Early weight bearing and mobilization decrease perioperative complications in patients after ankle fracture; the retrospective multicenter (TRON group) study.

BACKGROUND: Open reduction and internal fixation (ORIF) for unstable ankle fractures (AF) are relatively predictable with excellent outcomes. Rehabilitation strategies are still being debated after surgical intervention for AF: non-weight bearing and cast immobilization for six weeks after the surgical repair of unstable AF or early functional treatment with partial weight bearing. This study aimed to compare early weight bearing and functional outcomes and complications. METHODS: Between April 2014 and March 2019, 1421 patients with AF underwent ORIF at 11 institutions (TRON group). The patients were divided into two groups: Group E started weight bearing within six weeks after surgery, and group L started weightbearing for more than six weeks after. To adjust for baseline difference between groups, a propensity score-matched algorithm was used to match Group E with Group L in a 1:1 ratio of 294 cases each. We compared the American Orthopedic Foot and Ankle Society (AOFAS) score as the functional outcome, the rate of wound dehiscence, superficial and deep infections, blistering, nonunion, neurapraxia, and reoperation at 3, 6, and 12 months after surgery. RESULTS: The mean period of non-weight bearing was significantly shorter in group E (3.68 ± 1.02 vs. 6.67 ± 1.43; P < 0.001). The mean period of cast immobilization term were shorter in group E (1.84 ± 1.35 vs. 2.65 ± 1.51; P < 0.001). There were no differences in the AOFAS score at any period. The rates of deep infection and reoperation in Group E were significantly lower than those in Group L (1.7% vs. 6.1%; P = 0.009, 2.0% vs. 7.8%; P = 0.002, respectively). There were no significant differences in superficial infection (9 vs. 15; P = 0.297), nonunion (9 vs. 15 P = 0.30), blistering (4 vs. 3; P = 1.00), neurapraxia (2 vs. 1; P = 1.00), and wound dehiscence (15 vs. 18; P = 0.72). CONCLUSIONS: Although functional outcome was similar depending on whether early weight bearing was allowed, the rates of deep infection and reoperation decreased in patients with early weight bearing. We recommend early postoperative weight bearing in patients with a surgically treated AF.

Addition of aerobic training to conventional rehabilitation after hip fracture: a randomized, controlled, pilot feasibility study.

OBJECTIVES: To determine the feasibility and safety of aerobic training with an arm crank ergometer and its effectiveness in improving functional capacity and gait in patients with recent hip fracture. DESIGN: Randomized, controlled, assessor-blinded pilot study, with intention-to-treat analysis. SETTING: Inpatients, rehabilitation department. SUBJECTS: 40 patients with hip fracture surgically treated. INTERVENTIONS: Training group performed aerobic exercise with an arm crank ergometer (15 sessions, 30 minutes/day) at an intensity of 64% to 76% of maximum heart rate, in addition to conventional inpatient rehabilitation. MAIN MEASURES: Primary outcome was the feasibility (including eligibility rate, recruitment rate, number of drop-outs and adverse events, adherence). Secondary measures were the Timed Up and Go test, ability to walk independently, muscle torque of knee extensors of fractured and non-fractured leg, Functional Independence Measure. RESULTS: Mostly due to pre-existing disability and fracture type, only 40/301 (13%) patients were eligible (age 84.6 ± 7.6 years, 75% female); all agreed to participate and 90% completed the trial, without adverse events. Adherence to aerobic exercise was good, with high attendance at sessions (93%), a strong compliance to exercise duration (95%) but lower compliance to the prescribed intensity (73%). After the program, more patients were able to walk independently in the training group (n = 18) compared to control (n = 13) (P < 0.05). Also the muscle torque of fractured leg knee extensors was higher in the training group (P < 0.05). CONCLUSION: Aerobic training in addition to conventional rehabilitation after a hip fracture is feasible and safe and it was effective in improving gait performance and strength of fractured leg. TRIAL REGISTRATION: NCT04025866.

Outcomes After Surgical Fixation of Posterior Sternoclavicular Physeal Fractures and Dislocations in Children.

BACKGROUND: Acute sternoclavicular fractures and dislocations (SCFDs) are a rare but important injury in pediatric patients. SCFDs are either true dislocations, or more commonly, physeal fractures in children. The reduction is advised given the proximity to surrounding vascular structures, and some authors advocate for routine fixation given rates of redisplacement after closed reduction. The purpose of the current study was to provide validated long-term functional outcome data following open reduction and surgical fixation of pediatric SCFDs, as well as provide injury and demographic information. METHODS: This is a retrospective observational study with a subset of patients reporting functional outcomes. Patients under the age of 18 that had surgically managed acute posterior SCFD from 1990 to 2018 were included. A retrospective chart review was performed to obtain demographic, clinical, and surgical details. Patients with a minimum of 6-month follow-up were contacted to assess outcomes. Functional outcomes of interest included QuickDash, Visual Analog Scale pain rating, Single Assessment Numeric Evaluation of shoulder function, and PROMIS Upper Extremity questionnaire. Statistical analysis included descriptive statistics. RESULTS: A total of 37 patients that sustained an acute posterior SCFD during the study period were included. The average age at the time of injury was 15.2±2.1 years and 89% were male. Patient-reported outcomes were obtained for 14 patients with a mean follow-up of 4.5 years. The mean QuickDash score was 5.1/100 with 0 being normal, and the mean Visual Analog Scale pain rating was 0.7/10. The mean Single Assessment Numeric Evaluation score was 96% with 100% being completely normal. The mean PROMIS score was 55 with 50 being the mean of the relevant reference population. Approximately 29% (4/14 patients) stated that their injury negatively affected their ability to participate in sports. CONCLUSIONS: There is a paucity of literature on functional outcomes after surgical management of pediatric acute posterior SCFD. Functional outcomes after surgery were satisfactory in this cohort with most patients being able to perform major activities of daily living. Additional future studies with larger cohorts and comparative groups are needed to better understand outcomes in this population. LEVEL OF EVIDENCE: Level IV.

Calcaneal fracture: results of earlier rehabilitation after open reduction and internal fixation.

INTRODUCTION: This study aimed to analyze the clinical and radiological outcomes of early weight-bearing and rehabilitation after open reduction and internal fixation (OR/IF) of calcaneal fracture. MATERIALS AND METHODS: This retrospective study was conducted on 78 patients with unilateral calcaneal fracture who underwent OR/IF. A mean follow-up period was 45.8 months (range 12-135). Two weeks after surgery, the range of motion (ROM) exercise was started, brace or heel off shoe was applied, and forefoot weight-bearing was allowed. Four weeks after surgery, tolerable weight-bearing ambulation without crutch was allowed. When the patient was not walking, the braces were removed to perform peritalar ROM exercises. Radiologic evaluation was performed by measuring the Böhler angle and incongruency of the subtalar joint surface. Paley grade was used to assess traumatic arthritis. Clinical evaluation was performed by measuring the foot and ankle outcome score (FAOS) and ankle ROM. RESULTS: The mean postoperative Böhler angle was 31.7° (P < 0.001) at 2 weeks, 31.2° at 3 months, and 30.1° at the last (P = 0.4). The average Paley grade of the subtalar OA was 1.12. CT imaging revealed that the average step-off of the subtalar joint was 1.26 mm in coronal and 0.84 mm in sagittal. The average ROM results were as follows (contralateral, affected side): there was no significant difference in dorsiflexion [16.9° vs. 16° (P = 0.6)], whereas plantarflexion and inversion were significantly decreased [39.5° vs. 35.3° (P = 0.049) and 50.5° vs. 34.8° (P = 0.04)]. The average FAOS score was 86.1 points, and the highest score was "function" (mean 92.5 points). CONCLUSIONS: Earlier rehabilitation after OR/IF is recommended for the treatment of calcaneal fracture.

Compared to conventional physiotherapy, does the use of an ankle trainer device after Weber B ankle fracture operation improve outcome and shorten hospital stay? A randomized controlled trial.

OBJECTIVE: To compare the functional outcomes and length of hospital stay for patients treated with conventional physiotherapy compared to a new ankle trainer device after Weber B ankle fractures. DESIGN: The patients were randomized, and then followed up at 3, 6, 12 and 52 weeks by a blinded physiotherapist. SETTING: This study was done at a level 1 trauma centre. SUBJECTS: One hundred and forty consecutive patients with Weber B ankle fractures that were operated on were screened for eligibility, of whom 113 were included in the study. INTERVENTIONS: Conventional physiotherapy with stretching exercises, using a non-elastic band or using new ankle trainer. MAIN MEASURES: Outcomes were evaluated with Olerud-Molander ankle score, Visual analogue scale for pain and ankle dorsiflexion at 3, 6, 12 and 52 weeks follow-up. Time of hospitalization and complications were registered. RESULTS: Superior Olerud-Molander ankle scores were observed at three weeks follow-up in the ankle trainer group 40.9 (10.8), compared to the conventional group 35.3 (14.2) (P = 0.021). At one-year follow-up, there was no difference between the groups (P = 0.386). The ankle trainer group had a shorter hospital stay with a mean 2.6 days (0.98) compared to 3.2 days (1.47) in the conventional group (P = 0.026). CONCLUSION: The patients who were treated with the new ankle trainer device recovered more rapidly, evaluated by the Olerud-Molander ankle score and had a shorter stay in hospital compared to the conventional physiotherapy group. No between group differences could be observed at long-term follow-up.

Better functional outcomes for ORIF in tibial eminence fracture treatment: a national comparative multicentric study of ORIF vs ARIF.

PURPOSE: Tibial eminence fractures can occur in adults and are equivalent to an acute ACL rupture. The purpose of this retrospective study was to compare the therapeutic outcomes of ARIF versus ORIF in tibial eminence fractures. Our hypothesis was that ARIF does not offer better results. METHODS: A retrospective national multicentric study was conducted in five university hospitals between 2010 and 2015. A total of 65 consecutive patients were included. 33 patients were treated with ARIF and 32 with ORIF. Clinical functional outcomes were assessed using the Lysholm score and IKDC score. Radiographic findings were recorded, and a statistical analysis carried out. RESULTS: IKDC score at the mean last follow-up of 68.8 ± 11.8 months was significantly higher in the ORIF group with a mean difference of 20.2 points ± 8.9 (p = 0.028). There were early osteoarthritis findings in 12 patients (18.4%). At last follow-up, 7 patients (10.7%) presented complications. CONCLUSION: In this retrospective multicentric study, better functional outcomes were observed in the ORIF group. This difference needs to be carefully interpreted as many confounding factors exist. In terms of complications, the results for both ORIF and ARIF are similar at midterm follow-up. ORIF should remain gold standard for tibial eminence fracture treatment. LEVEL OF EVIDENCE: III.

Rehabilitation after distal radius fractures: is there a need for immobilization and physiotherapy?

Although the literature generally agrees that displaced distal radius fractures require surgery, no single consensus exists concerning the length of immobilization and type of post-operative physiotherapeutic rehabilitation program. Palmar locking plate fixation represents a very stable fixation of the distal radius, and was assessed biomechanically in various studies. Surprisingly, most authors report additional immobilization after plate fixation. One reason might be due to the pain caused during active wrist mobilization in the early post-operative stages or secondly to protect the osteosynthesis in the early healing stages preventing secondary loss of reduction. This article addresses the biomechanical principles, current available evidence for early mobilization/immobilization and impact of physiotherapy after operatively treated distal radius fractures.

Displaced Clavicle Fractures in Cyclists: Return to Athletic Activity After Anteroinferior Plate Fixation.

BACKGROUND: One of the most commonly observed injuries in cycling is fracture of the clavicle. Nevertheless, there is limited literature available on clinical outcomes after plate fixation of clavicle fractures in cyclists, rehabilitation protocols, and the time to return to sports. PURPOSE: The aim of this study was to evaluate the functional outcome, complications, and return to athletic activity at short-term follow-up after surgical repair. STUDY DESIGN: Case series. METHODS: Between January 2008 and October 2014, all professional and recreational cyclists presenting with a new clavicle fracture at the emergency department were prospectively recorded. All patients had an anteroinferior plate fixation, variable angle locking compression plate (DePuySynthes). Patients were seen at 2, 6, and 24 weeks at the outpatient clinic to gather Disability of the Arm, Shoulder, and Hand (DASH) and Constant shoulder questionnaires and radiographs were made. Cyclists were allowed to resume outside training 1 week after surgery. RESULTS: Ten professional cyclists and 15 recreational cyclists were included. All (25/25) patients returned to cycling after plate fixation. Mean Constant scores and mean DASH scores of 96.8 ± 4.1 and 5.1 ± 5.5 at 6 weeks and 99.1 ± 1.5 and 2.9 ± 4.6 at 24 weeks were measured. There were 3 complications: 1 patient developed a nonunion, there was 1 wound infection requiring antibiotics, and in 1 patient, a refracture occurred. CONCLUSION: Plate fixation for cyclists with displaced clavicle fractures was successful in terms of fast return to previous level of athletic activity. It is a valuable and safe option for athletes in cycling.

Repair and augmentation of the lateral collateral ligament complex using internal bracing in dislocations and fracture dislocations of the elbow restores stability and allows early rehabilitation.

PURPOSE: Most elbow dislocations can be treated conservatively, with surgery indicated in special circumstances. Surgical options, apart from fracture fixation, range from repair or reconstruction of the damaged ligaments to static external fixation, usually entailing either a long period of immobilization followed by carefully monitored initiation of movement or dynamic external fixation. In general, no consensus regarding surgical treatment has been reached. A new method of open ligament repair and augmentation of the lateral ulnar collateral ligament using a non-absorbable suture tape in cases of acute and subacute elbow instability following dislocations has been described here, which allows an early, brace-free initiation of the full range of motion. This is the first description of the technique of internal bracing of the lateral elbow with preliminary patient outcome parameters for acute treatment of posterolateral rotatory instability. METHODS: Seventeen patients (14 males and 3 females) with acute or subacute posterolateral elbow instability as a result of dislocation or fracture dislocation were treated in our centre (Sporthopaedicum, Straubing, Regensburg, Germany) from 2014 to 2015 with open LUCL re-fixation and non-absorbable suture tape augmentation. The elbows were actively mobilized immediately after the operation and a maximum bracing period of 3 days. RESULTS: At 10 month median follow-up, none of the patients showed clinically apparent signs of instability or suffered subluxation or re-dislocation. One patient required re-operation for heterotopic ossification. The median range of motion was from 10° (0-40) to 130° (90-50) and median Oxford, Mayo Elbow Performance score, Simple Elbow Value, and DASH Scores were 41(29-48), 100 (70-100), 83% (60-95), and 18.5 (1.6-66), respectively. All patients reported a complete return to pre-injury level of activity. CONCLUSION: Augmentation with a non-absorbable suture tape acting as an 'Internal Brace' following an elbow dislocation is a safe adjunct to primary ligament repair and may allow the early mobilization and recovery of elbow stability and range of motion. LEVEL OF EVIDENCE: IV.

Use of a stainless steel locking calcaneal plate for quadrilateral plate buttress in the treatment of acetabular fractures.

Operative fixation of acetabular fractures involving the quadrilateral surface presents a challenging clinical scenario. Classically, quadrilateral plate buttress was achieved via the use of a "seven" plate. More recently, the use of an anatomic, pre-contoured design has been gaining popularity due to its pre-contoured shape and larger footprint, allowing for a wider quadrilateral plate buttress. The current study presents using a stainless steel locking calcaneal plate to obtain similar surface area coverage as the modern pre-contoured quadrilateral plate, but at a lower cost.Level of evidence IV.

How balance task-specific training contributes to improving physical function in older subjects undergoing rehabilitation following hip fracture: a randomized controlled trial.

OBJECTIVE: To evaluate the efficacy of a rehabilitation programme including balance task-specific training in improving physical function, pain, activities of daily living (ADL), balance and quality of life in subjects after a hip fracture. DESIGN: Randomized controlled trial. SUBJECTS: A total of 52 older subjects selected for internal fixation due to extra-capsular hip fracture were randomized to be included in an experimental ( n = 26) and control group ( n = 26). INTERVENTIONS: The experimental group underwent a rehabilitation programme based on balance task-specific training. The control group underwent general physiotherapy, including open kinetic chain exercises and walking training. Both groups individually followed programmes of 90-minute sessions five times/week for three weeks. OUTCOME MEASURES: The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a Pain Numerical Rating Scale, the Berg Balance Scale, the Functional Independence Measure and the 36-item Short-Form Health Survey. The participants were evaluated before and after training, and after 12 months. RESULTS: Significant effects of time, group and time × group were found for all outcome measures in favour of the experimental group. A clinically important between-group difference of 25 points was achieved after training and at follow-up in terms of the primary outcome (WOMAC function before treatment, after treatment and at follow-up was 84.8 (3.7), 39.8 (4.9) and 35.7 (6.2) for the experimental group and 80.9 (5.7), 65.2 (7.1) and 61.0 (11.1) for the control group). CONCLUSION: An inpatient rehabilitation programme based on balance task-specific training is useful in improving physical function, pain, ADL and quality of life in older patients after hip fracture.

Open reduction and internal fixation of comminuted patellar fractures with headless compression screws and wiring technique.

BACKGROUND: Management of a displaced comminuted patellar fractures is challenging, and various surgical fixation methods have been suggested. However, issues of loss of reduction and breakage of fixatives have not yet been resolved. In the current study, we describe a new technique for exposure and stabilization of comminuted patellar fractures and evaluate the clinical and radiologic outcomes of this new treatment. MATERIALS AND METHODS: Thirteen patellar fractures with articular comminution, which were treated by headless compression screws with additional separate vertical wiring were enrolled in this study. Loose articular fragments were fixed with headless compression screws under direct visual reduction of the articular surface, which was facilitated by the superior everting of the patella. Radiographs of the knee were obtained at routine follow-up to assess fracture healing and widening of articular step-off. Clinical outcomes including range of motion, quadriceps circumference, visual analog scale (VAS) related pain score, Lysholm, and Bostman grading scales were measured at the last follow-up. RESULTS: All the fractures healed at a mean of 15 weeks. No patient had loss of reduction, evidence of implant migration, or metallic failure. Articular step-off larger than 2 mm was not seen in any of the cases. The average range of motion arc was 134.2° (range, 120°-145°), and the mean Lysholm and Bostman scores were 94.4 (range, 84-100 points) and 28.7 (range, 25-30 points), respectively. Thigh muscle wasting was observed in four patients (33.3%), but no patient had >1.5 cm difference in thigh circumference girth between the injured and uninjured lower limbs. The average VAS-related pain score was 0.4. CONCLUSIONS: Articular fixations with headless compression screws under direct visual reduction of the articular surface resulted in good clinical outcomes and were considered clinically effective for comminuted patellar fractures.

[Simultaneous fracture of the acromion and coracoid process : Rare variant of double disruption of the superior shoulder suspensory complex]. / Gleichzeitige Frakturen von Acromion und Korakoid : Seltene Variante der doppelten Unterbrechung des "superior shoulder suspensory complex".

INTRODUCTION: Simultaneous fracture of the acromion and coracoid process represents a double disruption of the superior shoulder suspensory complex (SSSC). To date, the two largest reported series have comprised five and eight cases. The aim of this study was to investigate the functional outcome in patients who sustained this rare injury and to provide a review of the relevant literature. MATERIAL AND METHODS: In this retrospective study, patients who were surgically treated between 2009 and 2014 were identified from medical records and the patients were asked to attend a follow-up examination. Functional results, measured as the Constant score and Disabilities of the Arm, Shoulder and Hand (DASH) score, were the main outcomes of the study. RESULTS: A total of six patients underwent surgery for this type of double disruption of the SSSC. All but one patient suffered a high-impact trauma with other associated injuries. The coracoid fracture was classified as type I according to Ogawa in all cases, and the acromion fracture was type III according to Kuhn in 5 out of 6 cases. At least one of the fracture sites was stabilized. Of the patients one showed a concurrent lateral clavicle fracture, representing a third disruption of the SSSC, and another had a fracture of the medial third of the clavicle, representing a strut fracture. In these cases, two fracture sites were operated on. At an average follow-up period of 47 months all but one fracture had healed. In one patient, asymptomatic non-union of the acromion was found. The average DASH score was 22 points and the average Constant score was 74 points. CONCLUSION: This rare injury pattern is usually caused by high-impact trauma, and concomitant injuries frequently occur. Nevertheless, surgical stabilization of at least one of the fracture sites showed satisfactory functional results.

Measuring Recovery After Ankle Fractures: A Systematic Review of the Psychometric Properties of Scoring Systems.

Recovery after ankle fractures places a considerable burden on patients both short and long term. Numerous tools called patient-reported outcome measures (PROMs) have been developed to measure the outcome of ankle fractures. They can assist clinicians to measure the effect, guide intervention, and assess the rate of recovery. We identified and evaluated the psychometric properties of PROMs used in the assessment of ankle fractures. In a systematic search, we examined 4 databases from inception to December 4, 2016. Search terms included ankle fracture, ankle pain, disability, gait, questionnaire, and PROMs. Reference lists were also examined. The inclusion criteria were English studies and adult populations. The psychometric properties of the identified PROMs were examined, including internal consistency, test-retest reliability, validity, floor-ceiling effects, and minimally important clinical differences. We identified 22 PROMs relating to ankle pain and disability. Only 5 were specifically used for ankle fractures. The 36-item short-form health survey and short musculoskeletal functional assessment reported floor-ceiling effects, and the lower extremity functional scale reported good responsiveness and content validity, although these are not tools specifically related to ankle fractures. The ankle-fracture outcome of rehabilitation measure (A-FORM) and the Olerud and Molander questionnaire were ankle fracture specific and assessed for internal consistency and validity. Clinicians should use the most appropriate PROM to evaluate patients' recovery from ankle fractures. The A-FORM currently has the most appropriate evidence supporting its use as a PROM for ankle fracture management and rehabilitation.

[Osteosynthesis of Anterior Pelvic Segment: New Symphyseal Plate - First Clinical Experience]. / Osteosyntéza predního segmentu pánve: nová symfyzeální dlaha ­ první klinické zkusenosti.

PURPOSE OF THE STUDY The aim of this study is to evaluate the first experience gained with the new type of anatomical symphyseal plates intended to stabilise ruptured symphysis and closely located fractures. MATERIAL AND METHODS A retrospective evaluation was performed in 5 patients who had undergone surgery in the period from July 2015 to the end of 2016 using a new anatomical symphysial plate for pelvic ring injury. In four cases a stabilisation of symphyseolysis was carried out and in one case osteosynthesis of bilateral rami fracture near the symphysis was performed. The posterior pelvic segment was fixed 3 times by iliosacral screws and 2 times by a transsacral bar. All the surgeries in symphysis region were performed via a modified anterior suprapubic approach. A total of 3 men and 2 women with the mean age of 54.6 years (range 19-77 years) were operated. The mean follow-up period of five patients was 12.6 months. Also, preliminary evaluation of postoperative clinical and radiological outcomes was conducted on a very heterogenous group of patients. RESULTS The postoperative radiological outcome assessed by Pohlemann score was excellent in all the cases. After 3-6 months, screw loosening was reported in 3 cases, with no impact on the overall result of the surgery, in one case the symphysis widened 2 mm with simultaneous loosening of two screws, with no impact on the clinical result either. Clinical evaluation of the results was conducted in 4 patients using the Majeed score with the mean follow-up of 12.6 months, the score achieved was 98, 86, 72 and 49 points. In one patient the results could not be evaluated due to concurrent spinal cord injury with quadriplegia. Nonetheless, even this patient has no difficulty in sitting in a rehabilitation wheelchair. No serious intraoperative or early postoperative complications were reported. As regards late complications, one female colostomy patient developed deep infection three months after the primary surgery. DISCUSSION The first clinical as well as radiological outcomes in our small group of patients are comparable to the outcomes of larger groups using multi-hole plates to stabilise the anterior segment, or the application of 2 plates. In agreement with other authors, the new plates can be applied through a less invasive operative approach avoiding the necessity to transect rectus abdominis muscles. The results of earlier biomechanical studies suggest that their strength will equal 2 inserted plates, or will be comparable to multi-hole plates. CONCLUSIONS The first experience with the use of new anatomical symphysial plates are promising. The new types of plates intended for anterior pelvic segment facilitate fixation by screws inserted at two levels. They significantly improve the stability of fixation and can replace the commonly used 2 plates. The only limiting factor of our group of patients is its small size. Comparative weight-bearing tests shall be performed in the future. Key words:symphysis pubic disruption, pelvic ring fractures, pelvic instability, new symphyseal plates.

Early range of motion exercise in pediatric patients with olecranon fractures treated with tension band suture with double loops and double knots.

BACKGROUND: Pediatric patients with olecranon fractures are uncommon. The tension band suture technique was introduced to reduce the burden of implant removal and other complications. However, to our knowledge, early range of motion (ROM) exercise has not been introduced in this population of patients. Double Vicryl loops and knots with 2 cross-pins are used to maintain the benefits of the tension band suture technique and to enhance fixation tensile strength. We believe that early ROM exercises could be achieved without nonunion or fixation failure. METHODS: Twelve pediatric patients with olecranon fractures were treated with tension band suture with double loops and knots between 2004 and 2015. Vicryl No. 1 was used for wiring. ROM exercises were initiated 1 week postoperatively with a customized functional brace. Early functional outcomes were evaluated by the Mayo Elbow Performance Score at every visit after 8 weeks postoperatively. RESULTS: Nine boys and 3 girls (average age, 10.6 years; range, 5 years 7 months-16 years 2 months) were included in the study. Initial displacement and angulation of the fractures were 5 mm (2-7 mm) and 12° (4°-25°), respectively. Two cases had radial neck fractures of the ipsilateral elbow. All patients had a perfect Mayo Elbow Performance Score after 8 weeks postoperatively. Pin removals were performed at 13.1 weeks. No complications, including growth arrest, were observed. DISCUSSION/CONCLUSION: Tension band suture with double loops and knots, combined with early ROM exercise, may be a complete alternative to tension band wiring.

Impact of the Holocaust on the Rehabilitation Outcome of Older Patients Sustaining a Hip Fracture.

BACKGROUND: Holocaust survivors report a much higher prevalence of osteoporosis and fracture in the hip joint compared to those who were not Holocaust survivors. OBJECTIVES: To evaluate whether being a Holocaust survivor could affect the functional outcome of hip fracture in patients 64 years of age and older undergoing rehabilitation. METHODS: A retrospective cohort study compromising 140 consecutive hip fracture patients was conducted in a geriatric and rehabilitation department of a university-affiliated hospital. Being a Holocaust survivor was based on registry data. Functional outcome was assessed by the Functional Independence Measure (FIM)TM at admission and discharge from the rehabilitation ward. Data were analyzed by t-test, chi-square test, and linear regression analysis. RESULTS: Total and motor FIM scores at admission (P = 0.004 and P = 0.006, respectively) and total and motor FIM gain scores at discharge (P = 0.008 and P = 0.004 respectively) were significantly higher in non-Holocaust survivors compared with Holocaust survivors. A linear regression analysis showed that being a Holocaust survivor was predictive of lower total FIM scores at discharge (ß = -0.17, P = 0.004). CONCLUSIONS: Hip fracture in Holocaust survivors showed lower total, motor FIM and gain scores at discharge compared to non-Holocaust survivor patients. These results suggest that being a Holocaust survivor could adversely affect the rehabilitation outcome following fracture of the hip and internal fixation.

[Osteosynthesis of metacarpal fractures with 2.0 mm LCP system and functional postoperative treatment]. / Osteosynthese von Metakarpalefrakturen mit 2,0-mm-LCP und funktionelle postoperative Nachbehandlung.

BACKGROUND: Locking head systems are an additional option in the surgical treatment of metacarpal fractures. In this clinic 2.0 mm locking compression plates (LCP) are used, which provide the possibility of functional postoperative treatment even for complex and osteoporotic metacarpal fractures. For simple fractures and good bone quality the LCP system is used as a compression or neutralization plate. Depending on the type and localization of the fracture, different osteosynthesis techniques are used in order to achieve a functional postoperative treatment in as many patients as possible. MATERIAL AND METHODS: Between July 2009 and December 2010 a total of 49 patients were enrolled in a prospective trial. All patients underwent surgical treatment with a 2.0 mm LCP system. Postoperative functionality of the hand was restored without immobilization. Clinical and radiological examinations were performed after 6 and 12 weeks and after 6 and 12 months with documentation of the range of motion (ROM), grip strength, fingertip to palm distance and the disabilities of the arm, shoulder and hand (DASH) score. RESULTS: After 6 months a good functional result was achieved in all patients with no cases of malrotation. Radiographs showed a completely consolidated bone healing. CONCLUSION: After osteosynthesis with 2.0 mm LCPs all types of metacarpal fractures can be treated without immobilization.

[Surgical treatment of a complex adolescent carpal fracture : A rare injury to the growing skeleton]. / Versorgung einer komplexen jugendlichen Handwurzelfraktur : Eine seltene Verletzung am wachsenden Skelett.

We report the case of a 15-year-old boy with combined fractures of the scaphoid, capitate, and hamate that represents a rare variation of the well-known Fenton's syndrome. Fixation was performed for the unstable fractures of the scaphoid and capitate with the use of cannulated Herbert screws and K­wires respectively. K­wires were removed after 6 months, with subsequent physiotherapy. After 6 months, CT confirmed complete consolidation of the two surgically treated carpal fractures and the conservatively treated fracture of the hamate. Regarding function, the patient is able to incorporate the hand into his school-related activities and has a good range of motion, with strong closure of the fist.

Early Protected Weightbearing After Ankle Fractures in Patients With Diabetes Mellitus.

The traditional protocol for treatment after ankle fracture in the diabetic patient involves a period of prolonged non-weightbearing to reduce the incidence of complications. The goal of the present study was to identify the risk factors and complications associated with early protected weightbearing after closed ankle fractures in patients with diabetes. The data from 73 diabetic patients with operatively and nonoperatively treated ankle fractures were retrospectively reviewed. All patients were allowed to begin protected weightbearing in a cast or removable boot at 2 weeks after the index injury or surgery. The mean follow-up period was 51 (range of 26 to 480) weeks. Complications occurred in 25% of the operative cases and 8% of the nonoperative cases. In both categories, the complication rate was less than that from existing reports using prolonged non-weightbearing. Wound dehiscence was the most common complication in the operatively treated patients (18.8%). A statistically significant difference was found in the complications rates for the patients aged >60 years (p = .0403). No statistically significant differences were identified according to hemoglobin A1c, the presence of peripheral neuropathy, smoking status, fracture type, or the presence of end-stage renal disease. The results of the present study suggest that early protected weightbearing after closed ankle fractures in diabetic patients is fairly safe, with an acceptable complication rate. However, the patients selected for early weightbearing had low comorbidity profiles, which might have accounted, in part, for the low complication rate.