Beneficial Perioperative Aspects Favor the Use of Percutaneous Crossed Pinning over Antegrade Nailing in Pediatric Supracondylar Fractures-A Retrospective Comparative Study.

(1) Background: Displaced supracondylar humeral fractures in pediatric patients can be treated by either antegrade nailing (AN) or percutaneous crossed pinning (PCP). The aim of this study was to compare the intra- and perioperative management, complications and outcome of AN and PCP. (2) Methods: This retrospective study enrolled 271 individuals (median age 5 years, IQR 4-7 years) who underwent AN (n = 173) or PCP (n = 98). Patient history was analyzed for incidence of nerve injuries, postoperative treatment, postoperative malrotation, time of hospital stay, time to implant removal and revision rate. Operative procedures were investigated for duration and radiation exposure. (3) Results: PCP was associated with a significantly lower radiation exposure (dose area product: PCP mean 20.1 cGycm2 vs. AN mean 34.7 cGycm2, p < 0.001; fluoroscopy time: PCP mean 1.1 min, range 0.1-8.1 min, vs. AN mean 1.5 min, range 0.1-7.1 min, p < 0.001), duration of surgery (PCP mean 32.2 min vs. AN mean 48.3 min, p < 0.001) and time to implant removal (PCP mean 37 days vs. AN mean 113 days, p < 0.001). Cast removal was performed earlier in the AN group (PCP mean 30.2 days vs. AN mean 20.4 days, p < 0.001) and there were fewer iatrogenic nerve lesions (PCP: 24% vs. AN: 8%, p < 0.001). (4) Conclusions: In the investigated study population, the analyzed parameters seem to favor the use of PCP. The advantages of AN should be weighed against its drawbacks. For special indications, AN remains a relevant technique in supracondylar fracture treatment, and surgeons should be familiar with this procedure.

A Prospective Randomized Study Comparing Functional Outcome in Distal Fibula Fractures between Conventional AO Semitubular Plating and Minimal Invasive Intramedullary "Photodynamic Bone Stabilisation".

(1) Background: As age in western populations is rising, so too are fractures, e.g., of the distal fibula. The aim of this study was to find out whether a novel, minimally invasive intramedullary osteosynthesis technique for the treatment of distal fibula fractures in elderly patients results in not only a reduction of postoperative complications, but also a shorter hospitalization time, an improved clinical outcome, and preserved autonomy in geriatric trauma patients. (2) Methods: In this prospective study, the results following surgical treatment for distal fibula fractures in geriatric patients after using DePuy Synthes® one-third semitubular plate (Group I) or a minimally invasive intramedullary photodynamic Bone StabilizationSystem (IlluminOss®) (Group II) were compared at 6 weeks, 12 weeks, 6 months, and 1 year after initial treatment. (3) Results: Significant improvement regarding clinical outcome was shown in Group II 6 and 12 weeks after surgery. (4) Conclusions: Our study results demonstrate that the use of this new intramedullary stabilization system in combination with an immediate postoperative weight bearing seems to be a safe and stable treatment option for ankle fractures in geriatric patients, especially in the early stages of recovery.

Standalone Axial Malrotation after Pediatric Supracondylar Fracture Does Not Seem to Be an Indication for Immediate Postoperative Revision Surgery.

Rotational spurs as evidence for post-surgical malrotation are frequently observed when treating pediatric supracondylar humeral fractures (SCHFs). This study aimed to investigate the long-term outcome of a pediatric cohort with unrevised axial malrotation and to discuss the indication for revision surgery. Postoperative radiographs of children treated for SCHFs over eight years were retrospectively analyzed. Children with radiological signs of malrotation (von Laer malrotation quotient) were invited for a follow-up clinical and radiological examination. Among 338 treated children, 39 (11.5%) with a mean age of 5.3 years (range 1.8-11.7 years) showed radiological signs for postoperative malrotation and were not revised and therefore invited to participate in the study. Twelve patients (31%) with a mean age of 11.3 years (range 8.8-13.8 years) took part in the follow-up examination after a mean of 7.1 years (range 5.4 to 11.3 years). The mean postoperative van Laer malrotation quotient was 0.15 (range 0.11-0.2). At follow-up, the range of motion of the elbow joint was not significantly different compared to the contralateral side. Apart from the humeral ulnar angle (p = 0.023), there were no significant differences in the radiological axes. The Flynn criteria were excellent and good in 90% of the cases. The mean was 1.7 points indicating excellent subjective results. Standalone postoperative malrotation did not lead to an adverse long-term outcome in a small cohort of pediatric patients with SCHFs and did not indicate immediate postoperative revision surgery. However, further investigations with larger cohorts should verify whether additional criteria such as stability of the osteosynthesis and signs for increasing valgus or varus displacement in the follow-up radiographs should get more importance in decision making.

Patient-Reported Outcome Following Operative and Conservative Treatment of Calcaneal Fractures: A Retrospective Analysis of 79 Patients at Short- to Midterm Follow-Up.

Background: Fractures of the calcaneus are severe injuries of the hindfoot, mostly resulting from high-energy axial loads, which still present enormous challenges to modern trauma surgery. Possible variables influencing the outcome are the type of fracture, age, and quality of fracture reduction. These might also be factors affecting the self-reported patient outcome, but large studies are still lacking. Therefore, the aim of this study was to analyze the patient-reported outcome of calcaneal fractures following operative and conservative treatment. Methods: All patients suffering from calcaneal fractures between 2002 and 2015 were enrolled in this retrospective analysis. The calcaneal fractures were classified according to Sanders and the AO classification system. For further analysis, two groups were formed: group I involved complex intra-articular fractures defined by the involvement of the posterior calcaneal facet, while group II consisted of extra-articular and process calcaneal fractures. Data were collected via the patient registry, radiographs, and a standardized questionnaire (Foot and Ankle Outcome Score, FAOS). For outcome analysis, non-parametric Mann-Whitney U-test was performed, and Spearman's rank correlation coefficient was calculated. Results: In total, the functional outcome of 79 patients with calcaneal fractures was analyzed. In group 1 (n = 43), the mean FAOS score was 65.5 ± 18.9. The surgically treated patients with a Sanders type II calcaneal fracture had a mean FAOS score of 72.9 ± 17.2, type III fractures had 65.6 ± 20.8, and type IV had 61.1 ± 19 (p = 0.15). The reoperation rate was 22%, most frequently caused by wound complications (10%). The mean follow-up time was 64.5 ± 44 months. The mean FAOS score of group 2 (n = 36) was 75.2 ± 18.4, and 83% of the patients (=30) were managed conservatively. Only one out of six operatively managed patients had a reoperation due to regular implant removal. The mean follow-up time was 31 ± 25.9 months. Conclusion: Intra-articular calcaneal fractures are severe injuries of the hindfoot leading to a fair to poor functional outcome in the majority of the patients. Complications regarding wound healing are the most common causes for revisional surgery. Extra-articular calcaneal fractures are a heterogenous entity commonly managed non-operatively. Overall, they show a better functional outcome in comparison to intra-articular calcaneal fractures.

Is early full weight bearing safe following locking plate ORIF of distal fibula fractures?

BACKGROUND: In the modern western world appraisal of economical points such as treatment and disability after trauma present a financial burden. In this context open reduction internal fixation techniques allowing for early full weight bearing might not only improve the clinical outcome but also shorten the period of disability in working life. The aim of the study was to analyze whether ORIF of ankle fractures using either a standard semitubular plate or a new polyaxial locking plate system result in a better clinical outcome. METHODS: In this prospective study, all patients with distal fibula fractures (AO 44 B1.1, B1.2, B1.3), with indication for surgery were included. Patients were randomized to either the DePuy Synthes® one-third semitubular plate (Group I) or NEWCLIP TECHNICS, Active Ankle® polyaxial locking plate (Group II). Primary outcome parameter was function of the ankle joint, assessed by the Olerud and Molander ankle score, Foot and Ankle outcome score and Karlsson and Peterson Scoring System for Ankle function. Secondary outcome parameter were postoperative complications. Superficial wound infection, delayed wound healing, mechanically prominent implant, skin irritations were considered as minor and deep wound infection, material loosening, loss of reduction were regarded as major complications requiring revision surgery. Clinical and radiological follow-up were performed 6 and 12 weeks, 6 months and 1 year postoperatively. RESULTS: Fifty-two patients (31 W/21 M) with a mean age of 43 yrs. (range 22-64 yrs.) were enrolled. Seven patients (13.5%) were excluded, so that 45 patients were available for follow up. Twenty-five patients were treated with DePuy Synthes® one-third semitubular plate (55.6%; group I) while 20 patients received an anatomically preformed polyaxial locking plate (44.4%, group II). Four minor complications occurred in Group I (16%) compared to two minor complications in group II (10%). Significant better clinical results regarding OMAS (p < 0.02, < 0.04), KPSS (p < 0.04) and FAOS (p < 0.02, < 0.03) were observed 6 and 12 weeks after surgery in group II. CONCLUSIONS: The results of the presented study demonstrate a significant better clinical functional outcome in the early postoperative follow-up in patients treated with a polyaxial locking plate. Furthermore, our data show that ORIF using polyaxial locking plates in combination with an early postoperative weight bearing presents a safe, stable treatment option for ankle fractures so that patients benefit especially in the early stages of recovery. TRIAL REGISTRATION: Registered 20 April 2020, retrospectively on ClinicalTrails.gov ( NCT04370561 ).

The Association between High Body Mass Index and Early Clinical Outcomes in Patients with Proximal Femur Fractures.

BACKGROUND: Fractures of the proximal femur constitute daily work in orthopedic trauma surgery. With the continuous increase of obesity in the general population, surgeons face several known technical challenges. The aim of this study was to investigate the association of high body mass index (BMI) in patients with proximal femur fractures with intra- and postoperative adverse events, as well as with functional outcomes after successful surgery. METHODS: In this retrospective, single-center cohort study, 950 patients who sustained a fracture of the proximal femur (femoral neck fracture or trochanteric fracture) and underwent surgical treatment at our level I trauma center between 2003 and 2015 were included. Patient-specific data were obtained in regard to demographics, comorbidities, and fracture morphology. In-hospital postoperative complications (i.e., need for revision surgery, wound site infection, pneumonia, urinary tract infection, necessary transfusion, and deep-vein thrombosis) were analyzed, along with the length of hospitalization and overall mortality rate. Functional outcome was assessed using the Barthel index and the patient's ability to walk on crutches. Mortality rate and need for revision surgery were assessed over a two-year time period. Any adverse event was correlated to one of the four WHO's BMI groups. RESULTS: The cohort included 80 (8.4%) underweight patients, 570 (60.0%) normal weight patients, 241 (25.4%) overweight patients, and 59 (6.2%) obese patients. We found more femoral neck fractures (506, or 53%) than trochanteric fractures (444, or 47%). In bivariate analysis, no significant difference was found in regard to overall mortality or postoperative complications. Hospitalization time (LOS) differed between the underweight (12.3 ± 4.8 days), normal (13.6 ± 7.8 days), overweight (14.2 ± 11.7 days), and obese patients (16.0 ± 9.7 days) (p = 0.040). Operation time increased stepwise with increasing BMI: underweight = 85.3 ± 42.9 min; normal weight = 90.2 ± 38.2 min; overweight = 99.9 ± 39.9 min; obese = 117.2 ± 61.5 min (p < 0.001). No significant difference was found by analyzing functional outcomes. However, patients with intermediate BMI levels (18.5-30 kg/m2) tended to achieve the best results, as represented by a higher Barthel index score and the patient's ability to walk on crutches. CONCLUSION: Increased BMI in patients with proximal femur fractures is associated with both longer operation time and length of hospitalization (LOS). Postoperative mobilization and functional outcomes appear to follow a reversed J-curve distribution (with overweight patients showing the best functional results), whereas both obese and underweight patients have associated poorer function.