Fracture Reduction Research Articles

Standard radiographic images in cephalomedullary nailing fixation for intertrochanteric femoral fractures

To review and summarize the projections of radiographic images during cephalomedullary nailing fixation for intertrochanteric femoral fractures, and to propose a set of three projections as standard requirement in immediate postoperative fluoroscopy. Papers on intertrochanteric femoral fractures treated with cephalomedullary nailing fixation that published in a three-year period of 2021-2023 in four leading English orthopedic trauma journals were searched in PubMed. The presented radiographic pictures were identified and scrutinized as whether they were in standard anteroposterior and/or lateral projections of the implanted nails. The nonstandard presence percentage was calculated. Combined with clinical experience, the standard anteroposterior and lateral perspective images of femoral neck, the current situation of radiographic imaging in the operation of cephalomedullary nails, the literature analysis of nonstandard images, the impact of limb rotation on image interpretation, and the characteristics of anteromedial 30° oblique perspective were summarized and analyzed. The presence of nonstandard radiographic pictures is 32.1% in anteroposterior view and 69.2% in lateral view in leading orthopedic trauma journals. In cephalomedullary nailing fixation operation of intertrochanteric femoral fractures, it is reasonable to use the radiographic images of the implanted nails to represent the fractured head-neck, as the head-neck implant (lag screw or helical blade) is aimed to put into centrally in femoral head in lateral projection. Limb rotation or nonstandard projections produced distortion of images, which interfers the surgeons' judgement of fracture reduction quality and the measurement of implant position parameters in femoral head (such as neck-shaft angle and tip-apex distance), and finally lead to a meaningless comparison with the accurate normal value. The 30° anteromedial oblique view from the true lateral (set as 0°) is a tangential projection of the cortices at the anteromedial inferior corner, which gives a clear profile for the determination of cortical apposition status and mechanical support. It is essential to get firstly the true standard lateral fluoroscopy of the nail (shown as a line), then rotate the C-arm to 90° and 30° to get anteroposterior and anteromedial oblique views, and use these three immediate postoperative radiographies as the baseline for evaluation of operative quality and follow-up comparisons. As for real-time monitoring of surgical steps, intraoperative fluoroscopy follows the "Enough is Good" principle, but as for immediate postoperative data storage and basis for operative quality evaluation and baseline for follow-up comparison, it is recommended to obtain a set of three standard radiographic pictures in anteroposterior, true lateral, and 30° anteromedial oblique fluoroscopic projections.

An unusual Ogden type V tibial tubercle avulsion fracture: a case report and literature review

BackgroundOgden type V tibial tubercle avulsion fracture is an unusual type of physial injury. Thus, little is known about its mechanism of injury and treatment. The type of osteosynthesis is variable and depends on the experience of the surgeon. We commonly used cancellous screws fixation combined with tension band wiring for displaced fracture of the anterior tibial tuberosity.Case presentationThe present manuscript describes a case of a Han nationality 13-year-old boy who presented with severe pain of the left knee, which began after landing following a high jump. He had no significant past medical history apart from a high body mass index of 30.3. Radiographs revealed that he had an unusual Ogden type V tibial tubercle avulsion fracture. He was treated by open reduction and combined fixation with cannulated screws and tension-band wiring. After 3 months, the fracture healed without any complications or knee symptoms with full range of motion. He underwent reoperation for symptomatic hardware, which was removed at 5 months after initial surgery, and returned to his prior level of sporting activity at 1 year follow-up.ConclusionOur case suggests that excellent functional outcome could be achievable by open reduction with the combination of internal fixation and tension-band wiring for Ogden type V tibial tubercle avulsion fracture. This type of osteosynthesis could not only achieve anatomical reduction and stable fixation for such fractures, but also avoid further damage to the proximal tibial epiphysis, which prevents serious complications, such difference in leg length.

Comparison of complications and degree of correction between the extensile lateral and sinus tarsi approaches in the treatment of calcaneus fractures: a cross-sectional observational retrospective study

Introduction: Calcaneus fractures are a challenge for traumatologists. Their complex anatomy, relative scarcity of surrounding soft tissue, and long learning curve for surgical treatment partly explain the difficulties encountered by surgeons, in addition to contributing to the high rate of complications. Objective: This study aimed to identify the differences in complication rates and degree of correction between extensile lateral access (ELA) and sinus tarsi (STA) approaches by reviewing medical records between 2018 and 2023 of patients who underwent open reduction and internal fixation of calcaneus fractures at a hospital in the interior of São Paulo. Methods: The present study followed a retrospective observational and cross-sectional model (STROBE). The Kolmogorov Smirnov test, Student-t test, Wilcoxon Rank test, Mann-Whitney test, Pearson Chi-Square test, and binary and predictive logistic regression analysis were used, adopting a confidence risk of 0.05. Results and Conclusion: A total of 77 patients were included (52 ELA and 25 STA). It was concluded that no statistical differences were observed after intergroup comparisons (ELA vs. STA). There was also no statistically significant influence of the predictor “age” on the predictors of the responses “Böhler and Gissane angles in degrees” in the final post-procedure phase. In general, STA presented a lower probability of complications with the use of the sinus tarsi route, reaching the same level of joint reduction and control of progression to osteoarthritis. All these results of the present study almost completely confirm the literary findings that appear under discussion.

Assessing the Need for Imaging after Distal Radius Fracture Fixation

Abstract Background Distal radius fractures are extremely common. Patients routinely undergo early imaging (around 2 weeks) after open reduction and internal fixation (ORIF) of distal radius fractures despite no clinical concerns. We analyzed the need for these radiographs by evaluating when imaging identifies complications after surgery. Methods All distal radius fractures treated with ORIF via a volar approach by the senior surgeon were included. Intraoperative and postoperative images were analyzed for maintenance of reduction and complications. Demographic data, fracture characteristics, and postoperative complications were also recorded. Results A total of 342 patients were identified. Postoperative images were obtained from 0 to 14, 15 to 90, 91 to 180, 181 to 365, or greater than 365 days after surgery. Some patients had multiple images. Measurements on postoperative images were statistically equivalent across all time points. Complications mostly occurred >90 days after surgery. Of the 26 patients with complications, 5 had a failure of reduction or plating seen on postoperative imaging. Two occurred after unrelated trauma; only three patients had unanticipated complications caught on routine imaging within 3 months after surgery. These patients had extraordinarily complex fractures in poor bone stock. Conclusion Early postoperative imaging is not necessary after ORIF for distal radius fractures unless the patient is elderly, or the fracture is severely comminuted with ulnar column or die-punch components. Thus, we suggest that patients have imaging only in the 3- to 6-month period to determine if the union has been achieved, which could provide cost savings to both surgeon and patient.

Study on the efficacy of 3D printing technology combined with customized plates for the treatment of complex tibial plateau fractures

BackgroundAnatomical reduction and stable fixation of complex tibial plateau fractures remain challenging in clinical practice. This study examines the efficacy of using 3D printing technology combined with customized plates for treating these fractures.MethodsWe retrospectively analyzed 22 patients treated with 3D printing and customized plates at the Orthopedic Department of the Central Hospital affiliated with Shenyang Medical College from September 2020 to January 2023. These patients were matched with 22 patients treated with traditional plates with similar baseline characteristics. Patients were divided into an experimental group (3D-printed models and customized plates) and a control group (traditional plates). The control group underwent traditional surgical methods, while the experimental group had a preoperative 3D model and customized plates for surgical planning. We compared baseline characteristics and recorded various indicators, including preoperative preparation time, surgical time, intraoperative blood loss, number of intraoperative fluoroscopies, hospital stay duration, fracture healing time, complications, knee joint range of motion (ROM), Rasmussen anatomical and functional scores, and HSS scores.ResultsAll surgeries were successful with effective follow-up. The experimental group had shorter surgical time, less intraoperative blood loss, and fewer intraoperative fluoroscopies (P < 0.05). At 6 months and 1 year postoperatively, the experimental group had better knee joint HSS scores than the control group. Preoperative preparation time and total hospital stay were shorter in the control group (P < 0.05). There were no significant differences in fracture healing time and follow-up duration between groups. The experimental group showed better knee joint flexion angles (P < 0.05). Rasmussen scores showed no statistical difference between groups (P > 0.05). The incidence of complications was slightly lower in the experimental group but not significantly different.Conclusion3D printing technology combined with customized plates for complex tibial plateau fractures enables precise articular surface reduction, significantly shortens surgical time, and reduces intraoperative blood loss. This method improves knee joint function, offering a more effective treatment option.

ROLE OF POSTOPERATIVE CT SCAN IN ASSESSING SYNDESMOTIC REDUCTION IN ANKLE INJURIES

Background: Accurate syndesmotic reduction is necessary for achieving joint congruity and better functional outcomes. Radiographs alone don’t suffice, and CT scans are required for the evaluation of postoperative syndesmotic reduction. Methods: All patients who underwent ankle syndesmotic reduction and fixation from December 2019 to July 2021 were taken into the study. Predefined measurements were taken in postoperative radiographs and axial CT images were taken postoperatively. Sensitivity and specificity of X-rays when compared to CT scan were evaluated. Results: Twenty eight patients were included in the study and 13 cases were found to have syndesmotic malreduction in radiographs as per TCS and TFO in AP view and TFO and MCS measurements in mortise view. Five out of 28 cases were found to have syndesmotic malreduction in CT axial cuts as per standard anterior and posterior measurements. Hence 17.85% cases were malreduced in our study as per the gold standard (CT scan). The incidence of syndesmotic malreduction after fixation was 17.85%. Radiographs had a sensitivity of 60% and specificity of 56.5% in detecting malreduction. Conclusion: CT scan is necessary to accurately diagnose syndesmotic malreduction after open reduction and internal fixation of ankle fractures with associated syndesmotic injuries.

WP6.9 - Essential Surgery Skills Course: A One Week Training Program to Prepare Surgeons for Humanitarian Deployment

Abstract Background Medical students, surgical trainees, and surgical faculty are increasingly interested in incorporating global surgery into their clinical practices and professional careers. However, many concerns remain about the preparation of surgeons for operating in resource-limited settings and their exposure to critical procedures such as cesarean sections, hysterectomies, or fracture reductions. In an attempt to address these concerns, academic institutions have developed advanced professional training programs for the global surgeon. Methods A six-day essential surgery skills conference was created at a large academic institution that provides trainees and surgeons with an overview of common surgical scenarios across orthopedics, urology, obstetrics, gynecology, general surgery, anesthesia and ultrasound in the form of didactics, simulations, and wet labs. Results 11 surgical trainees from four large academic institutions attended the essential surgery skills conference. Trainees attended sessions on point of care ultrasound, regional anesthesia, general anesthesia, hysterectomies, cesarean sections, post-partum hemorrhage, fracture reduction and fixation, ureteral injuries, and humanitarian deployment. A pre and post-test was administered. Improvement was noted in the trainees scores on the post-test in their knowledge of surgical subspecialty care. Trainees also reported feeling better prepared for humanitarian deployment. Conclusion Global surgery conferences can be designed to provide a networking and collaboration forum for improving access to surgical services worldwide. One-week predeparture conferences that discuss essential technical skills and relevant global surgery knowledge may better prepare surgeons to operate in resource-limited settings.

Development of the humeral head offset index for control of humeral torsion

BackgroundControl of humeral torsion can present a challenge, especially intraoperatively during closed reduction and fixation of humeral shaft fractures or 2-part surgical neck fractures of the proximal humerus. The objective of this study is to develop and validate an indirect method for the assessment of humeral torsion using an index that is linearly correlated with rotational arm position and can be derived from only a single plain radiographic image of the proximal humerus.MethodsThe Humeral Head Offset Index (HHOI) is calculated as the ratio of the medial and lateral offset of the humeral head measured from the outer cortices of the shaft on a plain radiographic or fluoroscopic image. The relationship of HHOI with humeral torsion was first verified on a sawbone model with radiopaque characteristics under fluoroscopic control. Different degrees of retroversion were simulated through manual rotation of the humerus with a digital protractor in 5° increments until 40° internally rotated and then in 5° increments until 40° externally rotated from the neutral position. The same procedure was subsequently performed digitally on Digitally Reconstructed Radiographs (DRRs) from computed tomography (CT) dataset of the sawbone. Next, the HHOI index was applied to eight randomly selected patients with total humerus CT using the same method. Spearman’s rho was calculated for the bivariate analysis of correlation between the simulated degree of retroversion and the HHOI. Strength of correlation was classified according to Koo and Li. Interrater and intrarater reliability of three blinded observers with repetition of measurement after three months were analyzed by assessing the intraclass correlation coefficient (ICC).ResultsBoth in the sawbone model and in DRRs, we demonstrated a high to very high significant linear correlation between simulated retroversion and the HHOI. ICC values demonstrated excellent interrater reliability and excellent intrarater reliability for measurement of the HHOI.ConclusionsThe HHOI is a new, simple, reliable index that has a linear relationship to the rotation of the humerus and can therefore allow an indirect control of humeral torsion in comparison to the contralateral side.

Long-term outcome of robotic-guided closed reduction internal fixation for Delbet II femoral neck fractures in children

ObjectiveTo retrospectively analyze and assess the long-term effectiveness of robotic navigation and traditional closed reduction internal fixation in the treatment of Delbet type II femoral neck fracture in children.MethodsA total of fifty-five patients diagnosed with pediatric Delbet type II femoral neck fracture, who were admitted to Foshan Hospital of Traditional Chinese Medicine between January 2018 and June 2022, were included in this study. Among them, 22 cases of nailing under robotic navigation were set as the observation group, and 33 cases of nailing under fluoroscopy of the C-arm machine were set as the control group. All patients had their femoral neck fractures closed and repositioned first. After confirming the satisfactory fracture repositioning under the fluoroscopic view of the C-arm machine, internal fixation was performed by inserting hollow compression screws in the corresponding surgical way.A comparative analysis was conducted between the two groups to assess the disparity in the amount of X-ray exposure during surgery, the number of guide pins inserted, and the duration of the surgical procedure. The quality of comparative fracture reduction was assessed according to the Haidukewych criteria on the first postoperative hip X-ray, and the parallelism and distribution of the comparative screws were measured. The incidence of hip function and postoperative complications according to the Ratliff criteria were evaluated between each of the subgroups at the final follow-up.ResultsComparison of general information, operation duration, and quality of fracture reduction between the two groups failed to reveal statistically significant results (P > 0.05). The observation group had a lower number of X-ray exposures and guide pin placements compared to the control group, and this difference was statistically significant (P < 0.05).At the last follow-up, the observation group exhibited superior screw parallelism and distribution, as well as hip joint function, compared to the control group, and this difference was statistically significant (P < 0.05). The incidence of complications in the observation group was lower than that in the control group; however, the difference was not statistically significant (P > 0.05).ConclusionClosed reduction and internal fixation under orthopedic robot navigation can achieve better long-term efficacy in treating Delbet type II femoral neck fracture in children.

Ankle Fractures Treated with Locked Fibular Intramedullary Nailing: Description and Outcomes of a Minimally Invasive Open Technique

OBJECTIVES: To describe and report outcomes of a minimally invasive open intramedullary (IM) fibular nailing technique for fixation of ankle fractures. METHODS: Design: Case Series Setting: Urban Level 1 trauma center Patient Selection Criteria: Adult patients with ankle fractures (OTA 44A-C) treated with locked fibular IM nailing via a minimally invasive open technique for fracture and syndesmotic reduction between 2021 and 2024. Outcome Measures and Comparisons: Quality of reduction, complications, and patient-reported outcomes (PRO). RESULTS: A total of 150 consecutive patients operated by a single surgeon were included. Mean age was 53.3 (17-97) years, and mean BMI was 30.6 ± 7.4 kg/m2. 93(62%) patients were female, and 78 (52%) patients were Caucasian. 72 (48%) patients were obese, 40 (27.7%) patients were current/former smokers, 39 (26%) patients were diabetic, and 23 (15.3%) patients had open fractures. 37 (24.7%) patients had isolated lateral malleolus fractures, 48 (32%) had bimalleolar fractures, and 65(43.3%) had trimalleolar fractures. 123 (82%) patients had 2 syndesmotic screws placed, 26 (17.3%) had 1 screw, and 1 (0.7%) had none. Quality of reduction was good for 98%, fair for 2%, and poor for none per McLennan’s criteria. 113 patients (75.3%) were followed until clinical and radiographic union for a mean of 7.6 months (range 3-22) months). 110 patients (97.3%) went on to successful clinical and radiographic union following the index procedure. No patient had a superficial surgical-site infection, and 3 (2.6%) had deep surgical-site infections. 3 patients had a loss of reduction, and 6 patients had implant failure (5 broken syndesmotic screws, and 1 medial malleolus screw). 9 (8%) patients had unplanned reoperations (3 for debridement, 2 for loss of reduction, and 4 for removal of symptomatic implants). Mean ankle range of motion at final follow-up visit was 12.9° (0-40) of dorsiflexion, 39.6° (10-70) of plantarflexion, 23.5° (5-40) of inversion, and 18.2° (5-50) of eversion. Mean PROs at final follow-up visit were: Global Physical Health: 42.4 (23.5-67.6), Global Mental Health: 47.5 (21-67.6), Physical Function: 37.5 (14.7-57.8), Pain: 54.9 (22-72) and Mobility: 36.9 (16-65.3). CONCLUSIONS: Minimally invasive open fibular IM nailing allowed for excellent reduction and results in union with low rates of complications and good patient reported outcomes. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Percutaneous Fixation in Intra-articular Calcaneal Fractures.

Displaced intra-articular calcaneal fractures have been proven to be challenging fororthopaedicsurgeons worldwidedue to the poor clinical outcomes. Historically, the decision whether for fixation or conservative management depended mostly on the literature of the time, initiallyfavouringconservative management but attitudes slowly shifted to operative intervention. Percutaneous fixation options have been increasingly popular for their ability for fracture reduction without skin and wound complications of the open method.A retrospective study of 17 patients with a total of 18 calcaneal fractures treated in our hospital by a single surgeon from January 2017 to December 2019 was conducted. Fixation was done percutaneously using cannulated screws, with the patients in a lateral position. Intraoperative imaging was done using a mini-image intensifier to visualise fracture reduction, and the O-arm was used in most cases.Using the Sanders classification, there were a total of 4 IIA, 3 IIB, 2 IIC, 2 IIIAB, and 7 IIIAC.Results showed that 16 calcaneal fractures (94%) had good to excellent outcomes with the American Orthopedic Foot and Ankle Society (AOFAS) score and Maryland Foot Score (MFS), while 14 calcaneal fractures (78%) showed good to excellent outcomeswith the Kerr calcaneal score. There were no wound complications encountered in our series. However, there was one patient with a k-wire broken intraoperative and left in situ and there were two patients with prominent screws.Despite this, our experience with percutaneous fixation of displaced intra-articular calcaneal fractures has been generallyfavourable, allowing for good outcomes and satisfactory reduction of the fracture fragments.

The reconstruction techniques and mid-term clinical outcomes of hip revision for acetabular bone defect after total hip arthroplasty

Objective: To analyze three reconstruction techniques and mid-term clinical outcomes of hip revision for acetabular bone defect after total hip arthroplasty (THA). Methods: This is a retrospective case series study. Included in the study were 109 patients (109 hips) with acetabular bone defect after THA reconstructions in hip revisions from January 2015 to December 2021 in the Senior Department of Orthopaedics, the Forth Medical Center of Chinese People's Liberation Army General Hospital and the Department of Orthopaedics, the First Medical Center of Chinese People's Liberation Army General Hospital. According to the preoperative simulated surgeries and different bone defect reconstruction techniques, patients were divided into a normal cup group, an augment group or a triflange group,respectively. There were 54 patients (54 hips) in the normal cup group, reconstructed with the uncemented porous metal cup (including Jumbo cup), with 23 males and 31 females, aged (59.6±9.9) years (range:32 to 76 years); 44 patients (44 hips) in the augment group, reconstructed with the individualized three-dimensional (3D) printed porous metal augment and uncemented porous metal cup, with 18 males and 26 females, aged (52.8±13.6) years(range:17 to 76 years); 11 patients (11 hips) in the triflange group, reconstructed by the individualized 3D printed porous metal triflange cup, with 5 males and 6 females, aged (59.4±11.2) years (range: 43 to 78 years). Radiographic results, including rotation center height, rotation center offset, and leg length discrepancy (LLD) and clinical results, including Harris hip score (HHS) and visual analogue scale(VAS) were evaluated outpatient at 3, 6, 12 months after the operation and annually thereafter. The last follow-up was completed in March 2024, and all parameters at the last follow-up and before the operation were compared. Paired sample t test and repeated measurement ANOVA were used for the radiographic and clinical parameters before and after the operation. Results: All hip revisions for patients with acetabular bone defect after THA were completed and followed for more than two years. The follow-up time of the normal cup group was (6.5±1.7) years (range: 2.8 to 9.3 years), and that of the augment group was (6.0±1.3) years (range: 3.5 to 9.0 years). The follow-up time of the triflange group was (2.8±0.6) years (range: 2.0 to 3.8 years). At the last follow-up, the rotation center height, rotation center offset and LLD of 54 hips in the normal cup group were (24.2±5.6) mm, (29.1±5.5) mm and (4.6±3.3) mm, respectively, and the rotation center height and LLD were significantly lower than those of the preoperative hips (t=9.671, P<0.01; t=6.073, P<0.01). In the augment group, the rotational center height, the rotation center offset and the LLD of 44 hips were (22.4±9.0) mm, (25.4±5.5) mm and (6.0±4.0) mm, respectively, which were significantly lower than those of the preoperative hips (t=9.071, P<0.01; t=11.345, P<0.01; t=4.927, P<0.01). In the triflange group, the rotational center height, the rotation center offset and LLD of 11 hips were (22.7±6.0) mm,(30.9±8.0) mm and (5.3±2.2) mm, respectively, and the rotation center height and LLD were significantly lower than those of the preoperative hips (t=2.716, P=0.022; t=6.226, P<0.01). At the last follow-up, fractures occurred in 3 patients and dislocation occurred in 1 patient in the normal cup group, and fracture reduction and closed reduction were administered under anesthesia, respectively. In the augment group, dislocation occurred in 1 patient and open reduction under anesthesia was performed. The HHS and VAS of the three groups improved significantly after surgery and the differences were statistically significant (all P<0.01). There was no complication in the triflange group. The X-ray at the last follow-up showed that all prostheses and augments were in stable positions and no loosening or migration was observed. Conclusions: For patients with acetabular bone defect after THA undergoing hip revisions, preoperative surgical simulation and rehearsal could help surgeons choose convenient and efficient reconstruction techniques. The targeted selection of Jumbo cup, individualized 3D printed metal augment, and customized triflange cup could achieve satisfactory clinical outcomes.

Post-operative outcomes of talus fracture open reduction internal fixation in patients with diabetes mellitus

Little is known regarding outcomes of talus fracture management among patients with diabetes mellitus. This study aimed to compare post-operative outcomes after open reduction and internal fixation for talus fracture in patients with complicated diabetes, uncomplicated diabetes, and patients without diabetes. We used the PearlDiver database to identify patients who underwent operative repair of talus fractures from 2009 to 2021. Complications were evaluated at 30-days, 90-days, and 1 year of surgery. As we performed multiple separate analyses, to minimize the risk of type 1 error we employed the Bonferroni correction for statistical significance (p< 0.017). The PearlDiver identified 5,232 patients with talus fracture that underwent open reduction internal fixation. Stratified by diabetes status, the “complicated diabetes,” “uncomplicated diabetes,” and “no diabetes” groups contained 223, 418, and 4591 patients, respectively. Reoperation, acute kidney injury, and myocardial infarction were increased among diabetes patients compared to non-diabetes patients, irrespective of diabetes severity within 3 months of surgery. Furthermore, patients with complicated diabetes were more likely to develop sepsis and wound disruption compared to their non-diabetes counterparts within 3 months. While not statistically significant, complicated diabetes patients were diagnosed with talar non-union at higher rates compared with non-diabetes patients. Further analysis may reveal a clinically significant discrepancy in non-union between these groups. Complicated diabetes is associated with significantly higher risk of multiple adverse events following talus fracture repair. Level of clinical evidence3

Conversion of Tibial Plateau Fractures to Total Knee Arthroplasty is Associated With Worse Patient-Reported Outcomes, Increased Operative Times, and Increased Complications

BackgroundPrior open reduction and internal fixation (ORIF) of tibial plateau fracture (TPF) adds complexity to subsequent total knee arthroplasty (TKA). The purpose of this study was to compare the outcomes of patients undergoing a TKA following prior ORIF of TPF to patients undergoing a primary TKA for osteoarthritis and an aseptic revision TKA. MethodsThere were 52 patients who underwent primary TKA following prior ORIF of TPF between January 2009 and June 2021, who were included and matched in a 1:4 ratio to 208 patients undergoing primary TKA. A second 1:1 matched comparison to 52 aseptic revision TKA patients was also included. The Knee injury and Osteoarthritis Outcome Score for Joint Replacement scores were obtained preoperatively and at two years postoperatively. Independent t-tests and Chi-square tests were used for statistical comparisons. ResultsThe TPF patients were significantly younger than both primary and revision cohorts (55 ± 14.0 versus 63 ± 16.3 versus 64 ± 9.5, P < 0.001). Compared to primary TKA patients, the TPF group had worse Knee injury and Osteoarthritis Outcome Score for Joint Replacement scores at two years (46.9 ± 18.5 versus 66.2 ± 17.8, P = 0.0152), higher rates of wound complications (15.4 versus 3.9%, P = 0.0020), and increased operative times (140.2 ± 45.3 versus 95.2 ± 25.7, P < 0.0001). Additionally, TPF patients were more likely to require a manipulation under anesthesia than both primary and revision patients (21.2 versus 5.8 versus 5.8%, P = 0.001). ConclusionsThe TKAs following ORIF of TPF are more like revision TKAs than primary TKAs in terms of patient-reported outcomes, operative times, and wound complications. The rate of manipulation under anesthesia was higher than in both matched groups. These findings provide valuable information that can affect preoperative patient education and postoperative management regimens. They also emphasize the need for a conversion TKA code due to increased complexity and complications seen in this more difficult subset of TKAs.

Do Postoperative Surgeon Phone Calls Improve Outcomes Following Mandibular Fracture Repair?

Complications of open reduction and internal fixation (ORIF) of mandibular fractures are influenced by several patient factors. A postoperative surgeon phone call could modify these factors through education and reinforcement of instructions, but its effect has not been studied. The purpose of this study was to measure and compare the frequencies of postoperative inflammatory complications (POICs) following ORIF of mandibular fractures in patients who did and did not receive a postoperative surgeon phone call. The authors conducted an ambispective cohort study consisting of patients with mandibular fractures treated with ORIF at a large urban trauma hospital with the prospective cohort from January 1, 2021 to March 31, 2022 and a retrospective cohort from April 1, 2020 to December 31, 2020. Prisoners and patients with gunshot wounds were excluded. The primary predictor variable was the surgeon call group. After January 2021, a postoperative call was implemented 1-3days following fracture repair to review instructions, such as nonchew diet and oral hygiene, and provide education, such as reviewing expectations. Prior to January 2021, patients were not called. This resulted in 3 categories: Not Called, Called and Answered, and No Answer. The primary outcome variable was POICs, defined as the occurrence of exposed or infected hardware, abscess formation, recurrent swelling/pain, nonunion, osteomyelitis, or fistula formation. Demographic variables, injury-related variables, and treatment-related variables were also measured. Statistical analysis was performed using Fisher's exact and Wilcoxon rank-sum tests, as well as multivariable logistic regression. A P value was considered significant if<.05. Of the 178 patients in the study, 137 (77%) were male and the average age was 39.9±12.6years. Sixty-five patients (36.5%) were not called. Of the patients called, 79 (44.4%) answered and 34 (19.1%) did not answer. POICs occurred in 9.2% of the Not Called group and 8.9% of the Called and Answered group (P=.99). In the No Answer group, 29.4% had POICs, which was higher than the other 2 groups (P=.01). A surgeon phone call was not associated with complication rates; however, patients in the No Answer group were significantly more likely to experience a POIC.

Comparing the risk of reoperation between pneumatic tourniquet and non-tourniquet use in surgical treatment of ankle fractures.

Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets. This was a population-based cohort study using data from the Danish Fracture Database with a follow-up period of 24 months. Data were linked to the Danish National Patient Registry to ensure complete information regarding reoperations due to complications, which were divided into major and minor. The relative risk of reoperations for the tourniquet group compared with the non-tourniquet group was estimated using Cox proportional hazards modelling. A total of 4,050 ankle fractures treated with open reduction and internal fixation between 15 March 2012 and 31 December 2016 were included, with 669 (16.5%) undergoing surgery with a tourniquet and 3,381 (83.5%) without a tourniquet. The overall reoperation risk was 28.2% with an adjusted relative risk of 1.46 (95% CI 0.91 to 2.32) for group comparison. The reoperation risk due to major complications was 3.1% with a tourniquet and 4.4% without a tourniquet, resulting in an adjusted relative risk of 1.45 (95% CI 0.91 to 2.32). For minor complications, there were 24.7% and 23.9% reoperations, resulting in an adjusted relative risk of 0.99 (95% CI 0.84 to 1.17). We found no significant difference in the reoperation rate when comparing ankle fractures treated surgically with and without the use of pneumatic tourniquets.

Open Reduction and Fixation of Late-Presenting Pediatric Supracondylar Humeral Fractures: A Prospective Study.

Supracondylar humeral fracture (SCHF) is a common injury in children, and early treatment provides excellent results and prevents disabilities. Delayed presentation is still prevalent, mainly in developing countries, because many factors hinder the opportunity to receive appropriate treatment. Currently, there are no standard treatment protocols, and there is insufficient published literature on this topic. This study aimed to evaluate the effectiveness and outcomes of open reduction and Kirschner wire fixation using a triceps-sparing posterior approach in neglected cases with complicated fractures. This was a prospective multicenter clinical study conducted between July 2016 and June 2021, which included 28 pediatric patients with neglected SCHF who presented to the hospital for definitive treatment five days or more after initial trauma without previous surgical intervention. All the patients underwent open reduction and K-wire fixation using a posterior triceps-sparing approach. The final functional outcome was assessed using the Mayo Elbow Performance Index (MEPI) and Flynn criteria. All fractures (100%) united within 3-5.5weeks (mean 4 ± 0.7 weeks). Excellent scores observed in 67.9% (n = 19), good in 21.4% (n = 6), fair in 7.1% (n=2), and poor in 3.6% (n = 1) patients according to MEPI. Correspondingly, Flynn's criteria showed 96.4% (n = 27) satisfactory and 3.6% (n = 1) unsatisfactory outcome. Open reduction and fixation using Kirschner wires through the posterior triceps-sparing approach is an effective treatment method for late-presenting SCHF in children with consequent satisfactory results.

Arthroscopic-Controlled Reduction of Hill-Sachs Lesions: Treatment Option for Off-Track Lesions in Young Patients?

Large Hill-Sachs lesions (HSL) are currently treated via a remplissage procedure. Although the good stabilizing properties of this surgery are apparent, there are some disadvantages in terms of the functional outcome. In the following Technical Note, we present a method of arthroscopic-controlled reduction of HSL for anatomical restoration of the humeral head without functional limitations. For HSL reduction, we place a 1.6-mm K-wire in the central lesion under arthroscopic and fluoroscopic control from posterior to anterior in lateral drilling direction. Then, a 7-mm cannulated drill is used for preparing the reduction canal. Afterward, the HSL is reduced via bone tamp, also under arthroscopic and fluoroscopic control. No bone substitution material is used to fill the canal; only a standard wound closure is performed. Arthroscopic-controlled reduction of impacted humeral head fractures seems to be a possible and relatively easy way to perform an anatomical restoration of HSLs. Because the exact location of HSLs can vary slightly, the exact surgical setting might be slightly different each time. Biomechanical studies already show similar stabilizing properties of this procedure compared with established techniques but without losing external rotation. Further studies need to review the potential rate of humeral head necrosis or secondary loss of reduction.

Virtual surgical planning in tripod zygomatico-maxillary complex fractures: A prospective comparison between two different strategies

Multifragmentary and displaced zygomaticomaxillary complex (ZMC) fractures are often a challenge for the maxillofacial surgeon. The aim of this study was to evaluate the improved performance in the management of patients with tripod fracture of the orbito-zygomaticomaxillary complex, using two different methods of virtual surgical planning — virtual reduction and mirroring — compared with traditional management. A cohort of 60 patients was selected and divided into three groups, each consisting of 20 individuals. Patients in the first group were managed using the virtual reduction method, those in the second group using the mirroring method, and those in the third group using a traditional surgical approach. Having achieved virtual fracture reduction, a stereolithographic model was printed, on which preplating of the plates was performed. The results showed that virtual reduction was the most accurate in absolute terms, with a mean discrepancy in juxtaposition of the preoperative and postoperative CT images of 0.175 mm (SD ± 0.147), compared with 0.403 (SD ± 0.166) for the mirror method (and traditional method (0.875, SD ± 0.112; p > 0.0001). The average surgical time for virtual reduction (89.5 min) was faster than for mirroring (94.25 min) and for the traditional approach (96.75 min). In conclusion, the use of virtual surgical planning allows greater intraoperative accuracy, reduced surgical time, and reduced postoperative complications compared with traditional surgery. Of the two methods, virtual reduction performed best for the outcomes decribed.

Nonanatomical reduction of femoral neck fractures in young patients with different Pauwels classifications: a retrospective study and finite element analysis

BackgroundPrevious studies have reported that positive buttress is as effective as anatomical reduction in treating young femoral neck fractures, but whether this effect is related to the Pauwels classification remains unclear. The purpose of this study was to retrospectively analyze the clinical prognosis of positive buttress in young femoral neck fractures with different Pauwels classifications, as well as to assess its biomechanical properties.MethodsA total of 170 young patients with femoral neck fractures who were treated with three cannulated screws were included in this study. Patients were divided into three groups based on their preoperative Pauwels classification. Each group was divided into three subgroups based on the reduction quality: positive buttress, negative buttress and anatomical reduction. The femoral neck shortening, the incidence of necrosis of the femoral head (AVN) and the Harris hip scores at the last follow-up were compared across the three reduction quality within each Pauwels classification. Subsequently, a volunteer was recruited, CT data of the hip was obtained, and finite element models representing different reduction quality under varying Pauwels classifications were established. The biomechanical properties of each model were then evaluated following the application of strains.ResultsIn Pauwels type I, there were no significant differences in postoperative femoral neck shortening, incidence of AVN, or Harris score among the three types of reduction quality (P > 0.05). However, positive buttress provided superior biomechanical stability compared to negative buttress and anatomical reduction. In Pauwels type II, the incidence of AVN was similar between the positive buttress and the anatomical reduction groups, and both were significantly lower than that in the negative buttress (P < 0.05). The Harris score of the positive buttress was higher than that of the negative buttress, and there was no significant difference in the occurrence of femoral neck shortening between the three groups (P > 0.05). Finite element analysis showed that the biomechanical stability of positive buttress was equivalent to anatomical reduction, and both were better than negative buttress. In Pauwels type III, the incidence of AVN in the anatomical reduction group was lower than that in both the positive buttress and negative buttress (P < 0.05). There was no significant difference in the occurrence of AVN or femoral neck shortening between positive buttress and negative buttress (P > 0.05). There was also no difference in postoperative Harris scores between the three reduction qualities (P > 0.05). Both positive buttress and negative buttress exhibited identical biomechanical qualities and were inferior to anatomical reduction.ConclusionsThe biomechanical and clinical dominance of positive buttress correlates with Pauwels type. Specifically, Positive buttress is biomechanically stable in Pauwels types I and II. In Pauwels type III, positive buttress is not advantageous. As the Pauwels angle increases, the biomechanical benefit of the positive buttress is lost. Therefore, regardless of the Pauwels classification, negative buttress should be avoided after reduction of femoral neck fractures in young patients.