Primary arthrodesis versus open reduction and internal fixation following intra-articular calcaneal fractures: a weight-bearing CT analysis.

PURPOSE: To compare primary arthrodesis (PA) versus open reduction and internal fixation (ORIF) in displaced intra-articular calcaneal fractures (DIACFs), based on clinical outcome and 2D and 3D geometrical analyses obtained from weight-bearing (WB) cone-beam CT images. MATERIALS AND METHODS: In this prospective study, 40 patients with surgically treated calcaneal fractures were included, consisting of 20 PA and 20 ORIF patients. Weight-bearing cone-beam CT-images of the left and right hindfoot and forefoot were acquired on a Planmed Verity cone-beam CT-scanner after a minimum of 1-year follow-up. Automated 2D and 3D geometric analyses, i.e., (minimal and average) talo-navicular joint space, calcaneal pitch (CP), and Meary's angle (MA), were obtained for injured and healthy feet. Clinical outcomes were measured using the EQ5D and FFI questionnaires. RESULTS: Overall, there were no differences in baseline patient characteristics apart from age (p < 0.005). The calcaneal pitch in 2D after treatment by ORIF (13.8° ± 5.6) was closer to the uninjured side (18.1° ± 5.5) compared to PA (10.9° ± 4.5) (p < 0.001). Meary's angle in 2D was closer to the uninjured side (8.7° ± 6.3) after surgery in the PA cohort (7.0° ± 5.8) compared to the ORIF cohort (15.5° ± 5.9) (p = 0.046). In 3D measurements, CP was significantly decreased for both cohorts after surgery (- 4.09° ± 6.2) (p = 0.001). MA was not significantly affected overall or between cohorts in 3D. Clinical outcomes were not significantly different between the ORIF and PA cohorts. None of the radiographic measurements in 2D or 3D correlated with any of the clinical outcomes studied. CONCLUSION: Three-dimensional WB CT imaging enables functional 2D and 3D analyses under natural load in patients with complex calcaneal fractures. Based on clinical outcome, both PA and ORIF appear viable treatment options. Clinical correlation with geometrical outcomes remains to be established.

Minifragment plating of the fibula in unstable ankle fractures.

INTRODUCTION: Only 6.4-17% of the load is transmitted through the fibula when weight-bearing. Plate fixation of distal fibular fractures using minifragments (≤ 2.8 mm) could lead to similar reduction with less implant removal (IR) rates, compared to small-fragment plates (3.5 mm). We hypothesized that the use of minifragment plates is at least similar in unscheduled secondary surgery. MATERIALS AND METHODS: In this retrospective cohort study, all patients with surgically treated distal fibular fractures between October 2015 and March 2021 were included. Patients treated with plate fixation using minifragments and patients treated with small-fragment plates were compared regarding the following outcomes: secondary dislocation, malreduction, implant malposition, nonunion, surgical site infections (SSI) and IR. RESULTS: Sixty-five patients (54.2%) received a minifragment implant (≤ 2.8 mm) and 55 patients (45.8%) received a small-fragment implant (3.5 mm). There were no patients needing secondary surgery in the minifragment group compared to 9 patients following fixation using small-fragment implants (3 with secondary dislocation, 5 with malreduction and 1 with malposition, p = 0.001). SSI rates were 3.1% for minifragment and 9.1% for small-fragment implants (p = 0.161). Implant removal was performed significantly less often following use of minifragment implants (17.8% and 53.2%, p < 0.001). CONCLUSIONS: In this cohort, minifragment plate fixation for distal fibular fractures is an adequate fixation method offering stable fixation with significant lower need for implant removal and comparable complications to small-fragment plates, although an adequately powered randomized controlled study is needed for implementation in a clinical setting. LEVEL OF EVIDENCE: Therapeutic, III.

Cost-effectiveness of on-demand removal of syndesmotic screws.

PURPOSE: Syndesmotic screw removal following acute syndesmotic injury is a commonly performed procedure. However, recent studies suggest that the removal does not result in improved patient reported outcome, while the procedure has proved not to be without complications. The aim of this study was to present a health-economic evaluation of on-demand removal (ODR) compared to routine removal (RR) of the syndesmotic screw. METHODS: Data were collected from the RODEO trial, a randomized controlled non-inferiority trial comparing functional outcome of ODR with RR. Economic evaluation resulted in total costs, costs (in Euro) per quality adjusted life year (QALY) and costs per point improvement on the Olerud Molander Ankle Score (OMAS). This included both direct and indirect costs. RESULTS: Total costs for ODR were significantly lower with a mean difference of 3160 euro compared to RR (p < 0.001). The difference in QALY was not significant. The difference in OMAS at 12 months was 1.79 with an incremental cost-effectiveness ratio (ICER) of €-1763 (p = 0.512). The ICER was well below the willingness to pay. Although unit costs might vary between hospitals and countries, these results provide relevant data of cost-effectiveness. CONCLUSION: The clinical effectiveness of both ODR and RR can be considered equal. The costs are lower for patients treated with ODR, which leads to the conclusion that ODR is cost-effective.

Systematic review: Diagnostics, management and outcome of fractures of the posterior process of the talus.

BACKGROUND: Fractures of the posterior process of the talus are rare and frequently overlooked, possibly leading to pseudo-arthrosis and chronic pain. To gain more insight into the diagnosis, treatment and outcome of fractures of the posterior process of the talus (PPTF), a systematic review of the current literature was performed to provide recommendations for the management of PPTF. METHODS: A literature search in the electronic databases of PubMed, EMbase, Google Scholar and Cochrane library was performed in January 2020 to identify all clinical studies on PPTF with more than three patients. Amongst other variables, the type of study, number of patients, mechanism of injury, type of fracture (anatomy), imaging modality, treatment, postoperative protocol, outcomes, complications and duration of follow-up were noted for systematic analysis of the available evidence, adherent to the PRISMA guidelines. RESULTS: Seven original studies were included with a total of 66 patients. More than one third of patients presented with a (sub)talar joint dislocation (n = 25, 37.9%) and 51.5% sustained associated ipsilateral lower extremity fractures (n = 34). Delayed diagnosis occurred in 36.4% of patients (n = 24). Out of 48 patients with outcome data available, 41.7% (n = 20) reported impaired function. In the non-operative group, 64.7% (n = 11) had impaired functional outcome, compared to 33.3% (n = 6) in the ORIF group, and 30.8% (n = 4) in the fragment excision group (p < 0.001). One third of the patients developed one or more complications (n = 25, 37.9%), mostly found in the non-operatively treated group (73.7%, n = 14) compared to ORIF (25.0%, n = 8, p < 0.001). CONCLUSION: Early recognition and timely treatment is warranted in order to achieve pre-injury functional outcome and reduce morbidity. Given the significantly higher complication rate and lower return to the previous level of functionality reported after non-operative treatment, ORIF is recommended if there is (even minimal) displacement, articular involvement or if the fracture extends into the talus body.

Correction to: Routine versus on demand removal of the syndesmotic screw; a protocol for an international randomised controlled trial (RODEO-trial).

An amendment to this paper has been published and can be accessed via the original article.

The role of external fixation in the management of infected avascular necrosis after traumatic talus fractures.

PURPOSE: Avascular necrosis (AVN) after fractures of the talus is a distinct and challenging clinical entity that is associated with poor outcomes. Although several articles are published on the management of posttraumatic AVN of the talus, very little is known about the management of infected AVN after talus fractures. Therefore, three cases of infected AVN were treated successfully by extensive debridement, external fixation and arthrodesis. METHODS: Three cases of infected AVN of the talus were encountered after a mean of 3 months (range 2-6 months) after initial reconstructive surgery. Suspected infection was confirmed by positron emission tomography scan (PET-CT). Management involved extensive debridement, PMMA cement if necessary and final fusion using medial external fixator, accompanied by culture guided antibiotics. Functional outcome was assessed using the Foot Function Index (FFI) and the American Orthopaedic Foot and Ankle Society hindfoot score (AOFAS). Quality of life (QOL) was measured by the EuroQol-5D (EQ-5D). RESULTS: After a mean follow up of 24 months (range 13-29), FFI index scores ranged from poor to good (23, 50, 56) with similar AOFAS scores indicating poor to fair functional outcome (38, 41, 71). The EQ-5D score was 0.78. Overall patient satisfaction was high with a mean VAS of 8.3 (range 8-9). CONCLUSION: Infected talar AVN is a rare condition associated with severe long-term morbidity in term of joint function. The authors recommend extensive debridement and arthrodesis by means of external fixation, followed by post-operative culture-guided antibiotics for the treatment of infected avascular necrosis of traumatic talar fractures. Shared decision-making and expectation management are of crucial importance and may lead to high patient satisfaction despite low functional outcomes. LEVEL OF EVIDENCE: IV, Retrospective case series.

Risk factors for surgical site infections with the Sinus Tarsi Approach in displaced intra-articular calcaneal fractures; a prospective cohort study with a minimum of one year follow-up.

BACKGROUND: In the last decade, the sinus tarsi approach (STA) has gained interest over the extensile lateral approach (ELA) in the operative treatment of displaced intra-articular calcaneal fractures (DIACF's), mainly because of the lower rate of surgical site infections (SSIs). However, most studies are small and retrospective. The aim of this study was to evaluate the rate of SSIs of the STA in a large, prospective series of patients and to identify predictors for SSIs. METHODS: In this prospective cohort study, all consecutive patients who were operatively treated for a DIACF in our Level 1 trauma center between August 2012 and January 2019 were included and followed for at least one year. All operative procedures were performed by two specialized foot and ankle trauma surgeons using the STA. Using multinomial logistic regression, risk factors for SSIs were identified. RESULTS: A total of 237 calcaneal fractures in 214 patients were included, of which 179 underwent open reduction and internal fixation and 58 a primary arthrodesis. Most patients were male (73.6%) and the mean age was 45.9 years. There were 16 patients that developed a SSI (6.8%), of which 9 (3.8%) were deep and 7 (3%) were superficial infections. The multivariate analysis pointed out that surgery within one week after injury increased the chance of a SSI, as well as an ASA of 2 or higher and more than 150 cc of blood loss during the procedure. CONCLUSION: This study confirms the low risk of SSI in DIACFs treated via STA. Significant predictors for SSIs were surgery within one week after injury, ASA of 2 or higher and blood loss > 150cc.

Posterior malleolar fracture morphology determines outcome in rotational type ankle fractures.

INTRODUCTION: Rotational type ankle fractures with a concomitant fracture of the posterior malleolus are associated with a poorer clinical outcome as compared to ankle fractures without. However, clinical implications of posterior malleolar (PM) fracture morphology and pattern have yet to be established. Many studies on this subject report on fragment size, rather than fracture morphology based on computed tomography (CT). The overall purpose of the current study was to elucidate the correlation of PM fracture morphology and functional outcome, assessed with CT imaging and not with -unreliable- plain radiographs. METHODS: Between January 2010 and May 2014, 194 patients with an operatively (ORIF) treated ankle fracture, were prospectively included in the randomized clinical EF3X-trial at our Level-I trauma center. The current study retrospectively included 73 patients with rotational type ankle fractures and concomitant fractures of the posterior malleolus. According to the CT-based Haraguchi fracture morphology, all patients were divided into three groups: 20 Type I (large posterolateral-oblique), 21 Type II (transverse medial-extension) and 32 Type III (small-shell fragment). At 12 weeks, 1 year and 2 years postoperatively the Foot and Ankle Outcome Scores (FAOS) and SF-36 scores were obtained, with the FAOS domain scores at two years postoperative as primary study outcome. Statistical analysis included a multivariate regression and secondary a mixed model analysis. RESULTS: Haraguchi Type II PM ankle fractures demonstrated significantly poorer outcome scores at two years follow-up compared to Haraguchi Types I and III. Mean FAOS domain scores at two years follow-up showed to be significantly worse in Haraguchi Type II as compared to Type III, respectively: Symptoms 48.2 versus 61.7 (p = 0.03), Pain 58.5 versus 84.4 (p < 0.01), Activities of Daily Living (ADL) 64.1 versus 90.5 (p < 0.01). CONCLUSION: Posterior malleolar ankle fractures with medial extension of the fracture line (i.e. Haraguchi Type II) are associated with significantly poorer functional outcomes. The current dogma to fix PM fractures that involve at least 25-33% of the tibial plafond may be challenged, as posterior malleolar fracture pattern and morphology - rather than fragment size - seem to determine outcome.

Functional outcome of implant removal following fracture fixation below the level of the knee: a prospective cohort study.

AIMS: The aim of this study was to evaluate the functional outcome in patients undergoing implant removal (IR) after fracture fixation below the level of the knee. PATIENTS AND METHODS: All adult patients (18 to 75 years) undergoing IR after fracture fixation below the level of the knee between November 2014 and September 2016 were included as part of the WIFI (Wound Infections Following Implant Removal Below the Knee) trial, performed in 17 teaching hospitals and two university hospitals in The Netherlands. In this multicentre prospective cohort, the primary outcome was the difference in functional status before and after IR, measured by the Lower Extremity Functional Scale (LEFS), with a minimal clinically important difference of nine points. RESULTS: A total of 179 patients were included with a median age of 50 years (interquartile range (IQR) 37 to 60), of whom 71 patients (39.7%) were male. With a median score of 60 before IR (IQR 45 to 72) and 66 after IR (IQR 51 to 76) on the LEFS, there was a statistically significant improvement in functional outcome (p < 0 .001). A total of 31 surgical site infections (17.3%) occurred. CONCLUSION: Although IR led to a statistically significant improvement of functional outcome, the minimal clinically important difference was not reached. In conclusion, this study shows that IR does not result in a clinically relevant improvement in functional outcome. These results, in combination with the high complication rate, highlight the importance of carefully reviewing the indication for IR. Cite this article: Bone Joint J 2019;101-B:447-453.

The correlation between intra-operative 2D- and 3D fluoroscopy with postoperative CT-scans in the treatment of calcaneal fractures.

OBJECTIVES: The aim of this study was to determine the correlation of the intra-operative fluoroscopic 2D- and 3D-images compared with a postoperative CT-scan, in terms of quality of reduction and fixation of calcaneal fractures. METHODS: Patients requiring open reduction and internal fixation (ORIF) of a calcaneal fracture were recruited as part of the EF3X-trial. During surgery, intra-operative images of fluoroscopic 2D- and 3D-imaging were obtained to assess the quality of the reduction and implant position. All patients received a postoperative CT-scan within one week. The operating surgeon evaluated intra-operatively both 2D- and 3D-images according to a 23-item scoring protocol on a 3-point Likert scale. A scoring panel, consisting of three clinical experts, evaluated all images in a blinded and independent fashion. Intraclass correlation coefficients (ICC) with their 95% confidence intervals (CI) were calculated using a two-way-random model with absolute agreement. RESULTS: A total of 102 calcaneal fractures were included. Agreement of 3D-imaging for the quality of reduction was better than 2D-imaging, although still fair, but for fixation moderate to good. Agreement between the 2D-images and the CT-scans was poor to fair. Intra-operative 2D-imaging received the highest ratings for image quality and interpretability, followed by CT-scanning. CONCLUSION: Implant position can be evaluated satisfactory with the aid of intra-operative 3D imaging. Although intra-operative 3D imaging had a better agreement with postoperative CT-scanning than 2D-imaging, there is a need to improve image quality and suppress scattering from implants to improve the additional value of intra-operative 3D imaging in calcaneal fracture reduction and fixation.

The diagnosis and treatment of isolated type B fibular fractures: Results of a nationwide survey.

INTRODUCTION: In isolated Weber B fractures (type B fibular fractures), ruling out instability is critical for safe conservative treatment. In fractures without evident medial injury, additional diagnostics like MRI scan or gravity stress test should be done to differentiate between a stable and unstable fracture. The aim of the current study is to gain more insight in current practice and treatment of type B fractures by Dutch trauma- and orthopaedic surgeons. MATERIALS & METHODS: In December 2017 and January 2018, 559 trauma surgeons were invited by email to join an online survey. This survey consisted of questions regarding diagnostics and treatment of isolated distal fibula fractures. Also, respondents were asked to state their preferred treatment of eight separate cases. RESULTS: In total, 161 surgeons participated, covering 68 different hospitals in the Netherlands. Of them, 32.0% treat more than 30 ankle fractures a year. Based on regular mortise radiographs, 13.6% of the respondents chose surgical treatment in case of a medial clear space (MCS) > 4 mm, 33.8% in case of a MCS > 6 mm and 45.5% in case of a MCS > 4 mm in addition to the MCS ≥ superior clear space + 1 mm. Moreover, 18.2% make use of additional diagnostics (43.9% repeat mortise view after a week, 16.6% weight bearing radiograph, 8.6% gravity stress view, 7.9% exorotation radiograph, 6.5% MRI scan, 0.7% ultrasound, 16.8% other) and 8% establishes their decision not based on the mortise radiograph. Fibular dislocation of ≥ 2 mm was used as an indication for surgical treatment by 69%. Of them, 56% decides to treat surgically in these cases, even with proven medial stability. CONCLUSION: Many surgeons treat type B fibular fractures with a MCS > 4 mm at mortise view surgically, even without proven medial injury. Rarely, additional diagnostics as MRI or gravity stress test are performed in cases with a MCS 4-6 mm. Consequently many stable ankle fractures are treated operatively unnecessarily.

Routine versus on demand removal of the syndesmotic screw; a protocol for an international randomised controlled trial (RODEO-trial).

BACKGROUND: Syndesmotic injuries are common and their incidence is rising. In case of surgical fixation of the syndesmosis a metal syndesmotic screw is used most often. It is however unclear whether this screw needs to be removed routinely after the syndesmosis has healed. Traditionally the screw is removed after six to 12 weeks as it is thought to hamper ankle functional and to be a source of pain. Some studies however suggest this is only the case in a minority of patients. We therefore aim to investigate the effect of retaining the syndesmotic screw on functional outcome. DESIGN: This is a pragmatic international multicentre randomised controlled trial in patients with an acute syndesmotic injury for which a metallic syndesmotic screw was placed. Patients will be randomised to either routine removal of the syndesmotic screw or removal on demand. Primary outcome is functional recovery at 12 months measured with the Olerud-Molander Score. Secondary outcomes are quality of life, pain and costs. In total 194 patients will be needed to demonstrate non-inferiority between the two interventions at 80% power and a significance level of 0.025 including 15% loss to follow-up. DISCUSSION: If removal on demand of the syndesmotic screw is non-inferior to routine removal in terms of functional outcome, this will offer a strong argument to adopt this as standard practice of care. This means that patients will not have to undergo a secondary procedure, leading to less complications and subsequent lower costs. TRIAL REGISTRATION: This study was registered at the Netherlands Trial Register (NTR5965), Clinicaltrials.gov ( NCT02896998 ) on July 15th 2016.

Two-stage treatment in patients with patients with high-energy femoral fractures does not lead to an increase in deep infectious complications: a propensity score analysis.

PURPOSE: In patients following severe trauma sometimes the physiological condition or soft tissue status may not allow definitive fixation of a femoral fracture. In these patients, an external fixator can be placed to temporarily stabilise the fracture, after which definitive fixation can be performed in a second procedure. The aim of this study was to compare the postoperative wound infection and union rates of patients treated with direct intramedullary nailing (IMN) and patients treated with the 'two-stage treatment'. METHODS: All patients with high-energy femoral fractures treated with IMN between 2000 and 2016 in a single Level 1 trauma centre were eligible. Electronic charts were reviewed for patient and surgical characteristics; furthermore, the development of complications was noted. A propensity score analysis was performed to assess the attributed risk of the external fixator on the development of postoperative wound infections. RESULTS: A total of 149 patients were included in this study; 93 underwent direct IMN and 56 underwent the two-stage treatment. Patients who underwent two-stage treatment were more severely injured, reflected by lower EMV and higher ISS on admission. Patients in the two-stage treatment group had a significant higher risk of postoperative wound infections (OR: 4.698, 95% CI: 1.203-18.339) but not a higher risk on deep postoperative wound infections (OR 2.345, 95% CI: 0.439-12.540). Union rate did not differ between the two groups (94% vs 94% NS). CONCLUSIONS: The two-stage treatment is a safe treatment option in patients with a high-energy femoral fracture in terms of postoperative wound infections. Union rates are also comparable between the two treatment groups.

C-reactive protein kinetics and its predictive value in orthopedic (trauma) surgery: A systematic review.

In Orthopedic Trauma Surgery (OTS), C-reactive- protein (CRP) is a widely used marker for the diagnosis of postoperative wound infections (POWI's) and other complications. The aim of this systematic review was to describe specific CRP kinetics and to evaluate the diagnostic value of CRP for te detection of post-operative complications in OTS. The same pattern is reported consistently, where the highest levels of CRP are found at post-operative-day two or three, returning to normal in three weeks. Amplitude varies per procedure. Persistently high CRP levels or secondary increases may indicate complications. A low CRP may be used to rule out complications.

Safety in the operating room during orthopedic trauma surgery-incidence of adverse events related to technical equipment and logistics.

BACKGROUND: Safety in the operating room is widely debated. Adverse events during surgery are potentially dangerous for the patient and staff. The incidence of adverse events during orthopedic trauma surgery is unknown. Therefore, we performed a study to quantify the incidence of these adverse events. Primary objective was to determine the incidence of adverse events related to technical equipment and logistics. The secondary objective was to evaluate the consequences of these adverse events. METHODS: We completed a cross-sectional observational study to assess the incidence, consequences and preventability of adverse events related to technical equipment and logistics during orthopedic trauma surgery. During a 10 week period, all orthopedic trauma operations were evaluated by an observer. Six types of procedures were differentiated: osteosynthesis; arthroscopy; removal of hardware; joint replacement; bone grafting and other. Adverse events were divided in six categories: staff dependent factors; patient dependent factors; anaesthesia; imaging equipment; operation room equipment and instruments and implants. Adverse events were defined as any factor affecting the surgical procedure in a negative way. RESULTS: Hundred-fifty operative procedures were included. In 54% of the procedures, at least one adverse event occurred. In total, 147 adverse events occurred, with a range of 1-5 per procedure. Most adverse events occurred during joint replacement procedures. Thirty-seven percent of the incidents concerned defect, incorrect connected or absent instruments. In 36% of the procedures adverse events resulted in a prolonged operation time with a median prolongation of 10.0 min. CONCLUSION: In more than half of orthopedic trauma surgical procedures adverse events related to technical equipment and logistics occurred, most of them could easily be prevented. These adverse events could endanger the safety of the patient and staff and should therefore be reduced. LEVEL OF EVIDENCE: 4.

Acute syndesmotic instability in ankle fractures: A review.

Ankle fractures are among the most common fracture types, and 10% of all ankle fractures lead to accessory syndesmotic injury. An injury that is challenging in every respect is syndesmotic instability. Since the range of diagnostic techniques and the therapeutic options is extensive, it still is a controversial subject, despite the abundance of literature. This review aimed to summarize the current knowledge on syndesmotic instability in ankle fractures and to formulate some recommendations for clinical practice. Chronic instability and the operative osseous treatment of ankle fractures are not part of this review.

Effects of intra-operative fluoroscopic 3D-imaging on peri-operative imaging strategy in calcaneal fracture surgery.

INTRODUCTION: Previous studies demonstrated that intra-operative fluoroscopic 3D-imaging (3D-imaging) in calcaneal fracture surgery is promising to prevent revision surgery and save costs. However, these studies limited their focus to corrections performed after 3D-imaging, thereby neglecting corrections after intra-operative fluoroscopic 2D-imaging (2D-imaging). The aim of this study was to assess the effects of additional 3D-imaging on intra-operative corrections, peri-operative imaging used, and patient-relevant outcomes compared to 2D-imaging alone. PATIENTS AND METHODS: In this before-after study, data of adult patients who underwent open reduction and internal fixation (ORIF) of a calcaneal fracture between 2000 and 2014 in our level-I Trauma center were collected. 3D-imaging (BV Pulsera with 3D-RX, Philips Healthcare, Best, The Netherlands) was available as of 2007 at the surgeons' discretion. Patient and fracture characteristics, peri-operative imaging, intra-operative corrections and patient-relevant outcomes were collected from the hospital databases. Patients in whom additional 3D-imaging was applied were compared to those undergoing 2D-imaging alone. RESULTS: A total of 231 patients were included of whom 107 (46%) were operated with the use of 3D-imaging. No significant differences were found in baseline characteristics. The median duration of surgery was significantly longer when using 3D-imaging (2:08 vs. 1:54 h; p = 0.002). Corrections after additional 3D-imaging were performed in 53% of the patients. However, significantly fewer corrections were made after 2D-imaging when 3D-imaging was available (Risk difference (RD) -15%; 95% Confidence interval (CI) -29 to -2). Peri-operative imaging, besides intra-operative 3D-imaging, and patient-relevant outcomes were similar between groups. CONCLUSION: Intra-operative 3D-imaging provides additional information resulting in additional corrections. Moreover, 3D-imaging probably changed the surgeons' attitude to rely more on 3D-imaging, hence a 15%-decrease of corrections performed after 2D-imaging when 3D imaging was available. No substantiation for cost reduction was found through reduction in peri-operative imaging or in terms of improved patient-relevant outcomes.

Evaluation and quantification of geographical differences in wound complication rates following the extended lateral approach in displaced intra-articular calcaneal fractures - A systematic review of the literature.

INTRODUCTION: Calcaneal fracture surgery is often performed via the extended lateral approach (ELA). Large differences are reported in literature on wound complication rates. Aim was to perform a systematic review on reported postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following the ELA and evaluate and quantify geographical differences. METHODS: A literature search was conducted in the MEDLINE and EMBASE databases and Cochrane Library. Studies before 2000, with <10 patients, biomechanical studies and reviews were excluded. No restrictions regarding language were applied. RESULTS: 3068 articles were identified of which 123 were included, with 8584 calcaneal fractures in 28 different countries. The average total number of POWC was 14.3%, with 3.8% of superficial and 2.2% of deep infections. The highest POWI rate was found in Europe (12.1%) and the lowest in North America (2.8%). A significant difference in incidence of deep POWI between continents was detected (median 0-3.8%). No differences were found in incidence of POWC and POWI between retro- and prospective studies (respectively p=0.970, p=0.748) or studies with <10 or ≥10 operations per year (respectively p=0.326, p=0.378). However, lower rates of POWI were found in studies with a follow up of >3months (p=0.01). CONCLUSION: Large differences were detected in incidence of POWC and POWI following calcaneal fracture surgery with the ELA between countries and continents. We did not find a lower POWC or POWI rate in retrospective studies compared to prospective studies, larger studies or in studies in which more patients were treated annually. However, the rate of POWI was significantly lower in studies with a follow up of >3months. We advise the use of a reliable postoperative complication registration system and uniformity in the use of standardized definitions of wound complications for calcaneal fracture surgery.

Systematic CT evaluation of reduction and hardware positioning of surgically treated calcaneal fractures: a reliability analysis.

INTRODUCTION: Up to date, there is a lack of reliable protocols that systematically evaluate the quality of reduction and hardware positioning of surgically treated calcaneal fractures. Based on international consensus, we previously introduced a 23-item scoring protocol evaluating the reduction and hardware positioning in these fractures based on postoperative computed tomography. The current study is a reliability analysis of the described scoring protocol. METHODS: Three raters independently and systematically evaluated anonymized postoperative CT scans of 102 surgically treated calcaneal fractures. A selection of 25 patients was scored twice by all individual raters to calculate intra-rater reliability. The scoring protocol consisted of 23 items addressing quality of reduction and hardware positioning. Each of these four-option questions was answered as: 'optimal', 'suboptimal (but not needing revision)', 'not acceptable (needing revision)' or 'not judgeable'. We used intraclass correlation coefficients (ICC's) to calculate inter- and intra-rater reliability. RESULTS: Inter-rater reliability of the overall 23-item protocol was good (ICC 0.66, 95% CI 0.64-0.69). Individual items that scored an inter-rater ICC ≥0.60 included evaluation of the calcaneocuboid joint, the posterior talocalcaneal joint, the anterior talocalcaneal joint, the position of the plate and sustentaculum screws and screws protruding the tuber and medial wall. The intra-rater reliability for the overall protocol was good for all three individual raters with ICC's between 0.60 and 0.70. CONCLUSION: Our scoring protocol for the radiological evaluation of operatively treated calcaneal fractures is reliable in terms of inter- and intra-rater reliability.

Unstable fragility fractures of the ankle in the elderly: Transarticular Steinmann pin or external fixation.

INTRODUCTION: Because of poor skin conditions and comorbidity, open reduction and internal fixation in ankle fractures is frequently contra-indicated in the elderly. This study reports the results of two temporary fixation types in fragility fractures in the older patient: transarticular Steinmann pin fixation and external fixation. METHODS: Patients aged over 60 treated with a Steinmann pin or external fixation were retrospectively included. Patient, fracture and treatment characteristics were collected. RESULTS: Fifteen patients were included. Nine were managed using a Steinmann pin and six by external fixation. All reached fracture consolidation. Patients treated with a Steinmann pin underwent a median of 2 operations and the pin was left in situ for 80 days. Three patients suffered from superficial wound infection. X-ray showed malreduction in 67% and only two patients returned to pre-injury mobility. A median of 2 operations with 32 fixation days was reported in the external fixation group. This group showed one deep infection. In 50% there was malreduction, one patient experienced disability in ambulation at the end of treatment. CONCLUSION: Both techniques show few complications, but have, as expected, poor results in fracture reduction and functional outcome. External fixation and subsequent internal fixation could result in better functional outcome.