Soft Tissue Problems Research Articles

A novel reduction support frame for management of unstable tibial fractures with intramedullary nail: Preliminary report.

Management of unstable tibial fractures (UTF) can be challenging due to widening of the proximal and distal metaphyseal zone, soft tissue problems, and poor vascularity. We aimed to compare the effect of novel tibial orthopedic reduction support (TORS) frame constructed by re-used tubular external fixator systems and manual traction with regard to the quality of re-duction, and fracture healing. A total of 65 patients who were admitted with UTF and underwent intramedullary nailing were assessed; 43 patients un-derwent manual traction technique, and 22 patients underwent TORS technique. The sagittal and coronal plane angulations were eval-uated in initial postoperative radiographs, and radiologic union scores for tibial fractures (RUST) were compared at follow-up X-rays. The mean age of patients was 43.49±19.09 years in the manual-traction group and 43.41±16.8 years in the TORS group. The mean coronal plane angulation was 1.84±3.16 in the manual traction group and 1.86±4.21 in the TORS group. The mean sagittal plane angulation was 1.19±1.93 in manual traction group and 0.32±0.65 in the TORS group. The number of coronal and sagittal plane angulations >5° was higher in manual traction group than TORS group. The mean RUST was significantly higher in the TORS group than in the manual traction group at 6th, 9th, and 12th-month controls. The union rates were also higher in the TORS group at 9th and 12th-month controls. TORS frame is a simple and cheap technique and should be considered as reduction support in the management of UTF by intramedullary nailing.

Minimally invasive percutaneous plate osteosynthesis for lateral malleolus fractures

Background Lateral malleolus fracture is one of the most common fractures that may occur as a part of ankle joint trauma. Open reduction and internal fixation is considered as the state of the art for displaced lateral malleolar fractures in order to obtain congruent ankle mortise. But in certain conditions, soft-tissue status together with patient comorbidities may impede this technique. Minimally invasive percutaneous plate osteosynthesis (MIPPO) for lateral malleolus may be a suitable solution for ankle fractures with soft-tissue problems. Patients and methods Through the period between May 2012 and May 2016 in Ain Shams University hospitals, a prospective study on 51 patients with displaced lateral malleolus fractures as a part of ankle trauma with bad soft-tissue condition has been managed through the MIPPO approach. All patients have been evaluated as regards the grade of soft-tissue injury, timing of surgery from trauma, duration of the procedure, time to union, postoperative ankle function, and reported superficial peroneal nerve injury. Open fractures, associated pilon fractures, and established Charcot neuropathic joints had been excluded from the study. Results The minimum follow-up for all the patients was 12 months and maximum was 25 months with a mean of 13.7 months postoperatively. Thirty patients (58.8%) were grade III according to Tscherne classification of closed soft-tissue injury. Mean time of surgery from trauma was 45.9 h (12 h to 6 days). The average procedure time was 56 min (20–80 min). The average time to union was within 7 weeks (5–10 weeks), all patients had good-to-excellent ankle function with a mean of 89.9 according to the American Orthopedic Foot and Ankle Score, and no superficial peroneal nerve injury was documented. Conclusion MIPPO for lateral malleolus is an effective and safe technique, provided that ankle mortise congruity is obtained.

Effects of Low-Level Diode Laser on the Level of Interleukin 1-Beta in the Gingival Crevicular Fluid and the Incidence of Gingivitis Caused by the Use of Orthodontic Separators: A Randomized Clinical Trial

Background: In recent years, there has been an increased tendency for using dental lasers for the treatment of soft tissue problems. The aim of this study was to evaluate the effect of low-level diode laser (980 nm) on the level of interleukin 1 beta (IL-1β) in the gingival crevicular fluid (GCF) and the incidence of initial gingivitis caused by the use of orthodontic separators. Methods: In this randomized clinical trial, 30 patients, who were beginning a fixed orthodontic treatment without gingivitis, were randomly assigned to control and diode laser radiation (980 nm wavelength, 3 J of energy, a density of 3 J/cm2 , a power of 0.2 W, and at a distance of 1 cm away from the tissue for 15 seconds on the buccal and palatal sides of the tooth) groups. The gingival index (GI) and bleeding on probing (BOP) were measured at the beginning of the study and one week after the treatment. The level of IL-1β was evaluated using an enzyme-linked immunosorbent assay at the beginning of the study and one week after the placement of the separator. Finally, the inter-group and intra-group statistical analyses were performed using independent and paired t tests, and P<0.05 was considered as the significance level. Results: The evaluation of clinical variables in the entire mouth showed a slight clinical improvement in the experimental group although there was no significant difference between the two groups. No significant difference was observed between intra-group and inter-group evaluations of clinical indices in the studied specific teeth. Eventually, no difference was found between the two groups in terms of IL-1β changes. Conclusions: In general, the single-diode laser radiation session is not effective in the treatment of gingivitis in patients undergoing orthodontic treatment. Thus, it is recommended to perform frequent laser radiation sessions in further studies.

To asses the union time and pin track infection rate in ilizarov fixator using the Russian and rancho hybrid fixation technique

Introduction: The treatment of complex proximal tibial fractures with ilizarov external fixators is slowly gaining more popularity and acceptability in traumatology, complex tibial plateau fractures pose a significant risk of soft tissue problems, edema and compartment syndrome, its management throws a great challenge. These fractures were treated with ilizarov external fixators. Materials and Methods: The prospective study was conducted in JSS Medical College and Hospital over a period of April 2016 to September 2017. A total of 30 patients who were treated with ilizarov ring external fixator for schatzkers type V and VI tibial plateau fractures were included in the study, each patients were randomly assigned to be treated with two methods, the Russian technique and the Rancho hybrid fixation technique, these patients were followed up and their data with regard to fracture union time and pin tract infections were collected in a Microsoft excel and the results were scrutinised. Results: There was a predominantly male population and the road traffic accidents was the most common followed by self-fall, The mean union time was 18.27+_1.79 weeks in the Russian technique and 23.47+_2.72 weeks in the rancho hybrid system the union time was assessed using the RUST criteria and The Rancho technique pin tract infection rate was 20% and it was 26.67% in the Russian technique, the incidence of pin tract infection was even though a little higher in the Russian technique the difference was not statistically significant (OR1.45(0.26-8.1)p0.5) the pin track infection was graded using the checkers and buns. Conclusion: the ilizarov Russian technique fares over the rancho hybrid fixation technique in achieving union earlier by enhancing the micromotion at the fracture site being a less rigid construct. Keywords: Ilizarov fixator, Russian technique, Rancho technique, Schatzkers type V and VI fractures, Union time, Pin tract infections.

The AO triangular external fixator: a backup option in the treatment of ankle fractures in geriatric patients?

PurposeTo analyze the indications, radiological short-term outcomes, and complications of ankle fractures in geriatric patients treated with a triangular external fixator (AEF) until fracture healing. Furthermore, the effect of an additional osteosynthesis to AEF on the radiological outcome was investigated.MethodsRetrospective analysis of ankle fractures treated in a Level I Trauma Center between 2005 and 2015 with an AEF in patients aged ≥ 65 years until fracture has healed. The combination of AEF and at least one additional osteosynthesis of a malleolus was defined as hybrid external fixator (HEF). At the time of AEF removal, a preserved ankle joint congruity was defined as good radiological outcome. Incongruity more than 2 mm was defined as poor radiologic results.Results16 patients (13 women, 3 men) with a mean age of 74 years (SD 6.2) were treated with AEF until fracture healing, 9 with a single AEF and 7 with a HEF. Stabilization with HEF (n = 7 [100%]) showed higher rates of good radiological outcome than AEF alone (n = 4 [44%] of 9; p = 0.034). The duration of therapy did not differ between HEF and AEF (70 day vs 77 days). 4 patients (22%) required surgical revision.ConclusionIt could be shown that osteosynthesis in addition to AEF leads to a better radiological short-term results than using AEF alone. Therefore, in the situation where an AEF is considered as the definitive treatment option for an ankle fracture in geriatric patients with expected or existing soft tissue problems, it should be done or completed as a HEF.Level of evidenceTherapeutic level IV.

Percutaneous bridge plating of extra-articular distal fibular fracture for the management of distal tibia type III open fracture

PurposeThe aim of this study is to conduct clinical and radiographic evaluations of the use of percutaneous bridge plating for distal fibular fractures combined with distal tibia type III open fractures. MethodsThirty-four patients with acute distal third fibular shaft fractures (4F2A(c) and 4F2B(c) according to the AO/OTA classification) combined with distal tibia type III open fractures were enrolled. Concurrent fibular fractures were fixed with the percutaneous bridge plating simultaneously, while distal tibia open fractures were temporally stabilized with a spanning external fixator. Clinical and radiographic outcomes were evaluated using the Lower Extremity Functional Scale (LEFS), the proportional length difference of the fibula, the talocrural angle, the union rate of the fibula and tibia, the operation time, and complications at the final follow-up. ResultsAll fibular fractures healed with an average bone healing time of 20.7 ± 6.3 weeks (range, 16–35). The mean proportional length difference was 0.492 ± 0.732% compared with that in the uninjured fibula. The functional assessment result according to the LEFS was 74.0 ± 3.70 points (range, 57–80). No cases of fibula fracture infection developed throughout the follow-up period in any of the patients. Iatrogenic postoperative superficial peroneal nerve injury was not found in any of the patients. ConclusionWith the perspective of minimizing soft tissue problems due to high-energy trauma, the application of percutaneous bridge plating for the treatment of distal fibular fractures can be an alternative to conventional treatment methods.

Extrasinus Zygomatic Implants for the Immediate Rehabilitation of the Atrophic Maxilla: 1-Year Postloading Results From a Multicenter Prospective Cohort Study

The use of zygomatic implants is an alternative to major grafting procedures for the treatment of the atrophic posterior maxilla. However, only few studies reported solid and correct data about the use of extrasinus zygomatic implants. Starting from these considerations, this study aims to investigate the 1-year survival and success rates of extrasinus zygomatic implants immediately loaded in patients with severe atrophy of the posterior maxilla. Twenty-three consecutive patients fully edentoulus or with failing dentition in the upper arch and with a severe atrophy of the posterior maxilla were enrolled. All patients underwent prosthodontic rehabilitation with the application of implants in both anterior maxilla areas and zygomatic bone. All the zygomatic implants were inserted with an extrasinus path. Primary outcomes were prosthesis and implant failures. Secondary outcomes were complications, bleeding scores, probing pocket depths, and peri-implant marginal bone-level changes. A total of 98 implants were inserted. During the 1-year follow-up, no implant failure was reported as well as no pain and/or no sinusitis were detected. No other significant events were reported, except for minor soft tissue and technical problems. A maxillary sinus membrane rupture occurred during the surgical phase in 4 (17.4%) patients, but healing was not compromised. Peri-implant mucositis was observed in 2 (8.7%) patients. Twelvemonths after surgery, average bone loss around conventional implants was 1.11±0.23mm. In addition, no peri-implant radiolucency was observed around zygomatic implants. Within the limits of this study, preliminary short-term data (1-year after loading) suggested that extrasinus zygomatic implants represent a predictable treatment option for the atrophic maxilla. Further follow-up data (≥5years) are needed to confirm these results. The present study supports the conclusion that extrasinus zygomatic implants for the immediate rehabilitation of the atrophic maxilla have high success rate with minimal or no complications.

Experience of Snakebite Envenomation by a Desert Viper in Qatar.

Crotaline and elapid snakebites are reported all over the world as well as in the Middle East and other countries around this region. However, data regarding snakebites and their treatment in Qatar are limited. This review paper is going to investigate the presentation and treatment of snakebite in Qatar. A good assessment helps to decide on the management of the snakebites envenomation. Antivenom and conservative management are the mainstays of treatment for crotaline snakebite. Point-of-care ultrasound (POCUS) has been suggested to do early diagnosis and treatment of soft tissue problems, such as edema and compartment syndrome, after a snakebite. The supporting data are not sufficient regarding the efficiency of POCUS in diagnosing the extent and severity of tissue involvement and its ultimate effect on the outcome. Further research is suggested in this case. Systemic complications, such as bleeding diathesis, can be managed by administering clotting factors and platelets.

Clinical radiological & functional outcome of Tibial Bi-Condylar fractures treated surgically

Objectives: With the advancement in surgical, approaches, technique and newer fixation devices the treatment outcome of bicondylar proximal tibial fractures have improved. Therefore it is paramount to identify the appropriate treatment techniques for better functional outcomes in terms of better stability and early weight bearing without pain. Hence this study was carried out to study the functional outcomes of Intra-articular bicondylar tibial fractures, treated with operative management using contoured locking plate over both the condyles. Material and Methods: This study was carried out as a prospective study. Fifty (50 fractures) patients with acute, displaced Intra-Articular bicondylar tibial aged above 18 years, were enrolled in the study. Open fractures and fractures older than two weeks were excluded. The functional outcome was assessed every 4 weeks. Assessment included OA change, limitation of ROM, or malalignment. Results: Of the 50 patients, all were males. 35 patients had left sided fractures, while 15 had right sided fractures. Post operatively all 50 patients had swelling, 20 patients had persisting pain, 5 had superficial infections and 2 had deep infection. Superficial infections healed with antibiotics and dressings, while the patient with deep infection had persistent pain and difficulty in walking with discharge from surgical wound site. Both of them underwent implant removal and debridement after a year. Of the 50, 32 had OA changes, 14 had fair limited ROM and 4 had malalignment. Hence we conclude from the above findings that dual plate fixation helps in improving the functional outcome of the patients in view of their physical and radiological findings. Soft tissue problems should be kept in mind, and usage of locking plate can reduce the discomfort of hardware impingement effectively. Conclusion: A relatively better functional outcome was observed in displaced and comminuted fractures in dual plating, provided that the intra-articular congruity was restored. The technique of dual plate fixation is good with regards to fracture union and functional outcome.

Arthroscopic Treatment of Posttraumatic Elbow Stiffness Due to Soft Tissue Problems.

ObjectivesTo evaluate the effectiveness of arthroscopic management of posttraumatic elbow stiffness due to soft tissue problems.MethodsA retrospective review of 30 consecutive arthroscopic elbow releases for posttraumatic stiff elbow from November 2011 to December 2019 was conducted. Stiff elbows with bony problems, such as heterotopic ossification, intraarticular nonunion or malunion, and cartilage lesions were excluded from this study. Contracture and adhesion of soft tissue around the elbow were identified. Surgical treatments included arthroscopic capsulectomy, ligaments and muscle release, and ulnar nerve release. The results were evaluated using the Mayo elbow performance score (MEPS) and range of motion of the elbow. Surgery‐related complications were assessed.ResultsPatients who underwent arthroscopic release were followed up for between 6 and 35 months, with a mean follow‐up time of 10.1 months. The postoperative elbow ROM was 123.2° ± 19°, which was significantly different compared to the preoperative value of 68° ± 32°. In addition, the MEPS score improved from 71.2 ± 10.3 preoperatively to 93.7 ± 6.6 at the final follow‐up, a mean improvement of 22.5 (range, 0–55; P < 0.05). Postoperative complications included five cases of prolonged drainage from the portal site, three transient nerve palsies, and one hematoma in the medial elbow.ConclusionWith full recognition by the surgeon of the pathologic changes of the soft tissue around the elbow, arthroscopic release is usually safe and effective for posttraumatic elbow stiffness without symptomatic bony problems.

Long-term Effect of Cranioplasty on Overlying Scalp Atrophy.

Background:Scalp thinning over a cranioplasty can lead to complex wound problems, such as extrusion and infection. However, the details of this process remain unknown. The aim of this study was to describe long-term soft-tissue changes over various cranioplasty materials and to examine risk factors associated with accelerated scalp thinning.Methods:A retrospective review of patients treated with isolated cranioplasty between 2003 and 2015 was conducted. To limit confounders, patients with additional scalp reconstruction or who had a radiologic follow-up for less than 1 year were excluded. Computed tomography or magnetic resonance imaging was used to measure scalp thickness in identical locations and on the mirror image side of the scalp at different time points.Results:One hundred one patients treated with autogenous bone (N = 38), polymethylmethacrylate (N = 33), and titanium mesh (N = 30) were identified. Mean skull defect size was 104.6 ± 43.8 cm2. Mean length of follow-up was 5.6 ± 2.6 years. Significant thinning of the scalp occurred over all materials (P < 0.05). This was most notable over the first 2 years after reconstruction. Risk factors included the use of titanium mesh (P < 0.05), use of radiation (P < 0.05), reconstruction in temporal location (P < 0.05), and use of a T-shaped or “question mark” incision (P < 0.05).Conclusions:Thinning of the native scalp occurred over both autogenous and alloplastic materials. This process was more severe and more progressive when titanium mesh was used. In our group of patients without preexisting soft-tissue problems, native scalp atrophy rarely led to implant exposure. Other risk factors for scalp atrophy included radiation, temporal location, and type of surgical exposure.

The S2-Alar-Iliac Screw for Pelvic Trauma.

Percutaneous sacro-iliac screw osteosynthesis is considered to be standard of care for most posterior pelvic ring fractures. However, special situations require alternative strategies for sufficient stabilization. In these cases, stabilization can often be achieved using posterior instrumentation e.g. using SIPS-screws (spina-iliaca-posterior-superior screws). However, this often leads to implant-related aggravation of the sometimes already critical soft tissue conditions after pelvic trauma. S2-Ala-Ilium screws (S2AI screws) are a suitable alternative. The starting point lies medial of the posterior superior iliac spine below the iliac level. It is almost in line with a potential spinal instrumentation and therefore usually causes fewer soft tissue problems. Although this technique has been widely used in spinal surgery in recent years, its use in orthopaedic traumatology is largely unknown. The possibilities but also the limitations of this technique for the treatment of injuries to the pelvis are illustrated by this retrospective case series.

Low-profile double plating versus dorsal LCP in stabilization of the olecranon fractures

IntroductionProximal ulna fractures are common in orthopaedic surgery. Comminuted fractures require a high primary stability by the osteosynthesis, to allow an early functional rehabilitation as fast as possible, to reduce long-term limitations of range of motion. Classical dorsal plating is related to wound healing problems due to the prominence of the implant. New low-profile double plates are available addressing the soft tissue problems by positioning the plates at the medial and lateral side. This study analysed whether, under high loading conditions, these new double plates provide an equivalent stability as compared to the rigid olecranon locking compression plate (LCP).Materials and methodsIn Sawbones, Mayo Type IIB fractures were simulated and stabilized by plate osteosyntheses: In group one, two low-profile plates were placed. In group two, a single dorsal plate (LCP) was used. The bones was than cyclically loaded simulating flexion grades of 0°, 30°, 60° and 90° of the elbow joint with increasing tension forces (150 , 150 , 300 and 500 N). The displacement and fracture gap movement were recorded. In the end, in load-to-failure tests, load at failure and mode of failure were determined.ResultsNo significant differences were found for the displacement and fracture gap widening during cyclic loading. Under maximum loading, the double plates revealed a comparable load at failure like the single dorsal plate (LCP). The double plates failed with a proximal screw pull-out of the plate, whereas in the LCP group, in 10 out of 12 specimens the mode of failure was a diaphyseal shaft fracture at the distal plate peak.ConclusionBiomechanically, the double plates are a good alternative to the dorsal LCP providing a high stability under high loading conditions and, at the same, time reducing the soft tissue irritation by a lateral plate position.

Correction of the soft tissue problem using triamcinolone injection after rhinoplasty

Correction of the soft tissue problem using triamcinolone injection after rhinoplasty

Extendable Endoprostheses in Skeletally Immature Patients: A Study of 124 Children Surviving More Than 10 Years After Resection of Bone Sarcomas.

Extendable endoprostheses are used to reconstruct segmental defects following resection of bone sarcomas in skeletally immature patients. However, there remains a paucity of studies with regard to long-term outcomes. We retrospectively reviewed 124 skeletally immature children who underwent an extendable endoprosthetic replacement and survived more than 10 years after the surgical procedures. Anatomical sites included the distal part of the femur (n = 66), the proximal part of the femur (n = 13), the proximal part of the tibia (n = 29), and the proximal part of the humerus (n = 16). Complications and implant survival were classified according to the modified Henderson criteria. The mean follow-up was 24 years (range, 10 to 36 years). The mean age at the time of the extendable endoprosthetic replacement was 9 years (range, 2 to 16 years). All patients had reached skeletal maturity at the last follow-up. The 10-year endoprosthetic failure-free survival rate was 28%. A total of 243 complications occurred in 90% of patients; these complications were most frequently related to soft-tissue problems (27% of complications). The incidence of and cumulative survival with respect to each failure mode varied between anatomical sites. Soft-tissue failures occurred most frequently in the proximal part of the femur (77%; p = 0.003), and the distal part of the femur was the most frequent site of aseptic loosening (52%; p = 0.014) and structural failure (55%; p = 0.001). Excluding lengthening procedures, 105 patients (85%) underwent an additional surgical procedure, with a mean of 2.7 surgical procedures per patient (range, 0 to 7 surgical procedures per patient). The mean limb-length discrepancy at the final follow-up was 1 cm (range, 0 to 9 cm). Limb salvage was achieved in 113 patients (91%). The mean Musculoskeletal Tumor Society functional score (the percentage of a total score of 30 points) was 82% (range, 40% to 100%) in 115 patients with available data at the last follow-up. Extendable endoprostheses are associated with a high complication rate and a need for additional surgical procedures over time. Despite this, successful limb salvage with reasonable function and small limb-length discrepancy is achievable in the long term. Our study provides benchmark data for individual anatomical sites for further improvements of outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Limb reconstruction system (LRS) in infected non union of femur: A case series

Objective: To evaluate the clinical and functional outcomes of limb reconstruction system (LRS) in infected non union of femur.Background: LRS is an effective alternative in treating the failed osteosynthesis in long bone fractures, due to infection, loosening of implant, non union, poor bone quality and bone loss associated with deformities, limb length discrepancy, soft tissue problems, and functional issues.Methods: We did a prospective study of 30 cases of infected non union of femur (10 plating, 19 nailing & 1 k-wire with plaster) between April 2014 to November 2018 treated with LRS. Initially we managed by implant removal, freshening of fracture site or radical debridement followed by LRS application. In 13 cases corticotomy & lengthening was performed. Monofocal lengthening was done in 5 cases. Bifocal corticotomy done in 8 cases. Average duration of frame was 14 months (8-18 months).Results: Bone united in 24 cases (80%), Number of cases underwent lengthening -14. Average lengthening achieved-5 cm (2-11 cm). We had 86% excellent and 10 % poor bony result. Functional result was excellent in 40%, good in 50% and failure in 10% cases according to ASAMI scoring system.Conclusions: LRS is found to be effective in managing infected non union in long bones because of its simplicity, short learning curve, ease of use with better patient compliance and is an alternative to Ilizarov.

Interphanlangeal and First Metatarsophalangeal Joint Fusion for Osteomyelitis and Septic Arthritis in Patients with Forefoot Diabetic Foot Ulcers

Category:Diabetes, infectionIntroduction/Purpose:In cases of Diabetic Foot ulcers over joints with assocuated septic arthritis or osteomylitis, the erradication of the infection can be difficult to achieve. In order to avoid amputations which are often associated with reduced quality of life, we try to be as conservative as possible in order to save as many big toes as possible.The backbone of our noval treatment protocol involve performing a thorough soft tissue and bony debridement, stabilizing the infected bones or joint by fusing them in the acute phase, and closing the skin over the infected ulcer.We present our experience of this concept.Methods:Retrospective study between the years 2012-2016, in a single centre, treating diabetic foot patients.29 patients, 31 feet, were identified with IPj or 1st MTPJ fusion for Infection. All patients had a combination of bone and soft tissue infections. All patients had a preoperative radiograph, 22patients had a pre-operative MRI scan to define the extent of the bony and soft-tissue infection.In all cases the involved joint was fused in the acute phase using screws, kw’s, plates, combination of the above fusion techniques. In all cases the skin was closed above the infected ulcer.Results:Closed ulcers of the fitst ray after fusing the infected joint were achieved in 26 patients (84%) by 12 months after surgery. The radiographic fusion rate was 55% by one year after surgery while 77% of the cases were clinically stable by 1 year after surgery. 5 patients (16%) endend up with an amputation. In 4 of them the base of the proximal phalangx could be left to ensure the biomechanical properties as good as possible. 1 patient needed a BKA.In 26 patients, pathogens could be identified; in 77%, polymicrobial flora were found.Conclusion:Arthrodesis of IPJ- or 1st MTPJ in diabetic foot patients presents a successful way of treatmentin order to achieve a stable situation which allow healing of bony and soft-tissue problems.Fusing an infected joint is a safe procedure that allows maintaining functional capabilities.

Retrospective analysis of 514 cases of tibial plateau fractures based on morphology and injury mechanism

BackgroundTibial plateau fractures remain a clinical challenge due to the complexity of the fracture patterns which have been repeatedly categorized by many researchers. However, limitations do exist in some respects. So we aimed to reclassify tibial plateau fractures based on injury mechanism and morphological characteristics.MethodsFive hundred fourteen cases of tibial plateau fractures were enrolled. The X-rays and CT scans were analyzed.ResultsAccording to our observation and analysis, tibial plateau fractures can be categorized into the following six types: (1) Lateral condylar fractures (axial force applied while knee extending in valgus position). Two hundred fifty-one cases were included (48.83%). (2) Fracture dislocation (multiple forces especially rotational stress while knee extending). Fifty-five out of 514 cases belong to this pattern (10.70%). Correction of the subluxation remains primary and crucial during surgical procedures. (3) Simple medial condylar fractures (axial force applied while knee extending in varus position). One third of which were associated with an avulsion fracture of fibular head. Fifteen cases were included (2.92%). (4) Bicondylar fractures (axial forces applied while knee extending). One hundred twelve cases were included (21.79%). Surgical algorithm greatly depends on soft tissue conditions. (5) Posterior condylar fractures (axial stress applied while knee flexing). Sixty-five cases were seen in our study (12.65%), most of which were associated with an avulsion fracture of the intercondylar eminence (49/65, 75.38%). The fracture of posteromedial part, posterolateral part, and intercondylar eminence forms a unique pattern of injury defined as “Posterior Condylar Triad.” (6) Anterior condylar compression fractures (axial, varus, or valgus forces applied while knee overextending). Posterior structural complexes, crucial ligaments, or even popliteal arteries are prone to be damaged. Sixteen cases were identified (3.11%).ConclusionOur classification system has instructive significance in overall preoperative evaluation of fracture features and soft tissue problems as well as guiding clinical management for better functional outcomes.

Therapeutic effect of laser on pediatric oral soft tissue problems: a systematic literature review.

In recent years, extensive evidence has been published about usage of laser in oral lesions. The aim of the present study was to review the effectiveness of laser radiation in the treatment of pediatric oral soft tissue problems. The relevant keywords were searched in EBSCO, Medline (via Ovid), PubMed, Scopus, and Web of Science (WOS) databases. Then, eligible case series and controlled clinical trial studies, which published up to the end of 2018, were extracted and scrutinized. In this study, the age range of ≤ 21years or the average age of ≤ 21years was considered as the pediatric group. After limiting the search results, removing duplicate titles and eligibility evaluation, 17 papers were enrolled to the study (seven controlled clinical trials and ten case series). Er:YAG (2940nm), CO2 (10,600nm), Er,Cr:YSGG (2780nm), and diode (650, 660, and 975nm) lasers indicated successful clinical results on mucocele excision, frenectomy, gingival incision and re-contouring, and treatment of vascular malformations. In addition, 660-nm diode laser radiation was an effective adjuvant treatment for halitosis and gingivitis induced by multi-bracket appliances. Reduction or absence of pain and bleeding, suitable homeostasis, reduction of operation time, less analgesic consumption, and antibacterial effect were among the advantages of the laser radiation in the studies. Laser as a main or adjuvant tool can have an effective role in surgical and non-surgical treatments of pediatric oral soft tissue problems. Conducting further randomized controlled trial studies on different soft tissue lesions can contribute to drawing better conclusions.

Arch-shaped approach : New modified medial approach for the treatment of talus fractures

Anatomical reduction and fixation of complex talar fractures (Hawkins typeIII andIV, Marti typeIII andIV) using amedial approach. Displaced talar fractures (Hawkins typeIII andIV, Marti typeIII andIV) with the need for amedial malleolar osteotomy or the simultaneous treatment of amedial malleolus fracture. High perioperative risk, severe soft tissue injuries in the medial approach area, infected soft tissues. Medial arch-shaped approach about 12 cm in length over the medial malleolus using asimultaneous medial malleolus fracture or via an additional medial malleolar osteotomy. Dissection and retraction of the terminal branches of the saphenous vein and the saphenous nerve. Protection of the blood supply in the area of the medial talus and in the sinus tarsi. Reduction of the talar joint surfaces and reconstruction of the anatomical axes according to the preoperative planning by means of native radiological and computed tomographic imaging. Osteosynthesis adapted to the fracture type using Kirschner wires, conventional screws, cannulated screws, double-threaded screws, resorbable pins, magnesium screws, small fragment plates. Lower leg splint or orthesis for 6weeks, partial weight-bearing with 20 kg for 10-12weeks. Early range of motion exercise of the ankle, subtalar and mid-tarsal joints. In the past 5years, 11patients with either Hawkins typeIII andIV or Marti typeIII andIV fractures were treated operatively using the arch-shaped approach. No soft tissue problems were seen related to the arch-shaped approach. Of the 7patients who could be followed up after an average of 2years, the mean American Orthopedic Foot and Ankle Score was73. Avascular necrosis occurred in 3cases (43%). These were partial necroses of less than one third of the talar body with asymptomatic course at the time of examination. In 4patients (57%) radiographic signs of osteoarthritis occurred within 2years, whereby in two of those cases (29%) an arthrodesis of the upper ankle was performed.