Quality of fracture reduction assessed by radiological parameters and its influence on functional results in patients with pilon fractures-A prospective multicentre study.

INTRODUCTION: The management of pilon fractures remains a challenging issue. Due to the complexity of factors that influence the outcome, it has been questioned if anatomical reductions of articular fracture are relevant. The lack of a commonly accepted assessment of quality of fracture reduction compounded the uncertainty of the importance of anatomical reduction in pilon fracture. The current study aimed to define parameters that can better assess the reduction quality and to investigate the influence of reduction quality on functional outcomes. METHODS: Patients with unilateral pilon fracture of the AO/OTA type 43-B or 43-C were consecutively recruited to the study and followed up for 2 years after surgery. Postoperative radiographs of the injured and the contralateral joints were evaluated and 13 radiological parameters measured by 2 independent surgeons. The reliability of the measurements for each parameter was assessed by the Intraclass Correlation Coefficient (ICC), and 4 parameters with the highest ICC scores were deemed most reliable and were selected for further analyses. Functional outcome was assessed by the Foot and Ankle Ability Measure (FAAM) for daily living and sports activities. The 4 most reliable radiologic parameters, together with 3 possible baseline confounders (age, AO/OTA fracture type, and open versus closed injury), were analysed using both univariable and multivariable analysis for their association with the FAAM scores. Secondary outcome measures including pain, ankle range of motion (ROM), quality of life (QoL), and adverse events were also reported. RESULTS: The length of lateral malleolus (LLM), anterior distal tibia angle, anterior talar shift, and length of medial malleolus scored highest on reliability in ICC assessment (ICC=0.76, 0.72, 0.58, and 0.45, respectively). Only LLM exhibited statistical significant association with the 2-year FAAM results. At the 2-year follow-up, the injured joints on average achieved a ROM of 70.7% (95% CI=63.9-77.6) when compared to the contralateral joints, and patients did not regain the pre-injury QoL overall. CONCLUSION: The multivariable analysis showed that LLM (independent of age, AO/OTA fracture type, and open/closed injury) was a reliable indicator of reduction quality and a prognostic factor for patient outcome in pilon fracture surgery.

Cross-Cultural Adaptation and Validation of the Lower Extremity Measure Into German.

INTRODUCTION: The Lower Extremity Measure (LEM) was developed to provide a specific instrument to detect changes in physical function in patients with hip fracture. Of 29 questions, 3 have a valid "not applicable" answer option. The goal of this study was to validate the LEM in German and to determine the added value to the physical functioning (pf) subscale of the Short Form 36 (SF-36). MATERIALS AND METHODS: The LEM was translated according to published guidelines and administered to patients with hip fracture (31 A1-A3 and 31 B1-B3) shortly after surgery (baseline), at 3 months (3M), and for reliability testing at 3 months plus 1 week (3M+). The reproducibility, internal consistency, floor and ceiling effects, construct validity, and responsiveness of the German LEM were assessed. RESULTS: A total of 106 patients completed the LEM and SF-36 (mean age 75.5; 67% women) at baseline (mean of 4.9 days after operation), and 88 completed both questionnaires at both the 3M and 3M+ assessments. At each assessment time point, between 6% and 23% of the patients answered 7 questions as "not applicable." Reproducibility and internal consistency were high (intraclass correlation coefficient = 0.93; Cronbach's α = .96). No floor effect (0%) and a minor ceiling effect (7.87%) were found for the total LEM score. The strongest correlation was found between the LEM and the SF-36 subscale pf (Spearman ρ = .93). Responsiveness was similar for the SF-36 pf subscale and the LEM when using effect size (SF-36 pf 0.71 vs LEM 0.72) and better for the LEM when using standardized response mean (SF-36 pf 0.65 vs LEM 0.76). DISCUSSION: The German LEM is a reliable, valid, and responsive measure for the self-assessment of patients after hip fracture surgery. As a number of questions are not applicable to elderly patients, the added value of this lengthy questionnaire in these often frail, sometimes cognitively impaired patients is still open for debate.

Central head perforation, or "cut through," caused by the helical blade of the proximal femoral nail antirotation.

OBJECTIVE: This study was designed to investigate the specific type and incidence of implant failure in patients with a proximal femur fracture treated with a proximal femoral nail antirotation. This device has a helical-shaped blade as a neck-head holding device, instead of the lag screw used in other intramedullary nails. The advantage of the blade is believed to originate from bone impaction and a larger bone-implant interface in comparison with the lag screw design, with consequential greater mechanical resistance to torsion in the cancellous bone. PATIENTS AND METHODS: This is a retrospective cohort study conducted at the state hospital of Winterthur, Switzerland. From December 2006 until November 2008, 210 consecutive patients were treated with a pertrochanteric femur fracture (OTA type 31-A1, 31-A2, and 31-A3) using a proximal femoral nail antirotation. One hundred and twelve patients were followed up clinically for a minimum of 12 months after discharge. Clinical and radiologic assessment of fracture healing and/or implant failure was investigated. RESULTS: We report 7 cases of implant failure with a "Cut Through," defined as a postoperative central perforation of the spiral blade into the hip joint, without any displacement of the neck-head fragment. CONCLUSIONS: Cut through needs to be distinguished from the well-known anterocranial perforation combined with a varus displacement of the neck-head fragment, known as "Cut Out," seen with intramedullary nails utilizing lag screws. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Anatomic reconstruction of unstable lateral clavicular fractures.

BACKGROUND: Fractures of the lateral clavicle result in a high rate of nonunion compared with midshaft fractures. Many operative treatment methods of unstable lateral clavicle fractures have been described, but no single method has become generally accepted. This study reports our experience treating unstable lateral clavicle fractures with coracoclavicular ligament rupture. METHODS: Within 7 years, 19 patients with acute unstable lateral clavicle fractures were treated using a 2.4-mm T-plate and a coracoclavicular polydioxanone cord. The follow-up averaged 5.3 years (range, 2.0-8.8). Shoulder function was assessed using the Constant score and Disabilities of the Arm, Shoulder and Hand score. General health of the patients was evaluated according to the Short Form 36 questionnaire. RESULTS: Eighteen of the 19 patients treated with our method achieved union at 8.8 weeks (range, 6-14), a Constant Murley score of 91.5 (range, 72-100) on the injured side versus 93.5 (range, 80-100) on the contralateral side, a Disabilities of the Arm, Shoulder and Hand score of 1.4 (range, 0-9.2), and a Short Form 36 Health Score of 85 (range, 89-100). One patient showed breakage of the plate and a delayed union at the radiologic follow-up 4 months after surgery. CONCLUSION: This study shows that treatment of unstable lateral clavicular fractures with an angular stable locking plate together with a polydioxanone cord ligament augmentation leads to excellent results with a 95% union rate. Additional coracoclavicular augmentation next to plate fixation of the clavicle may partially solve the problem of uncertain plate fixation if the lateral fragment is small and multifragmented, as often observed.

Characterization of the lignin signature in Lake Mead, NV, sediment: comparison of on-line flash chemopyrolysis (600 degrees C) and off-line chemolysis (250 degrees C).

The distribution of lignin in sediment is a useful tool for tracing the transport of land-derived organic matter in an aquatic environment. Tetramethylammonium hydroxide (TMAH) flash chemopyrolysis, or chemolysis followed by GC-MS analysis can be used for evaluating the origin of organic carbon in sediments. TMAH chemopyrolysis or chemolysis of organic matter produces a myriad of semi-volatile products. Among these products are methylated phenols which are an indirect measure of lignin in sediment. In this study, total organic carbon, elemental carbon, and lignin were measured in Lake Mead sediments. This study indicates that terrestrial runoff makes a contribution to Lake Mead sediments, and that this contribution is most apparent in sediment that is close to the Las Vegas Wash. Two chemolysis methods (on-line and off-line) were examined and compared for detection of lignin phenols. The results from these sediment cores indicate that comparable results can be obtained from the two approaches, although detection levels are significantly lower for the off-line approach.

Excess plutonium in soil near the Nevada Test Site, USA.

Two soil profiles were collected from undisturbed areas near the Nevada Test Site (NTS). The activity of 137Cs in the surface layer of the downwind Queen City Summit profile is three times higher than at the upwind site at Searchlight, NV (41.1+/-0.6 mBq/g vs. 13.0+/-0.4 mBq/g), and the 239,240Pu activity is 100 times greater (51+/-2 mBq/g vs. 0.52+/-0.03 mBq/g). An examination of the literature suggests that the 137Cs/239,240Pu and the 239,240Pu/238Pu activity ratios in soils and sediments from the northern hemisphere, due to fallout from atmospheric atomic weapons testing, have generalized values of 36+/-4 and 30+/-4, respectively (as of 1 July 1995). Deviations from these values may indicate possible contamination by sources other than fallout. Data from the surface soil of the downwind Queen City Summit profile yield a 137Cs/239,240Pu ratio of 0.81+/-0.02 and a 239,240Pu/238Pu ratio of 78+/-6. Clearly, an increase in 239,240Pu relative to 137Cs or 238Pu can account for these observations. There is compelling evidence that this "excess" 239,240Pu came from activities at the NTS during the aboveground testing of nuclear devices, more than likely from safety tests, some 40 years ago, and/or during the interim by the wind-driven resuspension of contaminated surface soil on the NTS and its transport off-site. Moreover, the two concentration profiles show that high percentages of both of these elements are retained for decades in the upper few centimeters of soil in Nevada's desert environment.