Orthopaedic Trauma Surgeons Research Articles

Trauma simulation training: a randomized controlled trial ­evaluating the effectiveness of the Imperial Femoral Intramedullary Nailing Cognitive Task Analysis (IFINCTA) tool

Background and purpose — Cognitive task analysis (CTA) has been used extensively to train pilots and in other surgical specialties. However, the use of CTA within orthopedics is in its infancy. We evaluated the effectiveness of a novel CTA tool to improve understanding of the procedural steps in antegrade femoral intramedullary nailing.Material and methods — Design: A modified Delphi technique was used to generate a CTA from 3 expert orthopedic trauma surgeons for antegrade femoral intramedullary nailing. The written and audiovisual information was combined to describe the technical steps, decision points, and errors for each phase of this procedure Validation: A randomized double-blind controlled trial was undertaken with 22 medical students (novices) randomized into 2 equal groups. The intervention group were given the CTA tool and the control group were given a standard operative technique manual. They were assessed using the validated “Touch Surgery™” application assessment tool on femoral intramedullary nailing.Results — The pre-test scores between the two groups were similar. However, the post-test scores were statistically significantly better in the intervention group compared with the control group. The improvement (post-test median scores) in the intervention group compared with the control group was 20% for patient positioning and preparation, 21% for femoral preparation, 10% for proximal locking, and 19% for distal locking respectively (p < 0.001 for all comparisons).Interpretation — This is the first multimedia CTA tool in femoral intramedullary nailing that is easily accessible, user-friendly, and has demonstrated significant benefits in training novices over the traditional use of operative technique manuals.

Management of elderly hip fractures by an orthopaedic trauma surgeon reduces surgical delays but does not improve outcomes compared to non-trauma surgeons.

Recent literature on hip fractures has focussed on the optimal environment for best outcomes. One factor that has not been studied is the managing surgeon's training background. Our study aims to examine if hip fracture patients managed by fellowship-trained orthopaedic trauma surgeons have better outcomes compared to non-trauma trained general orthopaedic surgeons. This is a retrospective study performed at a tertiary hospital with an established orthogeriatric co-managed hip fracture care pathway. All surgically treated elderly hip fracture patients over a period of 2years were included and divided into 2 groups based on the managing surgeon: trauma and non-trauma. Patient characteristics, fracture and surgery information, post-operative complications, 1year mortality and the Modified Barthel Index (MBI) scores were collected and compared. 871 patients were included. 32.1% (N = 280) were managed by trauma surgeons and 67.9% (N = 591) by non-trauma surgeons. There was no significant difference in the MBI scores pre-operatively and at 6 and 12 months post-operatively between the 2 groups. There was no difference in the incidence of postoperative complications and mortality. However, patients managed by trauma surgeons had significantly shorter time to surgery (p = 0.028) and higher proportion of surgeries performed within 48h (p = 0.039). Trauma surgeons also took a shorter time to fix intertrochanteric fractures (p = 0.000). This study did not find any difference in the functional outcomes of hip fracture patients managed by trauma surgeons or non-trauma surgeons. However, trauma surgeons had faster times to surgery and shorter surgical times when fixing intertrochanteric fractures.

Asociación de Cirujanos Traumatólogos de las Américas: Development of a Latin American Research Consortium.

Trauma continues to be a leading cause of mortality and morbidity in lower to middle-income countries. To meet the ever-growing need of musculoskeletal care in trauma patients, orthopaedic surgeons play an instrumental role in providing care, guided by relevant clinical research studies. Promoting research and publishing results are both crucial to influencing trauma-related skeletal injury treatment in lower to middle-income countries. Currently, few opportunities exist for trauma surgeons in Latin America to participate in clinical research or to contribute to academic publications, thereby limiting their ability to address potentially critical treatment questions faced by their specific patient populations. In response to these obstacles, in 2017, a group of 60 surgeon leaders representing 18 countries throughout Latin America developed the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR; www.actuarla.org). The ACTUAR supports investigative opportunities for Latin American orthopaedic trauma surgeons who want to contribute through collaborative research work. This pioneering initiative aims to improve trauma-related research, clinical care, and health care policies through the development of an international network across the Americas.

Indications for Open Reduction Internal Fixation of Anterior Pelvic Ring Disruptions.

In acute trauma, pelvic ring instability can lead to hemorrhage and hemodynamic instability. Pelvic ring instability and displacement that is not stabilized may lead to chronic pain, sitting imbalance, and limb length inequality. Methods and timing of securing anterior pelvic ring injuries operatively is controversial and debatable. Many orthopaedic trauma surgeons would agree that acceptable methods to treat a disrupted anterior pelvic ring fracture include nonoperative care, external fixation, internal spanning fixators, intramedullary superior ramus screws, and open reduction internal fixation. We will review the indications for open reduction internal fixation fractures and disruptions of the anterior pelvic ring.

Helical Blade Versus Screw Fixation in the Treatment of Hip Fractures With Cephalomedullary Devices: Incidence of Failure and Atypical "Medial Cutout".

To evaluate the rates and mechanisms of failure for cephalomedullary nail fixation using helical blade versus screw fixation and to identify the predictors of failure. Retrospective study. Community teaching hospital. A total of 126 patients were treated with cephalomedullary fixation for low-energy hip fractures. All procedures used the Trochanteric Fixation Nail (Synthes) with either a helical blade [71 (56.3%)] or screw [55 (43.7%)]. Failures, defined by nonunion, hardware cutout, and need for revision surgery were independently reviewed by a fellowship-trained orthopaedic trauma surgeon for an assessment of reduction quality and hardware placement. Seven failures of fixation (5.6%) occurred, all of which used a helical blade. Five failures resulted from medial migration of the helical blade through the femoral head, whereas 2 resulted from typical superolateral cutout and varus collapse. There was no difference in the average tip apex distance between the cases using blade versus screw fixation or between failures and the remainder of the cohort. Basicervical fractures had a significantly higher rate of failure than other fracture patterns. This study showed a higher failure rate with use of the blade and supports the use of screw fixation in these fractures. In addition, we confirm an atypical mode of failure, lateral migration of the femoral head with protrusion of the helical blade, which contributes significantly to the overall failure rate of this implant and occurs despite appropriate fracture reduction and hardware placement. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Reverse shoulder arthroplasty for proximal humerus fractures: Is the glenoid implant problematic?

Reverse shoulder arthroplasty (RSA) is a key tool in the orthopedic trauma surgeon's arsenal, especially when faced with a proximal humerus fracture in older patients. However, few studies have focused on the glenoid side of RSA in this indication as the implant is placed in a generally healthy scapula. Glenoid implants for RSA after trauma are well positioned and do not often cause complications. Retrospective multicenter study of 513 patients who underwent RSA because of a proximal humerus fracture. The mean follow-up was 55months. Radiographs were used to assess the height and tilt of the glenoid implant, along with the development of scapular notching or loosening. The clinical outcomes were determined based on the Constant score. At the last follow-up, 44% of shoulders had scapular notching, 7% of which were severe (stages 3-4). This notching was progressive, with two resulting in loosening. The rate of severe notching was higher in patients with a high glenoid implant (62.5% vs. 42.3%, p=0.03) or glenosphere with superior tilt (58.3% vs. 37.8%, p=0.02). Nine patients had confirmed loosening and 63 had potential loosening. This was more common in cases with superior tilt (9.3% vs. 0.4%, p<0.001). Patients with a high glenoid implant had a lower Constant score (57 vs. 45, p<0.001). There fewer cases of severe notching when a lateralized glenoid implant was used (0% vs. 7%, p<0.05) and/or the humeral implant had a smaller neck-shaft angle (implants<155°: 3% vs. implants at 155°: 8.5%, p=0.03). Glenoid loosening and severe scapular notching are related to poor positioning and/or incorrect orientation of the glenosphere. Implant selection is important, as there is little to no notching when less-angled humeral implants and lateralized glenoid implants are used. IV.

Complexities of Perioperative Pain Management in Orthopedic Trauma

This review discusses both obvious and hidden barriers in trauma patient access to pain management specialists and provides some suggestions focusing on outcome optimization in the perioperative period. Orthopedic trauma surgeons strive to provide patients the best possible perioperative pain management, while balancing against potential risks of opioid abuse and addiction. Surgeons often find they are ill-prepared to effectively manage postoperative pain in patients returning several months following trauma surgery, many times still dependent on opioids for pain control. Some individuals from this trauma patient population may also require the care of pain management specialists and/or consultation with drug addiction specialists. As the US opioid epidemic continues to worsen, orthopedic trauma surgeons can find it difficult to obtain access to pain management specialists for those patients requiring complex pain medication management and substance abuse counseling. The current state of perioperative pain management for orthopedic trauma patients remains troubling due to reliance on only opioid analgesics, society-associated risks of opioid medication addiction, an "underground" prescription drug marketplace, and an uncertain legal atmosphere related to opioid pain medication management that can deter pain management physicians from accepting narcotic-addicted patients and discourage future physicians from pursuing advanced training in the specialty of pain management. Additionally, barriers continue to exist among Medicaid patients that deter this patient population from access to pain medicine subspecialty care, diminishing medication management reimbursement rates make it increasingly difficult for trauma patients to receive proper opioid analgesic pain medication management, and a lack of proper opioid analgesic medication management training among PCPs and orthopedic trauma surgeons further contributes to an environment ill-prepared to provide effective perioperative pain management for orthopedic trauma patients.

Surveying the management of Achilles tendon ruptures in the Netherlands: lack of consensus and need for treatment guidelines

PurposeThis study aimed to describe and analyse usual care of Achilles tendon ruptures (ATRs) by orthopaedic surgeons and trauma surgeons in the Netherlands.MethodsA nationwide online survey of ATR management was sent to all consultant orthopaedic and trauma surgeons in the Netherlands, requesting participation of those involved in ATR management. Data on individual characteristics and the entire ATR management (from diagnosis to rehabilitation) were gathered. Consensus was defined as ≥ 70% agreement on an answer.ResultsA total of 91 responses (70 orthopaedic surgeons and 21 trauma surgeons) were analysed. There was consensus on the importance of the physical examination in terms of diagnosis (> 90%) and a lack of consensus on diagnostic imaging (ultrasound/MRI). There was consensus that non-surgical treatment is preferred for sedentary and systemically diseased patients and surgery for patients who are younger and athletic and present with larger tendon gap sizes. There was consensus on most of the non-surgical methods used: initial immobilisation in plaster cast with the foot in equinus position (90%) and its gradual regression (82%) every 2 weeks (85%). Only length of immobilisation lacked consensus. Surgery was generally preferred, but there was a lack of consensus on the entire followed protocol. Orthopaedic and trauma surgeons differed significantly on their surgical (p = 0.001) and suturing techniques (p = 0.002) and methods of postoperative immobilisation (p < 0.001). Orthopaedic surgeons employed open repair and Bunnell sutures more often, whereas trauma surgeons used minimally invasive approaches and bone anchors. Rehabilitation methods and advised time until weight-bearing and return to sport varied. Orthopaedic surgeons advised a significantly longer time until return to sport after both non-surgical treatment (p = 0.001) and surgery (p = 0.002) than trauma surgeons.ConclusionThis is the first study to describe the entire ATR management. The results show a lack of consensus and wide variation in management of ATRs in the Netherlands. This study shows that especially the methods of the perioperative and rehabilitation phases were inconclusive and differed between orthopaedic and trauma surgeons. Further research into optimal ATR management regimens is recommended. In addition, to achieve uniformity in management more multidisciplinary collaboration between Dutch and international surgeons treating ATRs is needed.Level of evidenceCross-sectional survey, Level V.

Use of reprocessed external fixators in orthopaedic surgery: a survey of 243 orthopaedic trauma surgeons

BackgroundThe increasing financial burden of orthopaedic implants on our health care system has prompted cost-control measures, such as implant reprocessing. The purpose of this study was to describe the current usage by orthopaedic trauma surgeons of reprocessed external fixators (EFs) for treatment of complex fractures.MethodsA 16-question survey about use and perceptions of reprocessed EFs was distributed to 894 Orthopaedic Trauma Association members between August 2016 and June 2017 using a web-based survey system.ResultsThe authors received 243 responses (27%). Thirty-seven percent of respondents reported using reprocessed EFs. Nonprofit hospitals used reprocessed EFs more commonly than did for-profit hospitals (41% vs 15%, P = .0004). Eighty-seven percent of respondents believed reprocessing could be cost-effective. The most common reason (32%) for not using reprocessed EFs was coordination/logistics of reprocessing. Concern about litigation was also reported as a main reason for not using (20%) or having recently stopped using (21%) reprocessed EFs.ConclusionsMany orthopaedic traumatologists are interested in the reprocessing of EF components but few have reprocessing systems in place at their institutions. A major barrier to implementation is concern about litigation, which is likely unwarranted on the basis of Food and Drug Administration approval and a lack of previous litigation. Reprocessing by the original device manufacturers has yielded substantial savings at our institution and is an example of the cost savings that can be expected when implementing an EF reprocessing system.

Commentary

Total ankle arthroplasty (TAA) has been used with increasing frequency for the treatment of end-stage ankle arthritis. The rate of periprosthetic joint infection for TAA varies in the literature. When it occurs, it can have devastating consequences. Despite the large amount of literature published on the workup, treatment, and outcomes of periprosthetic joint infection in other areas of the body, there is a paucity of studies when it comes to the ankle. The results of surgical treatment of infected TAA are mixed and complication rates are high. The experience gained by the hip and knee surgeons, shoulder and elbow surgeons, and orthopedic trauma surgeons with regards to infection should be considered when managing patients with infected total ankle replacements. At the same time, it is critical that the issues unique to TAA infections be identified and discussed in the hope of defining a “standard of care” for these patients. Level of Evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of the Acute and Chronic Infected Total Ankle Arthroplasty

Total ankle arthroplasty (TAA) has been used with increasing frequency for the treatment of end-stage ankle arthritis. The rate of periprosthetic joint infection for TAA varies in the literature. When it occurs, it can have devastating consequences. Despite the large amount of literature published on the workup, treatment, and outcomes of periprosthetic joint infection in other areas of the body, there is a paucity of studies when it comes to the ankle. The results of surgical treatment of infected TAA are mixed and complication rates are high. The experience gained by the hip and knee surgeons, shoulder and elbow surgeons, and orthopedic trauma surgeons with regards to infection should be considered when managing patients with infected total ankle replacements. At the same time, it is critical that the issues unique to TAA infections be identified and discussed in the hope of defining a “standard of care” for these patients. Level of Evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Management of a Complex Lower Limb Open Fracture in a Teenage Patient: A Case Report

The challenges of managing Gustilo IIIB tibial fractures (ie, high energy trauma with a contaminated wound >10 cm in length, severe comminution ["crumbling"] or segmental fractures, and periosteal stripping) in children are unique in part because no clear guidelines exist and the injuries may cause short-term and long-term complications. Repeated wound debridement and secondary reconstruction are required in approximately 20% of these cases in both adults and children. A 13-year-old girl presented with severe polytrauma including an open Gustilo type IIIB fracture of the left lower leg. The patient declined limb amputation; a multidisciplinary team (plastic, pediatric, orthopedic-trauma surgeons, pediatrician, psychiatrist, clinical pharmacologist, anesthesiologist, physiotherapist, nurses) was assembled in order to give the patient the best chance of a successful outcome. Multiple limb salvage and reconstructive procedures including wound debridements, necrectomies, long-term negative pressure wound therapy, soft tissue reconstructions, external bone fixation, bone osteosynthesis, multiple skin grafts, and free-flap reconstruction were provided over a period of 6 months with great success. The patient is doing well 3 years after initial injury and is walking without complications. A multidisciplinary approach and structured treatment plan are important to minimize complications, avoid unnecessary delays in treatment, decrease morbidity, and provide the patient with the best result possible. Studies examining optimal treatment strategies for children and adolescents with these complicated fractures are needed.

Opioid Prescribing Practices by Orthopaedic Trauma Surgeons After Isolated Femur Fractures.

The purpose of this retrospective study was to identify opioid prescribing practices, determine the number of morphine milliequivalents (MMEs) prescribed by orthopaedic/nonorthopaedic members to narcotic naive and previously exposed patients, and provide narcotic prescribing recommendations. Patients older than 18 years with an isolated femur fracture sustained between 2013 and 2015 were identified using the CPT code 27506. Prescribing information was obtained from the State Controlled Substance Monitoring Database. Descriptive analysis of MMEs was then performed. Outliers and patients without prescriptions from orthopaedic providers were excluded to eliminate skewing of data. Mean and standard deviations were then calculated for patients without a history of opiates prescribed within 1 year of injury and for patients with a history of opiates prescribed within 1 year before the injury. Forty-five percent (40/88) of patients were opiate exposed at the time of injury. Previously exposed patients received 1491 MMEs (SD, 1044; median, 1350; range, 210-5140) and nonexposed patients received 1363 MMEs (SD, 977.2; median, 1260; range, 105-4935) from orthopaedic providers (P = 0.1473). Nonorthopedists prescribed 530 MMEs (SD, 780.7; median, 140; range, 0-3515) to previously exposed patients and 175 MMEs (SD, 393; median, 140; range, 0-1890) to patients without exposure (P < 0.0001). Patients with prior exposure are more likely to be prescribed more opiates after femoral shaft fracture treatment. We recommend a protocol of prescribing half the mean of MMEs currently prescribed by orthopedists equating to 47 (711 MMEs) pills of oxycodone 10 mg in up to 3 prescriptions.

Intrapelvic Protrusion of a Broken Guide Wire Fragment during Fixation of a Femoral Neck Fracture.

Breakage of DHS guide wire during surgery and its migration into the pelvis through the hip joint is a rare complication and its removal can be very challenging for the surgeon. We share our experience of a similar case wherein we used an ‘iliofemoral’ approach to successfully remove the broken transfixing guidewire from the hip joint. Although iliofemoral approach is similar to the lateral window of conventional ilioinguinal approach, yet it is less invasive, has lesser complications, requires less expertise and is easily reproducible by an average orthopaedic trauma surgeon. We recommend that surgical approaches for removal of these broken or migrated wires should be individualized depending upon the exact location of the wire tip in the hip joint or pelvis and need for exposure.

Perioperative management of external fixation in staged protocols: an international survey.

Despite the frequent use of external fixation, various regimes of antibiotic prophylaxis, surgical technique and postoperative pin care exist and underline the lack of current evidence. The aim of the study was to assess the variability or consensus in perioperative protocols to prevent implant-associated infections for temporary external fixation in closed fractures of the extremities. A 26-question survey was sent to 170 members of the Traumaplatform. The survey included questions concerning demographics, level of training, type of training and perioperative protocols as: antibiotic prophylaxis, intraoperative management, disinfection and postoperative pin site care. All responses were statistically analysed, and intraoperative measures rated on a 5-point Likert scale. The responses of fifty orthopaedic trauma and general surgeons (response rate, 29.4%) were analysed. The level of experience was more than 5years in 92% (n=46) with up to 50 closed fractures of the extremities annually treated with external fixation in 80% (n=40). Highest consensus could be identified in the following perioperative measures: preoperative antibiotic prophylaxis with a second-generation cephalosporin (86%, n=43), changing gloves if manipulation of the external fixator is necessary during surgery (86%, n=43; 4.12 points on the Likert scale), avoid overlapping of the pin sites with the definitive implant site (94%, n=47; 4.12 points on the Likert scale) and soft tissue protection with a drill sleeve (83.6%, n=41). Our survey could identify some general principles, which were rated as important by a majority of the respondents. Futures studies' focus should elucidate the role of perioperative antibiotics and different disinfection protocols on implant-associated infections after temporary external fixation in staged protocols. This study provides Level IV evidence according to Oxford centre for evidence-based medicine.

International survey among orthopaedic trauma surgeons: Lack of a definition of fracture-related infection

IntroductionFracture-related infection (FRI) is one of the most challenging musculoskeletal complications in orthopaedic-trauma surgery. Although the orthopaedic community has developed and adopted a consensus definition of prosthetic joint infections (PJI), it still remains unclear how the trauma surgery community defines FRI in daily clinical practice or in performing clinical research studies.The central aim of this study was to survey the opinions of a global network of trauma surgeons on the definitions and criteria they routinely use, and their opinion on the need for a unified definition of FRI. The secondary aims were to survey their opinion on the utility of currently used definitions that may be at least partially applicable for FRI, and finally their opinion on the important clinical parameters that should be considered as diagnostic criteria for FRI. MethodsAn 11-item questionnaire was developed to cover the above-mentioned aims. The questionnaire was administered by SurveyMonkey and was sent via blast email to all registered users of AO Trauma (Davos, Switzerland). ResultsOut of the 26'563 recipients who opened the email, 2'327 (8.8%) completed the questionnaire. Nearly 90% of respondents agreed that a consensus-derived definition for FRI is required and 66% of the surgeons also agreed that PJI and FRI are not equal with respect to diagnosis, treatment and outcome. Furthermore, “positive cultures from microbiology testing”, “elevation of CRP”, “purulent drainage” and “local clinical signs of infection” were voted the most important diagnostic parameters for FRI. ConclusionThis international survey infers the need for a consensus definition of FRI and provides insight into the clinical parameters seen by an international community of trauma surgeons as being critical for defining FRI.

Appropriateness of patients transferred with orthopedic injuries: experience of a level I trauma center.

Trauma patients are frequently transferred to a higher level of care for specialized orthopedic care. Many of these transfers are not necessary and waste valuable resources. The purpose of this study was to quantify our own experience and to assess the appropriateness of orthopedic transfers to a level I trauma center emergency department. A retrospective review of orthopedic emergency department transfers to a level I trauma center was performed. Data collected included time of transfer, injury severity score (ISS), age, gender, race, orthopedic coverage at transfer institution, and insurance status. Two orthopedic trauma surgeons graded the appropriateness of transfer. A weighted logistic regression model was used to compare dependent and independent variables. A total of 324 patient transfers were reviewed; 65 (20.1%) of them were graded as inappropriate. There was no statistically significant relationship between appropriateness of transfer and age, availability of orthopedic coverage, night/weekend transfer, or insurance status. Regression analysis showed that only ISS (OR 1.130, p=.008) and "polytrauma" (OR 25.39, p<.0001) designation were associated with increased odds ratio of appropriate transfer. The kappa coefficient for inter-rater reliability between the two raters was 0.505 (95% CI, 0.388-0.623) reflecting moderate agreement. Inappropriate transfers create a significant medical burden to our health care system using valuable resources. Our study found similar results of inappropriate transfers compared to previous studies. However, we did not find a relationship between insurance status or nights/weekends and transfer appropriateness.

Retrospective analysis of surgical management of patients with distal femur fracture by locking compression plates

Introduction: The following study was conducted to examine the short term clinical and radiological results particularly early complications and healing rate of distal femur fracture treated with distal femur LCP. Materials and Methods: The study was conducted in patients treated for distal femur fracture (type A, B & C – AO classification) at Mandya Institute of Medical Sciences, Mandya from month of Nov 2015 to Oct 2017. Forty distal femur fracture patients in this study, were fixed with DF-LCP with Bone grafting where the distal femur fractures were associated with extensive bone loss. Patients’ age ranged from 18 to 80 years with mean of 49. Results: The sample consisted forty patients, 23 were males and 17 females. The patients’ ages ranged from 18 - 80 years with mean of 49 years. The causes of fractures were motor vehicle accident in 26 patients and fall in 14 patients. 27 fractures involved the right side and 13 involved the left. The average hospitalization was 15 days with a range of 10 to 20 days. The average number of days from injury to surgery was 5 days with a range of 02 to 07 days. Functional outcome was rated as per NEER’S RATING SCORE, we got excellent results in 18 cases, good in 14, fair in 06 and poor in 02 patients. Conclusion: The distal femur LCP with accurate positioning and fixation is a good implant to use for fracture of distal femur. We recommend use of this implant in Type A, B, C and osteoporotic fractures with satisfactory results. In our study, we found excellent results in type C and osteoporotic fractures, however, long term studies are needed to prove definitively acceptable outcomes so that this technique can become part in the armamentarium of the orthopedic trauma surgeon.

2D and 3D assessment of sustentaculum tali screw fixation with or without Screw Targeting Clamp

IntroductionPrecise placement of sustentaculum tali screw(s) is essential for restoring anatomy and biomechanical stability of the calcaneus. This can be challenging due to the small target area and presence of neurovascular structures on the medial side. The aim was to evaluate the precision of positioning of the subchondral posterior facet screw and processus anterior calcanei screw with or without a Screw Targeting Clamp. The secondary aim was to evaluate the added value of peroperative 3D imaging over 2D radiographs alone. MethodsTwenty Anubifix™ embalmed, human anatomic lower limb specimens were used. A subchondral posterior facet screw and a processus anterior calcanei screw were placed using an extended lateral approach. A senior orthopedic trauma surgeon experienced in calcaneal fracture surgery and a senior resident with limited experience in calcaneal surgery performed screw fixation in five specimens with and in five specimens without the clamp. 2D lateral and axial radiographs and a 3D recording were obtained postoperatively. Anatomical dissection was performed postoperatively as a diagnostic golden standard in order to obtain the factual screw positions. Blinded assessment of quality of fixation was performed by two surgeons. ResultsIn 2D, eight screws were considered malpositioned when placed with the targeting device versus nine placed freehand. In 3D recordings, two additional screws were malpositioned in each group as compared to the golden standard. As opposed to the senior surgeon, the senior resident seemed to get the best results using the Screw Targeting Clamp (number of malpositioned screws using freehand was eight, and using the targeting clamp five). In nine out of 20 specimens 3D images provided additional information concerning target area and intra-articular placement. Based on the 3D assessment, five additional screws would have required repositioning. Except for one, all screw positions were rated equally after dissection when compared with 3D examinations. ConclusionThis study does not show a substantial benefit between the Screw Targeting Clamp and the freehand technique as well between experienced and inexperienced surgeons. Data suggest that the clamp might help positioning sustentaculum tali screws, especially for inexperienced surgeons. Perioperative 3D recordings facilitate identification of malpositioned screws.

Surgical management of distal tibia fracture by mippo using locking compression plate

Introduction: The following study was conducted to examine the short term clinical and radiological results particularly early complications and healing rate of distal tibia fracture treated by MIPPO using LCP. Methodology: The study was conducted in patients treated for distal tibia fracture (type A, B & C – AO classification) at Adichunchanagiri Institute of Medical Science, BG Nagar from the month of Nov 2013 to Nov 2015. Twenty distal tibia fracture patients were taken into the study, all were fixed with LCP by mippo, some with Bone grafting where the distal tibia fractures were associated with bone loss and communition. Patients’ age ranged from 27 to 68 years with a mean of 50. Results: The sample consisted of twenty patients with 11 males and 09 were female. The patients’ ages ranged from 27-68 years with a mean age of 50 years. The causes of fractures were motorvehicle accident in 13 patients and fall in 07 patients. There were no sports or industrial accidents. 12 fractures involved the right side and 08 involved the left. The average length of hospitalisation was 15 days with a range of 10 to 20 days. The average number of days from injury to surgery was 5 days with a range of 2 to 10 days. The operative time ranged from 45 minutes to 120 minutes. Patients were followed up from 01 to 24 months. Functional outcome was rated as per The modified ankle score of Olerud and Molander, we got excellent results in 10 cases, good in 07, fair in 02 and poor in one patient. Conclusion: The LCP is a good implant to use for fractures of the distal tibia by mippo method. However, accurate positioning and fixation are required to produce satisfactory results. We recommend use of this implant in Type A, B and C, osteoporotic fractures. Our early results were encouraging but long term studies are needed to prove definitively acceptable outcomes so that the technique can become part of the armamentarium of the orthopaedic trauma surgeon.