Open Reduction Research Articles

Ankle fracture surgery in patients experiencing homelessness: a national evaluation of one-year rates of reoperation.

To evaluate the impact of homelessness on surgical outcomes following ankle fracture surgery. Retrospective cohort study. Mariner claims database. Patients older than 18 years who underwent open reduction and internal fixation (ORIF) of ankle fractures between 2010 and 2021. A total of 345,759 patients were included in the study. Study patients were divided into two cohorts (homeless and nonhomeless) based on whether their patient record contained International Classification of Disease (ICD)-9 or ICD-10 codes for homelessness/inadequate housing. One-year rates of reoperation for amputation, irrigation and debridement, repeat ORIF, repair of nonunion/malunion, and implant removal in isolation. Homeless patients had significantly higher odds of undergoing amputation (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.08-2.27, P = 0.014), irrigation and debridement (aOR 1.22, 95% CI 1.08-1.37, P < 0.001), and repeat ORIF (aOR 1.16, 95% CI 1.00-1.35, P = 0.045). Implant removal was less common in homeless patients (aOR 0.65, 95% CI 0.59-0.72, P < 0.001). There was no significant difference between homeless and nonhomeless patients in the rate of nonunion/malunion repair (aOR 0.87, 95% CI 0.63-1.18, P = 0.41). Homelessness is a significant risk factor for worse surgical outcomes following ankle fracture surgery. The findings of this study warrant future research to identify gaps in surgical fracture care for patients with housing insecurity and underscore the importance of developing interventions to advance health equity for this vulnerable patient population. Prognostic Level III.

Management of fractures involving the mandibular body, parasymphyseal, and subcondylar regions

Background: The mandibular bone plays a crucial role in various aspects of facial anatomy, including digestion, speech, and facial aesthetics. Given its significance in these functions, surgeons must not only address functional aspects but also consider aesthetic concerns during treatment. Mandibular fractures represent a prevalent form of traumatic injury in the maxillofacial region. Despite the existence of established treatment methods that have been in use for a considerable time, untreated fractures and complications following surgery can still significantly impact the patient's quality of life. Purpose: Understand the principles of managing cases of mandibular corpus, mandibular parasymphysis, subcondyle fractures using a combination of Mini Plate and Reconstruction Plate. Case: A 54-year-old man with mandibular parasymphysis fracture Dekstra, corpus mandibular fracture sinistra, subcondyle fracture sinistra, dentoalveolar fracture regions 32-42 accompanied by avulsions 32, 31, 41, 42, and hypertension was reported. Results: The treatment in this case was Open Reduction and Internal Fixation (ORIF). Fixation of the fracture segments with 2 vertical mini-plates on the parasymphysis of the dextral mandible, 1 mini-plate and reconstruction plate on the corpus and subcondyle fracture sinistra. Conclusion: The use of two plates and screws in the parasymphysis of the mandible, one mini-plate and one reconstruction plate in mandibular corpus and subcondyle fractures, resulted in good occlusion with minimal complications.

To cast or not to cast? Postoperative care of ankle fractures: a meta-analysis of randomized controlled trials.

Postoperative care of ankle fractures treated with open reduction and internal fixation (ORIF) is a debated topic. A meta-analysis of Randomized Controlled Trials was conducted with the aim of comparing early mobilization and weightbearing to traditional postoperative protocols. A systematic search of electronic databases was conducted according to the PRISMA guidelines. Only randomized clinical trials were included. Data about clinical outcome, time to return to work and complications were extracted and summarized. Meta-analyses were performed. Twenty studies for a total of 1328 patients were included. Early mobilization was compared to immobilization in 724 patients: the two groups did not significantly differ in terms of short- and long-term clinical outcome (p = 0.08 and p = 0.41, respectively). However, early mobilization resulted to be significantly associated with faster return to work (p = 0.047). Early weightbearing was compared to nonweightbearing in 1088 patients. While the clinical difference between the two groups was not significant at short term (p = 0.08), it was significant at long term (p = 0.002). No other significant differences, in particular regarding complications, were highlighted between different groups. Early motion, early weightbearing and traditional postoperative protocols are all safe strategies after ORIF for unstable ankle fractures. Early mobilization is significantly associated with faster return to work and early weightbearing improves long term clinical outcome.Level of evidence: I.

Periprosthetic proximal humerus fractures require an individualized treatment approach-results of a multicenter retrospective study.

In the last years, there has been increasing use of shoulder arthroplasty. As a result, an increasing incidence of periprosthetic humerus fractures (PPHF) is expected. Therefore, this retrospective, multicenter analysis aimed to collect demographic data from patients with PPHF, their treatment strategies, and associated complications. Demographics of patients with PPHF were collected retrospectively from the database of six trauma hospitals between January 2000 and December 2020. All fractures were categorized according to the Wright and Cofield, and Worland classifications. In addition, the type of treatment for PPHF, as well as subsequent complications, were evaluated. A total of 72 patients with a PPHF were identified. The mean age of the 55 female and 17 male patients was 77years. PPHF occurred a mean of 50months after primary arthroplasty implantation, almost exclusively as a result of a fall from standing height (n = 67). In-situ implant was a RTSA in 40 patients and a hemiarthroplasty in 32 patients. More than half of the fractures (n = 38) were type B fractures, according to Wright and Cofield. According to Worland, the majority of patients also had a type B fracture (type B1 (n = 22), type B2 (n = 28), type B3 (n = 10)). Associated comorbidities were found in 21 patients. A total of 31 patients were treated non-operatively, 27 with Open Reduction Internal Fixation (ORIF), and 14 with a revision arthroplasty. Nine primary radial nerve palsies were found (pre-operatively), and seven secondarily (post-operatively). Nine patients suffered from non-union (ORIF 4, non operative 4,stem replacement 1). The treatment strategy for PPHF is primarily tailored to the individual patient. Decisive factors such as patient's age, fracture type, and primary palsies have to be considered for optimal treatment. In type B1 fractures, there is a recommendation for ORIF because of high non-union rates under non-operative treatment. In contrast, in type B2 fractures, a non-operative approach should be preferred, provided there are no radial nerve lesions. Level IV, epidemiologic study.

Correlation between Peripheric Blood Markers and Surgical Invasiveness during Humeral Shaft Fracture Osteosynthesis in Young and Middle-Aged Patients

The treatment for humeral shaft fractures (HSFs) is still controversial, consisting of a wide variety of orthopedic osteosynthesis materials that imply different grades of invasiveness. The aim of this study is to investigate the correlation between inflammatory blood-derived markers and the magnitude of the surgical procedure in young and middle-aged patients who sustained these fractures. Observational, retrospective research was conducted between January 2018 and December 2023. It followed patients diagnosed with recent HFSs (AO/OTA 12-A and B) and followed operative treatment. They were split in two groups, depending on the surgical protocol: group A, operated by closed reduction and internal fixation (CRIF) with intramedullary nails (IMNs), and group B, operated by open reduction and internal fixation (ORIF) with dynamic compression plates (DCPs). Statistically significant differences (p &lt; 0.05) between the two groups could be observed in injury on the basis of surgery durations, surgical times, pre- and postoperative neutrophil-per-lymphocyte ratio (NLR), postoperative platelet-per-lymphocyte ratio (PLR), monocyte-per-lymphocyte ratio (MLR), systemic inflammatory index (SII), systemic inflammatory response index (SIRI) and aggregate inflammatory systemic index (AISI). The multivariate regression model proposed revealed that NLR &gt; 7.99 (p = 0.007), AISI &gt; 1668.58 (p = 0.008), and the surgical times (p &lt; 0.0001) are strongly correlated to the magnitude of the surgical protocol followed. Using receiver operating characteristic (ROC) curve analysis, a balanced reliability was determined for both postoperative NLR &gt; 7.99 (sensitivity 75.0% and specificity 75.6) and AISI &gt; 1668.58 (sensitivity 70.6% and specificity 82.2%). Postoperative NLR and AISI as inflammatory markers are highly associated with the magnitude of surgical trauma sustained during humeral shaft fracture osteosynthesis in a younger population.

The Use of Knotless Suture Tape Construct vs Screw Fixation for Lisfranc Injuries: A Cadaveric Biomechanical Study.

Lisfranc injuries are often treated with open reduction and internal fixation using rigid fixation techniques. The use of flexible fixation to stabilize the Lisfranc joint is a newer technique. The purpose of this cadaveric study is to compare the amount of diastasis at the Lisfranc interval under diminished physiologic loads when treated with a knotless suture tape construct and a solid screw. Ten cadavers (20 feet) had native motion at the intact Lisfranc interval assessed at multiple increasing loads (69, 138, and 207 N). The Lisfranc ligamentous complex was then disrupted, and testing repeated to evaluate the amount of diastasis. Randomization was performed to determine the type of fixation for each cadaver: solid screw or knotless suture tape construct. Once fixation was completed, specimens were cyclically loaded for 10 000 cycles at loads, and diastasis was quantified after each load cycle to compare the interventions. Diastasis was measured using motion tracking cameras and retroreflective marker sets. A non-inferiority statistical analysis was performed. Diastasis mean values were confirmed to be >2 mm for all load bearing conditions in the injury model. Posttreatment, diastasis was significantly reduced when compared to the sectioned conditions (P < .01) for both treatment options. Non-inferiority analyses showed that the knotless suture tape construct did not perform inferior to screw fixation for diastasis at the Lisfranc interval at any of the compared load states. Under the loads tested, there is no significant difference in diastasis at the Lisfranc interval when treating ligamentous Lisfranc injuries with a knotless suture tape construct or solid screws. Both reduced diastasis from the injured state and were not different from the intact state. In this cadaveric model with ligamentous Lisfranc injury, diastasis of a knotless suture tape construct is compared to solid screw fixation as tested.

Temporary immobilization methods for closed low-energy ankle fracture-dislocations: comparative analysis of a retrospective cohort.

Ankle fracture-dislocations (AFD) often necessitate staged management involving temporary external fixation (EF) due to mechanical instability or blistering. However, limited literature exists on the optimal temporary immobilization method for low-energy closed AFD. This study compared baseline patient and fracture characteristics, along with clinical and radiological outcomes between AFD initially immobilized with EF versus splinting. A retrospective cohort study was conducted involving patients with AFD temporarily immobilized using EF or splinting, followed by definitive open reduction and internal fixation. Quality of reduction (QOR) was assessed for each patient post-initial immobilization and after the definitive surgery. The study encompassed 194 patients: 138 treated with a splint (71.1%) and 56 (28.9%) with EF. Secondary loss of reduction had occurred in three patients who were splinted (2.2%). The mean ages in the EF and splint groups were 63.2 and 56.1years, respectively (p = 0.01). Posterior malleolus fracture (PMF) and blisters were more prevalent in EF patients (69.6% vs. 43.5% for PMF and 76.8% vs. 20.3% for blisters, respectively; p = 0.05 and p < 0.01). Postoperative complication rates were 8.9% for EF versus 10.9% for splinting (p = 0.69). Satisfactory final QOR was attained in 79.8% of patients treated with a splint versus 64.3% with EF (p = 0.02). Patients immobilized by EF presented with poorer baseline characteristics and had more unstable injuries. Nevertheless, postoperative complication rates were comparable. Thus, EF appears to be a valuable tool for standardizing outcomes in AFD patients with a less favorable prognosis.

Double reverse traction repositor assisted closed reduction and internal fixation versus open reduction and internal fixation for treatment of lateral tibial plateau fractures among the elderly.

In elderly tibial plateau fractures (TPFs), the lateral condyles are involved frequently. This study aimed to compare the outcomes of open reduction and internal fixation (ORIF) and double reverse traction repositor (DRTR) assisted closed reduction and internal fixation (CRIF) in elderly patients with lateral TPFs. From January 2015 to July 2020, we retrospectively reviewed 68 patients treated surgically at our trauma center for lateral TPFs (Schatzker type I-III). 31 patients were eventually assigned to the DRTR assisted CRIF group, whereas 37 patients were assigned to the ORIF group. The primary outcomes included surgical details, radiological assessment, follow-up knee function, and complications. The DRTR assisted CRIF group experienced a 43.6mL decrease in intraoperative blood loss (161.3ml vs 204.9ml, p = 0.033), and the operation duration was 32.1min shorter than the ORIF group (83.8min vs 115.9min, p < 0.001). There was no statistically significant difference in terms of widening of the tibia plateau (WTP), depth of articular depression (DAD), medial proximal tibial angle (MPTA) and posterior tibial slope angle (PTSA) immediately after surgery and at the last follow-up. No differences in malreduction (p = 0.566) or reduction loss (p = 0.623) were observed between the groups, and Lysholm and HSS scores were similar between the two groups (83.6 ± 15.8 vs 83.4 ± 5.1, p = 0.934; 89.3 ± 7.8 vs 86.9 ± 6.2, p = 0.172; respectively). However, ORIF was associated with a greater increase in postoperative complications than DRTR assisted CRIF (3.2% vs 27%, p = 0.008). Both types of internal fixation provide good radiological outcomes and knee function in the treatment of lateral TPFs in the elderly. However, DRTR assisted CRIF has the advantage of a shorter duration of surgery, less blood loss, and fewer postoperative complications, and appears to be a better treatment option for elderly patients with lateral TPFs.

Comparative outcome of different treatment options for acetabulum fractures in elderly individuals—a retrospective analysis of 207 patients

Purpose Acetabular fractures are challenging injuries in the heterogeneous population of elderly patients. In patients able to partially bear weight, open reduction and internal fixation (ORIF) is indicated. In frail patients, ORIF combined with primary total hip arthroplasty (THA) allows early weight-bearing to preserve independence. This article systematically analyses a treatment algorithm that separates fractures into stable fractures treated conservatively and fractures needing surgical stabilization with osteosynthesis or osteosynthesis plus arthroplasty, dependent on patient characteristics but less on the fracture classification or energetic impact of the trauma. Methods Data on patients ≥50 years of age treated for acetabular fractures (2009–2019) were retrospectively analyzed. The primary outcome was loss of independence. In-hospital complications, length of stay, re-operations, the need for walking aids, and pain were analyzed as secondary outcomes. Results Out of 207 patients, 135 were male, average age was 70 years. Eighty-five patients were treated conservatively, 89 ORIF, and 33 ORIF plus arthroplasty in one operation. The initial morbidity of patients treated with the combined operation was higher than osteosynthesis alone, but the long-term outcome was favorable with less pain and fewer secondary interventions. Age and female gender were associated with the decision to treat the fracture with the combination of osteosynthesis and arthroplasty. Conclusions The results suggest that aged and potentially frail patients with acetabular fracture have better long-term outcome after ORIF combined with arthroplasty at the price of an initially higher risk of adverse outcomes. Females were more frequently treated with the combined operation independent of other risk factors

Late Manipulation under Anesthesia after Total Knee Arthroplasty: Improved Range of Motion and a Low Complication Rate.

The purpose of this study was to evaluate outcomes of late manipulation under anesthesia (MUA) for stiffness performed from ≥12 weeks to more than a year after primary total knee arthroplasty (TKA). A total of 152 patients receiving MUA ≥12 weeks after primary TKA from 2014 to 2021 were reviewed. The primary outcome measured was change in range of motion (ROM). We tracked intraoperative complications and the need for repeat MUA or open procedure for continued stiffness after initial MUA. Three subgroups were analyzed: Group 1 included 58 knees between 12 weeks and 6 months after TKA, Group 2 included 44 knees between 6 and 12 months after TKA, and Group 3 included 50 knees ≥12 months after TKA. Analysis included descriptive statistics and univariate analysis, with α <0.05. Groups 1 to 3 all significantly increased their overall ROM by 20.9, 19.2, and 22.0 degrees, respectively. All groups significantly increased their flexion and extension from preoperatively. Group 1 had one intraoperative supracondylar femur fracture (1.7%) requiring open reduction and internal fixation, and five patients required repeat MUA or open procedure (8.6%). Group 2 had no intraoperative fractures, and five patients required repeat MUA or open procedure (11.4%). Group 3 had one intraoperative tibial tubercle avulsion fracture managed conservatively (2.0%) and one repeat MUA (2.0%). Late MUA resulted in significantly improved ROM in all groups. ROM improved more as the time from index TKA increased, although statistically insignificant. Repeat MUA or open procedure rate decreased with MUA ≥12 months from TKA, although statistically insignificant. The overall intraoperative fracture risk was 1.3%.

Intraoperative 3D Fluoroscopy During Open Reduction for DDH: An Effective Alternative to Postoperative CT/MRI.

Computed tomography CT or magnetic resonance imaging (MRI) has been the most used imaging modality to assess hip reduction in developmental dysplasia of the hip (DDH) after open reduction (OR). In 2015, intraoperative 3D fluoroscopy (3D) was introduced at our center as an alternative to CT/MRI. 3D offers the advantage that if hip reduction is insufficient, it can be addressed at the time of surgery. The purpose of this study was to assess the efficacy of 3D in comparison to CT/MRI. This was a single-centre, retrospective comparative study of two consecutive cohorts: those with OR and 3D between 2015 and 2017 and those with OR and CT/MRI between 2012 and 2014. Time to imaging, re-imaging, length of stay (LOS), re-operation, and redislocation or subluxation after cast removal were evaluated. Forty-two patients (46 hips) had 3D, and 30 patients (32 hips) had CT/MRI. Significant differences were found between groups in time to imaging, cast changes, and LOS. All 3D was intraoperative (46 hips), and only 69% (22 hips) of CT/MRI was on the day of surgery (P<0.01). In the 3D group, 1 hip (2%) had a cast change under the same anesthetic, and 4 hips (13%) from CT/MRI had cast changes in subsequent surgery (P=0.03). The mean LOS in days for 3D was 1.72 and 2.20 for CT/MRI (P=0.03). There were no statistically significant differences between groups in further imaging and subluxations or re-dislocations at cast removal. Two hips (4%) in the 3D group had MRI, but with no further intervention (P=0.51), and at cast removal, there were 3 subluxations in each group (P=0.69) and 1 redislocation in the 3D group (P=1.00). Intraoperative 3D improved time to imaging, allowed for cast changes at surgery and had a shorter LOS. Moreover, there were no significant differences found in adverse outcomes between those who underwent 3D versus CT/MRI. 3D should thus be considered an effective alternative to CT/MRI for assessing hip reduction during OR for DDH. Diagnostic Study, level II.

Bilateral Asymmetrical Hip Dislocations after Falling from Height: A Case Report and Literature Review

Background: Hip dislocations, constituting 2-5 percent of all joint dislocations, predominantly present as posterior dislocations. Bilateral hip dislocations are rare, accounting for 1.25% of cases. Associated fractures often involve the proximal femur and acetabulum. Case Report: A 60-year-old man with no prior hip trauma history sustained bilateral hip dislocations after a 6-meter fall. Initial assessments and a hip computed tomography (CT) scan confirmed posterior dislocation of the right hip and anterior dislocation of the left hip. The patient underwent a successful closed pelvic reduction operation four hours post-injury, as confirmed by a post-reduction CT scan. Conclusion: The study, encompassing 11 relevant studies and 208 patients, predominantly men (81%), revealed that asymmetrical bilateral hip dislocations were exceptionally rare (0.01-0.02 percent). Contrary to expectations, this study challenges the presumed stronger association of traffic accidents with bilateral dislocations, presenting a statistically significant association between the type of dislocation and trauma mechanism. Associated fractures, such as acetabulum fractures in unilateral cases and posterior edge fractures in bilateral cases, varied. Avascular necrosis (AVN), a common complication, was not observed in the current case, where reduction occurred within the critical 6-hour timeframe. This report contributes valuable insights into the characteristics and associations of asymmetric bilateral hip dislocations, emphasizing the importance of prompt intervention to mitigate complications. Further research is needed to validate these findings and explore underlying patterns in this rare clinical scenario.

OPerative versus non-opERAtive management of isolated ULNAr diaphyseal fractures (OPERA-Ulna): protocol for a randomized controlled trial.

Isolated fractures of the ulnar diaphysis are uncommon, occurring at a rate of 0.02 to 0.04 per 1,000 cases. Despite their infrequency, these fractures commonly give rise to complications, such as nonunion, limited forearm pronation and supination, restricted elbow range of motion, radioulnar synostosis, and prolonged pain. Treatment options for this injury remain a topic of debate, with limited research available and no consensus on the optimal approach. Therefore, this trial aims to compare clinical, radiological, and functional outcomes of two treatment methods: open reduction and internal fixation (ORIF) versus nonoperative treatment in patients with isolated ulnar diaphyseal fractures. This will be a multicentre, open-label, parallel randomized clinical trial (under National Clinical Trial number NCT01123447), accompanied by a parallel prospective cohort group for patients who meet the inclusion criteria, but decline randomization. Eligible patients will be randomized to one of the two treatment groups: 1) nonoperative treatment with closed reduction and below-elbow casting; or 2) surgical treatment with ORIF utilizing a limited contact dynamic compression plate and screw construct. The primary outcome measured will be the Disabilities of the Arm, Shoulder and Hand questionnaire score at 12 months post-injury. Additionally, functional outcomes will be assessed using the 36-Item Short Form Health Survey and pain visual analogue scale, allowing for a comparison of outcomes between groups. Secondary outcome measures will encompass clinical outcomes such as range of motion and grip strength, radiological parameters including time to union, as well as economic outcomes assessed from enrolment to 12 months post-injury. This trial has been approved by the lead site Conjoint Health Research Ethics Board (CHREB; REB14-2004) and local ethics boards at each participating site. Findings from the trial will be disseminated through presentations at regional, national, and international scientific conferences and public forums. The primary results and secondary findings will be submitted for peer-reviewed publication.

Factors Associated with Infection in Patients with Combined Pelvic Ring and Bladder Injuries

OBJECTIVES: To identify the infection rate in patients with combined pelvic ring and bladder injuries. Secondary aims included identifying treatment and injury factors associated with infection. METHODS: Design: Retrospective Review Setting: Single Level I Tertiary Academic Center Patients Selection Criteria: All patients over a 12-year period with combined pelvic ring and bladder injuries were evaluated. Exclusion criteria were non-operative management of the pelvic ring, isolated posterior fixation, and follow-up less than 90 days. Outcome Measure and Comparisons: Primary outcome measured was deep infection of the anterior pelvis requiring surgical irrigation and debridement. RESULTS: 106 patients with anterior stabilization of the pelvis in the setting of a bladder injury were included. 7 (6.6%) patients developed a deep infection and required surgical debridement within 90 days. Patients undergoing open reduction and internal fixation (ORIF) with plating of the anterior pelvis and acute concomitant bladder repair had an infection rate of 2.2% (1/43). Patients undergoing closed reduction and anterior fixation with either external fixation or percutaneous rami screw post bladder repair had an infection rate of 17.6% (3/17). There was a higher infection rate among patients with combined intraperitoneal (IP) and extraperitoneal (EP) bladder injuries (23%) when compared to those with isolated EP (3.8%) or IP (9.1%) bladder injuries (p=0.029). CONCLUSIONS: Acute ORIF of the anterior pelvis in patients with combined pelvic ring and bladder injuries has a low infection rate. Patients with combined IP and EP bladder injuries are at increased risk of infection compared to those with isolated IP and EP injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Surgical management and functional outcomes of perilunate dislocations and fracture dislocations through the dorsal approach.

Perilunate dislocations and perilunate fracture dislocations (PLD/PLFDs) are rare injuries of the wrist, with surgical management leading to acceptable functional results. The purpose of this study was to assess the functional outcomes of the patients of our department who were treated with surgical management of PLDs/PLFDs through dorsal approach, as well as to report any complications on their follow-up. In this retrospective study, 52 patients with PLD/PLFD, fulfilling the inclusion and exclusion criteria of the study, underwent surgical management of their injury. All patients were followed up at 6weeks, 12weeks, 6months, 1year postoperatively with radiographic imaging as well as functional scores measured with the modified mayo wrist score and the QuickDASH questionnaire. The mean postoperative modified Mayo score was 76.8 ± 8.8 and the mean QuickDASH score was 1.52 ± 2.18. Of the 52 cases, 20% had excellent results, 42% had good results, 29% had fair results and 9% had poor results as per the modified Mayo wrist score. No patient signed any symptoms of median nerve neuropathy. In conclusion, open reduction and internal fixation through dorsal approach is a reliable technique to manage perilunate injuries in spite of radiological evidence of wrist arthritis, as it also provides consistently good results in terms of functional outcomes. Retrospective case series study.

Acetabular fractures in geriatric patients: epidemiology, pathomechanism, classification and treatment options.

The incidence of geriatric acetabular fractures has shown a sharp increase in the last decades. The majority of patients are male, which is different to other osteoporotic fractures. The typical pathomechanism generally differs from acetabular fractures in young patients regarding both the direction and the amount of force transmission to the acetabulum via the femoral head. Geriatric fractures very frequently involve anterior structures of the acetabulum, while the posterior wall is less frequently involved. The anterior column and posterior hemitransverse (ACPHT) fracture is the most common fracture type. Superomedial dome impactions (gull sign) are a frequent feature in geriatric acetabular fractures as well. Treatment options include nonoperative treatment, internal fixation and arthoplasty. Nonoperative treatment includes rapid mobilisation and full weighbearing under analgesia and is advisable in non- or minimally displaced fractures without subluxation of the hip joint and without positive gull sign. Open reduction and internal fixation of geriatric acetabular fractures leads to good or excellent results, if anatomic reduction is achieved intraoperatively and loss of reduction does not occur postoperatively. Primary arthroplasty of geriatric acetabular fractures is a treatment option, which does not require anatomic reduction, allows for immediate postoperative full weightbearing and obviates several complications, which are associated with internal fixation. The major issue is the fixation of the acetabular cup in the fractured bone. Primary cups, reinforcement rings or a combination of arthroplasty and internal fixation may be applied depending on the acetabular fracture type.

Standard or Fin SIGN® nail? which option is better for the treatment of femoral fractures in low and middle-income countries?

Femoral fractures are common in low and middle-income countries (LMIC), predominantly caused by high-energy trauma. The surgical implant generation network (SIGN®) program offers two different intramedullary nails in LMIC which are designed to be used without image intensifier free of charge for the patients: the SIGN standard nail (SSN®) and the SIGN Fin nail (SFN®). This study aimed to compare the results of the SSN® and the SFN® for the treatment of middle and distal shaft femoral fractures through a retrograde approach. This was a retrospective, descriptive, and non-experimental study including all consecutive patients who underwent surgical management of middle or distal shaft femoral fracture between January 2017 and May 2022 in an NGO hospital located in Freetown, Sierra Leone. The duration of surgery, type of reduction, complications like screw loosening, implant migration, anterior knee pain and non-union rate at sixmonths of follow up were evaluated. A total of 122 patients were included in the study. Group A: 60 patients were managed with SSN® and Group B: 62 patients with SFN®. The mean operative time was 104min with SSN® and 78 with SFN® (p < 0.001). Open reduction of the fracture was necessary in ten (16.7%) patients with SSN® and 12 (19.4%) patients treated with SFN® (p = 0.69). Non-union was observed in one (1.7%) patient with SSN® and two (3.2%) patients with SFN® (p = 0.57). Both options seem equally effective in treating midshaft and distal femoral shaft fractures. The SFN® reduces the surgical time, due to this fact, in polytraumatized patients, patients with bilateral femur fracture or patients with ipsilateral tibia fracture, it can be considered as the best option to be used. There was no statistical difference in the complications presented by the two groups.

External fixator versus elastic stable intramedullary nail for treatment of metaphyseal-diaphyseal junction fractures of the pediatric distal femur: a case-control study

BackgroundSeveral methods have been used for the treatment of pediatric distal femoral fractures, such as elastic stable intramedullary nail (ESIN), external fixator (EF) and plate osteosynthesis, but there has been no consensus about the optimal method. The purpose of this study was to compare the clinical outcome between EF and ESIN techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal femur.MethodsWe retrospectively analyzed operatively treated MDJ fractures of pediatric distal femur between January 2015 and January 2022. Patient charts were reviewed for demographics, injury and data of radiography. All of the patients were divided into EF and ESIN groups according to the operation techniques. Malalignment was defined as more than 5 degrees of angular deformity in either plane. Clinical outcomes were measured by Flynn scoring system.ResultsThirty-eight patients were included in this study, among which, 23 were treated with EF, and 15 with ESIN. The mean follow-up time was 18 months (12-24 months). At the final follow-up, all of the fractures were healed. Although there were no statistical differences between the two groups in demographic data, length of stay, estimated blood loss (EBL), rate of open reduction, time to fracture healing and Flynn score, the EF was superior to ESIN in operative time, fluoroscopic exposure and time to partial weight-bearing. The EF group had a significantly higher rate of skin irritation, while the ESIN had a significantly higher rate of malalignment.ConclusionEF and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal femur. ESIN is associated with lower rates of skin irritation. However, EF technique has the advantages of shorter operative time, reduced fluoroscopic exposure, and shorter time to partial weight-bearing, as well as lower incidence of malalignment.Level of evidenceLevel III.

Our Experience with Primary Trapeziometacarpal Implant Arthroplasty in Severely Comminuted Rolando Fractures

Abstract Background The concept of primary joint replacement in severely comminuted fractures in elderly patients has proven to be a suitable treatment option in the shoulder, elbow and knee joint. Comminuted intra-articular fractures of the first metacarpal base can pose significant technical challenges, and no established gold standard treatment currently exists. Conventional methods like open reduction and internal fixation or external fixation are commonly employed, emphasizing the importance of anatomical reduction for restoring the articular surface. However, achieving articular surface congruity is often unattainable in severely comminuted intra-articular fractures, leading to short-term joint stiffness and instability, as well as long-term complications like secondary osteoarthritis. Aims This case report aims to share our experience with the use of primary trapeziometacarpal implant arthroplasty in the treatment of two patients with severely comminuted Rolando fractures. Methods In two cases of comminuted Rolando fractures, a primary trapeziometacarpal prosthesis (MAÏA™) was implanted based on preoperative decision-making facilitated by 3D-CT analysis. Patient’s visual analogue score for pain, range of motion, pinch and grip strength compared to the contralateral side were asked and examined. Results Both patients exhibited successful adaptation to their daily routines within a three-month postoperative period. No complications, such as cup or stem loosening or dislocation, were identified. Both patients almost reached equal range of motion, pinch and grip strength compared to the contralateral side. Conclusion The use of primary trapeziometacarpal implant arthroplasty seems to be a viable alternative for managing severely comminuted Rolando fractures, particularly in elderly patients and those with pre-existing osteoarthritis. This approach offers promising outcomes. Studies with other implant arthroplasties have shown better outcomes in patients treated primarily, than after several failed surgeries. We suggest the same is true for the trapeziometacarpal joint. Further studies are necessary to validate the efficacy of this intervention in a larger cohort of patients.

EVALUATING SHORT-TERM OUTCOMES POST- INTRA-ARTICULAR CALCANEAL FRACTURE FIXATION VIA A SINUS TARSI APPROACH IN A NON-EXCLUSIVELY SELECTED COHORT

AimsManagement of intra-articular calcaneal fractures remains a debated topic in orthopaedics, with operative fixation often held in reserve due to concerns regarding perioperative morbidity and potential complications. The purpose of this study was to identify the characteristics of patients who developed surgical complications to inform the future stratification of patients best suited to operative treatment for intra-articular calcaneal fractures and those in whom surgery was highly likely to produce an equivocal functional outcome with potential post-operative complications.MethodsAll patients who underwent open reduction and internal fixation of calcaneal fractures utilizing the Sinus Tarsi approach between March 2014 and July 2018 were identified using theatre records. Patient imaging was used to assess pre- and post-operative fracture geometry with Computed Tomography (CT) used for pre-operative planning. Each patient's clinical presentation was established through retrospective analysis of medical records. Patients provided verbal consent to participation and patient reported outcome measures were recorded using the Maryland Foot Score.ResultsFifty-eight intra-articular calcaneal fractures (fifty-three patients including five bilateral, mean age = 46.91 years) were included. Forty-nine patients were injured as a result of a fall from a height (92.4%). Mean time from presentation to surgery was 3.23 days (range 0–21). Mean Maryland Foot score was found to be 77.6 (+/− 16.22) in forty-five patients. Five patients (9.4%) had wound complications; two superficial (3.7%) and three deep (5.6%).ConclusionIntra-articular fractures of the calcaneus should be considered for surgical intervention in order to improve long-term functional outcomes. The Sinus Tarsi approach provides the potential to decrease the operative complication rate whilst maintaining adequate fixation, however, the decision to surgically manage these fractures should be carefully balanced against the risk of post-operative complications. This increased risk of complication associated with smoking may tip the balance against benefit from surgical management.