Union Rate and Rate of Hardware Removal Following Plate Fixation of Metatarsal Shaft and Neck Fractures.

BACKGROUND: There have been very few studies related to the treatment of first, second, third, and fourth (MT) metatarsal shaft and neck fractures. In order to reduce metatarsal fracture malunion, many surgeons have turned from K-wire to plate fixation of these fractures. This study reports the healing rates, final fracture angulation, and need for hardware removal of operatively treated first to fourth MT shaft and neck fractures with plate fixation. METHODS: A retrospective review was performed on all metatarsal fractures at our institution between 2008 and 2014 to identify all first to fourth MT shaft and neck fractures. Medical records and radiographs were reviewed for evidence of union, sagittal, and coronal fracture angulation (degrees), time to full weight bearing, plate size, fracture location (neck vs shaft), and number of screws on each side of the fracture. Multiple linear regression analysis was used to make calculations of statistical significance. RESULTS: Forty-five patients with a total of 75 first to fourth MT fractures treated with plate fixation were included in this study. All fractures went on to union and full weight bearing. The average time to union and time to full weight bearing was 10.9 ± 2 weeks and 7.5 ± 1.6 weeks, respectively. The average coronal and sagittal plane angulation was 3.9 and 2.2 degrees, respectively. Fractures located in the neck were found to have higher coronal plane angulation malunion compared with fractures in the shaft ( P = .019). No variable was found to be related to final sagittal plane angulation. No patient had a plate removed, and 26 of 27 of patients did not want to have the plate removed. CONCLUSION: Metatarsal fractures fixed with plates had high rates of union and low final fracture angulation. No patient included in this study underwent hardware removal. LEVEL OF EVIDENCE: Level III, comparative study.

Malunion of post-traumatic thoracolumbar fractures.

Thoracolumbar malunion is the result of loss of correction, insufficient correction or even no correction (both in the frontal and sagittal planes) of a thoracolumbar fracture. The main causes are incorrect assessment of the fracture's complexity (burst fracture), its potential progression to kyphosis and associated disc or ligament damage. It can also be the result of a poorly conducted initial treatment. The types of malunion have changed over the years because of the introduction of vertebroplasty and kyphoplasty. The malunion can be well tolerated if there is only a moderate deformity. However, the functional and pain-related limitations can be severe with large deformities. Functional limitation is mainly related to sagittal imbalance, but also to sequelae associated with the injury in various ways (non-union, disc degeneration, spinal cord compression, syringomyelia, etc.). The deformity and its consequences are evaluated globally using full-body standing radiographs (EOS), CT scan and MRI. Comparison of MRI images taken in a lying position to weight bearing views or even dynamic ones is an additional means to evaluate whether the lesions are reducible. Differences in spine morphology and compensatory mechanisms to combat the sagittal imbalance induced by the deformity must also be analyzed. These provide more complete information about the consequences of the malunion and help to establish the best corrective strategy. These compensatory mechanisms consist of accentuation of lumbar lordosis along with reduction of thoracic kyphosis. As a last resort, the pelvis and femur contribute to this compensation when there is a large deformity or a stiff spine due to preexisting osteoarthritis. Treatment strategies are fairly well standardized. When the deformity is reducible, a two-stage surgery is indicated. When the deformity is not reducible, posterior transpedicular closed wedge osteotomy is the gold standard. Nevertheless, the best way to treat thoracolumbar malunion is to prevent it.

Percutaneous or Open Reduction of Closed Tibial Shaft Fractures During Intramedullary Nailing Does Not Increase Wound Complications, Infection or Nonunion Rates.

OBJECTIVE: To compare the incidence of complications (wound, infection, and nonunion) among those patients treated with closed, percutaneous, and open intramedullary nailing for closed tibial shaft fractures. DESIGN: Retrospective review. SETTING: Multiple trauma centers. PATIENTS: Skeletally mature patients with closed tibia fractures amenable to treatment with an intramedullary device. INTERVENTION: Intramedullary fixation with closed, percutaneous, or open reduction. MAIN OUTCOME MEASUREMENTS: Superficial wound complication, deep infection, nonunion. RESULTS: A total of 317 tibial shaft fractures in 315 patients were included in the study. Two-hundred fractures in 198 patients were treated with closed reduction, 61 fractures in 61 patients were treated with percutaneous reduction, and 56 fractures in 56 patients were treated with formal open reduction. The superficial wound complication rate was 1% (2/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 3.6% (2/56) for the open group with no statistical difference between the groups (P = 0.179). The deep infection rate was 2% (4/200) for the closed group, 1.6% (1/61) for the percutaneous group, and 7.1% (4/56) for the open group with no significant difference between the groups (P = 0.133). Nonunion rate was 5.0% (10/200) for the closed group, 4.9% (3/61) for the percutaneous group, and 7.1% (4/56) for the open group, with no statistical difference between the groups (P = 0.492). CONCLUSIONS: This is the largest reported series of closed tibial shaft fractures nailed with percutaneous and open reduction. Percutaneous or open reduction did not result in increased wound complications, infection, or nonunion rates. Carefully performed percutaneous or open approaches can be safely used in obtaining reduction of difficult tibial shaft fractures treated with intramedullary devices. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Primary Wound Closure After Open Fracture: A Prospective Cohort Study Examining Nonunion and Deep Infection.

OBJECTIVES: Determine the proportion of subjects developing deep infection or nonunion after primary wound closure of open fractures (humerus, radius/ulna, femur, and tibia/fibula). Secondarily, a matched-series analysis compared outcomes with subjects who underwent delayed wound closure. DESIGN: Prospective cohort between 2009 and 2013 of subjects undergoing primary closure. SETTING: Trauma center. PARTICIPANTS: Eighty-three (84 fractures) subjects were enrolled. Eighty-two (99%) subjects (83 fractures) provided follow-up data. Matching (age, sec, fracture location, and grade) was performed using study data of delayed wound closure undertaken at the same center between 2001 and 2009 (n = 68 matched subjects). INTERVENTION: Primary wound closure occurred when the fracture grade was Gustilo grade 3A or lower and the wound deemed clean at initial surgery. Standardized evaluations occurred until the fracture(s) healed; phone interviews and chart reviews were also undertaken at 1 year. MAIN OUTCOME MEASUREMENTS: Deep infection is defined as infection requiring unplanned surgical debridement and/or sustained antibiotic therapy after wound closure; nonunion is defined as unplanned surgical intervention after definitive wound closure or incomplete radiographic healing 1-year after fracture. RESULTS: Three (4%) subjects had deep infections, whereas 10 (12%) subjects developed nonunion in the primary closure cohort. In the matched analyses [n = 68 pairs; (136 subjects)], the primary closure cohort had fewer deep infections [n = 3 (4%) vs. n = 6 (9%)] and nonunions [n = 9 (13%) vs. n = 19 (29%)] than the delayed closure cohort (P < 0.001). CONCLUSIONS: Primary wound closure after an open fracture appears acceptable in appropriately selected patients and may reduce the risk of deep infection and nonunion compared with delayed closure; a definitive randomized trial is needed. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Healing of Atypical Subtrochanteric Femur Fractures After Cephalomedullary Nailing: Which Factors Predict Union?

OBJECTIVES: The purpose of this study was to determine the healing rate and time to union of atypical subtrochanteric fractures treated with cephalomedullary nailing. DESIGN: Retrospective review, descriptive, and analytic study. SETTING: Six level 1 trauma centers. PATIENTS/PARTICIPANTS: The study included 42 patients with 48 displaced, atypical, bisphosphonate-associated subtrochanteric femur fractures who underwent surgical intervention. INTERVENTION: Cephalomedullary femur nailing. MAIN OUTCOME MEASUREMENT: The main outcome measures were radiologic healing and time to union. RESULTS: The primary healing rate after cephalomedullary nailing of bisphosphonate-associated subtrochanteric femur fractures was 68.7% (33/48 patients). Mean time to union was 10.7 months. Malalignment was determined using the differences in neck-shaft angle (the difference between the normal side and the surgically repaired side) and sagittal angulation. These all proved to be significantly correlated with failure and delayed healing time. The cutoff points for neck-shaft angle, difference in neck-shaft angle, and sagittal angulation were 125.6, 4.4, and 5.5 degrees, respectively (receiver operating characteristic curve analysis). CONCLUSIONS: The healing rate of atypical subtrochanteric femur fractures treated with cephalomedullary nailing is lower than that previously reported for atypical femur fractures. The quality of fracture reduction proved to be the most important factor in bony union and time to union. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Does a Staged Posterior Approach Have a Negative Effect on OTA 43C Fracture Outcomes?

OBJECTIVE: To determine whether multiple approaches pose an increased risk to fracture healing when compared with a standard single approach in the treatment of pilon (OTA 43C) fractures. DESIGN: Retrospective review of a prospective database. SETTING: Level I academic trauma center and level II community trauma center. METHODS: From January 1, 2005 to December 31, 2011, all records of patients treated for OTA 43C fractures of the distal tibia were reviewed. Patients were grouped according to multiple (posterior-anterior) and single (anterior-alone) approaches. Medical charts and surgical documentation were reviewed and postoperative computed tomography (CT) scans were examined for residual articular displacement and quantified. Ultimate union rate was correlated with approach strategy. Articular reduction was subdivided into 3 groups (<1, 1-2, and >2 mm). RESULTS: A total of 116 patients were identified as having had 43C fractures treated surgically with postoperative CT scans completed. Twenty-six fractures presented as an open injury. Of these 116 patients, 35 underwent staged fixation of the posterior malleolar component at an average of 2 days postinjury, followed by delayed anterior fixation at an average of 14 days postinjury. The remaining 81 patients underwent anterior fixation alone, on average 17 days postinjury. Twenty-one patients were lost to follow-up before 12 months. Of the 95 patients with sufficient follow-up (≥12 months), there were 24 nonunions. There was a statistically significant association of nonunion with staged posterior approach (40% vs. 19%, P = 0.015). CT reduction for staged posterior versus anterior-alone approach was not significantly different for any of the 3 categories (63% vs. 57% <1 mm, 31% vs. 26% 1-2 mm, and 6% vs. 17% >2 mm). CONCLUSIONS: In this series, there was no statistically proven benefit to combined surgical approaches to tibial pilon fractures with regard to the quality of articular reduction. It appears from this investigation that there may be a significantly higher risk of nonunion associated with the addition of the staged posterior approach. Although articular reduction is of paramount importance, multiple approaches for direct reduction and fixation of all fragments may lead to further complications. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

[Over-reduction after distal radius fracture pinning in young active patients: Prevention by multiple mixed pinning]. / Hyperréduction après brochage des fractures de l'extrémité distale du radius chez le sujet jeune actif. Prévention par brochage mixte multiple.

Over-reduction is a classical complication following pinning of distal radius fractures. Indeed, the pinning techniques derived from Kapandji's technique do not allow anterior stabilization. A literature review and our experience show that it is an underestimated complication that can affect up to one-third of cases, but that is well tolerated if the anterior tilt is less than 20°. Excessive angulation of the dorsal intrafocal K-wires becomes a significant risk factor beyond 60°. Volar comminution of the fracture is an obvious predisposing factor. We will outline our ideas on the topic and present a new pinning technique, which has reduced the over-reduction rate to below 3 %: multiple mixed pinning combines two dorsal intrafocal K-wires with two trans-styloid K-wires along the anterior and posterior cortices of the radius to provide true sagittal stabilization of the fracture. This technique is suitable for fractures without major instability or associated anterior comminution-Milliez types 1 and 2 are its best indications. In our practice, there still is a place for pinning of non-complex fractures in young active subjects. More than 20° malunion in flexion can lead to symptoms; in this instance, isolated opening osteotomy of the radius is the most suitable technique.

Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) protocol: a pragmatic multi-centre randomised controlled trial of cast treatment versus surgical fixation for the treatment of bi-cortical, minimally displaced fractures of the scaphoid waist in adults.

BACKGROUND: A scaphoid fracture is the most common type of carpal fracture affecting young active people. The optimal management of this fracture is uncertain. When treated with a cast, 88 to 90 % of these fractures unite; however, for the remaining 10-12 % the non-union almost invariably leads to arthritis. The alternative is surgery to fix the scaphoid with a screw at the outset. METHODS/DESIGN: We will conduct a randomised controlled trial (RCT) of 438 adult patients with a "clear" and "bicortical" scaphoid waist fracture on plain radiographs to evaluate the clinical effectiveness and cost-effectiveness of plaster cast treatment (with fixation of those that fail to unite) versus early surgical fixation. The plaster cast treatment will be immobilisation in a below elbow cast for 6 to 10 weeks followed by mobilisation. If non-union is confirmed on plain radiographs and/or Computerised Tomogram at 6 to 12 weeks, then urgent surgical fixation will be performed. This is being compared with immediate surgical fixation with surgeons using their preferred technique and implant. These treatments will be undertaken in trauma units across the United Kingdom. The primary outcome and end-point will be the Patient Rated Wrist Evaluation (a patient self-reported assessment of wrist pain and function) at 52 weeks and also measured at 6, 12, 26 weeks and 5 years. Secondary outcomes include an assessment of radiological union of the fracture; quality of life; recovery of wrist range and strength; and complications. We will also qualitatively investigate patient experiences of their treatment. DISCUSSION: Scaphoid fractures are an important public health problem as they predominantly affect young active individuals in the more productive working years of their lives. Non-union, if untreated, can lead to arthritis which can disable patients at a very young age. There is a rapidly increasing trend for immediate surgical fixation of these fractures but there is insufficient evidence from existing RCTs to support this. The SWIFFT Trial is a rigorously designed and adequately powered study which aims to contribute to the evidence-base to inform clinical decisions for the treatment of this common fracture in adults. TRIAL REGISTRATION: The trial is registered with the International Standard Randomised Controlled Trial Register ( ISRCTN67901257 ). Date registration assigned was 13/02/2013.

Measurement of Malrotation on Direct Radiography in Pediatric Distal Radius Fractures: Prospective Observational Study.

UNLABELLED: The aim of this prospective study was to test a mathematical method of measuring the malrotation of pediatric distal radius fractures (PDRFs) from direct radiographs. A total of 70 pediatric patients who presented at the Emergency Department with a distal radius fracture were evaluated. For 38 selected patients conservative treatment for PDRF was planned. Anteroposterior and lateral radiographs were taken of all of the patients for comparison before and after reduction. Radius bone diameters were measured in the coronal and sagittal planes on the healthy and fractured sides. Using the diameter values on the healthy side and the new diameter values on the fractured side in the rotation formula, the degree of malrotation between the fracture ends was calculated. The mean follow-up period was 13.5 months. Patients' mean age was 10.00 ±â€Š3.19 years (range, 4-12 years). The rotation degree in the sagittal plane significantly differed between the proximal (26.52°±2.84°) and distal fracture ends (20.96°±2.73°) (P = 0.001). The rotation degree in the coronal plane significantly differed between the proximal (26.70°±2.38°) and distal fracture ends (20.26°±2.86°) (P = 0.001). The net rotation deformity of the fracture line was determined to be 5.55°± 3.54° on lateral radiographs and 5.44°± 3.35° on anteroposterior radiographs, no significant difference was observed between measurements (P >0.05). The malrotation deformity in PDRF occurs with greater rotation in the proximal fragment than in the distal fragment. The net rotation deformity created between the fracture ends can be calculated on direct radiographs. LEVEL OF EVIDENCE: Diagnostic, Level II.

Current Strategies for the Management of Pediatric Supracondylar Humerus Fractures: Tips and Techniques for Successful Closed Treatment.

Pediatric supracondylar humerus fractures are the most commonly encountered type of elbow fractures in children that require surgical fixation. Many pediatric supracondylar humerus fractures can be treated with closed reduction and percutaneous skeletal fixation. In difficult fractures, adjunct pin techniques, such as joystick wires and leverage pins, can be used to help attain a satisfactory and stable reduction before an open approach is used. After the fracture is reduced, optimal pinning, with the use of either crossed or lateral-entry techniques, and fixation that achieves maximal spread at the fracture site as well as bicortical engagement in both fragments are essential to maintain reduction and avoid complications that are associated with malunion. A practical approach as well as several tips and techniques may help surgeons attain and maintain stable closed reduction of pediatric supracondylar humerus fractures.

Open Reduction Techniques for Supracondylar Humerus Fractures in Children.

Supracondylar humerus fractures are the most common elbow fractures in children. Displaced supracondylar humerus fractures that are associated with neurologic and/or vascular injuries should be treated with timely reduction via closed techniques. If closed reduction fails, reduction via open techniques is indicated. There is controversy about which surgical approach yields the best cosmetic and functional outcomes while minimizing postoperative complications. Open reduction, if indicated, has been reported to yield good outcomes in patients in whom closed reduction fails.

Transphyseal Distal Humerus Fracture.

Transphyseal distal humerus fractures typically occur in children younger than 3 years secondary to birth trauma, nonaccidental trauma, or a fall from a small height. Prompt and accurate diagnosis of a transphyseal distal humerus fracture is crucial for a successful outcome. Recognizing that the forearm is not aligned with the humerus on plain radiographs may aid in the diagnosis of a transphyseal distal humerus fracture. Surgical management is most commonly performed with the aid of an arthrogram. Closed reduction and percutaneous pinning techniques similar to those used for supracondylar humerus fractures are employed. Cubitus varus caused by a malunion, osteonecrosis of the medial condyle, or growth arrest is the most common complication encountered in the treatment of transphyseal distal humerus fractures. A corrective lateral closing wedge osteotomy can be performed to restore a nearly normal carrying angle.

Economic Benefit of Calcium and Vitamin D Supplementation: Does It Outweigh the Cost of Nonunions?

OBJECTIVES: The purpose was to evaluate economic benefit of calcium and vitamin D supplementation in orthopaedic trauma patients. We hypothesized that reduced nonunion rates could justify the cost of supplementing every orthopaedic trauma patient. DESIGN: Retrospective, economic model. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Adult patients over 3 consecutive years presenting with acute fracture. INTERVENTION: Operative or nonoperative fracture management. MAIN OUTCOME MEASUREMENTS: Electronic medical records were queried for ICD-9 code for diagnosis of nonunion and for treatment records of nonunion for fractures initially treated within our institution. RESULTS: In our hospital, a mean of 92 (3.9%) fractures develop nonunion annually. A 5% reduction in nonunion risk from 8 weeks of vitamin D supplementation would result in 4.6 fewer nonunions per year. The mean estimate of cost for nonunion care is $16,941. Thus, the projected reduction in nonunions after supplementation with vitamin D and calcium would save $78,030 in treatment costs per year. The resulting savings outweigh the $12,164 cost of supplementing all fracture patients during the first 8 weeks of fracture healing resulting in a net savings of $65,866 per year. CONCLUSIONS: Vitamin D and calcium supplementation of orthopaedic trauma patients for 8 weeks after fracture seems to be cost effective. Supplementation may also reduce the number of subsequent fractures, enhance muscular strength, improve balance in the elderly, elevate mood leading to higher functional outcome scores, and diminish hospital tort liability by reducing the number of nonunions. LEVEL OF EVIDENCE: Economic Level V. See Instructions for Authors for a complete description of levels of evidence.

Mechanical Construct Characteristics Predisposing to Non-union After Locked Lateral Plating of Distal Femur Fractures.

OBJECTIVES: To identify discrete construct characteristics related to overall construct rigidity that may be independent predictors of nonunion after lateral locked plate (LLP) fixation of distal femur fractures. DESIGN: Retrospective case-control study. SETTING: Three level-1 urban trauma centers. PATIENTS/PARTICIPANTS: Two hundred and seventy-one supracondylar femoral fractures treated with LLP at 3 affiliated level 1 urban trauma centers between August 2004 and December 2010. METHODS: Nonunion was defined as a secondary procedure for poor healing. Construct variables included: (1) combined plate design and material variable, (2) Plate length, (3) # screws proximal to fracture, (4) total screw density (TSD), (5) proximal screw density (PSD), (6) presence of a screw crossing the main fracture, and (7) rigidity score multivariable analysis was performed using logistic regression to identify independent risk factors for nonunion. INTERVENTION: LLP fixation. MAIN OUTCOME MEASURE: Nonunion. RESULTS: Nonunion rate was 13.3% (n = 36). There was a significant association between plate design/material and nonunion with 41% of stainless constructs and 10% of titanium constructs resulting in a nonunion (P < 0.001). Rigidity scores reached significance (P = 0.001) with constructs resulting in a nonunion having higher scores. No significant univariate differences with respect to number of proximal screws, plate length, total screw density, or proximal screw density were observed between healed fractures and those with nonunion. Results of the multivariate analysis confirmed that the primary significant independent predictor of nonunion was plate design/material (odds ratio, 6.8; 95% CI, 2.9-16.1; P < 0.001). CONCLUSIONS: When treating distal femur fractures with LLP, combined plate design and material variable has a highly significant influence on the risk of nonunion independent of any other construct variable. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Expandable proximal femoral nail versus gamma proximal femoral nail for the treatment of AO/OTA 31A1-3 fractures.

INTRODUCTION: The gamma-proximal femoral nail (GPFN) and the expandable proximal femoral nail (EPFN) are two commonly used intramedullary devices for the treatment of AO 31A1-3 proximal femur fractures. The aim of this study was to compare outcomes and complication rates in patients treated by both devices. PATIENTS AND METHODS: A total of 299 patients (149 in the GPFN group and 150 in the EPFN group, average age 83.6 years) were treated for AO 31A1-3 proximal femur fractures in our institution between July 2008 and February 2013. Time from presentation to surgery, level of experience of the surgeon, operative time, amount of blood loss and number of blood transfusions were recorded. Postoperative radiological variables, including peg/screw location, tip to apex distance and orthopaedic complications, as, malunion, nonunion, surgical wound infection rates, cutouts, periprosthetic fractures and the incidence of non-orthopaedic complications. Functional results were estimated using the modified Harris Hip Score, and quality of life was queried by the SF-36 questionnaire. RESULTS: The GPFN and the EPFN fixation methods were similar in terms of functional outcomes, complication rates and quality of life assessments. More patients (107 vs. 73) from the GPFN group were operated within 48 h from presentation (44.8 h vs. 49.9 h for the EPFN group, p=0.351), and their surgery duration and hospitalisation were significantly longer (18.5 days vs. 26 days, respectively, p<0.001). The GPFN patients were frequently operated by junior surgeons: 90% (135) while 50.6% (76) of the EPFN operations were performed by senior doctors. Other intraoperative measures were similar between groups. Cutout was the most common complication affecting 6.7% of the GPFN group and 3.3% of the EPFN group (p=0.182). CONCLUSIONS: Good clinical outcomes and low complication rates in the GPFN and the EPFN groups indicate essentially equivalent safety and reliability on the part of both devices for the treatment of proximal femoral fractures.

Comparison of Surgical versus Non-Surgical Treatment of Displaced 3- and 4-Part Fractures of the Proximal Humerus: A Meta-Analysis.

PURPOSE/AIM: This meta-analysis compares the clinical outcomes of surgical versus conservative treatment of displaced, 3- or 4-part, proximal humeral fractures. MATERIALS AND METHODS:  Medline, Cochrane, EMBASE, and Google Scholar were searched for studies published until October 2013, reporting functional outcomes of 3- or 4-part fractures of the proximal humerus in skeletally mature patients. Only randomized controlled trials were included. The treatments that were evaluated included non-surgical, open surgery, intramedullary pin, locking plate, arthroplasty, and minimally invasive surgical treatments. A meta-analysis was performed on the difference in functional outcomes and quality of life (QoL) between participants undergoing surgical versus non-surgical treatment. RESULTS: Out of 254 participants in the studies who were analyzed, 127 were treated surgically. The difference in mean values of functional score showed similar results between surgical and non-surgical treatments (difference in mean values = 0.015, 95% CI = -0.232 to 0.261, p = .908).The difference in mean values of QoL showed that surgical treatment provided better post-operative QoL than non-surgical treatment (difference in mean values = 0.146, 95% CI = 0.052 to 0.240, p = .002). CONCLUSIONS: Surgical treatment of displaced, multi-fragment fractures of the proximal humerus did not improve shoulder functional outcome, based on the Constant-Murley Score, when compared with conservative and non-surgical treatments. However, health-related QoL was significantly improved with surgical treatment compared with conservative treatment.

Rotation technique of reduction malar plasty.

The 2 most common complications of reduction malarplasty are nonunion or malunion and cheek drooping. Because masseter muscle is attached from zygomatic process of the maxilla to inferior two thirds of the zygomatic arch, rigid fixation and intimate bone contact without creating a gap are crucial for reduction malarplasty.Mesial-clockwise rotation of the zygomaticomaxillary complex can produce intimate bone contact and facilitates reduction malarplasty.

Non-union in 3 of 15 osteotomies of the distal radius without bone graft.

BACKGROUND AND PURPOSE: Open-wedge osteotomies of the distal radius create a void that is usually filled with either iliac crest bone graft or bone substitute. Previous studies have suggested that this is unnecessary. We investigated the safety of omitting the filling procedure. PATIENTS AND METHODS: We included 15 patients with a dorsal malunion of a distal radius fracture. A palmar approach and angle-stable plates were used. The patients were followed until there was radiographic and clinical healing. RESULTS: Non-union occurred in 3 of the 15 patients. The study, which had been planned to include 25 patients, was then discontinued. 6 osteotomies created a trapezoid void (no cortical contact); 3 of these did not unite after the index procedure (p = 0.04), but did subsequently, after autogenous bone grafting. A trapezoid void was significantly associated with non-union (p = 0.04). INTERPRETATION: When a trapezoid defect is created, one should consider bone substitute or autogenous bone graft. This has been shown to be safe in other studies.

The outcome of conservative treatment of spiral metacarpal fractures and the role of the deep transverse metacarpal ligaments in stabilizing these injuries.

We carried out a prospective study to assess the outcome of spiral metacarpal fractures treated with early mobilization even in the presence of malrotation. We treated 30 patients of whom we assessed 25. Of these, 23 had an excellent outcome and two had good outcomes. Objectively all the fractures united with some shortening of between 2-5 mm. Only two cases reported mild dysfunction: one patient had a residual malrotation of 5° and one had some discomfort when boxing. We also carried out simple biomechanical studies on a cadaver and two patients undergoing ray amputations. These showed that, as the distal fracture fragment migrates proximally, any malrotation in a closed injury with intact deep transverse metacarpal ligaments corrects with flexion, which also helps to limit the shortening. Spiral metacarpal fractures, whether central or border, whether single or multiple, can usually be treated reliably with early mobilization as any malrotation corrects with flexion and the degree of shortening is limited.

Predictors of a persistent dislocation after reduction of syndesmotic injuries detected with intraoperative three-dimensional imaging.

BACKGROUND: In about 25% of cases, reduction of acute unstable syndesmotic injuries and stabilization with syndesmotic screws leads to an inadequate reduction. Conventional fluoroscopy does not provide reliable information about the reduction outcome. However, use of intraoperative 3D imaging can be more accurate. The purpose of this study was to identify predictors of inadequate reduction so that the need for intra- or postoperative 3D imaging could be assessed. Our hypothesis was that complex injuries of the syndesmosis present a higher risk of malreduction than simpler ankle fractures. METHODS: From August 2001 to February 2011, 251 unstable syndesmotic injuries were treated from a total of 2286 ankle fractures. In 61 of these cases, malreduction of the fibula into the fibular notch was detected by intraoperative 3D imaging. The influence of all possible concomitant and combination injuries of the ankle joint, surgeon's experience, and potential implant-related effects was analyzed. RESULTS: Thirty-seven Weber C fractures (60.7%), 13 Maisonneuve fractures (21.3%), 10 Weber B fractures (16.4%), and 1 syndesmotic injury without fracture (1.6%) were included. In 14 cases (23%) there was involvement of the posterior malleolus, in 10 cases of the medial malleolus (16.4%), and in 12 cases both (19.7%). The Weber C fractures included 10 bimalleolar fractures with involvement of the posterior malleolus. In neither this combination nor in any other possible injury configuration was it possible to identify a statistically significant correlation with malreduction of the fibula into the fibular notch. The surgeon's experience or an implant-related effect had no detectable influence either. CONCLUSION: Based on the factors studied, it is not possible to conclude whether a patient has an increased risk of malreduction. Therefore we still recommend verifying all reduction outcomes by intraoperative 3D imaging or postoperative computed tomography. LEVEL OF EVIDENCE: Level III, retrospective comparative study.