulna was proportional to the magnitude of angulation of the ulna (r=0.648, P=0.004), and a positive correlation was also seen between the lengthening and the interval (r=0.632, P=0.005) and the angulation and the interval (r=0.502, P=0.034). The PUL and MID were significantly increased from 1.06±0.03 and 1.11±0.26 to 1.13±0.11 (P=0.047) and 1.28±0.27 (P=0.021), separately.ConclusionsWe highlight ulnar osteotomy as the essential procedure during reconstruction surgeries. Stabilization of the radial head with adequate elongation and balanced angulation of the osteotomy through direct observation is the main way to ensure and maintain satisfactory outcomes. With the extension of the interval, it is more necessary to increase the lengthening and angulation in positive proportion. PUL is a useful parameter in evaluating the mismatch between ulna and radius in CMF.

Comparison of Open reduction and internal fixation by Stabilization with cross K-wires in early versus late presentation of Supracondylar Humeral Fractures in Children

Objective: To compare open reduction and internal fixation by stabilization with cross k-wires in early (within 6 days of injury) versus late (2 to 4 weeks) presentation of supracondylar humeral fractures in children. Study Design: A quasi experimental study Place and Duration: Department of Orthopedic, Lahore General Hospital, Lahore from 1st January 2021 to 30th June 2021. Methodology: A total of 42 cases (21 children in Group-A with early presentation and 21 in Group-B with late presentation) of Gartland’s type II and III humeral supracondylar fracture were included. All open reduction and internal fixation procedures were done by a single surgical team while post-surgical follow up consisted of 3-months. Functional and cosmetic outcome of surgery were observed in terms of decrease in carrying angle and elbow movements as per Flynn’s criteria. Results: Out of a total of 42 cases, there were 71.4% male and 28.6% female. The mean age of children in Group-A was 8.29±1.85 years while it was 7.43±2.06 years in Group-B. Mean procedure time was noted to be 0.91±0.35 hours in Group-A and 1.38±0.25 hours in Group-B (p<0.001). All cases were found to have satisfactory wound condition and bony union. Decrease in range of motion of elbow as 0-50, 6-100,and 11-150 in 10, 9 and 2 cases in Group-A respectively in comparison to 4, 14 and 3 cases in Group-B respectively (p=0.145). Functional outcome in 33.3% cases was excellent, good in 54.8% and fair in 11.9% cases while there was no difference in between both study groups (p=0.145). Conclusion: There is no significant difference in functional outcomes of early or late presentation in children undergoing open reduction and internal fixation for supracondylar fractures. Keywords: Supracondylar fracture, Humerus, Children, Early presentation, Late presentation, Open reduction, Internal fixation, K-wire stablization, Functional outcome.

Comparison of Propofol-Fentanyl Versus Propofol-Ketamine Combination as Total Intravenous Anesthesia in Maxillofacial Surgical Procedures – A Prospective Randomized Controlled Study

Background: Total intravenous anesthesia (TIVA) is a technique where drugs are administered intravenously for the induction and maintenance of anesthesia instead of volatile drugs, avoiding some of the drawbacks of inhalation anesthesia providing rapid and complete recovery making it suitable for daycare surgeries. Aim: To compare the intraoperative and postoperative hemodynamic patterns, postoperative recovery time, and unwanted consequences such as post-operative nausea and vomiting (PONV) in various maxillofacial procedures using a combination of two drug regimens, namely propofol-ketamine and propofol-fentanyl. Patient & methods: 40 patients between the age group of 18-40 years of either gender were randomly divided into two groups with propofol-ketamine (group 1, n=20) and propofol-fentanyl (group 2, n=20) who underwent various surgical procedures like cyst enucleation, open reduction and internal fixation (ORIF) of facial fractures, orthognathic procedures such as maxillary or mandibular segmental osteotomy and genioplasty with the procedure lasting 60 to 75 minutes. This study compared the total amount of propofol, time of the infusion, and hemodynamic parameters like mean pulse rate (PR), oxygen saturation level (SpO2), systolic blood pressure (SBP) & diastolic blood pressure (DBP), emergence time & recovery time, undesirable sequels like postoperative nausea and vomiting (PONV) and any other side effects between both the groups. Results were analyzed statistically using an independent t-test and chi-square test. Results: A comparison of two groups revealed a significant rise in systolic blood pressure in group 1 as compared to group 2 and group 2 showed better emergence time & recovery time with fewer incidences of postoperative nausea and vomiting and other side effects. Conclusion: Since the propofol-fentanyl provided significantly good results it can be considered as an alternative to gaseous anesthetic agents in various maxillofacial surgical procedures mentioned in the materials with the surgical procedure lasting 60-75 minutes.

How Accurate Are Surgeons at Calculating Orbital Volumes?

Bilateral orbital volume (OV) symmetry is imperative for successful orbital reconstruction to prevent complications such as enophthalmos, diplopia, and orbital dystopia. The purpose of this study was to determine the accuracy of surgeon-led in-house OV calculation for reconstructed orbits after orbital floor fracture. This is a retrospective cross-sectional observational study of maxillofacial computed tomography scans for patients undergone orbital fracture repair by Emory Oral and Maxillofacial service at Grady Memorial Hospital (Atlanta, Georgia) from 2018 to 2020.The primary predictor variable was OV calculation approach (outsourced vs surgeon-led in-house approach). The primary outcome variable was OV. Secondary variables were age, gender, and race. Interobserver reliability was calculated with a 2-way mixed-effects model, intraclass correlation coefficients, 95% confidence intervals, and Pvalues. Differences between OV (in-house and outsourced) were calculated using student t-test. Statistical significance was determined at P<.05. During the study period, 172 patients sustained orbital floor fracture. Of them, 49 patients (31 male, 18 females; 98 orbits) with the mean age of 41.3years (range, 19 to 89 years) met inclusion criteria. Subjects with incomplete medical records and inadequate computed tomography scans were excluded from the study. The racial distribution in descending order was 87.8% African American, 8.2% Caucasian, 2% Hispanic, and 2% Asian. There was excellent inter-rater reliability for calculating uninjured OV (OV-U, P<.0001) and reconstructed OV (OV-R, P<.0001). The mean OV difference of outsourced approach was 0.8cm3and for surgeon-led in-house approach was 0.07cm3. There was no significant difference in OV difference between outsourced and in-house approach (P=.16). In conclusion, using open-source 3-dimensional imaging software is a reliable and a predictable method at calculating reconstructed OV in patients who underwent open reduction and internal fixation of orbital fractures. By having this software in our personal computers and laptops, one can easily calculate OVs in an efficient manner.

Functional Outcome Of Extra-Articular Distal Humerus Fracture Fixation Using A Lateral Column Locking Compression Plate.

: A host of different methodologies have been implemented in the management of distal humerus fractures, including conservative measures and surgical fixation with a variety of plates. This study was conducted to evaluate the functional outcome of open reduction and internal fixation of extra articular distal humerus fractures with distal humerus locking compression plate. This is a retrospective cohort study of patients with close extra articular distal humerus fractures who underwent open reduction and internal fixation with a distal humerus locking compression plate at Ghurki Trust Teaching Hospital from July 2017 to December 2019. Various demographic indicators were used for data analysis and radiological union was assessed in serial follow-ups. Functional outcome was evaluated using the Mayo Performance Elbow Score at the final follow-up. Thirty-one patients presented with extra-articular fracture of humerus (N=31) with average age 33.5±9.90 years. The average follow-up period was 13.8 months. Radiological union was achieved in 14.8 weeks (range 12-20 weeks). Out of 31 patients, 28 had excellent results with mean Mayo Elbow Performance Score of 94.8. Two patients (6.5%) had radial nerve palsy post-operatively. This study shows that open reduction and internal fixation of extra-articular distal humerus fractures with distal humerus locking compression plates allows for stable fixation, good functional outcome, and low complication rates.

Sleep Apnea and Postoperative Medical Complications and Health Care Expenditures Following Open Reduction and Internal Fixation of Bimalleolar Ankle Fractures.

Sleep Apnea (SA) is a common sleep disorder that increases postoperative morbidity. There is limited research on how SA influences outcomes following operative fixation of ankle fractures. Therefore, the aim of this study was to determine whether patients who undergo surgical fixation for bimalleolar ankle fractures have higher rates of medical complications and health care expenditures. A retrospective review from January 1, 2005 to March 31, 2014 was conducted using the parts A and B Medicare Data from PearlDiver database. Patients with and without SA on the day of the primary open reduction and internal fixation (ORIF) of their bimalleolar ankle fractures were queried using the International Classification of Diseases, Ninth Revision codes. Welch'st-tests were used to compare costs of care. A multivariate binomial logistic regression model was used to calculate the odds ratio (OR) of adverse events. A P-value <.001 was considered statistically significant. There were 20 560 patients (SA = 3150; comparison cohort = 17 410) who underwent ORIF for bimalleolar ankle fractures during the study period. Sleep apnea patients were found to have significantly higher rates and odds of 90-day medical complications (21.42% vs 7.47%, OR: 3.11, P < .0001) and 90-day costs of care ($7213.12 vs $5415.79, P < .0001). This research demonstrates an increased risk of postoperative medical complications and health care costs among patients with SA undergoing ORIF for bimalleolar ankle fractures. Therapeutic, Level IV: Retrospective.

The radiographic soft tissue thickness is associated with wound complications after open reduction and internal fixation of patella fractures

BackgroundDisplaced patella fracture is commonly treated with open reduction and internal fixation (ORIF). Wound complications after surgery often lead to prolonged hospitalization and dissatisfaction of patients. Periarticular adiposity and swelling may be associated with wound complications. The purpose of this study is to determine the relationship between periarticular soft tissue thickness and wound complications after ORIF of patella fractures.MethodsWe retrospectively studied 237 patients undergoing ORIF for patella fractures from June 2017 to February 2021 at our institution. We established periarticular soft tissue thickness ratio (PSTTR) to evaluate soft tissue status on lateral knee X-ray radiographs. Univariate analysis was performed to identify the association between PSTTR and postoperative wound complication. A receiver-operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of PSTTR.ResultsThe incidence of postoperative wound complication was 10.5%. Minor wound complication occurred in 24 patients, and major wound complication occurred in one patient. The average femoral PSTTR (fPSTTR) was 0.94 ± 0.17 and the average tibial PSTTR (tPSTTR) was 0.66 ± 0.16. fPSTTR proved to be associated with postoperative wound complication. In the ROC analysis of fPSTTR predicting postoperative wound complication, the area under curve (AUC) was 0.676, which indicated a moderate predictive value.ConclusionsPSTTR was a feasible method to assess periarticular soft tissue. The increased fPSTTR was associated with wound complications after ORIF of patella fractures.

Calcaneus fractures: characteristics of radiological and clinical outcomes of surgery treatment

Background: Calcaneus fracture is one of the types of fractures that have a fairly frequent clinical frequency. Recently, there are many other values on X-rays and CT scans of the calcaneus used for diagnosis, evaluation, and prognostic in outcomess.This study aims to evaluate the imaging characteristics on radiographs and CT scans of calcaneus fractures and surgical treatment outcomes in patients with calcaneus fractures as well. Materials and Method: from October 2019 to June 2021, 32 patients with calcaneus fractures were diagnosed and underwent open and internal fixation surgery at Department of Orthopedic-Thoracic Trauma Surgery, Hue University of Medicine and Pharmacy Hospital. All calcanues were estimated for Boehler angle, Gissane angle, height, length, and calcasneus width, the results of treatment are evaluated on the scale of the American Orthopaedic Foot &amp; Ankle Society (AOFAS). Results: There were 20 cases of left and 12 cases of right calcaneus. The average follow-up period is 03-06 months.The average AOFAS score at post-operative 3 and 6 months was 78.73 ± 11.86 (65-93) and 88.44 ± 4.98 (81-97), respectively. Boehler angle value preoperative 10.56 ± 9.410 increased post-operative 24.34 ± 9.360, p&lt;0.001, Gissane angle pre-operative 93.580 (850 - 1000) increased post-operative 114.70 ± 5.230, p&lt;0.001. The width of the pre-surgery heel bone is 65.4 (60-68) mm and post-operative 60.1 (58-63) mm. Pre-operative heel bone height was 37.1 (26-49) while post-surgery calcaneus height was 48.2 (41-58) p&lt;0.05. Pre-operative calcaneus length was 83.2 (75-92) and post-operative calcaneus length was 82.7 (75-91) p&gt;0.05. Conclusion: The findings of the study reveal that open reduction and internal fixation for calcaneal fractures has positive results in terms of imaging and ankle function for patients. Furthermore, the inclusion of extra characteristics on calcaneus X-rays and CT scans helps to improve treatment outcomes in calcaneal fracture surgery. Key words: calcaneus fractures, calcaneus fractures open reduction and internal fixation

Long-Term Trajectory of Recovery Following Pilon Fracture Fixation.

To describe the trajectory of recovery following fixation of pilon fractures from baseline to 5-year follow-up. Prospective cohort study. Level-1 trauma center. Patients with pilon fractures (OTA/AO 43.C) treated with open reduction and internal fixation. None. Patient-reported outcome measures were measured at baseline, 6 months, 1 year, and 5 years using the Short-Form 36 Health Survey (SF-36) Physical Component Score and Mental Component Score, Short Musculoskeletal Functional Assessment, and the Foot and Ankle Outcome Score. One hundred two patients were enrolled: mean age was 42.6 years; 69% were males; 88% had an injury severity score of 9; 74 patients (73%) completed 1-year follow-up; 40 patients (39%) completed 5-year follow-up. Trajectory of recovery of physical function showed a significant decline between baseline and 6 months, with significant improvement between 6 months and 1 year and then ongoing but slower improvement between 1 year and 5 years. Sixty-four patients returned to baseline SF-36 Physical Component Score at 5 years. Pain was a persistent issue and remained significantly worse at 5 years when compared with baseline. Psychological well-being (SF-36 Mental Component Score) did not significantly change from baseline at 5 years. Functional recovery following open reduction and internal fixation for pilon fractures was characterized by an initial decrease in function from baseline, followed by an increase between 6 months and 1 year, and then slower but continued increases from 1 year to 5 years. Function did not return to baseline levels, pain was a persistent issue, and mental well-being showed no change from baseline at 5 years. This information may be useful when counselling patients. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Assessing technical skill in ankle fracture surgery from the postoperative radiograph : pilot development and validation of a final product analysis core outcome set.

AimsTo identify a core outcome set of postoperative radiographic measurements to assess technical skill in ankle fracture open reduction internal fixation (ORIF), and to validate these against Van der Vleuten’s criteria for effective assessment.MethodsAn e-Delphi exercise was undertaken at a major trauma centre (n = 39) to identify relevant parameters. Feasibility was tested by two authors. Reliability and validity was tested using postoperative radiographs of ankle fracture operations performed by trainees enrolled in an educational trial (IRCTN 20431944). To determine construct validity, trainees were divided into novice (performed < ten cases at baseline) and intermediate groups (performed ≥ ten cases at baseline). To assess concurrent validity, the procedure-based assessment (PBA) was considered the gold standard. The inter-rater and intrarater reliability was tested using a randomly selected subset of 25 cases.ResultsOverall, 235 ankle ORIFs were performed by 24 postgraduate year three to five trainees during ten months at nine NHS hospitals in England, UK. Overall, 42 PBAs were completed. The e-Delphi panel identified five ‘final product analysis’ parameters and defined acceptability thresholds: medial clear space (MCS); medial malleolar displacement (MMD); lateral malleolar displacement (LMD); tibiofibular clear space (TFCS) (all in mm); and talocrural angle (TCA) in degrees. Face validity, content validity, and feasibility were excellent. PBA global rating scale scores in this population showed excellent construct validity as continuous (p < 0.001) and categorical (p = 0.001) variables. Concurrent validity of all metrics was poor against PBA score. Intrarater reliability was substantial for all parameters (intraclass correlation coefficient (ICC) > 0.8), and inter-rater reliability was substantial for LMD, MMD, TCA, and moderate (ICC 0.61 to 0.80) for MCS and TFCS. Assessment was time efficient compared to PBA.ConclusionAssessment of technical skill in ankle fracture surgery using the first postoperative radiograph satisfies the tested Van der Vleuten’s utility criteria for effective assessment. 'Final product analysis' assessment may be useful to assess skill transfer in the simulation-based research setting.Cite this article: Bone Jt Open 2022;3(6):502–509.

Surgeon volume and risk of deep surgical site infection following open reduction and internal fixation of closed ankle fracture.

Increasing evidences have shown that surgeon volume was associated with postoperative complications or outcomes in a variety of orthopaedics surgeries, but few were focused on ankle fractures. This study aimed to investigate the deep surgical site infection (DSSI) in association with the surgeon volume following open reduction and internal fixation (ORIF) of ankle fractures. This was a retrospective analysis of the prospectively collected data on patients who underwent ORIF for acute closed ankle fractures between October 2014 and June 2020. Surgeon volume was defined as the number of ORIF procedures performed within 12 months preceding the index operation. The receiver operating characteristic (ROC) curve was constructed to determine the optimal cut-off value, whereby surgeon volume was dichotomized as high or low. The outcome was DSSI within 1year postoperatively. Multivariate logistics analysis was performed to examine the DSSI in association with surgeon volume and multiple sensitivity/subgroup analyses were performed to refine the findings. Among 1562 patients, 33 (2.1%) developed a DSSI. The optimal cut-off value was 7/year. Low-volume (<7/year) was significantly associated with a 5.0-fold increased risk of DSSI (95%CI, 2.2-11.3; P < .001). Sensitivity/subgroup analyses restricted to patients aged <65 years, with or without concurrent fractures, with unimalleolar fractures, bi- or trimalleolar fractures, receiving ORIF within 14 days and those operated by ≥10-year experience surgeons showed the consistently significant results (ORs, 2.7-6.8, all P < .05). The surgeon volume of <7 cases/year is associated with an increased risk of DSSI. It is more feasible that patients with complex fractures or conditions (eg, bi- and trimalleolar or presence of concurrent fractures) are preferentially directed to high-volume and experienced surgeons.

Risk factors for fracture-related infection after open reduction and internal fixation of proximal humerus fractures: A multicenter retrospective study of 496 fractures (TRON group study)

One of the complications of the surgical therapy for proximal humerus fractures is fracture-related infection (FRI). This multicenter study aimed to investigate the incidence of FRI and clarify the risk factors associated with FRI in patients receiving open reduction and internal fixation for proximal humerus fracture. Among 684 patients diagnosed as having proximal humerus fracture and who were treated by surgical therapy in 13 institutions (named TRON group) from 2015 through 2020, 496 patients (men, n=134, women, n=362; mean [SD] age, 68.5 [14.5] years; mean [SD] body mass index [BMI], 23.0 [4.4] kg/m2) were included as subjects. Excluded were 188 patients due to less than 12 month's follow-up, patients who underwent osteosynthesis using neither plate nor nail and those with open fracture. We extracted the following as risk factors of FRI: sex, BMI, smoking status, diabetes, glenohumeral fracture dislocation, fracture classification, approach, implant, waiting period, type of anesthesia, operative time and blood loss during surgery. We conducted logistic regression analysis to investigate the risk factors of FRI using these extracted items as explanatory variables and the presence or absence of FRI as the response variable. FRI occurred after surgery for proximal humerus fracture in 9 of the 496 patients (1.8%). The causative organism was methicillin-susceptible Staphylococcus aureus in 4 patients, Pseudomonas aeruginosa in one patient and Enterococcus faecalis in one patient. In the other 3 patients, causative organisms were not detected. The univariate analysis showed significant differences for present of glenohumeral fracture dislocation (p=0.004). Logistic regression analysis showed glenohumeral fracture dislocation to be the significant explanatory factor for FRI (odds ratio 12.3, p=0.0375). This study revealed an infection rate following open reduction and internal fixation of proximal humerus fracture of 1.8% (9 patients) and that Staphylococcus was the most frequent causative organism. Glenohumeral fracture dislocation is a significant risk for postoperative FRI.