Inter- and intra-observer variability of the AO/OTA classification for sternal fractures: a validation study.

INTRODUCTION: Recently, a new classification system for sternal fractures has been published in the Journal of Orthopedic trauma by the Arbeitsgemeinschaft für Osteosynthesefragen (AO) foundation and the Orthopaedic Trauma Association (OTA). The aim of this study was to evaluate inter- and intra-observer variability of the AO/OTA classification for sternal fractures. MATERIALS AND METHODS: Twenty multidetector computed tomography (CT) scans of patients with sternal fractures were classified independently by six senior and six junior orthopedic trauma surgeons of two level-1 trauma centers. Assessment was done on two occasions with an interval of 6 weeks. The kappa value was calculated to determine variability. RESULTS: The inter-observer variability of the AO/OTA classification for sternal fractures showed fair-to-moderate agreement (kappa = 0.364). There was no significant difference between junior and senior surgeons. Analyses of the separate components of the classification demonstrated that agreement was lowest for classifying fracture type within the sternal body (kappa = 0.319) followed by manubrium (kappa = 0.525). The intra-observer variability showed moderate agreement with a mean kappa of 0.414. CONCLUSION: The inter- and intra-observer variability of the AO/OTA classification for sternal fractures shows fair-to-moderate agreement. The overall performance of the classification might be improved with minor modifications. LEVEL OF EVIDENCE: Diagnostic cross-sectional study (level I).

Selective fasciotomy for acute traumatic lower leg compartment syndrome: is it feasible?

INTRODUCTION: The standard treatment for an acute compartment syndrome (ACS) of the lower leg is a four compartment fasciotomy. It can be performed through either one lateral or a lateral and medial incision. Selective fasciotomy, only opening the compartments with elevated pressure, is a less invasive procedure. The aim of this study was to describe a procedure of selective fasciotomy after pressure measurement and to determine its feasibility in a retrospective cohort study. METHODS: All patients with an ACS of the lower leg due to a proximal or tibia shaft fracture (AO 41 or 42) who received either a four compartment fasciotomy or a selective fasciotomy after pressure measurement between 2006 and 2016 were included. Every compartment with an intracompartment pressure of more than 30 mmHg was opened. The primary outcome was any missed compartment syndrome after selective fasciotomy. Secondary outcomes were reoperations for completing four compartment fasciotomy and persistent sensomotoric deficits. RESULTS: Fifty-one patients with a mean age of 43 years (6-76) were included. Of these, 41 (80%) had a selective fasciotomy. There was no missed compartment syndrome. One patient had a reoperation 8 h after primary selective fasciotomy due to ACS of the superficial and deep flexor compartment. The anterior compartment had to be released in all patients. In 67%, the release of 2 compartments was sufficient. Six patients had postoperative sensomotoric deficits at discharge with full recovery during follow-up. CONCLUSION: Selective fasciotomy is feasible and seems to be safe. Future comparative studies will have to focus on possible benefits of this less invasive treatment.

Long-term follow-up after MIPO Philos plating for proximal humerus fractures.

INTRODUCTION: Minimally invasive plate osteosynthesis (MIPO) has been described as a suitable technique for the treatment of proximal humerus fractures, but long-term functional results have never been reported. The aim of this study was to describe the long-term functional outcome and implant-related irritation after MIPO for proximal humerus fractures. METHODS: A long-term prospective cohort analysis was performed on all patients treated for a proximal humerus fracture using MIPO with a Philos plate (Synthes, Switzerland) between December 2007 and October 2010. The primary outcome was the QuickDASH score. Secondary outcome measures were the subjective shoulder value (SSV), implant related irritation and implant removal. RESULTS: Seventy-nine out of 97 patients (81%) with a mean age of 59 years were available for follow-up. The mean follow-up was 8.3 years (SD 0.8). The mean QuickDASH score was 5.6 (SD 14). The mean SSV was 92 (SD 11). Forty out of 79 patients (50.6%) had implant removal, and of those, 27/40 (67.5%) were due to implant-related irritation. On average, the implant was removed after 1.2 years (SD 0.5). In bivariate analysis, there was an association between the AO classification and the QuickDASH (p = 0.008). CONCLUSION: Treatment of proximal humerus fractures using MIPO with Philos through a deltoid split approach showed promising results. A good function can be assumed due to the excellent scores of patient oriented questionnaires. However, about one-third of the patients will have a second operation for implant removal due to implant-related irritation.

[Pilon fractures-considerations for treatment strategies and surgical approaches]. / Pilonfrakturen ­ Überlegungen zur Versorgung und Zugänge.

The majority of pilon or tibial plafond fractures are complex articular fractures and the treatment strategy, including the choice of the ideal surgical approach, is essential for a good functional outcome. In this paper, we discuss the considerations for dealing with such fractures as well as the pro and cons of the different approaches. The standard protocol consists of a two-staged procedure following the slogan span-scan-plan. After applying an ankle-spanning external fixator (span), the diagnostic work-up is completed by a CT scan with axial views, two-dimensional and three-dimensional reconstruction (scan) to fully understand the fracture pattern. Using this information, in coordination with the soft tissue situation, the ideal approaches, type and position of implants are planned in detail. This article, supported by clinical cases, describes different surgical approaches and the areas of interest which can be seen through these approaches as well as the implant position.

Predicting suitability of intramedullary fixation for displaced midshaft clavicle fractures.

PURPOSE: Implant-related irritation is a technique-specific complication seen in a substantial number of patients treated with intramedullary nailing for clavicle fractures. The purpose of this study was to identify predictors for developing implant-related irritation in patients with displaced midshaft clavicle fractures treated with elastic stable intramedullary nailing. METHODS: A retrospective analysis of the surgical database in two level 2 trauma centers was performed. Patients who underwent intramedullary nailing for displaced midshaft clavicle fractures between 2005 and 2012 in the first hospital were included. Age, gender, fracture comminution and fracture location were assessed as possible predictors for developing irritation using multivariate logistic regression analysis. These predictors were externally validated using data of patients treated in another hospital. RESULTS: Eighty-one patients were included in initial analysis. In the multivariate analysis, comminuted fractures in comparison to non-comminuted fractures (72 vs. 38%, p = 0.027) and fracture location (p < 0.001) were significantly associated with the development of implant-related irritation. In particular, lateral diaphyseal fractures caused irritation compared to fractures on the medial side of the cut-off point (88 vs. 26%). External validation of these predictors in 48 additional patients treated in another hospital showed a similar predictive value of the model and a good fit. CONCLUSION: Comminuted and lateral diaphyseal fractures were found to be statistically significant and independent predictors for developing implant-related irritation. We, therefore, believe that intramedullary nailing might not be suitable for these types of fractures. Future studies are needed to determine whether alternative surgical techniques or implants would be more suitable for these specific types of fractures.

End cap versus no end cap in intramedullary nailing for displaced midshaft clavicle fractures: influence on implant-related irritation.

PURPOSE: Implant-related irritation at the entry site is a known disadvantage of intramedullary nailing for clavicle fractures. The purpose of this study was to compare implant-related irritation rates of intramedullary nailing with or without an end cap for displaced midshaft clavicle fractures. METHODS: Two cohorts of patients treated with intramedullary nailing with or without an end cap were matched and compared. Primary outcome was patient-reported implant-related irritation. Secondary outcome parameters were complications. RESULTS: A total of 34 patients with an end cap were matched with 68 patients without an end cap. There was no difference in implant-related irritation (41 versus 53%, P = 0.26). Significantly more minor revisions were observed in the group without an end cap (15 versus 0%, P = 0.03). For complications requiring major revision surgery, significantly more implant failures were observed in the end cap group (12 versus 2%, P = 0.04). Regardless of their treatment, patients with complex fractures (AO/OTA B2-B3) reported significantly more medial irritation compared to patients with simple fractures (AO/OTA B1)(P = 0.02). CONCLUSION: The use of an end cap after intramedullary nailing for displaced midshaft clavicle fractures did not result in lower patient-reported irritation rates. Although less minor revisions were observed, more major revisions were reported in the end cap group. Based on the results of this study, no end caps should be used after intramedullary nailing for displaced midshaft clavicle fractures. However, careful selection of simple fractures might be effective in reducing implant-related problems after intramedullary nailing.