Effect of a Percutaneous Screw Guide on Screw Placement for Posterior Talar Fractures.

AIM: This study aimed to evaluate the hypothesis that the utilization of percutaneous screw guides enhances the precision of screw placement in the surgical fixation of talar fractures. METHODS: Computed tomography (CT) scans of ankle joints were obtained from 40 healthy adults and 10 cadaveric specimens between April 2019 and August 2020 at Ningbo No. 6 Hospital. The acquired CT data were imported into Materialise Interactive Medical Image Control System (MIMICS) software for processing. Three-dimensional (3D) digital models of the ankle joints were reconstructed, and relevant anatomical parameters were measured. A percutaneous screw guide (PSG) was designed and fabricated to facilitate accurate screw placement in the posterior talar process. Ten eligible cadaveric ankle joints were selected for further analysis and their 3D models were reconstructed using the MIMICS software. Screw trajectory parameters were then measured and analyzed based on these cadaveric models, forming the model group for comparative analyses. Ten cadaveric specimens were utilized in this study, equally divided into two groups: a guider group (n = 5) and a free-hand group (n = 5). In the guider group, talar posterior process screws were inserted using percutaneous screw guidance. In the free-hand group, screws were inserted into the talar posterior process without guidance. Post-operative CT scans were performed on all specimens. The following parameters were quantitatively compared between the two groups: screw trajectories, entry point distances in specimens with preselected screws, entry point distance trajectories in the 3D model, operation time, frequency of fluoroscopic imaging, and number of drilling attempts. RESULTS: Following the generation of the 3D models from 10 cadavers, a virtual screw was digitally inserted into each model. In the model group, the preselected screw trajectory was oriented towards the medial aspect of the talar neck base, with a cephalad inclination angle (CIA) of 3.1° ± 1.5° in the transverse~plane and a medial diverge angle (MDA) of 12.0° ± 1.4° in the coronal plane. The CIA and MDA of the screw trajectory in the guider group were 2.1° ± 1.7° and 11.2° ± 1.6°, respectively, whereas the CIA and MDA in the free-hand group were 6.0° ± 2.2° and 18.8° ± 1.6°, respectively. Statistical analysis revealed significant differences in both CIA and MDA between the two groups (p < 0.05). Furthermore, the guider group yielded superior outcomes in terms of entry point distance, operation time, fluoroscopic exposure time, and number of drilling attempts compared to the free-hand group (p < 0.05). CONCLUSIONS: Percutaneous screw guidance can improve the accuracy and safety of the posterior process of the talar screws, which can be feasible for percutaneous fixation. Further studies are required to confirm the efficacy and clinical outcomes of percutaneous screw guidance.

[Treatment of Tile type C pelvic ring fracture using orthopedic robot combined with Starr pelvis reduction frame].

OBJECTIVE: To investigate the clinical effect of orthopedic robot combined with Starr pelvic reduction frame in the treatment of Tile type C pelvic ring fracture. METHODS: From October 2019 to May 2021, 14 patients with type C pelvic ring fracture were treated with robotic combined with Starr pelvic reduction frame, including 9 males and 5 females. The age ranged from 33 to 69 years. All the 14 patients had fresh closed fractures without femur, tibia and fibula fracture. Surgery was completed from 4 to 7 d after hospital admission. During the operation, the X-ray carbon bed was used, the pelvic ring was reduced by Starr pelvis reduction frame, and pelvic ring fracture was treated by orthopedic robot. Operation time, bleeding volume, fluoroscopy times of single screw placement, fracture reduction quality, affected limb function and complications were observed. Radiological reduction was evaluated using Matta scoring standard, and clinical efficacy was evaluated by Majeed pelvic function scoring system at the final follow-up. RESULTS: All of 14 patients successfully completed the operation, the operation time was 84 to 141 min, the bleeding volume was 20 to 50 ml, and the fluoroscopy times of single screw insertion was 4 to 9 times. All of 14 patients were followed up for 12 to 24 months. The healing time was 3 to 7 months. No complications such as fracture of internal fixation, screw loosening, infection and nerve injury were found. According to the evaluation criteria of Matta imaging reduction, 9 cases were excellent, 4 cases were good, and 1 case was fair. At the final follow-up, Majeed pelvic function scoring system was used:10 cases were excellent, 4 cases were good. CONCLUSION: The treatment of type C pelvic ring fracture with robotic combined Starr pelvis reduction frame is simple, time-saving, less trauma, less complications and effective.

Harnessing ResNet50 and SENet for enhanced ankle fracture identification.

BACKGROUND: Ankle fractures are prevalent injuries that necessitate precise diagnostic tools. Traditional diagnostic methods have limitations that can be addressed using machine learning techniques, with the potential to improve accuracy and expedite diagnoses. METHODS: We trained various deep learning architectures, notably the Adapted ResNet50 with SENet capabilities, to identify ankle fractures using a curated dataset of radiographic images. Model performance was evaluated using common metrics like accuracy, precision, and recall. Additionally, Grad-CAM visualizations were employed to interpret model decisions. RESULTS: The Adapted ResNet50 with SENet capabilities consistently outperformed other models, achieving an accuracy of 93%, AUC of 95%, and recall of 92%. Grad-CAM visualizations provided insights into areas of the radiographs that the model deemed significant in its decisions. CONCLUSIONS: The Adapted ResNet50 model enhanced with SENet capabilities demonstrated superior performance in detecting ankle fractures, offering a promising tool to complement traditional diagnostic methods. However, continuous refinement and expert validation are essential to ensure optimal application in clinical settings.

Biomechanical insights into ankle instability: a finite element analysis of posterior malleolus fractures.

BACKGROUND: Posterior malleolus fractures are known to be associated with ankle instability. The complexities involved in obtaining precise laboratory-based spatial pressure measurements of the ankle highlight the significance of exploring the biomechanical implications of these fractures. METHODS: Finite element analysis was utilized to examine the stress distribution across the contact surface of the ankle joint, both in its natural state and under varied sagittal fracture line angles. The study aimed to identify stress concentration zones and understand the influence of sagittal angles on stress distribution. RESULTS: Three distinct stress concentration zones were identified on the ankle's contact surface: the anterolateral tibia, the anteromedial tibia, and the fracture line. The most significant stress was observed at the fracture line when a fracture occurs. Stress at the fracture line notably spikes as the sagittal angle decreases, which can potentially compromise ankle stability. Larger sagittal angles exhibited only minor stress variations at the contact surface's three vertices. It was inferred that sagittal angles below 60° might pose risks to ankle stability. CONCLUSIONS: The research underscores the potential implications of fractures on the stress profile of the ankle joint, emphasizing the role of the contact surface in ensuring stability. The identification of three zones of stress concentration and the influence of sagittal angles on stress distribution offers a valuable reference for therapeutic decision-making. Further, the study reinforces the importance of evaluating sagittal fracture angles, suggesting that angles below 60° may compromise ankle stability.

"In-Out-In" Percutaneous Reduction Technique for Treatment of Valgus-Impacted Femoral Neck Fractures: A Technical Trick and Case Series.

OBJECTIVE: Valgus-impacted femoral neck fractures with or without posterior tilt of the femoral head are very common and full of pitfalls in clinical practice, which may lead to femoral neck shortening (FNS) and avascular necrosis (AVN). The study tries to introduce a novel technical trick aiming at anatomical reduction of valgus-impacted femoral neck fracture with minimally invasive procedure, and summarize the clinical prognosis in case series. METHODS: In this retrospective study, 24 patients (seven men and 17 women) with valgus-impacted femoral neck fractures between May 2017 and July 2020 were managed by "in-out-in" percutaneous reduction technique (percutaneous reduction group). Another 24 cases (10 men and 14 women) suffering the fractures underwent in situ fixation were enrolled as control group for function comparison (in situ fixation group). All patients were followed up for 24-42 months. The clinical outcomes included complications after operations (χ2 test) and Harris Hip Score (HHS) for hip function (unpaired t test) in the two groups. The radiographic outcomes were evaluated by collodiaphyseal angle, posterior tilt angle, and FNS before the operation and during the follow-up in the percutaneous reduction group (unpaired t test). RESULTS: Patients' preoperative data, including age, sex, affected side, fracture types, and medical history, were similar between the two groups, respectively (p > 0.05). After surgery, the mean HHS at 6, 12, and 24 months were all better in the percutaneous reduction group (76 ± 6.72, 85.34 ± 6.33 and 90.54 ± 5.81) than that in the in situ fixation group (70.86 ± 6.91, 80 ± 6.11 and 84.1 ± 7.82), respectively (p < 0.05). One patient suffered fixation failure with screws retreat and one patient suffered AVN in the percutaneous reduction group. In the in situ fixation group, AVN occurred in two patients at last follow-up. There was no significant difference in complication amounts between the two groups (p > 0.05). In the percutaneous reduction group, collodiaphyseal angle, posterior tilt angle, and amount of FNS were significantly different between preoperative cases and immediately postoperative cases (p < 0.05). However, there was no statistical difference of the measurements among postoperative cases at different time points (within 24 h, 6 months, and 2 years postoperatively) (p > 0.05). CONCLUSIONS: Our experience of the technique and the case series show that "in-out-in" percutaneous reduction technique for treatment of valgus-impacted femoral neck fracture with or without posterior tilt of the femoral head is safe and effective for achieving successful bone union and satisfactory function.

Unilateral transforaminal lumbar interbody fusion through a modified hemilateral spinous process-splitting approach.

Objective: To describe unilateral transforaminal lumbar interbody fusion (TLIF) via a modified hemilateral spinous process-splitting (MHSPS) approach and determine its effectiveness. Methods: Sixty-five consecutive patients with the lumbar degenerative disease who underwent MHSPS TLIF between August 2020 and July 2021 were retrospectively analyzed. Japanese Orthopedic Association (JOA) score and visual analog scale (VAS) scores for back and leg pain were evaluated before surgery and at the last follow-up. Postoperative paraspinal muscle atrophy was evaluated on axial T2-weighted magnetic resonance imaging. Results: Mean JOA score increased from 13.6 ± 3.21 before surgery to 24.72 ± 3.34 at last follow-up (p < 0.001). The mean recovery rate was 68.2% ± 5.68%. Clinical outcome was excellent in 22, good in 35, and fair in 8 patients. The VAS score for low back pain was significantly lower at the last follow-up than before surgery (1.18 ± 0.99 vs. 3.09 ± 1.35; p < 0.001). The VAS score for leg pain was also significantly lower at the last follow-up than before surgery (1.13 ± 0.91 vs. 6.61 ± 1.23; p < 0.001). The mean paraspinal muscle atrophy rate did not significantly differ between the symptomatic side (6% ± 3.8%) and asymptomatic side (4.8% ± 3.3%) at last follow -up (p = 0.071). Conclusion: MHSPS TLIF is an effective minimally invasive surgical treatment for selected types of degenerative lumbar disease. This technique can achieve effective spinal decompression and interbody fusion. Its advantages include direct and adequate visualization, vast surgical working space, short operation time, and minimal muscle injury.

Clinical Comparison of the "Windowing" Technique and the "Open Book" Technique in Schatzker Type II Tibial Plateau Fracture.

OBJECTIVE: Surgical treatment for Schatzker type II tibial plateau fractures remains challenging and requires high-quality research. The aim of the study is to compare the "windowing" and "open book" techniques for the treatment of Schatzker type II tibial plateau fractures. METHODS: In this prospective study, all patients with Schatzker type II tibial plateau fractures between January 2014 and December 2017 were managed by open reduction and internal fixation using an anterolateral incision approach. "Windowing" group included 78 patients (53 men and 25 women), with an average age of 57.7 ± 13.5 years, who underwent the "windowing" technique, in which the procedure was performed through a small cortical window against the depressed zone of the lateral plateau. The "open book" group included 80 patients (56 men and 24 women), with an average age of 54.8 ± 12.4 years, who underwent the technique. The clinical outcomes included the Rasmussen classification of knee function and grading of post-traumatic arthritis. The radiographic outcome (x-ray and computed tomography [CT]) was the reduction quality of the lateral plateau based on the modified Rasmussen radiological assessment. The patient-reported outcome was visual analogue scale (VAS) scores. RESULTS: The mean follow-up time for the158 patients was 32 months (range, 24-42 months). The time elapsed from injury to surgery in "windowing" group and "open book" group were 3.7 ± 1.2 (range, 1-10 days) and 3.5 ± 1.4 days (range, 1-11 days), respectively, with no significant difference between the groups (P > 0.05). The operation times did not differ significantly between the "windowing" group (61.0 ± 8.3 min, range, 45-120 min) and the "open book" group (61.2 ± 10.4 min, range, 40-123 min) (P > 0.05). After surgery, CT revealed five (6.4%) and 15 (18.8%) cases of articular depression in the "windowing" and "open book" groups, respectively. Significant differences were observed in the articular depression of tibial plateau fractures between the groups (P < 0.05). However, condylar widening or valgus/varus did not differ significantly between the groups. Furthermore, no significant differences in knee function were observed during follow-up (P > 0.05). VAS scores were similar between the groups at 24 months after surgery (P > 0.05). There were significant differences in the number of severe post-traumatic arthritis (grades 2 and 3) cases between the groups (P < 0.05). CONCLUSIONS: The "windowing" and "open book" techniques are both effective for the treatment of Schatzker type II tibial plateau fractures. However, the "windowing" technique provides better reduction quality, leading to a satisfactory prognosis.

Comparison of Percutaneous Kyphoplasty with or without Pedicle Screw Fixation in Osteoporotic Thoracolumbar Vertebral Fractures: A Retrospective Study.

BACKGROUND: Osteoporotic thoracolumbar compression fractures have become a great social burden due to the aging tendency of population. This study is aimed at comparing the clinical and radiological outcomes of percutaneous kyphoplasty with or without pedicle screw fixation in patients with osteoporotic thoracolumbar fractures. Hypothesis. There is a difference in clinical outcomes between percutaneous kyphoplasty with pedicle screw fixation and percutaneous kyphoplasty. METHODS: This retrospective study included 87 patients who received percutaneous kyphoplasty with or without pedicle screw fixation between October 2015 and October 2017 at Ningbo No.6 Hospital and were followed for 2 years. A total of 40 patients received percutaneous kyphoplasty with pedicle screw fixation (PKPF group), and the other 47 patients had percutaneous kyphoplasty only (PKP group). The outcomes were measured using the visual analogue scale (VAS), Oswestry Disability Index (ODI), Cobb angle (CA), and anterior vertebra height rate (AVHr), which were calculated at preoperative admission and each follow-up visit. Complications including postoperative back pain, refracture, and fixation failure were collected from medical records. RESULTS: There was no significant difference in baseline characteristics or preoperative data between the two groups (p < 0.05) but significantly better improvements in VAS, ODI, CA, and AVHr at 12- and 24-month follow-up visits in the PKPF group compared with those of the PKP group. 23 (48.9%) patients in the PKP group had complications, whereas only 5 (12.5%) patients in the PKPF group presented complications including 2 postoperative back pain and 1 fixation failure (p = 0.04). CONCLUSIONS: PKPF obtained longer correction and better improvement in VAS, ODI, and CA in patients with osteoporotic thoracolumbar vertebral fractures than PKP.

Application of MALDI-TOF MS Profiling Coupled With Functionalized Magnetic Enrichment for Rapid Identification of Pathogens in a Patient With Open Fracture.

Posttraumatic infections can occur in orthopedic trauma patients, especially in open fractures. Rapid and accurate identification of pathogens in orthopedic trauma is important for clinical diagnosis and antimicrobial treatment. Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) has been successfully used for first-line identification of pathogens grown on culture plates. However, for direct analysis of liquid clinical specimens, pre-purification of the sample is necessary. Herein, we investigated the feasibility of coupling Fc-MBL@Fe3O4 enrichment with MALDI-TOF MS profiling in the identification of pathogens in liquid-cultured samples. This method is successfully used for the identification of pathogens in a patient with an open-leg fracture obtained at sea. Pathogens were enriched by Fc-MBL@Fe3O4 from briefly pre-cultured liquid media and identified by MALDI-TOF MS. We identified an opportunistic pathogen, Vibrio alginolyticus, which is uncommon in clinical orthopedic trauma infection but exists widely in the sea. Therefore, combining Fc-MBL@Fe3O4 enrichment and MALDI-TOF MS profiling has great potential for direct identification of microbes in clinical samples.

Percutaneous posteroanterior screw fixation for Haraguchi type 1 posterior malleolar fracture in tri-malleolar fracture: Operative technique and randomized clinical results.

PURPOSE: The study described a novel surgical treatment of Haraguchi type 1 posterior malleolar fracture in tri-malleolar fracture and patient outcomes at intermediate period follow-up. METHODS: All patients from January 2015 to December 2017 with tri-malleolar fracture of which posterior malleolar fractures were Haraguchi type 1, were surgically treated in this prospective study. Lateral and medial malleolar fractures were managed by open reduction and internal fixation through dual incision approaches. 36 cases of Haraguchi type 1 posterior malleolar fractures were randomly performed by percutaneous posteroanterior screw fixation with the aid of medial exposure (group 1). And 40 cases were performed by percutaneous anteroposterior screw fixation (group 2). Clinical outcomes, radiographic outcomes and patient-reported outcomes were recorded. RESULTS: Seventy-six patients with mean follow-up of 30 months were included. There were no significant differences in the mean operation time (81.0 ± 11.3 vs. 77.2 ± 12.4), ankle function at different periods of follow-up, range of motions and visual analog scale (VAS) at 24 months between the two groups (p > 0.05). However, the rate of severe post-traumatic arthritis (Grade 2 and 3) and the rate of step-off rather than gap in radiological evaluation were lower in group 1 than that in group 2 (p < 0.05). CONCLUSION: Using our surgical technique, more patients had good outcome with a lower rate of severe post-traumatic arthritis, compared with the group of percutaneous anteroposterior screw fixation. Percutaneous posteroanterior screw fixation can be a convenient and reliable alternative in treating Haraguchi type 1 posterior malleolar fracture.

ACY­1215, a HDAC6 inhibitor, decreases the dexamethasone­induced suppression of osteogenesis in MC3T3­E1 cells.

Glucocorticoid­induced osteoporosis is the commonest form of drug­induced osteoporosis. Histone deacetylase 6 (HDAC6) is involved in the differentiation from mesenchymal stem cells to osteoblasts. However, the role of ricolinostat (ACY­1215, HDAC6 inhibitor) in the dexamethasone (Dex)­induced proliferation and differentiation of preosteoblasts remains to be elucidated. The protein expression and mRNA expression levels of HDAC6, osteopontin (OPN), runt­related transcription factor 2 (Runx2), osterix (Osx), collagen I (COL1A1) and glucocorticoid receptor (GR) in MC3T3­E1 cells were analyzed by western blot analysis and reverse transcription­quantitative PCR analysis. The cell viability was detected by CCK­8 assay. The alkaline phosphatase (ALP) activity and capacity of mineralization was determined by ALP assay kit and alizarin red staining. HDAC6 expression was increased in patient serum and Dex­induced MC3T3­E1 cells at a certain concentration range; 1 µM Dex was selected for further experimentation. Cell viability was decreased after Dex induction and restored following ACY­1215 treatment. The ALP activity and capability for mineralization was decreased when MC3T3­E1 cells were induced by 1 µM Dex and was gradually improved by the treatment of ACY­1215 at 1, 5 and 10 mM. The expression of OPN, Runx2, Osx and COL1A1 was similar, with the changes of capability for mineralization. Furthermore, GR expression was increased in Dex­induced MC3T3­E1 cells. ACY­1215 promoted the GR expression in MC3T3­E1 cells from 1­5 mM while GR receptor expression was increased with 10 mM ACY­1215 treatment. In conclusion, ACY­1215 reversed the Dex­induced suppression of proliferation and differentiation of MC3T3­E1 cells.

Clinical comparison of single-incision and dual-incision approaches for the treatment of distal tibial and fibular fractures: A randomized controlled trial.

PURPOSE: The purpose of this study was to clinically compare the single-incision and dual-incision approaches for the treatment of distal tibial and fibular fractures. METHODS: In total, 93 patients were enrolled, and the mean follow-up was 15 months (range 12-19 months). The patients treated for open reduction and internal fixation were randomly classified into two groups based on the approach used: 45 patients were treated using the single-incision approach (group 1) and 48 patients were treated using the dual-incision approach (group 2). In these two groups, operation time, discharge time, postoperative complications, and ankle function evaluations (Olerud-Molander Ankle Score) were compared between the two groups. RESULTS: There were no significant differences in the mean operation time (98.2 ± 18.5 vs. 103.6 ± 19.3), discharge time (11.1 ± 3.9 vs. 12.5 ± 5.7), overall surgical complication rates (9/45 vs. 15/48), or ankle function between the two groups (p > 0.05). However, the rate of soft tissue-related complications, such as skin slough, infection, nonunion, and delayed union, was significantly lower in group 1 (5/45) than in group 2 (14/48) (p < 0.05). CONCLUSION: The two incision approaches were found to have similar clinical outcomes. However, with regard to soft tissue conservation, the single-incision approach was superior to the dual-incision and maybe a reliable alternative.