Surgical outcomes of elderly patients aged more than 80 years with distal radius fracture: comparison of external fixation and locking plate.

BACKGROUND: To compare the outcomes after surgical intervention, including external fixation (EF) with the optional addition of K-pins or open reduction and internal fixation (ORIF) with a volar locking plate (VLP), in patients with distal radius fracture aged > 80 years. METHODS: We reviewed 69 patients with a distal radius fracture aged > 80 years who treated under surgical intervention from 2011 to 2017 retrospectively. Their demographic data and complications were recorded. Preoperative, postoperative, and last follow-up plain films were analyzed. The functional outcomes of wrist range of motion were also evaluated. RESULTS: 41 patients were treated with EF with the optional addition of K-pins, while 28 patients were treated with ORIF with a VLP. The radiological parameters, including ulnar variance and radial inclination, at the last follow-up were significantly more acceptable in the VLP group (p = 0.01, p = 0.03, respectively). The forearm supination was significantly better in patients treated with VLP (p = 0.002). The overall incidence of complications was lower in the VLP group (p = 0.003). CONCLUSION: VLP provides better radiological outcomes, wrist supination and lower complication rates than EF. Therefore, although EF is still widely used because of its acceptable results and easy application, we recommend VLP as a suitable treatment option for distal radius fracture in the geriatric population aged > 80 years.

Health Care Costs of Post-traumatic Osteomyelitis in China: Current Situation and Influencing Factors.

BACKGROUND: Currently, very limited information is available regarding the economic burdens of patients with extremity post-traumatic osteomyelitis (OM). This study aimed to investigate direct health care costs and utilization for inpatients with extremity post-traumatic OM and analyze its constituent ratios and influencing factors in Southern China. METHODS: We searched in the electronic medical record system for inpatients who had received surgical interventions at our department between 2013 and 2016 for extremity post-traumatic OM. Data of direct health care costs incurred during their hospitalizations were collected in six main categories (service, diagnosis, treatment, materials, pharmaceuticals, and miscellaneous expenses). In addition, data of total medical costs for contemporaneous inpatients with non-post-traumatic OM were also collected as controls. RESULTS: A total of 278 post-traumatic OM and 10,420 controls were included. The median cost for the post-traumatic OM inpatients was $10,504 US dollars, 4.8-fold higher than that for those with non-post-traumatic OM ($2189, P < 0.001). The direct cost in the category of materials accounted for the largest proportion (61%), followed by that in pharmaceuticals (12%) and treatment (11%). The median number of hospital admissions for post-traumatic OM patients was 1 time, with a median length-of-stay of 22 d. The most influencing factors for the health care costs of the post-traumatic OM inpatients were use of an external fixator ($16,016 for those who used versus $4956 for those who did not, P < 0.001), external fixator type ($19,563 for ring fixator versus $14,966 for rail fixator, P < 0.001), infection site ($13,755 for tibia, $14,216 for femur and $5673 for calcaneus, P < 0.001), and infection-associated injury type ($12,890 for infection after open fracture versus $8087 for infection after closed fracture, P = 0.001). CONCLUSIONS: An unexpectedly large proportion of the direct health care costs for inpatients with extremity post-traumatic OM went to cover an external fixator, with expenses for pharmaceuticals and treatment accounting for only a little more than the tenth of the total health care costs. Use of external fixator, external fixator type, infection site, and infection-associated injury type directly influenced the health care costs.

Surgical treatment strategies in pediatric trauma patients: ETC vs. DCO-an analysis of 316 pediatric trauma patients from the TraumaRegister DGU®.

PURPOSE: External fixation within the damage control concept in unstable multiple trauma patients is widely accepted. Literature about its usage in the pediatric trauma population, however, is rare. The aim of the present study was to elucidate the factors associated with the application of external fixation in the severely injured child. METHODS: Patients with severe trauma aged 0-54 years documented in the TraumaRegister DGU® were included in this study. Demographic data, pattern of injury, injury severity, use of the damage control orthopedics (DCO) or early total care (ETC) concept, duration of mechanical ventilation, intensive care stay, and total hospital stay as well as the occurrence of complications and mortality were evaluated. Statistical evaluation was performed using SPSS (Version 21.0.0) using Chi square tests and linear regression models. RESULTS: While injury severity was comparable between children and adults, type of accident and injury patterns showed significant differences, Overall, the majority of surgical fracture stabilization in AISExtremity ≥ 3 injuries followed the DCO concept in adults (60.3%) and the ETC protocol in children (49.4%). Conservative treatment was chosen for only 11.6% of all children and 9.6% of all adults. An increasing injury severity, AISExtremity ≥ 3 and AISExtremity ≥ 3 in ≥ 2 body regions, and a more advanced age were found to be independent factors in the use of the DCO concept in children. CONCLUSION: Use of external fixation increases with age and plays a minor role in the very young trauma population. However, this does not produce a difference in outcome between children and adults.

Is Knee Joint Distraction a Viable Treatment Option for Knee OA?-A Literature Review and Meta-Analysis.

Knee joint distraction (KJD) is a new application of an established technique to regenerate native cartilage using an external fixator. The purpose of this study is to perform a systematic review and meta-analysis of the literature to determine whether KJD is beneficial for knee osteoarthritis and how results compare with established treatments. Studies assessing the outcomes of KJD were retrieved, with three studies (one cohort and two randomized controlled trials), 62 knees, meeting the inclusion criteria. The primary outcome was functional outcome, assessed using a validated outcome score, at 1 year. Secondary outcomes included pain scores, structural assessment of the joint, and adverse events. KJD is associated with improvements in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) from baseline to 1 year as well as reductions in pain scores and improvements in structural parameters assessed radiographically and by magnetic resonance imaging. KJD is not associated with decreased knee flexion, but is associated with a high risk of pin site infection. In patients aged 65 years or under at 1 year, no differences in WOMAC or pain scores was detected between patients managed with KJD compared with high tibial osteotomy or total knee arthroplasty. KJD may represent a potential treatment for knee arthritis, though further trials with longer term follow-up are required to establish its efficacy compared with contemporary treatments. This is a Level I (systematic review and meta-analysis) study.

Intermediate-Term Outcome After Distal Radius Fracture in Patients With Poor Outcome at 1 Year: A Register Study With a 2- to 12-Year Follow-Up.

PURPOSE: Most patients recover well from a distal radius fracture (DRF). However, approximately one-fifth have severe disability after 1 year when evaluated using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire. In the present study, we evaluated this subgroup of patients in our register with an inferior outcome. We hypothesized that the patient-reported outcome would improve with time. METHODS: Since 2001, patients 18 years and older with a DRF, at the Department of Orthopedics, Skåne University Hospital (Lund, Sweden) are prospectively registered in the Lund Wrist Fracture Register. We have previously defined a DASH score above 35 at the 1-year follow-up as the cutoff of major disability. Between 2003 and 2012, 17% of the patients (445 of 2,571) in the register exceeded this cutoff. Three hundred eighty-eight were women and 57 men and the mean age was 69 years (range, 18-95 years). One-fourth had been surgically treated. In December 2014, 2 to 12 years after the fracture, a follow-up DASH questionnaire was sent to the 346 of 445 patients still alive. RESULTS: Seventy-three patients (27%) had initially been treated surgically and 196 (73%) nonsurgically for their DRF. Two hundred sixty-nine of 346 patients (78%) returned the follow-up DASH questionnaire at 2 to 12 years (mean, 5.5 years) after the fracture. The overall median DASH score improved from 50 at 1 year to 36 at the 2- to 12-year follow-up, (P < .05). Forty-seven percent had improved to a score below the cutoff 35, but 53% remained at a high suboptimal level. CONCLUSIONS: The subjective outcome after a DRF improves over time for patients with an inferior result at 1 year, but more than half of the patients continue to have major disability. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Distal radius fractures-Regional variation in treatment regimens.

OBJECTIVES: After recent technical innovations of fracture surgery implants, treatment traditions are changing for distal radius fractures, the most common orthopaedic injury. The aim of this study was to determine if the choice of surgical method for treatment of distal radius fractures differ between healthcare regions in Sweden. METHOD: The study was based on all (n = 22 378) adult patients who were registered with a surgical procedure due to a distal radius fracture during 2010-2013 in Sweden. Consecutive data was collected from the Swedish National Patient Registry. RESULTS: The proportions of use of surgical method varied among the 21 healthcare regions between 41% and 95% for internal fixation, between 2.3% and 44% for percutaneous fixation and between 0.6% and 19% for external fixation. Differences between regions were statistically significant in all but 6 comparisons when controlled for age and gender. Incidence rates of surgical treatment of a distal radius fracture varied between 4.2 and 9.2/10 000 person-years. CONCLUSION: We conclude that there is a large variation in operative management of distal radius fractures between Swedish healthcare regions.

How Often Are Protocols Followed at Level I Trauma Centers?

This study analyzes adherence to an evidence-based protocol established at two level I trauma centers to determine its effect on clinical decision making. The centers' trauma databases were retrospectively studied and 51 patients with long bone fractures were identified who required revascularization and orthopaedic intervention and survived long enough to receive an index intervention. An arterial shunt was the protocol's first step; the preprotocol rate of shunting was 9.5%, while the postprotocol rate of shunting was 3.3%. The protocol's next step was external fixation; among the cases managed without a shunt, external fixation was the index intervention in 63.2% of the preprotocol cases and 31.0% of the postprotocol cases. Definitive vascular surgery was routinely performed before external fixation in 28.6% of the preprotocol cases and 56.7% of the postprotocol cases. This study demonstrates that this evidence-based protocol had no effect on the management of patients with combined orthopaedic and vascular injuries. Protocols should never supersede clinical judgment, but poor protocol adherence may represent a need for trauma centers to routinely review their protocols' compliance and efficacy. (Journal of Surgical Orthopaedic Advances 27(2):109-112, 2018).

Surgical versus nonsurgical management for type II odontoid fractures in the elderly population: a systematic review.

BACKGROUND: Odontoid process fractures, of which type II constitute the majority, are an increasingly important cause of morbidity and mortality in the elderly population. The incidence of geriatric type II fractures is steadily increasing in line with the aging population. However, the decision between surgical and non-surgical intervention for type II fractures in the elderly remains controversial. PURPOSE: The present study aims to synthesize the current published literature comparing outcomes following surgical and non-surgical interventions for type II odontoid fractures in the elderly population (≥65 years old). STUDY DESIGN/SETTING: Systematic review and meta-analysis were performed. METHODS: A systematic search of MEDLINE, MEDLINE In-Progress & Other Non-Indexed Citations, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed to identify available evidence in English language. Studies with extractable data for all type II odontoid fractures in participants aged 65 years or older and which compared surgical and non-surgical intervention were included. Methodological quality was assessed using the Downs & Black checklist. Primary outcomes were mortality at short-term follow-up (≤3 months), mortality at long-term follow-up (predetermined study endpoint or mean follow-up length), and radiological union rate. Funding was provided by The University of Edinburgh for travel expenses to present this paper at the Society of British Neurological Sciences 2016 Conference ($170). RESULTS: Twelve studies (n=1,098), all non-randomized, met eligibility criteria. Methodological quality was particularly poor in the confounding, bias, and power domains of assessment. Substantial methodological and statistical heterogeneity allowed only a narrative synthesis of the primary outcomes. Overall, data on mortality at short-term follow-up appeared to favor neither surgical nor non-surgical intervention. A small favorable outcome in surgically managed patients over non-surgically managed patients in terms of mortality at long-term follow-up was not proven conclusive because of considerable heterogeneity in study methodologies. Inadequate reporting of the time point of union assessment introduced the potential for significant intra- and interstudy heterogeneity and precluded assessment of union rates. CONCLUSIONS: Evidence on this controversial topic is sparse, markedly heterogeneous, and of poor quality. Well-designed prospective trials adhering to guidance published by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) initiative are required to inform clinical practice on this contentious but growing issue. Future randomized controlled trials should include an assessment of frailty and medical comorbidities with suitable patients subsequently randomized to surgical or non-surgical treatment.

Humeral lengthening and proximal deformity correction with monorail external fixator in young adults.

PURPOSE: Several humeral lengthening or simultaneous deformity corrections through one osteotomy using various external fixators were reported, while literature regarding correction of shortening and proximal varus deformity is scarce. This retrospective clinical study evaluated the results of preforming an acute correction and delayed lengthening in young adults through two osteotomies using monorail external fixator. METHODS: We report seven patients with various pathologies who underwent humeral proximal deformity correction and lengthening between 2009 and 2015. Pre-operative and post-operative clinical and radiographic data were collected. The mean follow-up time was 33.4 months (25-46 months). RESULTS: The humeral neck-shaft angle improved from 97.9° (85-110°) to 138.6° (135-145°). The magnitude of lengthening achieved was average 7.6 cm (range, 6-10 cm) at an average healing index of lengthening of 30.2 days/cm (range, 27.7-35.4 days/cm). There was a significant increase in range of shoulder abduction, and active abduction improved from pre-operative 136.4° (range, 95-160°) to post-operative 166.4° (range, 150-180°). The DASH score improved significance from 23.29 ± 8.36 to 6.57 ± 3.65 (t = 4.848; p < 0.001). CONCLUSION: Acute deformity correction and gradual lengthening with the monorail external fixator can be used for humeral shortening and proximal varus angular deformity. Functional improvement is expected after surgery and post-operative therapy.

Femoral nonunion with segmental bone defect treated by distraction osteogenesis with monolateral external fixation.

BACKGROUND: Currently, the common treatment for femoral nonunion with large segmental bone defect is difficult and complex. The effective surgical methods are rare, include vascularized bone grafting, Masquelet technique and Ilizarov distraction osteogenesis. The objective of this study is to investigate the outcomes of segmental femoral defects treated with monolateral external fixation using the distraction osteogenesis. METHODS: We retrospectively analyzed patients with femoral nonunion with segmental bone defects (> 6 cm) between January 2010 and January 2014 in our single trauma center. All patients were treated by distraction osteogenesis with monolateral external fixation. All surgeries were performed by the same surgeon. Bone union, duration of distraction osteogenesis in days, time to consolidation in months, external fixation index (EFI), complications, and additional surgical interventions were recorded postoperatively. The modified Application of Methods of Illizarov (ASAMI) criteria were used to evaluate the operative effectiveness. RESULTS: Forty-one patients were enrolled in this study for analysis. The length of the bone defect ranged from 6 to 17 cm. All patients eventually achieved healing, and no patient experienced recurrence of infection or newly developed infection. The average time needed for healing was 13 months. In terms of the incidence of complications, 3 cases axial deviations, 5 cases docking site nonunion, 23 cases pin-tract infection, 14 cases knee joint stiffness or their joint mobility declined, 2 cases osteogenesis insufficient in the distraction area,1 case refracture, and 2 cases loose external fixation pins. In terms of the evaluations of fracture healing and function, 30 patients excellent, 6 patients good, 5 patients fair, and 0 patient poor. In terms of postoperative function evaluations, 21 patients excellent, 9 patients good, 7 patients fair, and 4 patients poor. CONCLUSION: For patients with femoral nonunion with large segmental bone defects, the monolateral external fixation can provide effective stability, improve compliance, and reduce complications.

Effect of Early Pelvic Binder Use in the Emergency Management of Suspected Pelvic Trauma: A Retrospective Cohort Study.

BACKGROUND: We aimed to evaluate the effect of early pelvic binder use in the emergency management of suspected pelvic trauma, compared with the conventional stepwise approach. METHODS: We enrolled trauma patients with initial stabilization using a pelvic binder when suspecting pelvic injury. The inclusion criteria were traumatic injury requiring a trauma team and at least one of the following: a loss of consciousness or a Glasgow coma score (GCS) of <13; systolic blood pressure of <90 mmHg; falling from ≥6 m; injury to multiple vital organs; and suspected pelvic injury. Various parameters, including gender, age, mechanism of injury, GCS, mortality, hospital stay, initial vital signs, revised trauma score, injury severity score, and outcome, were assessed and compared with historical controls. RESULTS: A total of 204 patients with high-energy multiple-trauma from a single level I trauma center in North Taiwan were enrolled in the study from August 2013 to July 2014. The two group baseline patient characteristics were all collected and compared. The trauma patients with suspected pelvic fractures initially stabilized with a pelvic binder had shorter hospital and intensive care unit (ICU) stays. The study group achieved statistically significantly improved survival and lower mean blood transfusion volume and mortality rate, although they were more severe in the trauma score. CONCLUSIONS: We recommend prompt pelvic binder use for suspected pelvic injury before definitive imaging is available, as a cervical spine collar is used to protect the cervical spine from further injury prior to definitive identification and characterization of an injury.

The treatment of segmental tibial fractures: does patient preference differ from surgeon choice?

INTRODUCTION: Segmental tibial fractures are complex injuries with a prolonged recovery time. Current definitive treatment options include intramedullary fixation or a circular external fixator. However, there is uncertainty as to which surgical option is preferable and there are no sufficiently rigorous multi-centre trials that have answered this question. The objective of this study was to determine whether patient and surgeon opinion was permissive for a randomised controlled trial (RCT) comparing intramedullary nailing to the application of a circular external fixator. MATERIALS AND METHODS: A convenience questionnaire survey of attending surgeons was conducted during the United Kingdom's Orthopaedic Trauma Society annual meeting 2017 to determine the treatment modalities used for a segmental tibial fracture (n=63). Patient opinion was obtained from clinical patients who had been treated for a segmental tibial fracture as part of a patient and public involvement focus group with questions covering the domains of surgical preference, treatment expectations, outcome, the consent process and follow-up regime (n=5). RESULTS: Based on the surgeon survey, 39% routinely use circular frame fixation following segmental tibial fracture compared to 61% who use nail fixation. Nail fixation was reported as the treatment of choice for a closed injury in a healthy patient in 81% of surgeons, and by 86% for a patient with a closed fracture who was obese. Twenty-one percent reported that they would use a nail for an open segmental tibia fracture in diabetics who smoked, whilst 57% would opt for a nail for a closed injury with compartment syndrome, and only 27% would use a nail for an open segmental injury in a young fit sports person. The patient and public preference exercise identified that sleep, early functional outcomes and psychosocial measures of outcomes are important. CONCLUSION: We concluded that a RCT comparing definitive fixation with an intramedullary nail and a circular external fixator is justified as there remains uncertainty on the optimal surgical management for segmental tibial fractures. Furthermore, psychosocial factors and early post-operative outcomes should be reported as core outcome measures as part of such a trial.

The Importance of Medical Readiness Training Exercises: Maintaining Medical Readiness in a Low-Volume Combat Casualty Flow Era.

INTRODUCTION: Ringed external fixation has demonstrated promising results in the management of severe combat-related extremity injuries. The purpose of this study was to identify and compare rates of wartime-related surgical cases at times of high and low casualty time periods, and then compare these case numbers with those performed during a 2-week Medical Readiness Training Exercise (MEDRETE) in Honduras. MATERIALS AND METHODS: A retrospective review was performed of patients treated at a single Military Treatment Facility with definitive ringed external fixators during a 2-year period of high-volume combat casualty flow (January 2009-December 2010) and a subsequent 2-year period of low-volume combat casualty flow (January 2013-December 2014). These data were then compared with cases performed over a 2-week period during a MEDRETE in 2011 to Honduras. RESULTS: Sixty-one cases were identified as having definitive treatment using ringed external fixation at the Military Treatment Facility during the high- and low-volume eras. During the high-volume era, 47 ringed external fixators were used as a definitive treatment. During the low-volume era, only 14 of the definitive ringed external fixation were identified. Of the 32 total cases performed during the 2-week MEDRETE to Honduras, 11 cases of definitive ringed external fixator placement were performed. This accounted for 34.4% of all cases performed during this 2-week period. CONCLUSION: Appropriately planned MEDRETEs can provide a concentrated case volume to allow maintenance of complex surgical skills related to the management of severe combat-related extremity injuries. These training exercises will be vital to maintain surgical skills during a low-volume combat casualty flow era.

The effect of 'Out of hours surgery Service' in Israel on hip fracture fixation outcomes: a retrospective analysis.

BACKGROUND: 'Out of Hours Surgery Service' (OHSS) was implemented in Israel, amongst other reasons, in order to reduce the time interval between hospital admission and surgery and consequently improve outcomes. The OHSS is currently operated in the public hospitals in Israel. In this study we compared the data of patients before and after OHSS implementation to determine its efficacy in improving patient care. METHODS: This is a retrospective observational study of 792 adult patients who underwent hip fracture surgery between 2002 and 2007 in a single hospital. The study population included two groups: patients that were operated before the implementation of the OHSS (2002-2004) and after the implementation of the OHSS (2005-2007). Data regarding all patients was collected using the institution's computer program. The following variables were analyzed: patients' demographics, time interval from hospitalization to surgery, causes for delaying surgery, post-operative length of hospitalization and mortality. RESULTS: Patients in the post-OHSS group had more illnesses and higher ASA classification than those in the pre-OHSS group. The post-OHSS group had a significantly decreased length of stay in the hospital before and after the surgery. After adjusting for ASA score and age, the post-OHSS group was found to have decreased post-operative hospitalization and lower post-operative mortality. Surgery was delayed in pre-OHSS period mainly due to operating rooms unavailability. CONCLUSION: Implementation of OHSS facilitated operating room availability, thus early operation and reduced post-operative mortality. In accordance with other studies, patient's outcome is greatly influenced by the time from admission to hip fracture surgery.

The role of the intramedullary implant in limb lengthening.

Limb lengthening is now an accepted practice in orthopaedic surgery. The principles of distraction osteogenesis have become well established with the use of external fixators, utilizing both monolateral and ring fixators. Corticotomy technique, frame stability, lengthening rate and rhythm all contribute to the formation of bone regenerate and tissues. Complications are however common including pin-site infection, soft tissue tethering from the pins and wires resulting in pain, regenerate deformity from soft tissue forces or fracture following frame removal and patient intolerance of the frames during treatment. Surgical techniques have changed to try and minimise these complications. The use of intramedullary nails have been used in conjunction with an external fixator or inserted after lengthening has been achieved, to reduce fixator time and prevent regenerate deformity. Implant innovation has led to the production of intramedullary lengthening nails. The initial devices used ratchet mechanisms with rotation of the bone fragments to achieve lengthening (Bliskunov, Albizzia and ISKD). More accurate control of lengthening and a reduction in pain, resulting from the manual rotation of the leg required to achieve the ratchet progression, was achieved by the use of a transcutaneous electrical conduit powered by external high frequency electrical energy (Fitbone). The most recent implant uses an external remote controller which contains two neodymium magnets. These are placed over the nail on the skin and rotate which in turn rotates a third magnet within the intramedullary nail (Precice). This magnet rotation is converted by a motor to extend or retract the extendible rod. There are multiple nail sizes and lengths available, and early results have shown accurate control with few complications. With such promising outcomes the use of this lengthening intramedullary nail is now recommended as the implant of choice in femoral lengthening. This article is an historical account of the intramedullary device and the impact on limb lengthening.

When Traditional Offloading is not an Option, Could an External Fixator be a Solution?: A Case Report.

Offloading is a cornerstone in managing diabetic plantar foot ulcers; however, it often represents one of the most challenging aspects of treatment for clinician and patient alike. The authors present a case of a 61-year-old African American man with type 2 diabetes and a limb-threatening plantar foot ulcer that required aggressive wound and surgical management. Due to the heavy drainage and patient adherence issues, traditional offloading techniques such as total contact cast, DH Pressure Relief Walker (Össur, Foothill Ranch, CA), and wedge shoes, among others, were not viable options. Without offloading, healing will be difficult to achieve and will take a long time, carrying a higher risk of limb loss. The decision was made to apply an Ilizarov circular frame with footplate to facilitate offloading and weight bearing in tandem with negative pressure therapy. Although this is still considered an unusual use of this device, the results were positive and the wound progressed to complete reepithelialization.

A Prospective Randomized Trial to Assess Fixation Strategies for Severe Open Tibia Fractures: Modern Ring External Fixators Versus Internal Fixation (FIXIT Study).

The treatment of high-energy open tibia fractures is challenging in both the military and civilian environments. Treatment with modern ring external fixation may reduce complications common in these patients. However, no study has rigorously compared outcomes of modern ring external fixation with commonly used internal fixation approaches. The FIXIT study is a prospective, multicenter randomized trial comparing 1-year outcomes after treatment of severe open tibial shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18-64. The primary outcome is rehospitalization for major limb complications. Secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. One-year treatment costs and patient satisfaction will be compared between the 2 groups, and the percentage of Gustilo IIIB fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated.

Distal tibial fractures: evaluation of different fixation techniques.

PURPOSE: The purpose of this study was the comparison of the most commonly used surgical techniques (external fixation, intramedullary nailing, and plate fixation) for the treatment of distal tibial fractures (AO/OTA classification 42-A, B, C or 43-A, B1). METHODS: A retrospective cohort study of patients who underwent surgical treatment for distal tibial fractures between 1992 and 2011 was performed. RESULTS: A total of 93 patients (52 male/41 female) met inclusion criteria. Statistically significant differences were found regarding the consolidation time of the intramedullary-nailing (147.32 ± 91.16 days) and the plate-fixation group (135.75 ± 110.75 days) versus the external-fixation group (163.12 ± 96.79 days; P = 0.001; P = 0.01). Significant differences were also observed in the range of motion (ROM) of the ankle joint in the intramedullary-nailing and plate-fixation group versus the ROM in the external-fixation group (P = 0.044; P = 0.025). The overall complication rate was 13/93 (14 %). Out of 66 patients treated with intramedullary nailing, 8 (12 %) suffered from complications. Out of the 15 patients treated with plate and 12 patients with external fixation, 2 (13 %) and 3 (25 %) showed complications, respectively. CONCLUSION: Our results demonstrate advantages in terms of shorter mobilization time and a better ROM of the ankle joint for intramedullary nailing and plate fixation compared with external fixation. Due to our results, we suggest internal fixation (intramedullary nailing or plate fixation) whenever patient's condition and the local fracture situation allow it.

Distal tibial fracture: An ideal indication for external fixation using locking plate.

OBJECTIVE: To evaluate the feasibility and efficiency of one-stage external fixation by using locking plate in distal tibial fractures. METHODS: In this non-control prospective study, 28 patients with distal tibial fractures were included and underwent one-stage external fixation by using locking plate. There were 21 males and 7 females, with a mean age of 43 years (19-63). According to AO/OTA fracture classification, there were 9 cases of Type A1, 9 of Type A2, 10 of Type A3 fractures. There were 21 close and 7 open fractures. The locking plate was placed on the anteromedial aspect of the tibia with 4-5 bicortical screws inserted in both distal met- aphysis and diaphysis. The radiographic and clinic results were evaluated. RESULTS: All patients were followed up for the average of 16 months (ranging from 12 to 21 months). The average surgery duration was 38 (25-60) minutes. The mean time to fracture healing were 14.6 ± 2.67, 17.5 ± 3.66, and 18.4 ± 3.37 (p < 0.05) weeks in type A1, A2, and A3 fractures respectively. By the end of the follow-ups, the mean AOFAS score were 96.11 ± 2.32, 92.67 ± 1.80 and 92.00 ± 2.06 (p > 0.05) in type A1, A2, and A3 fractures respectively. None of nonunion, deep infection, or breakage of screw or plate were observed. CONCLUSIONS: Distal tibial fracture was the ideal indication for external fixation using locking plate. The external plating is characterized by ease of performance, less invasive, fewer soft tissue impingement, improved cosmesis, and convenient for removal.

Percutaneous fixation of traumatic pubic symphysis diastasis using a TightRope and external fixator versus using a cannulated screw.

BACKGROUND: The aim of the study was to introduce a new percutaneous technique for the treatment of traumatic pubic symphysis diastasis using a TightRope and external fixator. A comparison between this technique and percutaneous fixation using a cannulated screw was performed. METHODS: From January 2009 to December 2013, 26 patients with type II traumatic pubic symphysis diastasis were treated at two level 1 regional trauma centers. Among them, 10 patients were treated with a percutaneous TightRope and external fixator and 16 patients were treated with percutaneous cannulated screw fixation. Functional outcomes were evaluated using the Majeed scoring system. Patient satisfaction was evaluated using the modified visual analog scale. Radiological results were assessed based on the width of pubic symphysis preoperatively, immediately postoperatively, and at the final follow-up. Postoperative complications were also recorded. RESULTS: There were no significant differences between the groups in Majeed scores and patient satisfaction (p > 0.05). There were no significant differences in the width of pubic symphysis preoperatively, immediately postoperatively, and at the final follow-up (p > 0.05). No significant differences were found regarding infection, fixation failure, or the need for revision surgery (p > 0.05). CONCLUSIONS: The new percutaneous technique using a TightRope and external fixator is a successful alternative for the treatment of type II traumatic pubic symphysis diastasis, which results in similar outcomes comparing to percutaneous cannulated screw fixation.