Sustentaculum fracture fixation with lateral plate or medial screw fixation are equivalent.

BACKGROUND: Fixation of sustentaculum tali fractures is important to maintain the biomechanical function of the subtalar joint. A common method of fixation is securing the sustentacular fragment by way of a laterally based locking plate (LP). A medial approach with a single screw (MS) has been proposed as an alternative method of fixation. METHODS: Five pairs of formalin-preserved cadaveric ankles with the subtalar joint and interosseous ligaments intact ("osseous cadavers") and four pairs of fresh-frozen cadaveric ankles with soft-tissue preserved dissected from mid-tibia down ("soft tissue cadavers") were used in the study. The left ankle was randomly assigned to one of the two fixation methods (LP or MS), while the right ankle was the opposite. These same steps for fixation were repeated for six synthetic ankle models. All models were loaded with a body mass of 80 kg. Statistical differences between LP and MS stiffness were determined using a paired t-test in cadavers and un-paired t-tests in synthetic ankles. RESULTS: For osseous cadaveric ankles, LP demonstrated a mean stiffness of 232.95(SD: 59.96) N/mm, while MS was 239.72(SD:131.09) N/mm (p = 0.9293). For soft tissue cadaveric ankles, LP mean stiffness was 133.58(SD:37.84) N/mm, while MS was 134.88(SD:20.75) N/mm (p = 0.9578). For synthetic ankles, LP mean stiffness was 220.40(SD:81.93) N/mm, while MS was 261.50(SD:100.21) N/mm (p = 0.6116). CONCLUSIONS: Across all three models, there was no significant difference between LP and MS methods. Retrospective observational studies are recommended to assess patient outcomes from each of the methods.

Incidence, risk factors, and prognosis of sciatic nerve injury in acetabular fractures: a retrospective cross-sectional study.

PURPOSE: This study aimed to investigate the incidence, risk factors of the sciatic nerve injury in patients with acetabulum fractures and assess its prognosis. METHODS: A retrospective cross-sectional review was conducted on 273 patients with acetabulum fractures who were treated between January 1st, 2017, and December 30th, 2019. The medical records and radiographs of these patients were analyzed. RESULTS: The overall nerve injury rate was 7.7% (21 of 273 cases), with 3.1% (8 of 273 cases) occurring because of the initial injury and 12.8% (13 of 101 cases) as post-operative complications. Among those with nerve injuries, 95.2% (20 of 21 cases) were males and the average age of the patients was 31.5 (SD 9.5) years. The most common mechanism of injury was motor vehicle collisions with 55.7% (152 of 273 cases), and the most common fracture pattern associated with nerve injury was posterior column and posterior wall fracture with 31.6% (6 of 21 cases). Hip dislocation was found in 16.5% (14 of 21 cases) of patients with nerve injury. The Kocher Langenbeck approach was the most common approach used for patients with post-operative nerve injury, and the prone position was significantly associated with sciatic nerve injury during the operation. Of all patients with nerve injury, 52% (11 of 21 cases) had fully recovered, 29% (6 of 21 cases) had partially recovered, and 19% (4 of 21 cases) had no improvement. The average follow-up was 15 months. CONCLUSION: This study emphasizes the incidence of sciatic nerve injuries in individuals with acetabulum fractures and highlights key risk factors, including hip dislocation, posterior column, and posterior wall fractures. It is noteworthy that the Kocher Langenbeck approach and the prone position may contribute to iatrogenic nerve injuries. Encouragingly, over half of the patients who suffered nerve injuries achieved full recovery, while nearly one-third experienced partial recovery. These findings underscore the vital significance of recognizing and addressing these risk factors in clinical practice.

The surgical outcomes of fixing ipsilateral femoral neck and shaft fractures: single versus double implants fixation.

BACKGROUND: Combined ipsilateral femoral neck and shaft fractures are rare and present a challenging management dilemma. This study aims to assess the outcome of concomitant fixation of the ipsilateral femoral neck and shaft fracture using single versus dual surgical implants. METHODS: A single-center retrospective analysis of patients who underwent fixation of ipsilateral femoral neck and shaft fractures was performed over a 13-year period. Different techniques were employed to fix the complex injury. Both the reduction and the union time were assessed radiographically. RESULTS: A total of 36 patients with ipsilateral femoral neck and shaft fractures were retrospectively identified and included in the study. Twenty-four patients (66.6%) were managed with a single cephalomedullary nail, while the remaining cases were treated with two devices. All cases were operated on within an average of 3.7 ± 7.1 days. Eight patients (22.2%) developed postoperative complications. The average follow-up period was 7.3 ± 6.8 months. Although there was no statistically significant difference between the two groups, the femoral neck fractures showed shorter union time in patients treated with one implant compared to patients treated with two implants (3.0 ± 2.3 months vs. 4.2 ± 2.6 months). Another observation was that higher percentages of implant removal/failure and malunion/nonunion were seen in patients who had one implant compared to the two implants group (12.5% vs. 8.3%). CONCLUSION: Early surgical fixation of both fractures is associated with good outcome results. No difference in outcome was observed between both groups.

Lateral epicondylitis of the elbow: an up-to-date review of management.

Lateral epicondylitis, also known as tennis elbow, is an overuse tendinopathy of the common extensor origin of the elbow in patients involved in repetitive movement of the wrist and forearm. Lateral epicondylitis is a self-limiting condition, with operative management only recommended in severe, recalcitrant cases. This article reviews the recent updates on operative and non-operative management of lateral epicondylitis.

Management of displaced intra-articular calcaneal fractures; current concept review and treatment algorithm.

Calcaneum fractures are debilitating injuries with high complication rates and poor functional outcomes after both operative and non-operative management. The optimal management of such fractures is still highly debated in the literature with conflicting evidence on the preferred management of displaced intra-articular calcaneum fractures (DICAF). This article reviews the current concepts in the management of DIACF.

The role of cerclage wiring in the management of subtrochanteric and reverse oblique intertrochanteric fractures: a meta-analysis of comparative studies.

PURPOSE: Subtrochanteric and reverse oblique intertrochanteric fractures are challenging and often difficult to reduce. While intramedullary nailing (IMN) is considered the standard treatment, achieving anatomic reduction prior to fixation is essential. This study aimed to assess the impact of cerclage wiring with IMN on the outcomes and complication rate in treating subtrochanteric and reverse oblique intertrochanteric fractures. METHODS: This meta-analysis was conducted in line with PRISMA guidelines. The primary outcome was the time to union. The secondary outcomes were operative time, blood loss, quality of reduction, reduction alignment (if in varus), complications and reoperations. PubMed, Cochrane, Web of Science and Google Scholar were searched till July 2021. Articles that compared intramedullary nailing (IMN) versus intramedullary nailing and cerclage wiring (IMN-C) in the treatment of subtrochanteric and reverse oblique intertrochanteric fractures were included. The risk of bias was assessed using the Newcastle-Ottawa scale. RESULTS: This meta-analysis included 415 patients with subtrochanteric and reverse oblique intertrochanteric fracture from six comparative studies. Our findings showed that IMN-C was significantly associated with higher mean duration of surgery and blood loss. However, IMN-C had significantly lower mean time to union compared to IMN alone. In addition, IMN-C had lower pooled prevalence of varus reduction and overall complications. CONCLUSION: This study showed that the use of cerclage wiring is associated with lower time to union, lower prevalence of varus reduction and overall complications. Therefore, cerclage wiring augmentation is a safe technique with low complication rate and may be advised whenever open reduction is needed in the management of subtrochanteric and reverse oblique intertrochanteric fractures.

Trends and Reported Complications in Ankle Arthroplasty and Ankle Arthrodesis in the State of New York, 2009-2018.

Background: Ankle arthroplasty has emerged as a viable alternative to ankle arthrodesis due in large part to recent advancements in both surgical technique and implant design. This study seeks to document trends of arthroplasty and arthrodesis for ankle osteoarthritis in New York State from 2009-2018 in order to determine if patient demographics play a role in procedure selection and to ascertain the utilization of each procedure and rates of complications. Methods: Patients 40 years and older from 2009-2018 were identified using International Classification of Diseases, Ninth and Tenth Revisions (ICD-9 and ICD-10), Clinical Modification (CM) diagnosis and procedure codes for ankle osteoarthritis, ankle arthrodesis, and ankle arthroplasty in the New York statewide planning and research cooperative system database. A trend analysis for both inpatient and outpatient procedures was performed to evaluate the changing trends in utilization of ankle arthrodesis and ankle arthroplasty over time. A multivariable logistic regression was used to assess the odds of receiving ankle arthrodesis relative to ankle arthroplasty. Complications were compared between inpatient ankle arthrodesis and arthroplasty using multivariable Cox proportional hazards regression. Results: A total of 3735 cases were included. Ankle arthrodesis increased by 25%, whereas arthroplasty increased by 757%. African American race, federal insurance, workers compensation, presence of comorbidities, and higher social deprivation were associated with increased odds of having an ankle arthrodesis vs an ankle arthroplasty. Compared with ankle arthroplasty, ankle arthrodesis was associated with increased rates of readmission, surgical site infection, acute renal failure, cellulitis, urinary tract infection, and deep vein thrombosis. Conclusion: Ankle arthroplasty volume has grown substantially without a decrease in ankle arthrodesis volume, suggesting that ankle arthroplasty may be selectively used for a different population of patients than ankle arthrodesis patients. Despite the increased growth of ankle arthroplasty, certain patient demographics including patients from minority populations, federal insurance, and from areas of high social deprivation have higher odds of receiving arthrodesis. Level of Evidence: Level III, retrospective cohort.

Tranexamic Acid Utilization in Foot and Ankle Surgery: A Meta-analysis.

BACKGROUND: Tranexamic acid (TXA) has been widely used in various orthopaedic subspecialities to decrease blood loss, transfusions, and wound complications. However, the role of TXA in foot and ankle surgery is not clearly delineated. This meta-analysis aims to report the efficacy and safety of TXA in relation to foot and ankle surgical procedures. METHODS: Database searches were conducted for eligible studies from data inception through January 2022. Clinical studies on the use of TXA in foot and ankle procedures reporting the desired outcomes were included. Outcomes were estimated blood loss, change in hemoglobin, and overall complications. Risk of bias was assessed using the Newcastle-Ottawa quality assessment scale and the Joanna Briggs Institute (JBI) critical appraisal tool. RESULTS: Nine studies met the inclusion criteria. A total of 752 foot and ankle procedures were included, in which 511 (67.95%) procedures received TXA whereas 241 (32.05%) served as controls and did not receive TXA. The pooled data of change in hemoglobin and overall complications showed no difference between the TXA and control group. Estimated blood loss was significantly lower in the patients who received TXA. CONCLUSION: In conclusion, TXA use was associated with lower estimated blood loss in foot and ankle surgeries without increased risk of thromboembolic events, wound complications, or changes in hemoglobin. LEVEL OF EVIDENCE: Level IV, meta-analysis.

Three-Dimensional Computed Tomography Reconstructions Do Not Improve the Interobserver Reliability of the AO/Orthopaedic Trauma Association and Young and Burgess Pelvic Fracture Classifications.

Purpose: To evaluate the value of three-dimensional (3D) computed tomography (CT) scans on the interobserver and intraobserver reliability of AO/Orthopaedic Trauma Association (OTA) and Young and Burgess (YB) classifications for pelvic ring injuries. Methods: Seven reviewers (four fellowship-trained orthopaedic trauma surgeons and three fellows) independently classified 36 pelvic ring injuries using radiographs and axial two-dimensional (2D) CT scan images and then repeated this process 2 months later with the addition of 3D CT images. Interobserver and intraobserver reliability was assessed. Results: The interobserver reliability of the AO/OTA classification using 2D vs. 3D CT scans was considered fair (k 0.23, CI 0.17-0.29) vs. slight (k 0.16, CI 0.09-0.22), with no observed difference [mean difference (MD) - 0.07, CI 0.16-0.01]. The interobserver reliability of the YB classification using 2D vs. 3D CT scans was considered fair for both (k 0.37, CI 0.32-0.42, vs. 0.37, CI 0.30-0.45), with no observed difference (MD - 0.0005, CI - 0.08 to 0.08). The intraobserver reliability of the AO/OTA vs. YB classifications was considered fair (k 0.35, CI 0.26-0.44) vs. moderate (k 0.49, CI 0.40-0.57), with the YB classification having higher kappa value (MD 0.13, CI 0.01-0.26, p = 0.03). Conclusion: The addition of 3D CT scan reconstructions to radiographs and 2D CT did not improve the interobserver reliability of AO/OTA and YB classifications for pelvic ring injuries.

Return to Play After Isolated Syndesmotic Ligamentous Injury in Athletes: A Systematic Review and Meta-analysis.

Background: Syndesmotic ankle sprains are common and challenging injuries for athletes. The management of such injuries is controversial, with a paucity of evidence on treatment protocols with unpredictability regarding the time lost to participate in sports following injury. The present study seeks to review and report the return to play (RTP) time and examine the outcomes and complications of ankle syndesmotic sprains in the athletic population. Methods: PubMed, Cochrane Library, and Google Scholar were queried in August 2021 for case series, cohorts, and randomized controlled trials that evaluated return to play time after ankle syndesmotic sprains. The primary outcomes were the rate and time to return to play after syndesmotic ankle sprains for both surgical and nonsurgical treatment. Secondary outcomes included short-term complications and recurrence. Results: Eighteen articles were eligible for meta-analysis with a total of 1133 syndesmotic sprains. The overall RTP was 99% (95% CI 0.96, 1.00), the overall mean RTP was 52.32 days (95% CI 39.01, 65.63). Pooled RTP for surgically treated patients was 70.94 days (95% CI 47.04, 94.85), whereas it was 39.33 days (95% CI 28.78, 49.88) for nonsurgically treated cases. A low incidence of recurrence and complications were reported. Conclusion: This article reports a high rate of RTP after syndesmotic sprains. Grade of injury and surgical vs conservative management can affect the time to RTP in high-level athletes.Level of Evidence: Level IV, systematic review and meta-analysis.

Traumatic Fibular Loss Managed with a Free Vascularized Fibular Graft: A Case Report.

CASE: A 25-year-old man involved in a jet skiing accident experienced a traumatic excision of his distal fibula in conjunction with other lower extremity injuries. He subsequently underwent a reconstruction of his lateral malleolus using an ipsilateral free vascularized fibular graft (FVFG) from his proximal fibular shaft, resulting in a preserved and stabilized ankle joint at 1 year. CONCLUSION: Traumatic distal fibular excision is a rare injury that can be successfully managed using an FVFG, with fusion of the distal syndesmosis and a symmetric ankle mortise observed at the 1-year follow-up.

Synovial fluid calprotectin in diagnosing periprosthetic joint infection: A meta-analysis.

PURPOSE: Periprosthetic joint infection (PJI) is one of the most debilitating complications following joint replacement surgery. Synovial biomarkers, such as Calprotectin, have become valuable in the diagnosis of PJI. This meta-analysis aimed to investigate the role of synovial Calprotectin as a diagnostic test in PJI. METHODS: This meta-analysis was conducted with adherence to PRISMA guidelines. PubMed, Cochrane, Web of Science, and Google Scholar were searched until February 2022. Inclusion criteria were as follows: all studies in which the patients with joint replacements were evaluated for PJI; synovial Calprotectin was the biomarker of choice to diagnose PJI; standardized guidelines were used as the gold standard for the diagnosis; and a comparison between the guidelines and Calprotectin results was made. Diagnostic parameters such as sensitivity, specificity, diagnostic odds ratio (DOR), positive predictive value, negative predictive value, and area under the curve (AUC) were calculated for the included studies to evaluate synovial Calprotectin for PJI diagnosis. RESULTS: The total number of the included patients was 618 from eight studies. The pooled sensitivity, specificity, and diagnostic odds ratio of Calprotectin test were 92% (95%CI: 84%-98%), 93% (95%CI: 84%-99%), and 187.61 (95%CI: 20.21-1741.18), respectively. The results showed that the negative and positive likelihood ratios of the Calprotectin test were 0.07 (95%CI: 0.02-0.22) and 9.91 (95%CI: 4.11-23.93), respectively. The SROC showed that the area under the curve for Calprotectin test was 0.935. CONCLUSION: Synovial Calprotectin is a valuable biomarker as it provides a reliable and rapid diagnosis of PJI. It has the potential to be used in clinical practice due to its high sensitivity and specificity that are comparable to the other utilized biomarkers. Another advantage is its low cost relative to other biomarkers.

The Reliability of Postoperative Radiographic Matta Grading for Quality of Reduction of Acetabular Fractures.

OBJECTIVES: To assess the reliability of the postoperative radiographic Matta grading for quality of reduction of acetabular fractures. DESIGN: An inter-reliability and intrareliability study. SETTING: Level I trauma center. PARTICIPANTS: 15 independent observers of different levels of experience who evaluated 115 sets of postoperative acetabulum radiographs in 35 consecutive patients with displaced acetabular fractures between January 2017 and January 2019. MAIN OUTCOME MEASUREMENTS: To assess the interobserver and intraobserver reliability of Matta radiographic grading for postoperative quality of reduction of acetabular fractures. RESULTS: The overall interobserver agreement was excellent among all groups with an average absolute intraclass correlation coefficient (ICC) of 0.91 (95% CI 0.93-0.97). When stratifying the agreement based on experience, the orthopaedic trauma fellow subgroup had the highest rate with an ICC of 0.92. The overall intraobserver agreement was good with an ICC of 0.81 (95% CI 0.74-0.85). CONCLUSION: The Matta radiographic grading was a reliable tool for the evaluation of quality of reduction after surgical fixation of acetabular fractures with excellent interobserver and good intraobserver reliabilities among different levels of observers.

Open reduction and tunneled suspensory fixation for lateral end of clavicle fractures: surgical technique.

Unstable distal end clavicle fractures are associated with significant rates of nonunion and poor functional outcomes. Surgical treatment is paramount for unstable fracture patterns; however, treatment options are various, with each having its advantages and drawbacks. Recently, suture-based coracoclavicular fixation techniques using suture buttons have been implemented with high union rates, satisfactory shoulder function, and low rates of complications. In this report, we demonstrate a modified fixation of unstable lateral clavicle fractures. Our technique entails open reduction and suspensory coracoclavicular fixation using suture anchors and suture button devices with supplemental acromioclavicular suspensory fixation.

Mobile-bearing versus fixed-bearing total knee arthroplasty: a meta-analysis of randomized controlled trials.

OBJECTIVE: The purpose of this study was to perform a meta-analysis comparing mobile-bearing with fixed-bearing total knee arthroplasty (TKA) in terms of all-cause revision rates, aspetic loosening, knee functional scores, range of motion and radiographic lucent lines and osteolysis. METHODS: PubMed, Cochrane Library, Google Scholar and Web of Science were searched up to January 2020. Randomized controlled trials that compared primary mobile-bearing with fixed-bearing TKA, reporting at least one of the outcomes of interest, at a minimum follow-up of 12 months were included. All outcomes of interest were pooled at short-term (< 5 years), mid-term (5 to 9 years) and long-term (> = 10 years) follow-up intervals. RESULTS: A total of 70 eligible articles were included in the qualitative and statistical analyses. There was no difference between mobile-bearing or fixed-bearing TKA at short-term, mid-term and long-term follow-ups in all outcome measures including all-cause revision rate, aseptic loosening, oxford knee score, knee society score, Hospital for Special Surgery score, maximum knee flexion, radiographic lucent lines and radiographic osteolysis. CONCLUSION: The current level of evidence demonstrated that both mobile-bearing and fixed-bearing designs achieved excellent outcomes, yet it does not prove the theoretical advantages of the mobile-bearing insert over its fixed-bearing counterpart. The use of either design could therefore be supported based on the outcomes assessed in this study. LEVEL OF EVIDENCE: Level II, Therapeutic.

Need for syndesmotic fixation and assessment of reduction during ankle fracture fixation, with and without contralateral fluoroscopic images, has poor interobserver reliability.

PURPOSE: To determine the interobserver reliability of syndesmosis assessment using intraoperative ankle mortise fluoroscopic images, with and without contralateral images. METHODS: A survey of 19 operative ankle fracture cases was administered to 17 orthopedic surgeons. Respondents were presented with fluoroscopic mortise and stress images of the ankle after fracture fixation and asked if they would fix the syndesmosis. Final fluoroscopic mortise images were then shown, and respondents were asked to assess the reduction of the syndesmosis. Six weeks later, the survey was administered again with the addition of contralateral fluoroscopic ankle mortise images. Responses were compared to a standard response agreed upon by fellowship-trained orthopedic trauma surgeons. RESULTS: Interobserver reliability for syndesmosis fixation and reduction, with and without contralateral images, was considered weak (kappa 0.48 and 0.43; mean difference 0.05, 95% confidence interval (CI) 0.01 to 0.1) and minimal (kappa 0.25 and 0.22; mean difference 0.02, CI - 0.02 to 0.08). With the addition of contralateral mortise images, the number of surgeons who changed their response for syndesmosis fixation and reduction quality ranged from 0% to 41% and 0% to 88%; with the number of responses matching the standard increasing for both fixation (proportional difference (PD) 7%, CI 1% to 14%) and reduction (PD 14%, CI 7% to 21%); CONCLUSIONS: Interobserver reliability of syndesmosis fixation and reduction remained weak to minimal between surgeons, with and without contralateral images. Future studies are necessary to understand the variability in surgeon responses in order to improve the intraoperative assessment and fixation of syndesmotic injuries.

The utilization of intraoperative contralateral ankle images for syndesmotic reduction.

PURPOSE: To evaluate the variability in ankle syndesmotic morphology on contralateral ankle fluoroscopic images and the reductions obtained utilizing these images. METHODS: A retrospective cohort study was performed at a level one trauma center including 46 adult patients undergoing operative fixation of malleolar ankle fractures that also had anteroposterior (AP) and lateral fluoroscopic images of the uninjured contralateral ankle intraoperatively. Contralateral and post-fixation fluoroscopic images were used to measure the tibiofibular clear space (TFCS) as a proportion of the superior clear space (SCS) on mortise images and the posterior tibiofibular distance (PTFD) as a proportion of the lateral superior clear space (LSCS) on lateral images. Differences between contralateral and post-fixation ankle measurements were compared between those patients with syndesmotic injuries and those without (control group). RESULTS: The mean TFCS/SCS and PTFD/LSCS ratios measured on contralateral ankle images were 1.2 (95% confidence interval (CI) 1.1 to 1.3; range 0.7 to 1.8) and 1.8 (95% CI 1.5 to 2; range 0.5 to 3.4). The mean difference between the contralateral and post-fixation TFCS/SCS and PTFD/LSCS in patients with and without syndesmotic fixation was 0.07 vs. 0.13 (F-ratio 0.3, p = 0.5) and -0.2 vs 0.5 (F ratio 5.2, p= 0.02). CONCLUSIONS: Contralateral syndesmotic measurements varied widely and the utilization of these images allowed for syndesmotic reductions with similar measurements. Intraoperative contralateral ankle images should be considered to assess syndesmotic reduction.

Hyperbaric oxygen therapy for the treatment of Steinberg I and II avascular necrosis of the femoral head: a report of fifteen cases and literature review.

PURPOSE: This article aimed to report a case series of pre-collapse avascular necrosis of the femoral head treated with hyperbaric oxygen and review the most recent literature on the topic. METHODS: The data from a prospectively followed registry of 15 patients with Steinberg I and II avascular necrosis of the femoral head was collected. Functional outcome, pain scores, and radiographic changes at an average follow-up of 22 months were analyzed and reported. RESULTS: Thirteen patients had satisfactory outcome at final follow-up with an average Oxford hip score of 37.3, pain scores were significantly improved at final follow-up (P < 0.001), and 26.7% of hips progressed to collapse on follow-up radiographs with no complications reported in all patients. CONCLUSION: Hyperbaric oxygen treatment for pre-collapse avascular necrosis of the femoral head is considered a safe alternative with satisfactory clinical and radiological outcomes and low complications rate.