Posterior Fragment Research Articles

Posterior malleolar fractures of the ankle.

Despite an increasing awareness of injuries to PM in ankle fracture-dislocations, there are still many open questions. The mere presence of a posterior fragment leads to significantly poorer outcomes. Adequate diagnosis, classification and treatment require preoperative CT examination, preferably with 3D reconstructions. The indication for surgical treatment is made individually on the basis of comprehensive assessment of the three-dimensional outline of the PM fracture and all associated injuries to the ankle including syndesmotic instability. Anatomic fixation of the avulsed posterior tibiofibular ligament will contribute to syndesmotic stability and restore the integrity of the incisura tibiae thus facilitating anatomic reduction of the distal fibula. A necessary prerequisite is mastering of posterolateral and posteromedial approaches and the technique of direct reduction and internal fixation. Further clinical studies with higher numbers of patients treated by similar methods and evaluation of pre- and postoperative CT scans will be necessary to determine reliable prognostic factors associated with certain types of PM fractures and associated injuries to the ankle.

Interobserver variation in classification of malleolar fractures.

Classification of malleolar fractures is a matter of debate. In the ideal situation, a classification system is easy to use, shows good inter- and intraobserver agreement, and has implications for treatment or research. Interobserver study. Four observers distributed 100 X-rays to the Weber, AO and Lauge-Hansen classification. In case of a trimalleolar fracture, the size of the posterior fragment was measured. Interobserver agreement was calculated with Cohen's kappa. Agreement on the size of the posterior fragment was calculated with the intraclass correlation coefficient. Moderate agreement was found with all classification systems: the Weber (K = 0.49), AO (K = 0.45) and Lauge-Hansen (K = 0.47). Interobserver agreement on the presence of a posterior fracture was substantial (K = 0.63). Estimation of the size of the fragment showed moderate agreement (ICC = 0.57). Classification according to the classical systems showed moderate interobserver agreement, probably due to an unclear trauma mechanism or the difficult relation between the level of the fibular fracture and syndesmosis. Substantial agreement on posterior malleolar fractures is mostly due to small (<5 %) posterior fragments. A classification system that describes the presence and location of fibular fractures, presence of medial malleolar fractures or deep deltoid ligament injury, and presence of relevant and dislocated posterior malleolar fractures is more useful in the daily setting than the traditional systems. In case of a trimalleolar fracture, a CT scan is in our opinion very useful in the detection of small posterior fragments and preoperative planning.

The Effect of Percutaneous Vertebral Augmentation on Stable and Unstable Vertebral Fracture Nonunion: A Three-Dimensional Finite Element Study

Introduction Our previous study suggested that vertebral fracture nonunion(VFNU) could be classified into stable and unstable types based on whether there are fracture fragment in the middle column of fractured vertebrae, and we hypothesize that vertebral augmentation could restore the stability of fractured vertebrae in unstable type of VFNU, this study is to determine the effect of percutaneous vertebral augmentation on stable and unstable vertebral fracture nonunion by three-dimensional finite element analysis. Material and Methods An elderly senior, who suffers from osteoporosis, but owns the normal alignment and profile of thoracolumbar spine was included into this finite element study and accepted CT examination. The finite element three-dimension model of physiological thoracolumbar spine (T11-L3) was established and investigated with Mimics, Rapidform, and Abaqus softwares, then wedge-shaped osteotomy was performed in L1 vertebral body to stimulate intravertebral bone defect, which is the main feature of VFNU, to make the pathological finite element model of type A VFNU, which is named pathological model A. Furthermore, the posterior–inferior region of vertebral body was cut to build a piece of separated fracture, with the purpose of simulation of the pathological feature of type B VFNU and establishment of corresponding Finite element model which is called as Pathological model B. After that, imitated bone cement augment was performed in pathological model A and B, distributing cement in the whole intervertebral cleft or 5 mm ahead posterior edge of vertebral body, to establish four therapy finite element model, which were called as therapy model A1, B1, A2, and B2. All of the models were calculated under the same axial loads of 400 N, to investigate the validity of physiological model and compare the mechanical status of different models. Results The physiological finite element model owns good mechanic conformity with the reported models. Compared with physiological model, there was notable stress, strain concentration in the L1 vertebral body of pathological model A, mainly distributing beside the posterior cortex and in the posterior inferior part of the vertebral body, which indicated that there was a risk of further fracture in this model. Although there was also stress and strain concentration in pathological model B, the extent and level of stress and strain were lower than the corresponding value in the pathological model A, furthermore, concentration mainly located in the posterior–inferior fracture piece, which implied that the separated posterior–inferior fracture piece of vertebral body intended to dislocate, and the stress, strain concentration were dispersed after pathological Model A became Model B. According to calculation of therapy model A1, A2, the stress and strain concentration could be dispersed with bone cement augmentation, and the mechanic conduction function of L1 vertebral body could be restored after imitated PVP, which indicated that vertebroplasty could be used effectively in VFNU patients with reliable mechanic stability. However, on the basis of the calculation of therapy model B1 and B2, the tendency of stress, strain concentration, and displacement of posterior–inferior fracture piece could be found, even though the whole concentration could be dispersed by cement augmentation, which implied that there was risk of dislocation of posterior–inferior fracture piece after bone cement augmentation in pathological model B. Conclusion A favorable mechanical performance was revealed in stable VFNU after PVA, but the risk of redislocation of posterior–inferior bony fragments might be increased result from PVA.

Anatomy and classification of the posterior tibial fragment in ankle fractures.

The aim of this study was to analyze the pathoanatomy of the posterior fragment on the basis of a comprehensive CT examination, including 3D reconstructions, in a large patient cohort. One hundred and forty one consecutive individuals with an ankle fracture or fracture-dislocation of types Weber B or Weber C and evidence of a posterior tibial fragment in standard radiographs were included in the study. The mean patient age was 49 years (range 19-83 years). The exclusion criteria were patients below 18 years of age, inability to provide written consent, fractures of the tibial pilon, posttraumatic arthritis and pre-existing deformities. In all patients, post-injury radiographs were obtained in anteroposterior, mortise and lateral views. All patients underwent CT scanning in transverse, sagittal and frontal planes. 3D CT reconstruction was performed in 91 patients. We were able to classify 137 cases into one of the following four types with constant pathoanatomic features: type 1: extraincisural fragment with an intact fibular notch, type 2: posterolateral fragment extending into the fibular notch, type 3: posteromedial two-part fragment involving the medial malleolus, type 4: large posterolateral triangular fragment. In the 4 cases it was not possible to classify the type of the posterior tibial fragment. These were collectively termed type 5 (irregular, osteoporotic fragments). It is impossible to assess the shape and size of the posterior malleolar fragment, involvement of the fibular notch, or the medial malleolus, on the basis of plain radiographs. The system that we propose for classification of fractures of the posterior malleolus is based on CT examination and takes into account the size, shape and location of the fragment, stability of the tibio-talar joint and the integrity of the fibular notch. It may be a useful indication for surgery and defining the most useful approach to these injuries.

Three-dimensional measurement of articular surface injury severity due to posterior malleolus fracture

Objective To establish a way to measure the injury severity of articular surface due to posterior malleolus fracture and investigate its clinical significance based on three-dimensional reconstruction technique. Methods Between May 2009 and March 2014, 138 cases of peri-ankle injury combined with posterior malleolus fracture were treated. Lateral radiographs were reviewed to measure the ratio of posterior fragment area to distal tibial plafond area using the common method. Three-dimensional CT images were examined to measure ratio of the area of injury using the three-dimensional measuring method. Statistical comparison was made using the t-test and intraclass correlation coefficient (ICC). Results Measurement failed on 33 lateral radiographs and 13 three-dimensional CT images. Six cases cannot be measured by both imaging technology, so results of 98 cases were compared. Ratio of posterior fragment area to tibial plafond area was (16.2±7.2)% measured by radiographs and was (29.6±10.1)% by three-dimensional CT scans (P<0.05). Three-dimensional CT measurements showed higher intra and inter-observer agreement (ICC of 0.973 to 0.942) than that in radiographic measurements (ICC of 0.875 to 0.860). Conclusion Three-dimension CT assessment of the extent of injury to articular surface because of posterior malleolus fracture is reliable and reproducible, but radiographic assessment may underestimate the injury and influence the choice of surgical indications. Key words: Ankle injuries; Imaging, three-dimensional; Tomography, X-ray computed

Influence of fragment size and postoperative joint congruency on long-term outcome of posterior malleolar fractures.

One of the factors contributing to long-term outcome of posterior malleolar fractures is the development of osteoarthritis. Based on biomechanical, cadaveric, and small population studies, fixation of posterior malleolar fracture fragments (PMFFs) is usually performed when fragment size exceeds 25-33%. However, the influence of fragment size on long-term clinical and radiological outcome size remains unclear. A retrospective cohort study of 131 patients treated for an isolated ankle fracture with involvement of the posterior malleolus was performed. Mean follow-up was 6.9 (range, 2.5-15.9) years. Patients were divided into groups depending on size of the fragment, small (<5%, n = 20), medium (5-25%, n = 86), or large (>25%, n = 25), and presence of step-off after operative treatment. We have compared functional outcome measures (AOFAS, AAOS), pain (VAS), and dorsiflexion restriction compared to the contralateral ankle and the incidence of osteoarthritis on X-ray. There were no nonunions, 56% of patients had no radiographic osteoarthritis, VAS was 10 of 100, and median clinical score was 90 of 100. More osteoarthritis occurred in ankle fractures with medium and large PMFFs compared to small fragments (small 16%, medium 48%, large 54%; P = .006). Also when comparing small with medium-sized fragments (P = .02), larger fragment size did not lead to a significantly decreased function (median AOFAS 95 vs 88, P = .16). If the PMFF size was >5%, osteoarthritis occurred more frequently when there was a postoperative step-off ≥1 mm in the tibiotalar joint surface (41% vs 61%, P = .02) (whether the posterior fragment had been fixed or not). In this group, fixing the PMFF did not influence development of osteoarthritis. However, in 42% of the cases with fixation of the fragment a postoperative step-off remained (vs 45% in the group without fixation). Osteoarthritis is 1 component of long-term outcome of malleolar fractures, and the results of this study demonstrate that there was more radiographic osteoarthritis in patients with medium and large posterior fragments than in those with small fragments. Radiographic osteoarthritis also occurred more frequently when postoperative step-off was 1 mm or more, whether the posterior fragment was fixed or not. However, clinical scores were not different for these groups. Level IV, retrospective case series.

Long-term functional and radiographic outcomes in 243 operated ankle fractures.

BackgroundLarge comparative studies that have evaluated long-term functional outcome of operatively treated ankle fractures are lacking. This study was performed to analyse the influence of several combinations of malleolar fractures on long-term functional outcome and development of osteoarthritis.MethodsRetrospective cohort-study on operated (1995–2007) malleolar fractures. Results were assessed with use of the AAOS- and AOFAS-questionnaires, VAS-pain score, dorsiflexion restriction (range of motion) and osteoarthritis. Categorisation was determined using the number of malleoli involved.Results243 participants with a mean follow-up of 9.6 years were included. Significant differences for all outcomes were found between unimalleolar (isolated fibular) and bimalleolar (a combination of fibular and medial) fractures (AOFAS 97 vs 91, p = 0.035; AAOS 97 vs 90, p = 0.026; dorsiflexion restriction 2.8° vs 6.7°, p = 0.003). Outcomes after fibular fractures with an additional posterior fragment were similar to isolated fibular fractures. However, significant differences were found between unimalleolar and trimalleolar (a combination of lateral, medial and posterior) fractures (AOFAS 97 vs 88, p < 0.001; AAOS 97 vs 90, p = 0.003; VAS-pain 1.1 vs 2.3 p < 0.001; dorsiflexion restriction 2.9° vs 6.9°, p < 0.001). There was no significant difference in isolated fibular fractures with or without additional deltoid ligament injury. In addition, no functional differences were found between bimalleolar and trimalleolar fractures. Surprisingly, poor outcomes were found for isolated medial malleolar fractures. Development of osteoarthritis occurred mainly in trimalleolar fractures with a posterior fragment larger than 5 %.ConclusionsThe results of our study show that long-term functional outcome is strongly associated to medial malleolar fractures, isolated or as part of bi- or trimalleolar fractures. More cases of osteoarthritis are found in trimalleolar fractures.

Approaches for surgical treatment of posterior malleolar fracture

Objective To compare the approaches for surgical treatment of posterior malleolar fracture in terms of their effect on the fracture prognosis.Methods We analyzed retrospectively the 69 patients with posterior malleolar fracture who had been treated by surgery from July 2000 to June 2013.They were 24 males and 45 females,14 to 80 years of age (average,46.2 years).By AO classification,there were 8 cases of type 44A,49 cases of type 44B and 12 cases of type 44C.American Orthopaedic Foot and Ankle Society (AOFAS) and visual analogue scale (VAS) scores were compared between the 27 patients with ≥25％ fragments which were fixated from the anterior to the posterior and the 15 ones with ≥25％ fragments which were fixated from the posterior to the anterior,as well as between the 15 patients with ＜ 25％ fragments which were fixated from the anterior to the posterior and the 12 ones with ＜ 25％ fragments which were fixated from the posterior to the anterior.Results This cohort obtained follow-up from 12 to 126 months (average,52.0 months).When the fragments ≥25％,there was no significant difference in AOFAS or VAS score between those fixated from the anterior to the posterior (94.4 ± 5.0 and 0.2 ± 0.4 respectively) and those fixated from the posterior to the anterior (94.1 ±7.0 and 0.4 ±0.8 respectively) (P ＞ 0.05).When the fragments ＜ 25％,those fixated from the anterior to the posterior had a significantly lower AOFAS score (93.2 ± 5.4) than those fixated from the posterior to the anterior (98.3 ± 3.9) (P =0.009),but there was no significant difference in VAS score between the 2 groups (0.1 ± 0.4 versus 0) (P =0.058).Conclusions In the treatment of posterior malleolar fracture with a ≥ 25％ fragment,as the operative approaches may exert little impact on the fracture prognosis,the approach from anterior to posterior may be a priority choice due to its simplicity and smaller incision.When a posterior malleolar fragment is less than 25％,it may be better to choose the approach from posterior to anterior. Key words: Ankle; Fractures, bone; Prognosis; Approach for surgical treatment

Results of Syndesmotic Screw Fixation versus Posterior Malleolus Fixation in Syndesmotic Injury at Pronation External Rotation Stage IV Ankle Fracture with Posterior Malleolus Fracture: Postoperative One Year Follow-up

Purpose: The purpose of this study is to compare the radiologic and clinical results of syndesmotic screw fixation and posterior malleolar fixation for syndesmotic injury in Lauge-Hansen classification pronation-external rotation (PER) stage IV ankle fractures with posterior malleolus fracture. Materials and Methods: We designed a retrospective study that included patients with Lauge-Hansen classification PER stage IV ankle fracture with posterior malleolus fracture. Of 723 patients who underwent ankle fracture surgery from March 2005 to November 2012, 29 were included in this study. In this study, syndesmotic injury was treated with syndesmotic screw fixation or posterior malleolus fixation. There were 15 cases of syndesmotic screw fixation and 14 cases of posterior malleolar fixation. We compared the radiologic and clinical results at one year postoperatively. Posterior malleolus fragment size on a pre-operative computed tomographic image, and tibiofibular overlap, medial clear space, articular step-off, Kellgren-Lawrence grade, and Takakura classification on a postoperative one year followup radiograph were used for comparison of the radiologic results. The clinical results were assessed using the American Orthopaedic Foot and Ankle Society score, visual analogue scale score, and patient subjective satisfaction score. Results: Posterior malleolar fragment size was 12.62%±3.01% of the joint space in the syndesmotic screw fixation group and 27.04%±4.34% in the posterior malleolar fixation group. A statistical difference was observed between the two groups. However, other results, including tibiofibular overlap, medial clear space, articular step-off, Kellgren-Lawrence grade, Takakura classification, and clinical scores showed no statistical difference. Conclusion: In the Lauge-Hansen classification PER stage IV ankle fracture with posterior malleolus fracture, if the posterior malleolus fracture can be reduced anatomically and fixated rigidly, syndesmotic screw fixation, which can cause several complications, is usually not required for achievement of a satisfactory syndesmotic stability; this would be a recommendable option for treatment of syndesmotic injury.

Asexual reproduction in holothurians.

Aspects of asexual reproduction in holothurians are discussed. Holothurians are significant as fishery and aquaculture items and have high commercial value. The last review on holothurian asexual reproduction was published 18 years ago and included only 8 species. An analysis of the available literature shows that asexual reproduction has now been confirmed in 16 holothurian species. Five additional species are also most likely capable of fission. The recent discovery of new fissiparous holothurian species indicates that this reproduction mode is more widespread in Holothuroidea than previously believed. New data about the history of the discovery of asexual reproduction in holothurians, features of fission, and regeneration of anterior and posterior fragments are described here. Asexual reproduction is obviously controlled by the integrated systems of the organism, primarily the nervous system. Special molecular mechanisms appear to determine the location where fission occurs along the anterior-posterior axis of the body. Alteration of the connective tissue strength of the body wall may play an important role during fission of holothurians. The basic mechanism of fission is the interaction of matrix metalloproteinases, their inhibitors, and enzymes forming cross-link complexes between fibrils of collagen. The population dynamics of fissiparous holothurians are discussed.

Assessment of the severity of femoral neck fractures with CT scan

Objective To develop a quantitative assessment of the severity of femoral neck fractures with CT scan.Methods The preoperative X-ray and CT data were reviewed of 229 patients with femoral neck fracture who had been treated in our department from December 2008 to April 2012.Posterior fracture fragment,posterior angulation,longitudinal maximum displacement,location of fracture line,and difference in neck-shaft angle were measured in the 3-D reconstruction images of CT scans.The severity of the fracture was categorized as slight,(score ≤5,grade Ⅰ),moderate (score 6 to 8,grade Ⅱ) and severe (score ≥9,grade Ⅲ) according to the measurements of the above 5 indexes.A comminuted fracture was categorized into grade Ⅲ.Results Posterior comminutions were found in 35 cases (15.3％),but not in the other 194 ones (84.7 ％).No posterior angulation was observed in 27 cases (11.8％).Posterior angulation ≤30° was found in 44 cases (19.2％),that from 30° to 60° in 115 cases (50.2％),and that ≥60° in 43 cases (18.8％).Twenty patients(8.7％) had no displacement.Fracture displacement ≤ 10 mm was observed in 96 cases (41.9％),that from 10 to 20 mm in 96 cases (41.9％),and that ≥20mmin 17 cases (7.4％).The facture line was located below the head in 131 cases (57.2％),at the head-neck in 88 cases (38.4％),and across the neck in 9 cases (3.9％).The difference in neck-shaft angle was 0° in 12 cases (5.2％),≤ 10° in 105 cases (43.4％),10° to 20° in 84 cases (35.3％) and ≥20° in 28 cases (17.6％).In the 229 cases,our severity scores were related to Garden classification in the following manners:all Garden Ⅰ cases belonged to grade Ⅰ; Garden Ⅱcases contained grade Ⅰ in 15 cases (45.5％) and grade Ⅱ in 18 cases (54.5％);Garden Ⅲ cases included grade Ⅰ in 6 cases (3.1％),grade Ⅱ in 123 cases (64.7％) and Grade Ⅲ in 61 cases (32.2％); all Garden Ⅳ cases were Grade Ⅲ.Conclusion In assessment of the severity of femoral neck fractures,CT scans can be more accurate,objective and reliable,and can be quantified as well. Key words: Femur; Fracture, bone; Tomography, spiral computed

AB0258 Cataract extraction (CE) and intraocular lens implantation (IOL) in patients with rheumatoid arthritis (RA)

BackgroundInflammation caused by arthritis and long-term use of steroids such as prednisone contributes to the development of cataracts and a significant visual disability. Cataracts are commonly and very successfully treated...

Locking plate fixation for calcaneal fractures of Sanders type IV: a finite element analysis

Objective To evaluate the biomechanical performance of a calcaneal locking plate in fixation of calcaneal fractures of Sanders type IV through finite element（FE） analysis. Methods A healthy male volunteer was enrolled for this study who were 26 years old and 70 kg in weight. A 3D FE model of calcaneal fracture of Sanders type IV fixated with a ealcaneal locking plate （Synthes） was reconstructed using software Mimics 13.0 and Geomagic 10. 0 based on the 3D CT images of the volunteer＇s both feet. An axial load of 700 N was applied through the talus. The stress distribution and peak stress of fracture fragments and internal fixator, and the maximum stress point and maximum displacement area of the calcaneus and internal fixator as well, were analyzed. Results The lateral stresses on the calcaneus were concentrated on the 4 areas： the medial side of the subtalar joint （15. 224 MPa）, the bone-screw interface below the subtalar joint （13. 083 MPa）, the bone-screw interface beside the heel （9. 786 MPa） and the bone-screw interface beside the calcaneocuboid joint （7. 632 MPa）. The peek stress on the plate was about 260. 1 MPa, distributed on the fracture line between the posterior fragment and the median-anterior fragment. The maximal displacements occurred on the sustentaculum tali （0. 403 mm）, the interface between the posterior fragment and median fragment （0. 320 mm） and the interface between the anterior fragment and median fragment （0. 319 ram）. The maximal displacement of the plate-screw occurred on the distal side of the proximal screws, especially the one used to fixate the sustentaculum tali, about 0. 390 mm. Conclusions Since fixation with a locking plate for calcaneal fractures of Sanders type IV may lead to a high risk of traumatic arthritis, it is suggested that primary external fixation followed by subtalar fusion be a better choice or appropriate modifications be made of the current locking plate to achieve better mechanical performance. Key words: Calcaneal fracture; Finite element analysis; Computer simulation; Fracturefixation, internal

The indication for surgical treatment of posterior malleolar fracture

Objective To explore the indication for surgical treatment of posterior malleolar fracture by observing the effects of bone fragment size and fixation on the fracture healing.Methods We retrospectively analyzed 73 patients with posterior malleolar fracture who had undergone surgical treatment from January 2004 to December 2011.By AO classification,there were 19 cases of type 44A,37 cases of type 44B and 17 cases of type 44C.Fixation of the posterior malleolus was conducted in 30 cases (45.2％) and not in 43 cases (54.8％).American Orthopaedic Foot and Ankle Society (AOFAS) score and the Mos 36-item Short Form Health Survey (SF-36 score) were used for functional evaluation.Articular smoothness and degeneration in the X-ray films were considered as image evaluation criteria.The AOFAS and SF-36 scores were compared between the fixation and non-fixation groups as well as between the ≥25％ bone fragments and the ＜ 25％ones.Results Sixty-five patients completed the follow-ups which ranged from 2 to 84 months (average,44.3 months).Irregular articular surface was observed in 4 cases and mild to moderate degeneration in 5 cases.Infective infection of the lateral malleolar skin occurred early in 2 cases and poor internal implantation in one,but their functional recovery was not affected.The AOFAS and SF-36 scores for patients with ≥25％bone fragments in the fixation group were respectively 94.2 ± 9.8 and 107.5 ± 11.8 points,significantly higher than those in the non-fixation group (87.4 ± 6.7 and 92.8 ± 18.5 respectively) (P ＜ 0.05).The AOFAS and SF-36 scores for patients with ＜ 25％ bone fragments in the fixation group were respectively 91.3 ± 13.2 and 104.2 ± 14.2 points,with no significant differences from those in the non-fixation group (91.8 ± 10.9 and 102.3 ± 16.6 respectively) (P ＞ 0.05).Conclusions When a posterior fragment is larger than 25％ of the articular surface,open reduction and internal fixation should be considered.When a posterior fragment is less than 25％ of the articular surface,conservative treatment may be a better choice. Key words: Ankle; Fracture; Prognosis

A new species of fox from the Australopithecus sediba type locality, Malapa, South Africa

ABSTRACT The 1.977 Ma site of ‘Malapa’ (Gauteng, South Africa) has yielded important new fossils, including the type specimens of the new hominin species Australopithecus sediba. Recently, we reported the first Carnivora specimens to have been recovered from the site. That sample included members of Felidae, Herpestidae and Hyaenidae. That first report also included three associated small canid specimens (an M2, a rib and a posterior mandibular fragment including the P4, M1, coronoid, condylar and angular processes) that we attributed to Vulpes cf. V. chama. In this paper, we compare these specimens to a broad sample of modern and fossil foxes and conclude that these specimens are distinct enough to be referred to a new species, here described and named Vulpes skinneri.

Tibial Tuberosity Fractures in Adolescents

Tibial tuberosity fractures have been described as uncommon injuries, but their frequency appears to be increasing. Because of the relatively few cases reported in the literature, little is known regarding risk factors for complications. In a large group of adolescents with tibial tuberosity fractures, we noted more frequent complications in patients who had posterior metaphyseal fractures in addition to tibial tuberosity avulsion fractures. The purpose of this study was to examine the outcomes associated with this fracture pattern and compare them with tibial tuberosity fractures without the posterior component. All patients who had closed or open reduction and internal fixation of a tibial tuberosity fracture between January 2003 and December 2010 were identified. All radiographs and medical records were reviewed. Fifty-three tibial tuberosity fractures had radiographs available for review; 15 (28%) fractures had a posterior component identified by either radiograph or computed tomography scan. Four of these combined injuries had an adverse event: 1 patient had compartment syndrome affecting all 4 compartments and 3 patients had refractures after closed reduction and casting. None of the 38 tibial tuberosity fractures without a posterior metaphyseal component had these complications. All patients had complete fracture healing and had returned to full activity at last follow-up. In this study, a posterior metaphyseal fracture associated with a tibial tuberosity fracture was a marker for potential complications. If radiographs suggest that a fracture line extends through the posterior metaphysis, computed tomography imaging is recommended to confirm the fracture pattern. Open reduction and internal fixation that includes both the anterior and posterior fragments is recommended for all fractures with these combined components, including nondisplaced fractures, because of an increased risk of refracture. Level IV (case study).

The cranial anatomy of the sauropod Turiasaurus riodevensis and implications for its phylogenetic relationships

The skull of Turiasaurus is known from a nearly complete posterior section (e.g. braincase, skull roof, quadrates and left mandible) and fragments of the snout (e.g. portions of premaxilla, maxilla, nasal and lacrimal). Skull material of the holotypic individual was discovered in close association. Comparisons with other sauropods suggest that the Turiasaurus skull most closely resembled those of Jobaria, Camarasaurus and Mamenchisaurus youngi, possessing large spatulate teeth, enlarged and partially retracted external nares, and a broadly rounded muzzle. The list of autapomorphies for Turiasaurus is augmented by the new cranial data, including features such as: (1) a shelf-like projection of bone from the medial surface of the distal end of the maxillary ascending process; and (2) a rounded boss-like area on the lateral surface of the jugal. There are also unusual character states, such as the excavation of the posterior surfaces of the basal tubera (present in Turiasaurus and Losillasaurus) that probably have a wider phylogenetic significance. Phylogenetic analyses, using two different datasets, support the view that Turiasaurus, Losillasaurus and Galveosaurus form a monophyletic Turiasauria clade that lies just outside of Neosauropoda. The addition of the new cranial data slightly strengthens the support for this topology, but the relationships of other taxa (such as Jobaria) become less stable. The Turiasauria might represent a distinct group of non-neosauropods with a wide geographic distribution across Europe and Africa during the Late Jurassic.

Staged Posterior Tibial Plating for the Treatment of Orthopaedic Trauma Association 43C2 and 43C3 Tibial Pilon Fractures

Obtaining an accurate reduction of the posterior malleolar fragment in high-energy pilon fractures can be difficult through standard anterior or medial incisions, resulting in a less than optimal articular reduction. The purpose of this study was to report on our results using a direct approach with posterior malleolar plating in combination with staged anterior fixation in high-energy pilon fractures. Prospective clinical cohort. A Level I trauma and tertiary referral center. From January 1, 2005, to December 31, 2008, 19 Orthopaedic Trauma Association 43C pilon fractures (16 C3 and 3 C2) with a separate, displaced, posterior malleolar fragment were treated by the authors. Nine patients were treated with posterior plating of the tibia (PL) through a posterolateral approach followed by a staged direct anterior approach. Ten patients with similar fracture patterns were treated using standard anterior or anteromedial incisions (A) with indirect reduction of the posterior fragment. All 19 patients were available for follow-up at an average of 40 months (range, 28-54 months). All patients were treated with open reduction and internal fixation for their pilon fractures. Quality of reduction was assessed using postoperative plain radiographs and computed tomography. Serial radiographs were taken during the postoperative course to assess the progression of healing and the development of joint arthrosis. Clinical follow-up included physical examination and evaluation of the ankle using the American Orthopaedic Foot and Ankle Society Ankle & Hindfoot score, Maryland Foot Score as well as noting all complications. There were no differences in injury pattern or time to surgery between groups. Of the 10 patients who were in the A group, 4 (40%) had more than 2 mm of joint incongruity at the posterior articular fracture edge as compared with no patients in the PL group as measured on postoperative computed tomography scans. At latest follow-up, 7 (70%) patients in the A group had radiographic evidence of joint space narrowing compared with 3 (33%) in the PL group. Ankle range of motion for the A group was 35.8° versus 34.2° for the PL group (nonsignificant). There were 2 delayed wound healing complications in the A group with one deep infection in the PL group. Two patients in the A group required arthrodesis procedures resulting from posttraumatic arthrosis compared with none in the PL group. No significant difference was seen in postoperative complications across both groups. The average Maryland Foot Score and American Orthopaedic Foot and Ankle Society/Ankle & Hindfoot score for the PL group was 86.4/85.2 compared with 69.4/76.4 for the A group. The addition of a posterior lateral approach offers direct visualization for reduction of the posterior distal fragment of the tibial pilon. Although the joint surface itself cannot be visualized, this reduction allows the anterior components to be secured to a stable posterior fragment at a later date. This technique improved our ability to subsequently obtain an anatomic articular reduction based on computed tomography scans and preservation of the tibiotalar joint space at a minimum 1-year follow-up. Furthermore, it correlated with an improvement in clinical outcomes with increases in Maryland Foot Score and Ankle & Hindfoot score for the posterior plating group. Although promising, continued follow-up will be needed to determine the long-term outcome using this technique for treating tibial pilon fractures.

Results of staged posterior fixation in the treatment of high-energy tibial pilon fractures

Summary High-energy pilon fractures are difficult injuries to treat. They often involve displaced posterior malleolar fragments. With the advent of staged management for treatment of these injuries, the posterior fragment(s) are difficult to address in a delayed fashion through standard anterior incisions. The goal of the current study is to evaluate the role for staged fixation of the posterior aspect of the tibia, and fibula if fractured, through a posterolateral approach with later reconstruction of the anterior fragments through traditional anterior exposures. Eighteen patients with high energy pilon fractures (16 OTA 43C.3 and 2 OTA 43C.2) were treated with this approach. Patients were evaluated at a minimum of 24 months following surgery. The average arc of motion at the ankle joint was 34.3 ± 7.4 o . The quality of reduction was determined by post-operative computed tomography. Eleven patients had 2 mm of incongruity at the level of the joint. Functional outcomes were assessed using the AOFAS ankle and hindfoot score and the MFS. The average AOFAS score was 83.8 and the average MFS score was 84.7. This technique allows for improved articular reduction with encouraging clinical and functional outcome results.

Comment on Sen et al.: Posterior wall reconstruction using iliac crest strut graft in severely comminuted posterior acetabular wall fracture

Dear Sir, We read with interest the article entitled Posterior wall reconstruction using iliac crest strut graft in severely comminuted posterior acetabular wall [6]. In the study, the authors used iliac crest strut graft for reconstruction of the comminuted posterior acetabular wall fracture. A series of eight patients were evaluated clinically by Merle d’Aubigne and Postel score and radiologically by Matta score at their final follow-up. The outcome after a mean follow-up of 3.34 years (minimum two years and maximum five years) showed a good-to-excellent result in seven patients (87.5%) clinically and in five patients (62.5%) radiologically [6]. We appreciate the described technique using iliac crest strut graft for reconstruction of the comminuted posterior acetabular wall fracture, and also the medium-term clinical and radiological results of this technique are satisfactory. However, in their discussion, the authors concluded “Iliac crest strut graft can be better compared to a single fragment of posterior acetabulum wall which has lost its soft tissue attachment”; we have doubts about this conclusion. There is consensus that good prognosis is clearly related to anatomical reduction and stable fixation of posterior wall fractures. Only 30% of posterior-wall acetabular fractures involve a single large fragment. The majority are multifragmentary or have areas of impaction, where open reduction is often necessary with elevation of the depressed articular fragments [1]. Whether the fragments have soft-tissue attachments or not was rarely mentioned in published reports. In our experience, although soft-tissue stripping was done extremely carefully intra-operatively, we often found fragments became free after elevation and reduction in severely comminuted posterior acetabular wall fractures. This has also been mentioned by Giannoudis et al. in their report [3]. Using primary severely comminuted fragments, which may be without soft tissue attachment, to reconstruct the posterior wall produced good results for different authors. The following patients were all evaluated clinically by modified Merle d’Aubigne and Postel score and radiologically by Matta score at their final follow-up. Im et al. retrospectively examined 15 patients with a single fragmented or moderately comminuted posterior acetabular wall fracture using screws alone, whereby 14 patients (94%) had a good-to-excellent result clinically after a follow-up period of more than two years [4]. Ebraheim et al. retrospectively studied 32 comminuted posterior acetabular wall fractures combining a spring plate and reconstruction plate to reconstruct the posterior wall; the average follow-up was 43 months (range 24–70 months), and clinical evaluation gave a good-to-excellent result in 24 patients (76%) and radiologically in 23 patients (73%) [2]. Recently, Giannoudis et al. reported a two-level reconstruction technique using subchondral miniscrews for the stabilisation of comminuted posterior wall marginal acetabular fragments before applying lag screws and a buttress plate to the main overlying posterior fragment. The clinical outcome was graded as a good-to-excellent result in 27 patients (93%), and radiological outcome was graded as a good-to-excellent result in 25 patients (86%) at a mean follow-up of 35 months (range 24–90) [3]. No complication in the form of non-union, loss of fixation and absorption of fragments was noticed. As the Spearman correlation between the original and modified Merle d’Aubigne-Postel Score was R = 0.89, it is equivalent to using the two grading systems clinically [5]. From these data, we therefore favour using primary severely comminuted fragments to generate better results. Whether the iliac crest strut graft is better than a single fragment without soft-tissue attachment or not, requires further study. Furthermore in our opinion, to ensure the blood supply of the bone graft, using muscle pedicle bone graft is a reliable and easy technique in the clinical setting. However, in the study of Sen et al., the authors did not mention whether the iliac crest strut graft had a muscle pedicle or not, but Fig. 3b in that article shows a free iliac crest strut graft. In conclusion, only with muscle pedicle iliac crest strut graft application in this study, can we conclude that it is better than a single fragment of posterior acetabulum wall which has lost its soft tissue attachment. The word “definative” in the last paragraph, it should be “definitive”.