Fixing Cho Type IIC Distal Clavicle Fractures with Hook Plates Leads to a High Incidence of Subacromial Osteolysis: A Retrospective Study and Literature Review.

Background: This retrospective study investigates the complications, particularly subacromial osteolysis (SAO), associated with hook plate (HP) fixation, in the treatment of unstable distal clavicle fractures characterized by complete coracoclavicular (CC) ligament rupture. The decision-making process for employing HP in fractures of this nature, such as Neer types IIB and V and Cho classification IIC, involves considerations of distal fragment size and displacement. While HP offers advantages in clinical practice, it is not without complications, with SAO being a notable concern. Factors such as non-anatomic hook tip placement and fracture classification may influence the risk of SAO. Methods: The study comprises a retrospective analysis of unstable distal clavicle fractures treated with HP at our institution from 2019 to 2022. Exclusions include non-displaced fractures, those treated with other locking plates, and pathologic fractures. A total of 91 patients with displaced distal clavicle fractures underwent open reduction and internal fixation with HP. Cho classification was employed to differentiate cases with CC ligament rupture. Patient demographics, classifications, postoperative radiographs, distal fragment size, plate position, timing of implant removal, and complications, including SAO, were recorded. Results: Among the 91 patients, 32 were classified as Cho IIB, 43 as Cho IIC, and 16 as Cho IID. Ninety-one percent exhibited solid union before implant removal. The prevalence of SAO was 43.8%, 76.7%, and 62.5% in Cho IIB, IIC, and IID, respectively. Univariate analysis revealed a significant difference only in Cho classification (p = 0.014). Binary logistic regression identified Cho classification type IIC as the sole risk factor for SAO (p = 0.021; odds ratio, 4.48; 95% confidence interval, 1.56-12.87). Conclusions: Cho type IIC fractures, characterized by CC ligament deficiency causing horizontal instability, demonstrated the highest SAO rate. In contrast, Neer type IIB fractures retained the trapezoid ligament, and Neer type V fractures had intact CC ligaments, resulting in lower SAO rates. Biomechanically, combining HPs with CC ligament reconstruction provided better structural stability than using HPs alone in treating Cho type IIC fractures.

Is Staged Surgery Always Necessary for Schatzker Type IV-VI Tibial Plateau Fractures? A Comparison Study.

AIMS: This study aims to compare the outcomes of immediate (followed by closed-incision negative-pressure therapy use) versus delayed ORIF in patients with Schatzker type IV-VI TPFs. PATIENTS AND METHODS: A prospective study of patients undergoing ORIF between January 2018 and December 2019 was performed. The inclusion criteria were patients (>18 years) with a closed fracture sent to the emergency room (ER) within 24 h of injury. All the patients underwent preoperative image evaluation. Two senior orthopedic trauma surgeons evaluated the soft tissue condition in the ER by 5P's of the compartment syndrome, judging the timing of the operation of definitive ORIF. Group 1 (n = 16) received delayed ORIF. Group 2 (n = 16) received immediate ORIF and ciNPT use. Patient follow-up occurred after 2 and 6 weeks and 3, 6, and 12 months after surgery. The assessments included the time to definitive fixation, the length of hospital stay, the time to bone union, surgical site complications, and reoperation within 12 months. A universal goniometer was used to measure the postoperative 3 m, 6 m, and 12 m ROM. RESULTS: The patient demographics were similar between the groups (p > 0.05). Group 2 displayed significantly a shorter time to definitive fixation (5.94 ± 2.02 vs. 0.61 ± 0.28, p < 0.0001) and hospital stay (14.90 ± 8/78 vs. 10.30 ± 6.78, p = 0.0016). No significant difference was observed in the time to bone union, surgical site complication incidence, and reoperation rates (p > 0.05). Flexion and flexion-extension knee ROM were demonstrated to be significantly improved in Group 2, 3, 6, and 12 months postoperatively (p < 0.0001). CONCLUSIONS: In this study, early ORIF and ciNPT use resulted in a shorter hospital length of stay, a reduced time to early active motion of the knee, and improved knee ROM. These results suggest that early ORIF with ciNPT for Schatzker type IV-VI TPFs is safe and effective in some patients. However, further research to confirm these findings across larger and more diverse populations is needed.

Using Trident distal radial locking plate to fix the fracture of distal radius volar rim.

BACKGROUND: The volar locking plates have been widely used in a variety of distal radius fractures, but they still have several limitations when dealing with small fragments located around the watershed line with widely reported complications. The volar rim fragments play a critical role in radiocarpal joint stability and failing to secure the volar rim fragment usually results in carpal instability, subluxation, or even dislocation. This study investigates clinical outcomes in the use of a novel implant, the Trident distal radial (TDR) locking plate to treat distal radius fracture with the intermedium column edge (lunate fossa volar rim) fragment involvement. METHODS: A retrospective study of 25 patients was conducted, all patients had intermedium column fractures with lunate fossa volar rim involvement and treat with the TDR between January 2016 and December 2019. The clinical assessment outcomes included VAS Pain, PRWE, and DASH scores. Objective measurements included ROM of the injured wrist and grip strength. Final radiographs were used to evaluate radial inclination, volar tilt, ulnar variance, and distal radioulnar joint instability. Secondary operations related to hardware complications were also recorded. RESULTS: The outcome revealed that the mean VAS Pain Score was 1.3, mean DASH score was 10.5, and mean PRWE score was 9.3. Objective measurements revealed good ROM recovery and an 89% gripping strength recovery compared with contralateral hand. Radiographic measurements revealed good maintenance of volar tilt, radial inclination, and mean ulnar variance. There were no complications related to the implant and all fracture sites were union. CONCLUSION: We believe that the TDR provided more stable fixation among distal radial fractures that predominantly involved the intermedial column and volar rim fragment, and allowing early rehabilitation. We could obtain excellent results in the wrist ROM, gripping power, and Pain Score (VAS).

It is Time to Replace Large Drains with Small Ones After Fixation of Rib Fractures: A Prospective Observational Study.

INTRODUCTION: Large-bore chest tubes are usually applied after thoracic surgery. Recently, small-bore tubes have been increasingly considered owing to the extensive use of video-assisted thoracoscopic surgery (VATS). This study assessed the differences in outcomes between large-bore and small-caliber drainage tubes in patients undergoing surgical stabilization of rib fractures (SSRF) with VATS. METHODS: Overall, 131 patients undergoing SSRF with VATS were prospectively enrolled, including 65 patients receiving 32-Fr chest tubes (group 1) and 66 patients receiving 14-Fr pigtail catheters (group 2) for postoperative drainage. The clinical characteristics and perioperative outcomes of the patients were compared. RESULTS: All patients underwent SSRF with VATS within 4 days after trauma. After the operation, the mean duration of chest tubes was longer than that of pigtail catheters, with statistical significance (5.08 ± 2.47 vs 3.11 ± 1.31, P = 0.001). Length of stay (LOS) was also longer in group 1 (10.38 ± 2.90 vs 8.18 ± 2.44, P = 0.001). After multivariate logistic regression, the only independent factors between the two groups were duration of postoperative drainage (adjusted odds ratio [AOR] 1.746; 95% confidence interval [CI] 0.171-10.583, P = 0.001) and hospital LOS (AOR 1.272; 95% CI 0.109-4.888, P = 0.027). CONCLUSION: After reconstruction of the chest wall and lung parenchyma, small-caliber drainage catheters could be easily and safely applied to reduce hospital LOS.

Functional outcomes following fixation of a marginal distal radius fracture with two commonly used volar locking plates: a retrospective cohort study.

INTRODUCTION: The volar locking plate has been widely used for unstable distal radius fractures to provide early recovery of wrist function. Volar plate prominence to the watershed line has been reported to be related to flexor tendon irritation, and avoid implant prominence in this area was suggested. On the other hand, marginal distal radius fracture patterns required the plate to cross the watershed line, making conflict over plate positioning on marginal distal radius fractures. This study compared functional outcomes in patients with marginal distal radius fractures treated with two different implants. MATERIALS AND METHODS: A retrospective study was conducted, all patients who received a Synthes 2.4 mm LCP or an Acumed Acu-Loc VLP between January 2015 and December 2018 were reviewed. The marginal distal radius fracture pattern was the most distal horizontal fracture line within 10 mm of the lunate fossa's joint line. The primary outcomes including patient-reported pain scores, range of motion, and grip strength were assessed. Secondary outcomes included patient-based subjective satisfaction scores of the injured wrist and hand function. The Mayo Wrist Score and the requirement for a secondary procedure related to hardware complications were also recorded. RESULTS: Forty-two patients met our inclusion criteria. Twenty-one patients were treated with the Synthes 2.4 mm LCP, and 21 patients with the Acumed Acu-Loc VLP. The primary outcome revealed that post-operative range of motion (P = 0.016) and grip strengths (P = 0.014) were significantly improved in the Acu-Loc VLP group. The MAYO wrist score in the Acu-Loc VLP group was also significantly better (P = 0.006). CONCLUSIONS: Despite advances in implant designs, flexor tendon irritation or rupture is still a complication following distal radius's volar plating. We believe the Acumed Acu-Loc VLP design provided better functional outcomes than the Synthes 2.4 mm LCP if appropriately and carefully placed into its designed-for position. This positioning results in promising patient satisfaction when treating marginal distal radius fractures.

Single pulley double-strand anchor suture fixation of the coronoid process in terrible triad of the elbow injury.

BACKGROUND: Terrible triad of the elbow injury is difficult to manage, and the role of the coronoid process in instability is very important. We describe a simple, modified suture technique to fix a coronoid process fragment using suture anchor fixation. METHODS: Eight patients (three female and five male) with coronoid process injuries with the fragment involving <50% of the total height (Regan-Morrey type I/II) in terrible triad of elbow injury were included. Patients were treated operatively via a lateral Kocher's approach, and coronoid process fractures were repaired with a single pulley double-strand suture technique. Structures were addressed in a sequential fashion-the coronoid process, radial head, lateral ulnar collateral ligament. RESULTS: All patients were treated with the single pulley double-strand anchor suture technique and the coronoid process fragment was found to be in good contact with the original avulsion site using the method. The final Mayo Elbow Performance Score was excellent (> 90) in six patients and good (between 85 and 89) in two patients after operation 6 months. CONCLUSION: The single pulley double-strand suture tie method using a suture anchor is a less invasive and simpler fixation method for the repair of coronoid process fractures in patients with terrible triad of the elbow injuries and results in good outcomes.

Immediate application of negative pressure wound therapy following lower extremity flap reconstruction in sixteen patients.

Negative pressure wound therapy (NPWT) is usually applied in wound management and soft-tissue salvage after the development of complications. However, immediate postoperative application of NPWT over the flap coverage is seldom reported. We evaluate the effectiveness of immediate postoperative application of NPWT following fasciocutaneous or muscle flap coverage for lower leg reconstruction. A retrospective review of patients who underwent either fasciocutaneous or muscle flap coverage of lower leg soft-tissue defects applied with NPWT immediately after surgery was conducted in a level I trauma center. Sixteen patients, with an average age of 51.2 years, were included in the study. Nine patients had trauma-related soft-tissue loss, six had subsequent soft-tissue defects after debridement, and one had burn injury. Two patients had been treated with free anterolateral thigh flaps, 11 with pedicle flaps, and three with muscle flaps. All flaps survived except for those in two patients with venous congestion on postoperative day 1, which needed further debridement and skin grafting. Therefore, the use of immediate incisional NPWT is an alternative for wound care following flap coverage. The U-shaped design allows easy flap observation and temperature check. Furthermore, this method eliminates any concerns of vascular pedicle compression under negative pressure.

Supercritical carbon dioxide decellularized porcine cartilage graft with PRP attenuated OA progression and regenerated articular cartilage in ACLT-induced OA rats.

Knee osteoarthritis (OA) is a common degenerative articular disorder and considered one of the primary causes of pain and functional disability. Knee OA is prevalent in 10% of men and 13% of women aged 60 years above. The study aims to use cartilage tissue engineering that combines the triads of decellularized porcine cartilage graft as "scaffold," plasma rich platelet (PRP) as "signal" and chondrocytes from rat as "cell" to attenuate ACLT-induced OA progression and regenerate the knee cartilage in rats. Decellularization of the porcine cartilage was characterized by hematoxylin and eosin, 4,6-Diamidino-2-phenylindole staining, scanning electron microscopy and residual DNA quantification. The protective effect of decellularized porcine cartilage graft (dPCG) was evaluated by intra-articular administration in surgically induced anterior cruciate ligament transection (ACLT) rat osteoarthritis (OA) model. Supercritical carbon dioxide technology completely decellularized the porcine cartilage. Intra-articular administration of dPCG with or without PRP significantly reduced the ACLT-induced OA symptoms and attenuated the OA progression. Pain-relief by dPCG with or without PRP was assessed by capacitance meter and improved articular cartilage damage in the rat knee was characterized by X-ray and micro-CT. Besides, the histological analysis depicted cartilage protection by dPCG with or without PRP. The repairation and attenuation effect by dPCG with or without PRP in the articular knee cartilage damage were also explored by safranin-O, type II collagen, aggrecan and SOX-9 immuno-staining. To conclude, intra-articular administration of dPCG with or without PRP is efficient in repairing the damaged cartilage in the experimental OA model.

The elastic stable intramedullary nails as an alternative treatment for adult humeral shaft fractures.

BACKGROUND: Plate and locked intramedullary nailing for humeral fractures are golden standard procedure, but the humerus is a nonweight-bearing bone and can tolerate a larger range of acceptable alignment. We believe the elastic stable intramedullary nails (ESINs) can provide enough relative stability for humeral shaft fractures in certain adult patients. METHODS: There are four new indications for using ESINs: (1) patient could not tolerate a sugar-tong splint but was a high risk for general anesthesia, (2) intramedullary canal narrowing (<7 mm), (3) long spiral or oblique fracture over the metadiaphyseal junction, and (4) obesity. All patients received retrograde fixation with two titanium elastic nails, except for one patient with a long spiral fracture over the proximal metadiaphysis. Patients had routine follow-up plain radiographs until bone union, and we evaluated functional results of patients by Mayo Elbow Performance Score and asked to complete Quick Disabilities of the Arm, Shoulder and Hand score at the last outpatient clinic visit. RESULTS: A total of 16 patients with a mean age of 54.4 years were included. The mean follow-up time was 14 ± 2.5 months, and the average time to bone union was 16 ± 4.3 weeks. There were no wound infections, loss of reduction, fracture nonunion, implant failure, or skin irritation expect for one nail back-out because of osteoporosis. CONCLUSION: We have reported good results using ESINs for the displaced fractures of the humerus in the four indication adults who would not be able to tolerate plate fixation or intramedullary nailing. The ESINs fixation method is a simple procedure that provides a small incision, minimal blood loss, short surgical time, and relative stability fixation.

A novel low-profile external skeletal fixator for type IIIB open tibial fractures: A biomechanical and clinical pilot study.

BACKGROUND: Although external fixator is standard for managing staged treatment of open tibial fracture, the main disadvantage of this device is too bulky to be tolerated by most patients for longtime use. The purposes of this pilot study were to compare the biomechanical properties of a novel low-profile external fixator (LP-ESF) with a traditional ESF and also to evaluate its performance in patients with Gustilo type IIIb tibial open fractures. METHODS: A prospective clinical pilot study started from January 2015 to December 2017, and 18 patients with Gustilo type IIIb open tibial fractures underwent the fixation with a novel LP-ESF system. The biomechanical properties of the LP-ESF were compared with the Synthes External Fixation System according to the standard ASTM F1541-02. These patients were divided into two groups according to the size of bony defect. The postoperative clinical outcomes were subsequently collected. RESULTS: The biomechanical properties of the LP-ESF were comparable with those of Synthes External Fixation System and had an improved the axial/torsional stiffness and ultimate strength. In the clinical study, all patients with LP-ESF had fracture union. The duration of application of LP-ESF was 3.5 to 18 months until fracture union. In 10 of 18 patients, their fractures were immobilized with the LP-ESF until bone union, and no pin tract infection and no chronic osteomyelitis were recorded. The 36-Item Short Form Health Survey life quality and health survey were good to excellent in these patients. Notably, the LP-ESF allowed a patient with severe bone and soft-tissue defects to preserve the leg and joints function. CONCLUSION: In this study, we found that the novel LP-ESFs had improved clinical outcomes. The long-term LP-ESF application seems to be tolerable in our patients. This novel approach permits better controls in deep infection and faster healing of fractures, and thus may provide a viable alternative treatment for Gustilo type IIIb open tibial fractures.

Using multiple-steps bioinformatic analysis to predict the potential microRNA targets by cardiogenic HoxA11.

BACKGROUND: In this study, our major aim is to using multiple-steps bioinformatic analysis to predict cardiogenic genes with targeting mRNA profiling for predicting cardiogenic HoxA11 gene. METHODS: We first analyzed the microarray data with bioinformatic measurement, including combining with panel module 1 (mouse embryonic stem cells), panel module 2 (mouse induced pluripotent stem cells), and panel module 3 (gene list form literature of heart development). A literature-based comparison of the two microarrays and a software-based (Targetscan program, www.targetscan.org) comparative analysis of the two datasets. Furthermore, we select the common central pathways and potential candidate genes involved in the cardiomyocyte-lineaged differentiation and development. RESULTS: Schematic presentation of a putative miR181a target site in Hox-A11 3'UTR. The bioinformatic result showed that potential interacted cardiogenic targets of Tbx5, Tbx20, Mal2c, Nkx2.5, cTNT, Cx43, MHC, and MCK in different treatment groups of pluripotent stem cells by using a literature-based comparison of the two microarrays and a software-based gene-lineage system. CONCLUSION: Our findings support that mir181a is an up-stream regulating microRNA to target the 3'UTR of HoxA11 mRNA during the process of cardiomyocyte differentiation.

A systematic review of the methodology of sonographic assessment of upper limb activities-associated carpal tunnel syndrome.

BACKGROUND: Various upper limb activities were speculated to be associated with the development of carpal tunnel syndrome (CTS). Nonetheless, there are currently no standardization on the uses of parameters in CTS assessments, nor are there any conclusive findings regarding the usefulness of various sonographic measurements in studies of different upper limb activities. In this review, we intend to evaluate the methodology of assessing CTS induced by upper limb activities with ultrasonographic technique and provide corresponding suggestions. METHODS: Clinical studies on the association between upper limb activities and prevalence of CTS using ultrasonography were recruited in a database research on the basis of a procedural selection criteria and reviewed. The following qualitative items were extracted: characteristics of studies, scanning methods, selection of sonographic parameters, and related article findings. RESULTS: Eleven studies were qualified for this review. Three studies were computer keyboard typing related, five studies were electronic device related, and three studies were wheelchair-related. All sampled articles included cross-sectional area (CSA) at the pisiform level. The swelling ratio (SR) and flattening ratio (FR) at the hamate level are also used in most studies in addition to the CSA at the pisiform level. The effectiveness of such parameters is subjected to various confounding factors such as age, weight, body mass index, and wrist anthropometrics, suggesting CSA and SR with sufficient levels had significant values as sonographic parameters. Values of parameters were found affecting symptomatic signs and hand dominance. CONCLUSION: Ultrasound scan is a suitable tool to assess the relationship between upper limb activity and CTS. CSA at the pisiform level and SR and the FR at the hamate levels are generally suitable in upper limb-associated CTS investigations. Specific study designs are required to eliminate different confounding factors accordingly.

A strategy to prevent complications of hyperextension type tibial plateau fracture.

BACKGROUND: Tibial plateau fractures (TPFs) are the most common among periarticular fractures. Mechanism of injuries is most from varus/valgus and flexion injury. Hyperextension type injuries are rare and easily to be overlooked. We reported 12 cases of this fracture type. Complications of early cases were reported, and treatment strategies of late cases were suggested. MATERIALS AND METHODS: From 2010 to 2016, we performed a retrospective analysis of 248 cases of TPFs in our institute and 12 cases of hyperextension bicondylar TPFs were diagnosed. Diagnostic method is from both plain films and CT scans. The features of this injury included sagittal plane malalignment with loss of the normal posterior slope of the tibial plateau, tension failure of the posterior cortex, and compression of the anterior cortex. Surgical approach is predominantly via an anterolateral and/or posteromedial double incision at the first. Then anteromedial with adequate grafting to support the bone defect was modified. Postoperative radiographic analysis, physical examination findings, and complications were reported. Patient reported outcome scores from the Knee Injury and Osteoarthritis Outcome Score (KOOS) were recorded. RESULTS: Twelve patients were followed up for a mean period of 16.6 months (range 12-26 months). The mean time to radiographic bony union was 3.6 months (range 3-9 months, SD 8.5). About complications, the incidence of popliteal artery occlusion received PTA was 8% (1/12). And 3/12 (25%) patients had either partial or complete peroneal nerve injury. 2/12 (16%) patients developed a leg compartment syndrome. 33% (4/12) demonstrated associated injuries including posterolateral complex injuries mostly and posterior cruciate ligament avulsion fracture in one case. The average range of motion of the affected knees was 3.4-130° postoperatively. Analysis of complication about surgery included inadequate reduction and fixation in two cases, insufficient bone grafting in one case. The mean mPTA was significantly improved after fixation (preoperative 82° postoperative 3 months 86°). The mean posterior slope (PTA) was preoperative  - 3° and postoperative 3 months 3°. And mean KOOS was 80. CONCLUSIONS: Hyperextension bicondylar tibial plateau fractures show a special characteristic of changes in posterior tibial slope angle and are easy to be overlooked. Complication rate is high after injury and after ineffective fixation. Choosing correct approach with sufficient grafting and stable fixation for treatment of hyperextension bicondylar tibial plateau fractures should be used to improve patients' outcome.

3D composite engineered using supercritical CO2 decellularized porcine cartilage scaffold, chondrocytes, and PRP: Role in articular cartilage regeneration.

At present, no definitive treatment for articular cartilage defects has been perfected. Most of the previous treatments involved multiple drilling and microfracture over defect sites with repair-related substances, which poses a limited therapeutic effect. End-stage therapy includes artificial knee joint replacement. In this study, we prepared a novel decellularized natural cartilage scaffold from porcine articular cartilage by supercritical CO2 extraction technology and three-dimensional (3D) composites made using decellularized porcine cartilage graft (dPCG) as scaffolds, platelet-rich plasma (PRP), thrombin as signals and chondrocytes as cells for the treatment of articular cartilage defects. In this study, in vitro and in vivo cartilage regeneration and the expression of chondrogenic markers were examined. Decellularized cartilage graft (dPCG) was evaluated for the extent of cell and DNA removal. Residual cartilage ECM structure was confirmed to be type II collagen by SDS PAGE and immunostaining. The new 3D composite with dPCG (100 mg and 2 × 106 chondrocytes) scaffold promotes chondrogenic marker expression in vitro. We found that the in vivo 3D composite implanted cartilage defect showed significant regeneration relative to the blank and control implant. Immunohistochemical staining showed increase of expression including Collagen type II and aggrecan in 3D composite both in vitro and in vivo studies. In this study, the bioengineered 3D composite by combining dPCG scaffold, chondrocytes, and PRP facilitated the chondrogenic marker expression in both in vitro and in vivo models with accelerated cartilage regeneration. This might serve the purpose of clinical treatment of large focal articular cartilage defects in humans in the near future.

Protocols for the preparation and characterization of decellularized tissue and organ scaffolds for tissue engineering.

Extracellular matrix (ECM) scaffolds are extensively used in tissue engineering studies and numerous clinical applications for tissue and organ reconstructions. Due to the global severe shortage of human tissues and organs, xenogeneic biomaterials are a common source for human tissue engineering and regenerative medicine applications. Traditional methods for decellularization often disrupt the 3D architecture and damage the structural integrity of the ECM scaffold. To efficiently obtain natural ECM scaffolds from animal tissues and organs with intact architecture, we have developed a platform decellularization process using supercritical CO2 and tested its potential application in tissue engineering. A combination of human mesenchymal stem cells with a decellularized dermal matrix scaffold allowed complete regeneration of skin structure in a porcine full-thickness wound model.

Peri-implant Fractures Following Hook Plate Fixation for Unstable Distal Clavicle Fractures.

Clavicle hook plate is a common implant for treating distal clavicle fracture. Although high bone union rate and good functional outcome have been reported, so have several complications, such as osteolysis and fracture of the acromion, loss reduction, hook impingement, and rotator cuff tear. Peri-implant fracture over the medial side of the hook plate is a rare complication. Sporadic cases have been reported, and most of them have had no history of trauma. Between June 2015 and August 2018, 7 patients treated for distal clavicle fracture with a 3.5-mm locking compression hook plate with no history of trauma experienced peri-implant fracture of the medial clavicle. This complication occurred at a mean of 29 days. The incidence rate was 9.8%. Peri-implant fracture following hook plate fixation for distal clavicle fracture was not rare. Small hook angle, prolonged retention of the implant, an eccentric medial screw, high plate screw density, and small clavicle diameter may be risk factors for peri-implant fracture. Regarding treatment, 2 patients chose fracture revision with a distal clavicle locking plate and 5 patients chose conservative treatment. All patients achieved bone union at fracture sites. Surgical and conservative management of peri-implant fracture can achieve good functional outcome. [Orthopedics. 2020;43(5);e359-e363.].

Safety and Efficacy of Prophylactic Closed Incision Negative Pressure Therapy after Acute Fracture Surgery.

INTRODUCTION: Soft tissue swelling after acute fracture surgery is a challenge which may increase wound dehiscence, delay early range of motion, and increase infection rate postoperatively. This study investigates closed incision negative pressure therapy (ciNPT) using wide-range cover over the incision site and the peripheral swelling trauma zone to promote early active motion and to mitigate joint stiffness, bulla formation, and tendon adhesion. METHODS: Twenty-nine patients were enrolled between January 2018 and December 2018. Patients with high-energy soft tissue trauma and comminuted fractures over distal end of limbs (hand and foot; wrist and ankle) or muscle scarcity areas (tibial shaft or patella) were included. ciNPT was applied over closed incisions in the operating room and subatmospheric pressure (-125 mmHg) initiated continuously for 5~7 days. RESULTS: In hand and foot patients (n= 8), active motion over all fingers or toes occurred after post-operative Day 2. Mild swelling without any bullous formation was observed over the dorsal aspect of hand. In wrist and ankle patients (n= 16), flexion angle over the finger joints over 90 degrees was observed after 5 days post-surgery. For patients with tibial shaft comminuted fractures with impending compartment syndrome, early active motion of knee and ankle joint was observed as soft tissue swelling and distension pain had subsided after surgery. CONCLUSION: The prophylactic ciNPT use in the trauma area after surgery reduced postoperative distension pain and improved early range of motion of the tendon and joint in these patients.

Facilitating ventilator weaning through rib fixation combined with video-assisted thoracoscopic surgery in severe blunt chest injury with acute respiratory failure.

BACKGROUND: Severe blunt chest injury sometimes induces acute respiratory failure (ARF), requiring ventilator use. We aimed to evaluate the effect of performing rib fixation with the addition of video-assisted thoracoscopic surgery (VATS) on patients with ARF caused by blunt thoracic injury with ventilator dependence. METHODS: This observational study prospectively enrolled patients with multiple bicortical rib fractures with hemothorax caused by severe blunt chest trauma. All patients received positive pressure mechanical ventilation within 24 h after trauma because of ARF. Some patients who received rib fixation with VATS were enrolled as group 1, and the others who received only VATS were designated as group 2. The length of ventilator use was the primary clinical outcome. Rates of pneumonia and length of hospital stay constituted secondary outcomes. RESULTS: A total of 61 patients were included in this study. The basic demographic characteristics between the two groups exhibited no statistical differences. All patients received operations within 6 days after trauma. The length of ventilator use was shorter in group 1 (3.19 ± 3.37 days vs. 8.05 ± 8.23, P = 0.002). The rate of pneumonia was higher in group 2 (38.1% vs. 75.0%, P = 0.005). The length of hospital stay was much shorter in group 1 (17.76 ± 8.38 days vs. 24.13 ± 9.80, P = 0.011). CONCLUSION: Rib fixation combined with VATS could shorten the length of ventilator use and reduce the pneumonia rate in patients with severe chest blunt injury with ARF. Therefore, this operation could shorten the overall length of hospital stay.

Management of bone defects due to infected non-union or chronic osteomyelitis with autologous non-vascularized free fibular grafts.

OBJECTIVES: Bone defects as a result of infected non-union or chronic osteomyelitis are difficult to manage. The purpose of this study was to present the results of treatment of bone defects of < 6 cm due to a previous infected non-union or chronic osteomyelitis with autologous non-vascularized fibular grafts in a 2-stage surgery. PATIENTS AND METHODS: The records of patients who were treated with autologous non-vascularized fibular grafts for bone defects of < 6 cm due to a previous infected non-union or chronic osteomyelitis between 2008 and 2013 were retrospectively reviewed. Primary complete bone union was the primary outcome. Time until fracture union, and return to normal daily activities or previous work were recorded. Radiographs were evaluated for graft hypertrophy as well as for stress fracture and other complications. RESULTS: A total of 27 cases were included. The mean length of the bone defects was 4.4 cm (range 2 - 6 cm). Complete union and healing occurred in 25/27 patients (primary success rate of 92.6%). Non-union was present in two patients with suboptimal soft tissue condition 10 months after surgery, one patient was subsequently treated with a vascularized free fibular graft from the contralateral fibula, and the other patient was treated with distraction osteogenesis, bone union was achieved after the second surgery. Average time to return to normal daily activity after surgery was 7.82 months (6 ~ 11 months). Graft hypertrophy occurred in 15 cases 15/25 (60%) two years post-surgery. There were no other surgical or postoperative complications. CONCLUSIONS: With careful evaluation of soft-tissue condition surrounding bone defect, management of infected bone defects with autologous non-vascularized fibular grafts technique has a high success rate with few complications.

Popliteal artery occlusion concomitant with a tibial plateau fracture and posterior cruciate ligament avulsion fracture.

In acute trauma, posterior cruciate ligament (PCL) injury may occur concomitantly with a bony fracture and be easily overlooked. A popliteal artery injury associated with a tibial plateau fracture and PCL avulsion fracture is rare. Missed or delayed diagnosis of this condition leads to a high amputation rate. Therefore, close attention is required with this type of injury. The limb can be saved though early detection and immediate reconstruction of the injured artery, followed by fasciotomy. We report here a rare case of popliteal artery occlusion proximal to the surgical zone, which was diagnosed after fixation of a medial tibial plateau fracture and posterior cruciate avulsion injury. In dashboard injuries without knee dislocation, the arterial intima may be injured and become vulnerable, even with an initial ankle brachial index greater than 0.9. This can cause concomitant occlusion of the popliteal artery due to iatrogenic retraction during surgery. Therefore, a neurovascular examination should be repeated to prevent delayed-onset thrombosis. To the best of our knowledge, this is the first case of popliteal artery injury concomitant with a tibial plateau fracture and PCL avulsion owing to initial dashboard injury-related arterial intima injury, which can present with a normal ankle brachial index.