Syndesmosis Malposition Assessed on Weight-Bearing CT Is Common After Operative Fixation of Intra-articular Distal Tibia Plafond Fracture.

OBJECTIVES: To evaluate reliability of measurement techniques for syndesmosis position after operative fixation of distal tibia plafond fracture on weight-bearing computed tomography (WBCT), identify risk factors for syndesmosis malposition, and determine if syndesmosis malposition is associated with higher pain and lower physical function. DESIGN: Prospective cohort study. SETTING: Three Level 1 trauma centers. PARTICIPANTS: Twenty-six subjects who underwent open reduction and internal fixation of distal tibia plafond fractures with bilateral ankle WBCT 1 year or greater after injury were included in the study. INTERVENTION: Operative fixation of distal tibia plafond fracture. MAIN OUTCOME MEASUREMENT: Fibula position in the tibia incisura, injury characteristics, and patient-reported outcomes were the main outcome measurements. RESULTS: Interrater reliability for syndesmosis position measurements were excellent for the Phisitkul technique on both injured and healthy ankles (intraclass correlation coefficients [ICCs]: 0.93-0.98). The Nault technique demonstrated moderate-to-excellent interrater reliability (ICCs: 0.67-0.98), apart from the angle of rotation measurement (ICCs: 0.18-0.67). Sixteen of 26 subjects (62%) had syndesmosis malposition defined as >2 mm difference comparing the tibial-fibular relationship in injured and uninjured ankles using these 2 methods. Patients with syndesmosis malposition reported lower Foot and Ankle Ability Measure: Activities of Daily Living scores; other recorded patient-reported outcomes were not significantly different. CONCLUSIONS: Measurement techniques for syndesmosis position on WBCT were reliable after operative fixation of distal tibia plafond fracture. Syndesmosis malposition is common after these injuries and predicted impaired physical function. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Resident education in orthopaedic trauma: the future role of competency-based medical education.

As residency training programmes around the globe move towards competency-based medical education (CBME), there is a need to review current teaching and assessment practices as they relate to education in orthopaedic trauma. Assessment is the cornerstone of CBME, as it not only helps to determine when a trainee is fit to practice independently, but it also provides feedback on performance and guides the development of competence. Although a standardised core knowledge base for trauma care has been developed by the leading national accreditation bodies and international agencies that teach and perform research in orthopaedic trauma, educators have not yet established optimal methods for assessing trainees' performance in managing orthopaedic trauma patients. This review describes the existing knowledge from the literature on assessment in orthopaedic trauma and highlights initiatives that have recently been undertaken towards CBME in the United Kingdom, Canada and the United States. In order to support a CBME approach, programmes need to improve the frequency and quality of assessments and improve on current formative and summative feedback techniques in order to enhance resident education in orthopaedic trauma. Cite this article: Bone Joint J 2016;98-B:1320-5.

Healing results of periprosthetic distal femur fractures treated with far cortical locking technology: a preliminary retrospective study.

INTRODUCTION: Periprosthetic distal femur fractures are severe injuries occurring in the often osteoporotic bone of the elderly. Far cortical locking (FCL) screws, which have been shown to promote increased callus formation in animal models, have recently become available for clinical use. The purpose of this study is to report preliminary healing and complication rates of periprosthetic distal femur fractures treated with FCL constructs. MATERIALS AND METHODS: A retrospective review of 20 patients who underwent open reduction and internal fixation of periprosthetic distal femur fractures using FCL constructs was performed. Healing was assessed radiographically and clinically at 6, 12 and 24 weeks post-operatively. Construct failure was defined as any hardware breakage or bone-implant dissociation leading to loss of reduction. RESULTS: Complete data through the 24 week study period was available for 18/20 patients. Bridging callus was identified in 16/18 patients by the 24 week follow up for a healing rate of 88.9%. In patients that healed, the average time to medial bridging callus formation was 10.7 ± 6.7 weeks, 11.0 ± 6.6 weeks for anterior fracture line and 13.4 ± 7.5 weeks for the posterior fracture line. both patients that failed to heal underwent revision surgery. DISCUSSION: The initial results of this study are comparable to results reported for distal femur periprosthetic fractures treated with locking plate fixation without FCL screws, although it was difficult to compare time to healing between previously published studies. It is the impression of the authors that callus appears earlier and is more robust and uniform between the three cortices in FCL cases compared to their previous experiences with traditional locking plate periprosthetic distal femur fractures. This work suggests that FCL screws may be superior to traditional locking constructs but further studies are needed to directly compare the two methods.

Far cortical locking technology for fixation of periprosthetic distal femur fractures: a surgical technique.

Far cortical locking screws have been shown to form greater amounts of callus in ovine studies when compared to traditional locking plates. These screws have recently become available for clinical use. This article describes the indications and surgical technique for far cortical locking screws, with a focus on distal femur periprosthetic fractures.

Locking plates for distal femur fractures: is there a problem with fracture healing?

OBJECTIVES: Fractures of the distal femur are severe injuries that present many clinical challenges. Nonunion, delayed union, implant failure, and the need for secondary procedures can reflect complications of healing. This article reviews the literature on distal femur fractures treated with locking plates to determine the reported rate of healing difficulties. DATA SOURCES: The PubMed database and the Orthopaedic Trauma Association and American Academy of Orthopedic Surgeons abstract archives were searched for studies including the key words distal femur fracture, supracondylar femur fracture, or locking plate from the year 2000 to the present. STUDY SELECTION: Reports were included when distal femur fractures were treated with locking plates and when the number of healed fractures was identified in the study. The reported healing rates and the rate of healing complications were determined from the studies. The time to implant failure was recorded. Those articles that included periprosthetic fractures were separated from those only including acute distal femur fractures. DATA SYNTHESIS: Fifteen full-length publications and three abstracts were included. The rate of complications related to healing ranged from 0% to 32% in these studies. Implant failures occurred late with 75% of the failures occurring after 3 months and 50% occurring after 6 months. CONCLUSIONS: Complications of healing including nonunion, delayed union, and implant failure are not infrequent and represent ongoing problems with distal femur fracture treatment. Further clinical research combined with innovation in surgical techniques and implant design will be necessary to improve the results of the last decade.

A Percutaneous Technique for Reduction and Internal Fixation of Displaced Intra-Articular Calcaneal Fractures.

INTRODUCTION: A retrospective cohort study demonstrated that, in comparison with open reduction and internal fixation through an extensile lateral approach, our percutaneous technique for reduction and internal fixation of displaced intra-articular calcaneal fractures decreases the rate of complications and achieves and maintains extra-articular fracture reductions just as well. STEP 1 PATIENT POSITIONING AND IMAGING: Position the patient correctly to obtain excellent fluoroscopic views, which are key to the procedure. STEP 2 FRACTURE REDUCTION: The techniques for reducing and fixing joint depression and tongue-type calcaneal fractures differ and will be described separately. STEP 3 SCREW FIXATION: Identify screw entry points and paths using fluoroscopic images, and confirm the final positions with c-arm imaging. STEP 4 POSTOPERATIVE MANAGEMENT: Apply a splint; then obtain postoperative images to confirm fracture reduction and screw placement. RESULTS & PREOP/POSTOP IMAGES: The results of percutaneous reduction of displaced intra-articular calcaneal fractures in seventy-nine patients with a total of eighty-three fractures were compared with those obtained by another surgeon using the extensile lateral approach. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.

Acute articular fracture severity and chronic cartilage stress challenge as quantitative risk factors for post-traumatic osteoarthritis: illustrative cases.

Novel biomechanical methods have been developed to objectively measure acute fracture severity (from inter-fragmentary surface area) and chronic contact stress challenge (from patient-specific finite element analysis) in articular fractures. These new methods help clarify the pathomechanics of the development of post-traumatic osteoarthritis, and can contribute directly to the clinical care of patients. In this manuscript, the value of these two new measures is demonstrated in three illustrative tibial plafond fracture cases, in which both metrics are correlated with cartilage status and with patient outcomes at a minimum of two years after injury. These clinical cases demonstrate the utility of new biomechanical variables to advance clinical research and patient care, by providing a basis to predict outcome and select treatment.

Does a trauma course improve resident performance on the trauma domain of the OITE?

BACKGROUND: Lecture-based courses are common in orthopaedic surgery; however, their effectiveness in improving medical knowledge has not been widely assessed. The Orthopaedic Trauma Association conducts a resident trauma course that occurs four to six weeks prior to the Orthopaedic In-Training Examination (OITE). The purposes of this study were to determine whether residents who had taken this course performed better on the trauma domain of the OITE and to compare the effect of the course with the effect of a focused rotation in orthopaedic trauma. METHODS: The percentile scores on the trauma domain of the OITE for forty-seven residents in postgraduate year (PGY) 2 were reviewed. Twenty-nine residents who took a trauma course within six weeks before the OITE were compared with eighteen residents who took the course after the OITE. As a secondary analysis, the effect of a trauma rotation for the same PGY-2 residents before and after the OITE was also assessed. Baseline orthopaedic knowledge was assessed with use of the overall OITE percentage scores. RESULTS: The trauma domain scores were not significantly better among the residents who took the course (mean and standard deviation, 62.2 ± 9.9) compared with those who had not taken it (mean, 59.2 ± 6.2) (p = 0.2). A significant difference (p = 0.04) was found for a trauma rotation, with the residents who had a trauma rotation scoring better (mean, 64.5 ± 6.8) than the residents who had not (mean, 58.8 ± 8.9). The subgroup of residents who had both a course and a trauma rotation before the test scored significantly better (p = 0.01) than the subgroup that had neither of these experiences before the test (mean, 65.6 ± 8.0 and 56.9 ± 6.4, respectively). CONCLUSIONS: An orthopaedic trauma course alone does not enhance an orthopaedic resident's trauma medical knowledge as assessed on a standardized test. However, a trauma rotation before, and in particular the combination of both a course and a trauma rotation, can improve trauma test scores.

Percutaneous reduction and fixation of displaced intra-articular calcaneus fractures.

OBJECTIVES: The purpose of this study is to assess the initial results of percutaneously reducing and fixing calcaneus fractures compared with a concurrent control group that was openly reduced and internally fixed through an extensile lateral approach. DESIGN: Retrospective cohort study, consecutive series. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: One hundred twenty patients with 125 intra-articular calcaneus fractures were selected as a consecutive series with treatment method randomized by surgeon and time of presentation. INTERVENTION: Patients treated with open reduction and internal fixation (OR group) had an extended lateral approach and fractures were fixed with plates and screws. Patients treated with percutaneous reduction (PR group) had small incisions with indirect fragment manipulation, and the reduction achieved was secured with screws alone. MAIN OUTCOME MEASUREMENT: Clinical and radiographic assessment. RESULTS: There were 41 patients with 42 fractures in the OR group and 79 patients with 83 fractures in the PR group. There were no significant differences in sex, age, open fractures, fracture classification, or initial Bohler's angle between the two groups. Bohler's angle was improved after surgery by an average of 22.4 degrees in the OR group and 25.3 degrees in the PR group (P = 0.31). The average loss of reduction at healing (minimum 4 months postoperatively) was not significantly different between the two groups. Deep infection occurred in six of 42 of the OR group and zero of 83 of the PR group (P = 0.002). The incidence of minor wound complications was nine of 42 in the OR group and five of 83 in the PR group (P = 0.03). The need for late subtalar fusions (two of 26 and three of 41 with full 2-year follow-up) and implant removal (five of 42 and 10 of 83) was not significantly different. CONCLUSIONS: The results of this study suggest that in comparison to open reduction, this method of percutaneously reducing and fixing calcaneus fractures minimizes complications and achieves and maintains extra-articular reductions as well as the standard extensile open reduction and internal fixation. Further study of this technique is warranted. This should include assessment of articular reduction and longer follow-up of a larger number of patients.

A Wnt kinase network alters nuclear localization of TCF-1 in colon cancer.

Constitutive activation of the Wnt/beta-catenin pathway has been implicated as the primary cause of colon cancer. However, the major transducers of Wnt signaling in the intestine, T-cell factor 1 (TCF-1) and TCF-4, have opposing functions. Knockout of TCF-4 suppresses growth and maintenance of crypt stem cells, whereas knockout of TCF-1 leads to adenomas. These phenotypes suggest that TCF-4 is Wnt-promoting, whereas TCF-1 acts like a tumor suppressor. Our study of TCF expression in human colon crypts reveals a mechanistic basis for this paradox. In normal colon cells, a dominant-negative isoform of TCF-1 (dnTCF-1) is expressed that is equally distributed between nuclear and cytoplasmic compartments. In colon cancer cells, TCF-1 is predominantly cytoplasmic. Localization is because of active nuclear export and is directed by an autocrine-acting Wnt ligand that requires Ca2+/calmodulin-dependent kinase II (CaMKII) activity for secretion and a downstream step in the export pathway. TCF-4 remains nuclear; its unopposed activity is accompanied by downregulation of dnTCF-1 and increased expression of full-length isoforms. Thus, the dnTCF-1 and TCF-4 balance is corrupted in cancer by two mechanisms, a Wnt/CaMKII kinase signal for nuclear export and decreased dnTCF-1 expression. We propose that dnTCF-1 provides homeostatic regulation of Wnt signaling and growth in normal colon, and the alterations in nuclear export and promoter usage contribute to aberrant Wnt activity in colon cancer.