Pins and Rubbers Traction System for Treatment of Intraarticular Fractures of Distal Interphalangeal Joint.

Background: The pins and rubber traction system (PRTS) has proven effective in managing intra-articular fractures of the proximal interphalangeal joint. However, there is scant evidence in the literature regarding its efficacy in treating distal interphalangeal joint (DIPJ). This study aims to investigate the outcomes of PRTS in the treatment of comminuted intra-articular fractures of the DIPJ. Methods: We conducted a retrospective review of patients with comminuted intra-articular fractures of the DIPJ treated with PRTS between 2017 and 2021. At the final follow-up, we measured and compared the active range of motion (ROM) in both affected and non-injured contralateral fingers. The subjective evaluation utilised the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) questionnaire and the Visual Analogue Scale (VAS). Results: Ten patients with a mean follow-up of 13.2 months (range: 12-17) were included in the study. Fracture locations included the base of the distal phalanx in two patients, the condyle of the middle phalanx in seven and both in one patient. At the final follow-up, the average VAS score was 0.5 (range: 0-2). The average active motion of the DIPJ was 61° (range: 50°-70°) for the injured side and 76° (range: 75°-80°) for the opposite side. The mean range of DIPJ movement was 80% (range: 68%-87%) of the non-injured side. Extension deficits were observed in five patients, with a median deficit value of 10° (range: 5°-10°). The average Quick-DASH score was 2.9 (range: 0-11.3). Conclusions: The PRTS can be considered as an effective surgical technique in managing comminuted intra-articular fractures of the DIPJ. Level of Evidence: Level IV (Therapeutic).

Implant Choice and Outcomes of the Sinus Tarsi Approach for Displaced Intra-articular Calcaneal Fractures.

BACKGROUND: Operative fixation of displaced intra-articular calcaneal fractures is considered the gold standard, for which multiple fixation methods are available. This study compares the (functional) outcome of screw fixation (SF), plate fixation (PF), and anatomical plate fixation (APF) via the sinus tarsi approach (STA). METHODS: A total of 239 patients (265 fractured calcanei) who received surgical treatment of a displaced intra-articular calcaneal fracture via STA between 2011 and 2022 were included. RESULTS: Böhler angle (BA) measured immediately postoperatively (BA post-OR) and the decrease in BA at 1 year (∆BA) differed significantly in favor of PF/APF compared with SF (BA post-OR: SF vs PF P = .010 and SF vs APF P = .001; ∆BA: SF vs PF P = .032 and SF vs APF P = .042). Implant removal surgery was performed significantly less in the APF group as compared to the SF/PF groups (APF vs SF/PF; 9.9% vs 22.9%/23.7%, P = .015). Surgical site infections and secondary arthrodesis of the subtalar joint occurred equally in the 3 groups. Furthermore, the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot scale, Foot Function Index score, and EuroQOL-5D-index / visual analog scale score, did not differ notably between SF, PF, and APF. CONCLUSION: The results show that both PF and APF are favored over SF because of an improved correction of BA measured directly postoperatively, a lower secondary loss of BA and, for APF, a lower implant removal rate. There was no difference in the rate of surgical site infections, need for secondary arthrodesis, nor functional outcome scores between different implants using the STA. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Cost Analysis of Volar Plate Fixation Versus Plaster Cast Immobilization for Intra-Articular Distal Radial Fractures.

BACKGROUND: The aim of this study was to compare the cost-effectiveness and cost-utility between plaster cast immobilization and volar plate fixation for acceptably reduced intra-articular distal radial fractures. METHODS: A cost-effectiveness analysis was conducted as part of a randomized controlled trial comparing operative (volar plate fixation) with nonoperative (plaster cast immobilization) treatment in patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Health-care utilization and use of resources per patient were documented prospectively and included direct medical costs, direct non-medical costs, and indirect costs. All analyses were performed according to the intention-to-treat principle. RESULTS: The mean total cost per patient was $291 (95% bias-corrected and accelerated confidence interval [bcaCI] = -$1,286 to $1,572) higher in the operative group compared with the nonoperative group. The mean total number of quality-adjusted life-years (QALYs) gained at 12 months was significantly higher in the operative group than in the nonoperative group (mean difference = 0.15; 95% bcaCI = 0.056 to 0.243). The difference in the cost per QALY (incremental cost-effectiveness ratio [ICER]) was $2,008 (95% bcaCI = -$9,608 to $18,222) for the operative group compared with the nonoperative group, which means that operative treatment is more effective but also more expensive. Subgroup analysis including only patients with a paid job showed that the ICER was -$3,500 per QALY for the operative group with a paid job compared with the nonoperative group with a paid job, meaning that operative treatment is more effective and less expensive for patients with a paid job. CONCLUSIONS: The difference in QALYs gained for the operatively treated group was equivalent to an additional 55 days of perfect health per year. In adult patients with an acceptably reduced intra-articular distal radial fracture, operative treatment is a cost-effective intervention, especially in patients with paid employment. Operative treatment is slightly more expensive than nonoperative treatment but provides better functional results and a better quality of life. LEVEL OF EVIDENCE: Economic and Decision Analysis Level I. See Instructions for Authors for a complete description of levels of evidence.

Volar Plate Fixation Versus Cast Immobilization in Acceptably Reduced Intra-Articular Distal Radial Fractures: A Randomized Controlled Trial.

BACKGROUND: The evidence for the treatment of acceptably reduced intra-articular distal radial fractures remains inconclusive. We therefore compared the functional outcomes of cast immobilization (nonoperative) and volar plate fixation (operative) for patients with these fractures. METHODS: This multicenter randomized controlled trial enrolled patients between 18 and 75 years old with an acceptably reduced intra-articular distal radial fracture. Patients were randomized to nonoperative treatment or to operative treatment. The primary outcome measure was the Patient-Rated Wrist Evaluation (PRWE) score after 12 months. Secondary outcome measures were the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; the Short Form-36 (SF-36) questionnaire; a visual analog scale for pain; range of motion; grip strength; radiographic parameters; and complications. Analyses followed the intention-to-treat principle. RESULTS: A total of 96 patients were randomized, and 90 (46 in the nonoperative group and 44 in the operative group) were included in the analysis. Patients treated in the operative group had significantly better functional outcomes measured with the PRWE at 6 weeks, 3 months, 6 months, and 1 year. Additionally, a 28% rate of subsequent surgery was identified in the nonoperative group. CONCLUSIONS: Adult patients with an acceptably reduced intra-articular distal radial fracture have better functional outcomes for 12 months when treated operatively instead of nonoperatively. We therefore recommend surgical treatment for patients with these fractures. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Low-Intensity Pulsed Ultrasound Suppresses Synovial Macrophage Infiltration and Inflammation in Injured Knees in Rats.

This study was designed to investigate how low-intensity pulsed ultrasound (LIPUS) suppresses traumatic joint inflammation and thereafter affects the progression of posttraumatic osteoarthritis. Intra-articular fracture (IAF) was created in the right knee of rats. LIPUS was applied to the knees with IAFs for 20 min/d for 2 wk-LIPUS(+) group. The study controls included rats that underwent sham surgery but no LIPUS treatment (control group) or underwent IAF surgery without LIPUS treatment-LIPUS(-) group. By histology, at 4 wk, leukocyte infiltration in the synovium was reduced in the LIPUS(+) group. Furthermore, LIPUS treatment reduced CD68+ macrophages in the synovium and limited their distribution mostly in the subintimal synovium. Measured with enzyme-linked immunosorbent assay, interleukin-1ß (IL-1ß) in the joint fluid of the LIPUS(+) group was reduced to about one-third that in the LIPUS(-) group. By reducing synovial macrophages and lowering IL-1ß in the joint fluid, LIPUS is potentially therapeutic for posttraumatic osteoarthritis.

Evaluation of Long-Term Quality of Life Using the Foot and Ankle Outcome Score (FAOS) Questionnaire in Patients Treated by Minimally Invasive Reduction and Percutaneous Stabilization of Intra-Articular Calcaneal Fractures.

BACKGROUND Treatment of displaced intra-articular calcaneal fractures is controversial. Choosing the optimal surgical technique is very important for patient quality of life and activity. In this study, we asked the question: "What is the long-term quality of life of patients after intra-articular calcaneal fractures treated by minimally invasive reduction and percutaneous stabilization (MIRPS)?". MATERIAL AND METHODS We included 51 patients - 45 males (88%) and 6 females (12%) - who underwent MIRPS of intra-articular calcaneal fractures. The males were ages 22-63 years, with a mean age of 46 years, while the females were aged 31-63, with a mean age of 47 years. The FAOS (Foot and Ankle Outcome Score) survey was used. RESULTS Women's FAOS scores were 72-95%, with a mean of 82%, and varied according to type of fracture, surgery method used, and comorbid fractures. Men's FAOS scores were 50-95%, with a mean of 84%, and varied according to type of fracture, surgery method used, and comorbid fractures. CONCLUSIONS According to set criteria regarding the FAOS scale, mainly good and very good results were observed in patients treated surgically for intra-articular calcaneus fractures using MIRPS. Westhues' method scored a significantly higher foot rating than W-R (Westhues'-Rapala method). Patients with TTF (tongue-type fracture) scored higher in the FAOS than patients treated with JDTF (joint depression-type fracture). In other cases, no significant differences were observed.

Functional Outcomes of Tillaux and Triplane Fractures with 2 to 5 Millimeters of Intra-Articular Gap.

BACKGROUND: The treatment of transitional ankle fractures (Tillaux and triplane) is often dictated by the amount of displacement at the articular surface. Although >2 mm is a common indication for operative management, this practice has not been strongly supported by either the pediatric or adult literature. The purpose of this study was to determine whether operative treatment of transitional fractures with 2 to 5 mm of intra-articular gap leads to superior functional outcomes compared with cast management. METHODS: A retrospective review of all patients treated for distal tibial fractures at a single institution between 2009 and 2017 was conducted. Computed tomographic images obtained after closed reduction were reviewed to identify patients with 2 to 5 mm of displacement (either gap or step-off) at the articular surface of the tibial plafond. Complications were classified according to the modified Clavien-Dindo system. Only patients with functional outcome data (Foot and Ankle Ability Measure [FAAM]) at a minimum of 2 years after treatment were included. Two multivariable linear regression models were developed using backward stepwise regression with either the FAAM Sports score or the Single Assessment Numerical Evaluation (SANE) Sports score as the dependent variables. RESULTS: Fifty-seven patients (34 with triplane fractures and 23 with Tillaux fractures) with a mean follow-up of 4.5 years (range, 2.0 to 9.2 years) met inclusion criteria. Thirty-four patients were treated operatively, and 23 patients were treated with closed reduction and cast application. Nonoperative treatment, greater intra-articular gap, and presence of a grade-III complication were associated with worse functional outcomes in both multivariable regression models. A gap after closed reduction remained a negative predictor of functional outcome even in patients who were treated operatively. Patients who were treated nonoperatively and had ≤2.5 mm of gap had a significantly higher mean SANE Sports score at 90% than those patients with >2.5 mm of gap at 75% (p = 0.03). CONCLUSIONS: In Tillaux and triplane fractures with 2 to 5 mm of gap at the tibial plafond, a greater gap after closed reduction, nonoperative treatment, and complications were negative predictors of functional outcome at a mean follow-up of 4.5 years. Surgical management likely conveys the greatest functional benefit when the intra-articular gap exceeds 2.5 mm. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Laboratory Monitoring of Bone Tissue Remodeling after Augmentation of Impression Intraarticular Fracture with Different Types of Bone Graft.

The effects of bone graft materials on the inflammatory response and biochemical markers of bone remodeling were studied on a rabbit model of fracture augmentation with the following grafts: ß-tricalcium phosphate, demineralized bone matrix, nanostructured carbon implant, and porous titanium implant made by additive 3D printing. The markers of bone remodeling and the blood system response in the postoperative period were studied. It was found that porous titanium implant and ß-tricalcium phosphate induced osteogenesis and minimized osteoclastic resorption. Augmentation with nanostructured carbon implant and demineralized bone matrix stimulated the processes of osteoclastic resorption.

Clinical, radiological and patient-reported outcomes in intra-articular calcaneal fractures: Comparison of conservative and surgical treatment.

OBJECTIVES: This study aims to compare the radiological, clinical and patient-reported outcomes of patients with intra-articular calcaneus fractures treated conservatively or surgically. PATIENTS AND METHODS: Fifty-four patients (30 males, 24 females; mean age 41.0 years; range, 18 to 73 years) treated due to calcaneus fracture were included in the study. Twenty-nine patients underwent conservative treatment (group 1) and 25 patients underwent surgical treatment (group 2). The fractures were classified according to Sanders. At the final follow-up, patients' Bohler's angle, The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score and Foot Function Index (FFI) were used to evaluate their radiological, clinical and patient-reported outcomes. Postoperative complications were also noted. RESULTS: The fracture was at the right foot in 28 patients and the left foot in 26 patients. The mean follow-up duration was 41.1±23.2 months (range, 24 to 126 months). No statistically significant differences were found between the groups in terms of gender, fracture side, mean age, or follow-up duration (p=0.951, p=0.571, p=0.326, and p=0.620, respectively). According to Sanders classification, 18 patients were type 2 and 11 patients were type 3 in group 1, while 11 patients were type 2 and 14 patients were type 3 in group 2. However, there was no statistically significant difference between the groups in terms of the type of the fracture (p=0.184). On the other hand, the outcomes were significantly better for group 2 compared to group 1 in terms of the Bohler's angle, AOFAS and FFI scores (p=0.004, p=0.003 and p=0.006, respectively). In group 1, subtalar arthritis developed in three patients. In group 2, wound healing problems and superficial infection developed in three patients, while subtalar arthritis developed in two patients. CONCLUSION: Surgical treatment is more effective in intra-articular calcaneus fractures compared to conservative treatment according to clinical, radiological and patient-reported outcomes. In addition, wound problems should be considered in surgical management.

Pediatric Hand and Wrist Fractures.

Hand and wrist fractures are common in the pediatric population. Accurate diagnosis relies on the understanding of the physeal anatomy and carpal ossification. Treatment of these fractures is largely influenced by physeal biology and compliance with treatment. A majority have a favorable outcome with nonoperative treatment. Operative treatment should be considered in patients with clinical deformity, open fractures, and significant fracture displacement. Physeal-friendly surgical approaches and implants should be used to minimize the sequelae of physeal injury.

Matrix-associated stem cell transplantation is successful in treating talar osteochondral lesions.

PURPOSE: Osteochondral lesions (OCLs) of the talus are a challenging and increasingly recognized problem in chronic ankle pain. Many novel techniques exist to try and treat this challenging entity. Difficulties associated with treating OCLs include lesion location, size, chronicity, and problems associated with potential graft harvest sites. Matrix-associated stem cell transplantation (MAST) is one such treatment described for larger lesions > 15 mm2 or failed alternative therapies. This cohort study describes a 3 year review of the outcomes of talar lesions treated with MAST. METHODS: A review of all patients treated with MAST by a single surgeon was conducted. Pre-operative radiographs, MRIs, and FAOS outcome questionnaire scores were reviewed. Intraoperative classification was undertaken to correlate with imaging. Post-operative outcomes included FAOS scores, return to sport, revision surgery/failure of treatment, and progression to ankle fusion. RESULTS: In this study, 38 OCLs in 32 patients were identified. Median patient age was 35 years of which (68.8%) were male. Median length of follow-up was 36.7 months (range 12-64 months). (83%) returned to playing sport. Twenty-three patients underwent MAST in the setting of a failed previous operative attempt, with just nine having MAST as a first option. Nine patients out of 32 had a further procedure. Improvements were seen in all domains of the FAOS (p < 0.05). CONCLUSION: MAST has demonstrated encouraging results in lesions which prove challenging to treat, even in a "failed microfracture" cohort. LEVEL OF EVIDENCE: IV.

Clinical Management of Acute, Closed Displaced Intra-Articular Calcaneal Fractures.

Performing a thorough clinical evaluation following an acute displaced intra-articular calcaneal fracture is paramount for optimal surgical timing and long-term outcome. Initial survey must entail a comprehensive evaluation to rule out concurrent injuries. Focused lower extremity examination must involve a complete neurovascular and soft tissue evaluation to identify such conditions as compartment syndrome or compromised integument, which necessitate urgent intervention. Establishing baseline radiographs and advanced imaging is vital for surgical planning. Once deemed stable, protocol-driven treatment is best to ensure proper control of pain and edema and adequate management of economic and patient safety concerns.

Fractures of the anterior process of the calcaneum; a review and proposed treatment algorithm.

BACKGROUND: There remains a lack of recognition of these fractures, which leads to a delay in diagnosis and appropriate management. METHODS: A comprehensive literature search was performed. Following inclusion and exclusion criteria, 23 studies were available for analysis. RESULTS: Delay in diagnosis is common and has a negative impact on outcome. If an APC fracture is suspected; anteroposterior, lateral and oblique plain radiographs should be requested. Further investigation with computed tomography or magnetic resonance imaging is indicated if plain radiographs are inconclusive and patient remains symptomatic. Non-operative measures are usually adequate for most undisplaced fractures, however surgical intervention maybe required for large, intra-articular fractures in the acute setting and for non-union. CONCLUSIONS: A treatment algorithm is suggested that may help with the diagnosis and management of these injuries. LEVEL OF EVIDENCE: Level IV.

Performance-Based Outcomes Following Lisfranc Injury Among Professional American Football and Rugby Athletes.

Professional National Football League (NFL) and rugby athletes have high rates of Lisfranc injuries. Although favorable return-to-play rates have been previously reported, a thorough assessment of postinjury performance is lacking. Professional NFL and rugby athletes who sustained a Lisfranc injury were identified using a well-established protocol confirmed by multiple sources of the public record. Return-to-play rate and time to return were determined for each athlete. League participation and game performance were collected 1 season prior to injury and up to 3 seasons after injury. Statistical analysis was performed, with P≤.05 being significant. A total of 47 athletes (NFL=35, rugby=12) with Lisfranc injuries were identified, having 23 ligamentous injuries and 24 fractures. Thirty-five (75%) were treated operatively. Among NFL players, 29 (83%) returned to play, taking 10.0±2.9 months to do so. Overall, NFL players started fewer games 2 and 3 seasons following surgery (P=.002 and .035, respectively) and showed a significant decline in performance 1 season after return compared with preinjury levels (21%; P=.05). Offensive players had a significantly greater decline in statistical performance compared with defensive counterparts (P=.02). Although professional NFL athletes return to play at a high rate (83%) following Lisfranc injury, their league participation and performance is significantly decreased on return. Ligamentous and bony injuries have similar prognoses; however, offensive players show greater declines in performance compared with defensive players. To best guide therapy, players, coaches, and team physicians should be aware of the impact of Lisfranc injuries on career performance and longevity. [Orthopedics. 2018; 41(4):e479-e482.].

Platelet rich concentrate enhances mesenchymal stem cells capacity to repair focal cartilage injury in rabbits.

BACKGROUND: It has been previously suggested that the use of regenerative promoters, which include bone marrow-derived mesenchymal stem cells (MSCs) or natural growth factors supplement such as platelet-rich concentrate (PRC) could promote cartilage regeneration. However, the notion that the concurrent use of both promoters may provide a synergistic effect that improves the repair outcome of focal cartilage injury has not been previously demonstrated. This study was thus conducted to determine whether the concomitant use of PRC could further enhance the reparative potential of MSCs encapsulated in alginate transplanted into focal cartilage injury in rabbits. METHODS: Artifically created full thickness cartilage defects were made on the weight-bearing region of medial femoral condyles in bilateral knees of New Zealand White rabbits (N = 30). After one month, the right knee was treated with either i) PRC (n = 10), ii) MSCs (n = 10), or, iii) a combination of PRC and MSCs (PRC + MSC) (n = 10), all encapsulated in alginate. The left knee remained untreated (control). Rabbits were sacrificed at 3 and 6 months after treatment. Cartilage tissue regeneration was accessed using ICRS morphologic scoring, histologic grading by O'Driscoll scoring, immunohistochemical staining and quantitative analysis of glycosaminoglycans (GAG) per total protein content. RESULTS: At 3 months, transplantation using PRC alone was equally effective as MSCs in inducing the repair of cartilage defects. However, PRC + MSC resulted in significantly higher ICRS and O'Driscoll scores (p < 0.05) as compared to other groups. The regenerated tissues from the PRC + MSC group also had stronger staining for Safranin-O and collagen type II. By 6 months, in addition to superior ICRS and O'Driscoll scores as well as stronger staining, glycosaminoglycan per total protein content was also significantly higher (p < 0.05) in the PRC + MSC group (3.4 ±â€¯0.3 µg/mg) as compared to the MSC (2.6 ±â€¯0.2 µg/mg) or PRC (2.1 ±â€¯0.2 µg/mg) groups. CONCLUSION: PRC enhances the reparative effects of MSC in treating focal articular cartilage injuries.

Osteochondral Injuries of the Knee in Pediatric Patients.

Osteochondral injuries in pediatric patients may occur as a result of a traumatic injury or secondary to an osteochondritis dissecans (OCD) lesion. Lateral patella dislocation is a common traumatic cause of osteochondral injury that typically occurs at the medial facet of the patella or at the lateral aspect of the distal femur. Multiple theories have been proposed for the cause of an OCD lesion in the knee, including trauma or repetitive microtrauma, local vascular insufficiency, and family history. The most "classic" location for OCD lesions of the knee is the lateral aspect of the medial femoral condyle of the distal femur. Multiple treatment options are available for both traumatic osteochondral injuries and OCD lesions, with important determining factors of treatment being skeletal maturity of the patient, instability of the fragment, lesion location, and size of the lesion. Nonsurgical management is appropriate in some situations. Surgical options range from simple fragment excision to internal fixation of the fracture fragment to more complex cartilage restoration or replacement procedures. This special focus section will discuss the diagnosis and treatment options for traumatic osteochondral knee injuries, including the subset secondary to juvenile OCD lesions.

Intra-articular distal radius fractures in elderly patients: a randomized prospective study of casting versus volar plating.

We compared outcomes in elderly patients with intra-articular distal radius fractures treated by closed reduction and plaster immobilization or open reduction and internal fixation with a volar plate. Ninety-seven patients older than 60 years were randomly allocated to conservative (47 patients) or surgical (50 patients) treatment. Over a 2-year period, we assessed patient-rated wrist evaluation score, DASH (disability arm, shoulder and hand) questionnaire, pain, wrist range of motion, grip strength, and radiological parameters. The functional outcomes and quality of life were significantly better after volar plating fixation compared with conservative treatment. We found that restoration of the articular surface, radial inclination, and ulnar variance affected the outcomes, but the articular step-off did not. Twenty-five per cent of the patients with conservative treatment had secondary loss of reduction. We conclude that surgical plating leads to better outcomes than conservative treatment for elderly patients with intra-articular distal radius fractures. LEVEL OF EVIDENCE: I.

A case report of Schatzker type VI tibial plateau fracture treated with double reverse traction closed reduction combined with minimally invasive percutaneous plate osteosynthesis technique: A case report.

RATIONALE: The knee joint is an important weight-bearing joint, tibial plateau fractures affect knee function and stability. High-energy intra-articular fractures involving the tibial plateau can cause management-related problems such as wound dehiscence; severe comminution leading to malalignment; and delayed complications such as varus collapse, implant failure, and arthritis of the knee joint. The treatment of severe or complex tibial plateau fractures can be quite difficult. Traditional methods of open reduction and plating require extensive exposures, which may further compromise soft tissue and devascularize bone fragments, leading to infection. In this case, a novel device, double reverse traction combined with MIPPO technique, was used and provided the possibility of minimally invasive and personalized orthopedic surgery to treat severe comminuted Schatzker type VI tibial plateau fracture and tibial shaft fracture and got satisfactory results. PATIENT CONCERNS: A previously healthy 56-year-old man presented to the emergency room after a fall from a height, who lost the movement of the left knee with pain and swelling. DIAGNOSES: X-rays showed a tibial plateau comminuted fracture, Schatzker type VI, and tibial shaft fracture. INTERVENTIONS: Applying less extensile exposure and the indirect reduction technique of double reverse traction and closed reduction combined with minimally invasive percutaneous plate osteosynthesis (MIPPO) technique, we got satisfactory recovery of the severe comminuted Schatzker type VI tibial plateau fracture and tibial shaft fracture. OUTCOMES: This severe comminuted fracture and tibial shaft fracture were successfully reduced and got satisfactory recovery of knee joint function. LESSONS: Double reverse traction combined with MIPPO technique can reduce the risk of surgical complications, such as bleeding, oozing, and wound infection. It can be applied in patients with comorbidities such as cardiac disease, hypertension, and heart failure who may otherwise not be candidates for surgery. The cost burden is lower than that of the traditional traction table.

Evaluation and quantification of geographical differences in wound complication rates following the extended lateral approach in displaced intra-articular calcaneal fractures - A systematic review of the literature.

INTRODUCTION: Calcaneal fracture surgery is often performed via the extended lateral approach (ELA). Large differences are reported in literature on wound complication rates. Aim was to perform a systematic review on reported postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following the ELA and evaluate and quantify geographical differences. METHODS: A literature search was conducted in the MEDLINE and EMBASE databases and Cochrane Library. Studies before 2000, with <10 patients, biomechanical studies and reviews were excluded. No restrictions regarding language were applied. RESULTS: 3068 articles were identified of which 123 were included, with 8584 calcaneal fractures in 28 different countries. The average total number of POWC was 14.3%, with 3.8% of superficial and 2.2% of deep infections. The highest POWI rate was found in Europe (12.1%) and the lowest in North America (2.8%). A significant difference in incidence of deep POWI between continents was detected (median 0-3.8%). No differences were found in incidence of POWC and POWI between retro- and prospective studies (respectively p=0.970, p=0.748) or studies with <10 or ≥10 operations per year (respectively p=0.326, p=0.378). However, lower rates of POWI were found in studies with a follow up of >3months (p=0.01). CONCLUSION: Large differences were detected in incidence of POWC and POWI following calcaneal fracture surgery with the ELA between countries and continents. We did not find a lower POWC or POWI rate in retrospective studies compared to prospective studies, larger studies or in studies in which more patients were treated annually. However, the rate of POWI was significantly lower in studies with a follow up of >3months. We advise the use of a reliable postoperative complication registration system and uniformity in the use of standardized definitions of wound complications for calcaneal fracture surgery.

Relevance of MRI for management of non-displaced lateral humeral condyle fractures in children.

INTRODUCTION: The treatment for non-displaced (<2 mm displacement) fractures of the lateral humeral condyle in children is controversial. Most studies recommend non-surgical treatment. However, plain radiographs are not sufficient to evaluate extension of the fracture line through the articular cartilage. This explains the high frequency of secondary displacements and non-unions, despite well-conducted conservative treatment. We hypothesized that MRI could be used to analyse whether the fracture is complete or incomplete. This could help to determine whether surgical or conservative treatment is indicated. MATERIAL AND METHODS: This prospective study enrolled children being treated for a non-displaced (< 2 mm gap) fracture of the lateral humeral condyle. All patients were treated with a long-arm cast in the emergency room. An MRI was done later on without sedation. A specific protocol was used to reduce the duration of the examination. T2-weighted and proton density fat-saturated sequences were used. RESULTS: Twenty-seven patients were enrolled: 16 boys and 11 girls with a mean age of 5 years (2-10). The MRI was performed an average of 7 days (1-23) after the fracture. The MRI could not be interpreted in two cases because the child had moved during the examination. In the other 25 patients, the fracture was incomplete in 17 patients and complete in 8 patients. Two children had secondary displacement diagnosed 7 and 11 days after the fracture event. These two patients underwent open reduction and internal fixation. There was no correlation between patient age and the fracture being complete or incomplete. There were no cases of non-union. CONCLUSION: MRI appears to be a reliable method for determining whether the fracture line is complete or incomplete. It can be performed without sedation, even in children as young as 2 years of age. Use of an injury-specific MRI protocol reduces the length of the examination, thereby improving its performance. We recommend that it be used to analyse non-displaced fractures of the lateral humeral condyle in children. LEVEL OF EVIDENCE: 3 Prospective study.