Transcutaneous osseointegration for amputees.

Transcutaneous osseointegration for amputees (TOFA) is an evolving technology that has the potential to revolutionize the interface between the amputee and their prosthesis, showing potential at many levels of amputation. While no amputation is without its challenges, TOFA requires a highly specialized prosthesis and a multidisciplinary team that includes specialized surgeons, physical therapists, wound care teams, and social workers who guide the amputee through surgery, postoperative rehabilitation, and the chronic wound care that goes into maintaining the prosthesis. The infrastructure required to facilitate care pathways that lead to reliable, successful outcomes are unique in each health care setting, including those in advanced health care systems such as the United States and Australia. This article details the emerging evidence supporting the use of this prosthetic interface design and many of the challenges that providers face when establishing programs to offer this type of care in the United States.

The local and systemic effects of immune function on fracture healing.

The immune system plays an integral role in the regulation of cellular processes responsible for fracture healing. Local and systemic influences on fracture healing correlate in many ways with fracture-related outcomes, including soft tissue healing quality and fracture union rates. Impaired soft tissue healing, restricted perfusion of a fracture site, and infection also in turn affect the immune response to fracture injury. Modern techniques used to investigate the relationship between immune system function and fracture healing include precision medicine, using vast quantities of data to interpret broad patterns of inflammatory response. Early data from the PRECISE trial have demonstrated distinct patterns of inflammatory response in polytrauma patients, which thereby directly and indirectly regulate the fracture healing response. The clearly demonstrated linkage between immune function and fracture healing suggests that modulation of immune function has significant potential as a therapeutic target that can be used to enhance fracture healing.

Fracture healing-orthobiologics: from basic science to clinical application.

Orthopaedics as a field and a profession is fundamentally concerned with the treatment of musculoskeletal disease, in all of its many forms. Our collective understanding of the cellular mechanisms underlying musculoskeletal pathology resulting from injury continues to evolve, opening novel opportunities to develop orthobiologic treatments to improve care. It is a long path to move from an understanding of cellular pathology to development of successful clinical treatment, and this article proposes to discuss some of the challenges to achieving translational therapies in orthopaedics. The article will focus on challenges that clinicians will likely face in seeking to bring promising treatments forward to clinical practice and strategies for improving success in translational efforts.

Osteoporosis and Fragility Fractures.

Osteoporosis and fragility fractures (FFs) are closely intertwined as the former is a common predisposing factor to the latter. This causal relationship is due to low bone density of osteoporosis and compromised bone microarchitecture, leading to structural failure, decreased ability to withstand applied stresses, and increased propensity to fracture. Osteoporosis can be idiopathic or due to a variety of secondary causes, and numerous treatment strategies are available. FFs are common injuries among the elderly and are caused by factors both intrinsic and extrinsic to the patient. The clinical and economic significances of osteoporosis and FFs are substantial, with considerable associated morbidity and mortality, and billions spent on healthcare expenditures in the US annually. Osteoporosis and FFs are two of the most important topics related to fracture liaison services (FLSs), and their understanding is integral to appreciating the benefits an FLS can provide for patients and providers.

Long-term Orthopedic Manifestations of COVID-19: Heterotopic Ossification and Digital Necrosis.

Despite its classification as an atypical pneumonia, COVID-19 is a disease that is capable of inflicting damage beyond the respiratory system. The wide range of musculoskeletal complications secondary to acute COVID-19 are a significant source of morbidity in hospitalized patients. We present the case of a 23-year-old woman with severe COVID-19 who required intubation and had a prolonged hospital course that was complicated by partial-thickness necrosis of her fingers and heterotopic ossification of the distal thigh. We review current treatments for these orthopedic conditions in the setting of SARS-CoV-2 infection as well as highlight areas for future research. Additionally, we discuss the subacute musculoskeletal complications of COVID-19, which are among the most common long-term manifestations of the disease and are increasingly important for a growing number of COVID-19 survivors.

Successful Fracture Healing for Femoral Neck Nonunion with Bone Marrow Aspirate Concentrate.

INTRODUCTION: Femoral neck fractures in the young patient require prompt anatomic reduction and stabilization to preserve the vascular supply to the femoral head and minimize future need for arthroplasty. Secondary to unique biomechanical and vascular considerations, these injuries are prone to nonunion. CASE REPORT: A 29-year-old male with a chronic femoral neck fracture nonunion who experienced successful fracture healing and symptom resolution following Bone Marrow Aspirate Concentrate (BMAC) administration. DISCUSSION: Femoral neck nonunion in young patients is a challenging problem with treatment strategies aimed at improving the biological and biomechanical fracture environment. While the use of both vascularized and nonvascularized bone grafting has shown promising results, they have high complication rates and substantial donor site morbidity. BMAC has demonstrated multiple uses throughout orthopedic surgery and may result in an improved fracture healing environment with minimal patient morbidity. CONCLUSION: The success of the BMAC procedure for this patient is promising and may be considered in similar patients, with or without revision internal fixation methods.

"Stress taper" fixation increases torsional failure strength in a cadaveric femur model.

BACKGROUND: To potentially limit peri-implant fractures our institution commonly implements a "stress-taper" fixation construct in which the screw lengths towards the proximal end of a construct are incrementally decreased, in order to avoid a focal stress-riser when loaded. To assess this construct, we asked: 1) Does the stress taper strategy increase torsional strength than the bicortical locking construct when biomechanically tested in a cadaveric femur model? 2) Does it fail in a less comminuted fracture pattern? METHODS: Seven matched pairs of cadaveric femora were randomly assigned to one of two distal femur fixation groups: plating with stress taper strategy or bicortical fixation. Specimens were first cyclically loaded, then axially rotated to failure under 800 N of compression. Peak torque at failure, degrees of rotation at failure, and energy to failure were calculated and compared using paired t-tests. Fractures were categorized with the assistance of fluoroscopy according to the Orthopedic Trauma Association classification, 32. FINDINGS: There was significantly greater peak torque (110.6 ± 49.7 Nm vs. 80.6 ± 35.2 Nm), rotation at failure (23.8 ± 5.3° vs 18.9 ± 4.5°) and energy to failure (25.3 ± 15.7 J vs. 14.1 ± 8.3 J) in the stress-taper group as compared to the bicortical group (p = 0.0424), (p = 0.0213) and (p = 0.0460), respectively. 6/7 fractures in the stress-taper group were classified 32 A1 with 1/7 classified A2. 5/7 fractures in the bicortical group were classified B1 and 2/7 classified A2. INTERPRETATION: 'Stress taper fixation' in distal femurs may be protective against peri-implant fractures compared to traditional bicortical fixation. The 'stress taper' concept can increase torsional failure strength in an in vitro model.

Antioxidant Activity and Cytotoxicity against Cancer Cell Lines of the Extracts from Novel Xylaria Species Associated with Termite Nests and LC-MS Analysis.

Xylaria species associated with termite nests or soil have been considered rare species in nature and the few which have been reported upon have been found to act as a rich source of bioactive metabolites. This study evaluated 10 ethyl acetate extracts of five new Xylaria species associated with termite nests or soil for their antioxidant activity, and cytotoxicity against different cancer and normal cell lines. DPPH and ABTS radical scavenging activities of the extracts demonstrated strong capacity with low IC50 values. The highest observed activities belonged to X. vinacea SWUF18-2.3 having IC50 values of 0.194 ± 0.031 mg/mL for DPPH assay and 0.020 ± 0.004 mg/mL for ABTS assay. Total phenolic content ranged from 0.826 ± 0.123 to 3.629 ± 0.381 g GAE/g crude extract which correlated with antioxidant activities. The high total phenolic content could contribute to the high antioxidant activities. Cytotoxicity was recorded against A549, HepG2, HeLa and PNT2 and resulted in broad spectrum to specific activity depending on the cell lines. The highest activities were observed with X. subintraflava SWUF16-11.1 which resulted in 11.15 ± 0.32 to 13.17 ± 2.37% cell viability at a concentration of 100 µg/mL. Moreover, LC-MS fingerprints indicated over 61 peaks from all isolates. There were 18 identified and 43 unidentified compounds compared to mass databases. The identified compounds were from various groups of diterpenoids, diterpenes, cytochalasin, flavones, flavonoids, polyphenols, steroids and derivatives, triterpenoids and tropones. These results indicate that Xylaria spp. has abundant secondary metabolites that could be further explored for their therapeutic properties.

Bone healing: Advances in biology and technology.

Fracture healing is a complex cascade of cellular and molecular processes. These processes require the appropriate cellular and molecular environment to ensure the restoration of skeletal stability and resolution of inflammation. In order for fracture healing to occur, the necessary building blocks for bone metabolism and synthesis must be supplied through proper nutrition. Pharmacologic therapies aimed at modulating the inflammatory response to fractures have the potential to interfere with the synthesis of molecules needed for the production of bone. Infection can interfere with, and even prevent normal fracture healing from occurring. Cellular and genetic treatment strategies are actively being developed to target deficiencies, and bridge gaps that can influence how fractures heal. Evolving technologies, including nutritional supplementation, pharmacotherapies, antibiotics, surgical techniques, as well as genetic and cellular therapies, have the potential to enhance, optimize, and even revolutionize the process of fracture healing.

The effect of trichloroethylene metabolites on the hepatic vitamin B12-dependent methionine salvage pathway and its relevance to increased excretion of formic acid in the rat.

The industrial solvent trichloroethylene (TCE) and its two major metabolites trichloroethanol (TCE-OH) and trichloroacetic acid (TCA) cause formic aciduria in male F344 rats. Prior treatment of male F344 rats with 1-aminobenzotriazole a cytochrome P450 inhibitor, followed by TCE (16mk/kg, po), completely prevented formic aciduria, but had no effect on formic acid excretion produced by TCA (8 or 16 mg/kg, po), suggesting TCA may be the proximate metabolite producing this response. Dow and Green reported an increase in the concentration of 5-methyltetrahydrofolate (5-MTHF) in the plasma of rats treated with TCE-OH, suggesting a block in the cycling of 5-MTHF to tetrahydrofolate (THF). This pathway is under the control of the vitamin B12-dependent methionine salvage pathway. We therefore treated rats with three daily doses of methylcobalamin (CH3Cbl) or hydroxocobalamin (OHCbl), a cofactor for methionine synthase, or L-methionine, followed by TCE (16 mg/kg) to determine if they could alleviate the formic aciduria. These pretreatments only partially reduced the excretion of formic acid in the urine. Although prior treatment with S-adenosyl-L-methionine had no effect on formic acid excretion. Consistent with these findings, the activity of methionine synthase in the liver of TCE-treated rats was not inhibited. Transcriptomic analysis of the liver-identified nine differential expressed genes, of note, was downregulation of Lmbrd1 involved in the conversion of vitamin B12 into CH3Cbl, a cofactor for methionine synthase. Our findings indicate that the formic aciduria produced by TCE-OH and TCA may be the result of a block in the recycling of 5-MTHF to THF, the effect on the methionine salvage pathway being a secondary response following acute exposure.

Opioid-Limiting Legislation Associated With Reduced Postoperative Prescribing After Surgery for Traumatic Orthopaedic Injuries.

OBJECTIVES: To evaluate opioid-prescribing patterns after surgery for orthopaedic trauma before and after implementation of opioid-limiting mandates in one state. DESIGN: Retrospective review. SETTING: Level-1 trauma center. PATIENTS/PARTICIPANTS: Seven hundred fifty-three patients (297 pre-law and 456 post-law) undergoing isolated fixation for 6 common fracture patterns during specified pre-law (January 1, 2016-June 28, 2016) and post-law (June 01, 2017-December 31, 2017) study periods. Polytrauma patients were excluded. INTERVENTION: Implementation of statewide legislation establishing strict limits on initial opioid prescriptions [150 total morphine milligram equivalents (MMEs), 30 MMEs per day, or 20 total doses]. MAIN OUTCOME MEASUREMENTS: Initial opioid prescription dose, cumulative MMEs filled by 30 and 90 days postoperatively. RESULTS: Pre-law and post-law patient groups did not differ in terms of age, sex, opioid tolerance, recent benzodiazepine use, or open versus closed fracture pattern (P > 0.05). The post-law cohort received significantly less opioids (363.4 vs. 173.6 MMEs, P < 0.001) in the first postoperative prescription. Furthermore, the post-law group received significantly less cumulative MMEs in the first 30 postoperative days (677.4 vs. 481.7 MMEs, P < 0.001); This included both opioid-naïve (633.7 vs. 478.1 MMEs, P < 0.001) and opioid-tolerant patients (1659.2 vs. 880.0 MMEs, P = 0.048). No significant difference in opioid utilization between pre- and post-law groups was noted after postoperative day 30. Independent risk factors for prolonged (>30 days) postoperative opioid use included male gender (odds ratio 2.0, 95% confidence interval 1.4-2.9, P < 0.001) and preoperative opioid use (odds ratio 5.1, 95% confidence interval 2.4-10.5, P < 0.001). CONCLUSIONS: Opioid-limiting legislation is associated with a statistically and clinically significant reduction in initial and 30-day opioid prescriptions after surgery for orthopaedic trauma. Preoperative opioid use and male gender are independently associated with prolonged postoperative opioid use in this population. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Growth inhibitory activity of biflavonoids and diterpenoids from the leaves of the Libyan Juniperus phoenicea against human cancer cells.

Three biflavonoids [cupressuflavone (1), amentoflavone (2), and sumaflavone (3)], four diterpenoids [13-epi-cupressic acid (4), imbricatholic acid (5), 3-hydroxy-sandaracopimaric acid (6), and dehydroabietic acid (7)], and one lignan [ß-peltatin methyl ether (8)] were isolated from the cytotoxic fractions of the extracts of the leaves of the Libyan Juniperus phoenicea L. The structures of these compounds were elucidated by spectroscopic means. Cytotoxicity of compounds 1-6 were assessed against the human lung cancer cell line A549 using the MTT assay. Compounds 1 and 3 showed cytotoxicity against the A549 cells (IC50  = 65 and 77 µM, respectively), whereas compound 2 did not show any activity. Diterpenes 4-6 exhibited weak cytotoxicity against the A549 cells with the IC50 values of 159, 263, and 223 µM, respectively. The cytotoxicity of each compound was compared with the anticancer drug, etoposide (IC50  = 61 µM). Cupressuflavone (1) was evaluated also for cytotoxicity against both the human PC3 cancer cell line and the normal prostate cell line (PNT2), and this compound revealed a high degree of cytotoxic selectivity towards the prostate cancer cells (PC3), with IC50 value of 19.9 µM, without any evidence of cytotoxicity towards the normal prostate cell line (PNT2).

Bioassay-guided isolation and structure elucidation of cytotoxic stilbenes and flavonols from the leaves of Macaranga barteri.

Bioassay-guided fractionation of the leaves of Macaranga barteri collected from Nigeria led to the isolation of three previously undescribed cytotoxic stilbenes, macabartebenes A-C (1-3), together with six known compounds including prenylated stilbenes: vedelianin (4), schweinfurthin G (5), and mappain (7), prenylated flavonols: 8-prenylkaempferol (6), and broussoflavonol F (8), and the geranylated flavonol, isomacarangin (9). The cytotoxicity of the compounds was evaluated against four human cancer cell lines, with vinblastine as the positive control and DMSO vehicle as the negative control. Vedelianin (IC50 = 0.32-0.54 µM) displayed the greatest antiproliferative activity across the panel of cancer cell lines amongst the compounds, while macabartebene A (IC50 = 0.60-0.79 µM) was the most potent of the previously unreported compounds. The compounds displayed varying selectivity towards the cancer cell lines compared to the normal human prostate cell line. The findings of this study revealed that M. barteri leaves contain several cytotoxic compounds.

Resveratrol derivatives from Commiphora africana (A. Rich.) Endl. display cytotoxicity and selectivity against several human cancer cell lines.

Commiphora africana (A. Rich.) Endl. (Burseraceae) is a medicinal plant widely used in Nigerian ethnomedicine. The in vitro cytotoxicity of the stem bark extract of C. africana and isolated cytotoxic compounds was investigated. Three resveratrol derivatives: (E)-resveratrol 3-O-rutinoside (1), 5-methoxy-(E)-resveratrol 3-O-rutinoside (2), and pinostilbene (3), together with 3-hydroxy-5-methoxybenzoic acid (4) were isolated from the methanol fraction of C. africana. Their structures were determined by extensive analysis of their HREIMS and NMR spectra. The cytotoxicity of the isolated compounds against four human carcinoma cells was determined using the MTT assay. Compound 1 displayed the highest antiproliferative effect on the cell lines, with IC50 values of 16.80, 21.74, 17.89, and 17.44 µM, against MCF7, A549, PC3, and HepG2 human cancer cell lines, respectively. In addition, compounds 1-3 showed low toxicity against normal human prostate cell line, with selectivity indices greater than five across the carcinoma cells, indicating that the compounds possess potential in the development of low-toxicity chemotherapeutic agents. These results support the traditional use of this plant in the treatment of cancer.

Acridone alkaloids from the stem bark of Citrus aurantium display selective cytotoxicity against breast, liver, lung and prostate human carcinoma cells.

ETHNOPHARMACOLOGICAL RELEVANCE: Citrus aurantium L. (Rutaceae) is used, either singly or as a part of a polyherbal preparation, in Nigerian traditional medicine for the management of cancer and inflammatory diseases. Currently, there is a dearth of knowledge demonstrating its anticancer potential. AIM OF THE STUDY: This study was carried out to determine the in vitro cytotoxicity of the crude extract of the stem bark of C. aurantium, identify and isolate the bioactive constituents and to establish the cytotoxicity of such constituents. MATERIALS AND METHODS: The powdered bark of C. aurantium was extracted by MeOH at room temperature (25-34 °C) and the crude extract was partitioned successively, with n-hexane, dichloromethane and methanol. Amongst the fractions, the DCM fraction was the most active and compounds were isolated from this fraction using a combination of chromatographic techniques. The structures of the isolated compounds were elucidated by spectroscopic means (MS, 1D and 2D NMR). The cytotoxicity of the extract, and the isolated compounds were evaluated by the MTT assay against four human cancer cell lines: A549 (lung), HepG2 (liver), MCF7 (breast) and PC3 (prostate). The selectivity of the isolated compounds was assessed using the normal human prostate epithelium cells (PNT2). RESULTS AND DISCUSSION: Of the three plant fractions, the DCM fraction showed significant cytotoxicity, with its highest activity against A549 cells (IC50 = 3.88 µg/mL) and the least activity on HepG2 cells (IC50 = 5.73 µg/mL). Six acridone alkaloids, citrusinine-I (1), citracridone-I (2), 5-hydroxynoracronycine (3), natsucitrine-I (4), glycofolinine (5) and citracridone-III (6), were isolated from the DCM fraction of C. aurantium. The isolated compounds demonstrated potent to moderate cytotoxicity (IC50 = 12.65-50.74 µM) against the cancer cells under investigation. It is noteworthy that the compounds exerted cytotoxicity at least four times more selective towards the carcinoma cells than the PNT2 cells. CONCLUSION: The results obtained from this study have provided some evidence for the ethnomedicinal use of C. aurantium against cancer and the acridone alkaloids present in its stem bark, have appeared to be responsible for the anticancer effects.

Analysis of mortality and fixation failure in geriatric fractures using quantitative computed tomography.

OBJECTIVES: While osteoporosis has been shown to be a contributing factor in low energy fractures in the elderly, limited data exists regarding the correlation of bone mineral density (BMD) and T-Scores to mortality and failure of fracture fixation. This study seeks to determine the relationship between femoral neck BMD in elderly patients with typical geriatric fractures and mortality and fracture fixation failure using Quantitative Computed Tomography (QCT). MATERIALS AND METHODS: Patients over the age of 65 who sustained fractures of the proximal humerus, distal radius, pelvic ring, acetabulum, hip, proximal tibia, and ankle who also underwent a CT scan that included an uninjured femoral neck were retrospectively reviewed. QCT was used to assess bone mineral density and T scores. Mortality and fixation failure were recorded. Standard descriptive statistics, as well as logistic regression were used to correlate BMD and mortality, and BMD and fixation failure. RESULTS: Of the 173 patients initially screened, 150 met inclusion criteria. Patients who remained alive at the end of the study (LP) had significantly (P = .019) higher adjusted mean femoral neck BMD (0.502 g/cm2) than non-polytrauma patients who died (MNPT) (0.439 g/cm2) when controlling for age, time to mortality, follow up, CCI, and ASA. Patients who had fixation failure events (FE) had significantly (P = .002) lower adjusted mean femoral neck BMD (0.342 g/cm2) than patients without failure events (NE) (0.525 g/cm2) when controlling for age and time to radiographic follow-up. CONCLUSIONS: Our study illustrates that QCT is a reliable method for the determination of femoral neck BMD in elderly patients with geriatric fractures. Furthermore, lower BMD/T-Scores are associated with increased mortality and fixation failures in this patient population.

Musculoskeletal function assessment outcomes scores over time for tibial plafond (OTA/AO 43) and proximal humeral (OTA/AO 11) fractures: a pilot project.

OBJECTIVES: What is the return to function after an isolated proximal humerus or tibial plafond fracture? DESIGN: Prospective observational. SETTING: Orthopaedic outpatient clinics. PATIENTS/PARTICIPANTS: Consecutive patients were enrolled with isolated proximal humerus (N = 155) and tibial plafond fractures (N = 120). INTERVENTION: None. MAIN OUTCOME MEASUREMENTS: Musculoskeletal Function Assessment. RESULTS: Patients who sustained isolated proximal humerus or tibial plafond fractures showed gradual improvement over 1 year. Women consistently demonstrated greater dysfunction than men at 6, 9, and 12 months after tibial plafond fracture. Age had an impact on return to function after injury for both fractures. Younger patients (18-29 years) with either type of injury tended to have better scores compared with the older patients. CONCLUSIONS: Detailed analysis of this data demonstrates variation in patient-based outcomes during recovery from a proximal humerus or tibial plafond fracture. These data need to be reviewed in the context of the individual patient when following a patient's recovery. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Determining the efficacy of screw and washer fixation as a method for securing olecranon osteotomies used in the surgical management of intraarticular distal humerus fractures.

OBJECTIVES: The purpose of this study was to critically evaluate the efficacy of single screw and washer fixation in comparison with other methods for securing olecranon osteotomies. The hypothesis is that screw and washer fixation is a safe and effective means of olecranon osteotomy fixation with fusion and complication rates similar to other methods of fixation. DESIGN: Retrospective review. SETTING: Two Level I Urban Trauma Centers. PATIENTS/PARTICIPANTS: Patients were treated within the last 20 years and received 1 of 4 types of fixation (screw and washer alone, screw and washer augmented with tension band, tension band alone, or plate and screws) after osteotomy. INTERVENTION: Open reduction and internal fixation of OTA/AO 13B/C distal humerus fractures with an olecranon osteotomy. MAIN OUTCOME MEASUREMENTS: The primary outcome measure was the presence of osteotomy union. Secondary outcome measures were olecranon nonunion, loss of articular reduction, and removal of hardware. Logistic regression was used to determine the associations between method of osteotomy fixation and removal of hardware or nonunion rates. Comorbidities were stratified using the Charlson comorbidity index. RESULTS: One hundred sixty patients met the inclusion criteria. Thirty-nine patients underwent screw fixation alone, 47 had tension band fixation, 16 had plate fixation, and 58 had tension band and screw fixation. Screw fixation demonstrated equal or better rates of union, maintenance of reduction, absence of infection, and implant removal compared with alternative fixation techniques. Higher Charlson scores were associated with higher rates of nonunion. CONCLUSIONS: Screw and washer fixation is a safe and effective means of securing an olecranon osteotomy. Charlson comorbidity score is one factor that may influence the development of nonunion after osteotomy. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Staged treatment of high energy midfoot fracture dislocations.

BACKGROUND: Staged care with interval external fixation is a successful established treatment strategy for high energy periarticular fractures with often extensive soft tissue damage such as the tibial plateau and plafond. The aim of the current study was to determine whether staged care of high energy midfoot fracture/dislocation with interval external fixation prior to definitive open reconstruction in the polytraumatized patient was both safe and efficacious. METHODS: One hundred twenty-three patients were operated on for high energy midfoot fracture/dislocation during the 8-year study period. Eighteen polytrauma patients were selectively treated with a staged protocol. Radiographic assessment was utilized to determine if the fixator achieved gross skeletal alignment. Further, final alignment after definitive reconstruction and postoperative complications were analyzed. RESULTS: The fixator improved both length and alignment of all high energy midfoot fracture/dislocations. Loss of acceptable reduction while in the temporary frame occurred in only 1 case. Final alignment after definitive reconstruction was anatomic in all cases. No cases of wound-related complication and/or deep infection occurred. CONCLUSION: Delayed reconstruction of high energy midfoot fracture/dislocation using interval external fixation should be an accepted care paradigm in selected polytrauma patients. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

Comparison of outcomes after triceps split versus sparing surgery for extra-articular distal humerus fractures.

OBJECTIVES: To compare elbow range of motion (ROM), triceps extension strength, and functional outcome of AO/OTA type A distal humerus fractures treated with a triceps-split or -sparing approach. DESIGN: Retrospective review. SETTING: Two level one trauma centres. PATIENTS: Sixty adult distal humerus fractures (AO/OTA 13A2, 13A3) presenting between 2008 and 2012 were reviewed. Exclusion criteria removed 18 total patients from analysis and three patients died before final follow-up. INTERVENTION: Patients were divided into two surgical approach groups chosen by the treating surgeon: triceps split (16 patients) or triceps sparing (23 patients). MAIN OUTCOME MEASUREMENTS: Elbow ROM and triceps extension strength testing were completed in patients after fractures had healed. All patients were also given the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. RESULTS: Compared to the triceps-split cohort, the triceps-sparing cohort had greater elbow flexion (sparing 143 ± 7° compared to split 130 ± 12°, p=0.03) and less extension contracture (sparing 6 ± 8° compared to split 23 ± 4°, p<0.0001). Triceps strength compared to the uninjured arm also favoured the triceps-sparing cohort (sparing 88.9 ± 28.3% compared to split 49.4 ± 17.0%, p=0.007). DASH scores were not statistically significant between the two cohorts (sparing 14.5 ± 12.2 compared to split 23.6 ± 22.3, p=0.333). CONCLUSIONS: A triceps-sparing approach for surgical treatment of extra-articular distal humerus fractures can result in better elbow ROM and triceps strength than a triceps-splitting approach. Both approaches, however, result in reliable union and similar functional outcome. LEVEL OF EVIDENCE: Level III.