Weber Ankle Fracture Classification System Yields Greatest Interobserver and Intraobserver Reliability Over AO/OTA and Lauge-Hansen Classification Systems Under Time Constraints in an Asian Population.

No previous studies have evaluated the intra- and interobserver reliability between the Weber, Lauge-Hansen and AO Foundation/Orthopaedic Trauma Association (AO/OTA) classification systems under time constraints. This study compares the interobserver and intraobserver reliability of the aforementioned classification systems under simulated time constraints. Anteroposterior and lateral radiographs of ankle malleolar fractures from 80 consecutive patients from 2015 to 2016 were classified by 2 independent observers according to Weber, Lauge-Hansen and AO/OTA. Classifications were conducted over 4 successive weeks under timed (25-seconds) and untimed conditions, with 1-week gaps between each classification. Cohen's kappa and percentage agreement were calculated. Cohen's kappa for interobserver agreement ranged 0.67 to 0.67 and 0.59 to 0.73 for untimed and timed classifications for Weber; 0.38 to 0.47 and 0.44 to 0.50 for Lauge-Hansen; 0.28 to 0.49 and 0.13 to 0.37 for AO/OTA. Intraobserver agreement ranged from 0.83 to 0.85 and 0.78 to 0.79 for untimed and timed classifications for Weber; 0.46 to 0.65 and 0.59 to 0.73 for Lauge-Hansen; 0.42 to 0.63 and 0.40 to 0.51 for AO/OTA. Based on the Landis and Koch's benchmark scale, there was substantial agreement in the inter- and intraobserver variables for Weber; moderate agreement in inter- and intraobserver variables for Lauge-Hansen; fair and moderate agreement in inter- and intraobserver variables respectively for AO/OTA. Interobserver and intraobserver reliability was the most substantial for Weber, followed by Lauge-Hansen and AO/OTA. Time constraint did not have a statistically significant effect on the reliability of classifications. We recommend concurrent usage of the Weber and Lauge-Hansen system, since they demonstrate the greatest reliability and reproducibility, and confer better understanding of the fracture type, respectively.

Hip Fracture Management Using External Fixation-A Systematic Review.

INTRODUCTION: Patients with significant comorbidities have high general anaesthetic risks and are often thought to be undesirable candidates for general anaesthesia and, therefore, surgery. External fixation uses local or regional anaesthesia, and allows patients with significant comorbidities to avoid the risks of general anaesthesia. It has been described to be successful in the management of high-risk patients with intertrochanteric fractures. However, published data have been derived from small case series, and no published literature has attempted to analyse them in totality. This review aims to pool together these case series, and to evaluate the outcomes and complications of external fixation when performed in high-risk patients with intertrochanteric fractures. MATERIALS AND METHODS: The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRSIMA) guidelines. All studies that reported the outcomes of external fixation for intertrochanteric fractures of high-risk patients were included. RESULTS: A total of 13 publications, involving 687 patients, were included in the review. All the studies reported postoperative radiological reduction and complete fracture healing with reduction of limb length discrepancy. One study using parallel placement of proximal fixation screws showed shorter operative duration as compared to convergent placement. Another study mentioned that there was no significant difference in mortality rates between patients with stable fractures and those with unstable fractures who underwent external fixation. All the studies reported a decrease in postoperative immobility, reduction in pain and improvement in clinical outcome hip scores. CONCLUSION: External fixation is promising and useful especially in the management of high-risk patients with intertrochanteric fractures. The procedure can help with radiological reduction of the fracture, reduction of limb length discrepancy, reduction of operative duration, decrease in postoperative immobility, reduction in pain and improvement in clinical outcome hip scores. The procedure is versatile and seems to be able to accommodate both stable and unstable fractures. However, unstable fractures may be associated with greater postoperative morbidity, and it may be worthwhile to prognosticate based on the stability of the patients' fracture for better risk-benefit analysis preoperatively. Shorter operative times can also be achieved through parallel proximal pin placement, without impact on mortality or morbidity.

Comparison of the use of antibiotic-loaded calcium sulphate and wound irrigation-suction in the treatment of lower limb chronic osteomyelitis.

AIMS: We sought to compare the efficacy of antibiotic-loaded calcium sulphate with wound irrigation-suction in patients with lower limb chronic osteomyelitis. PATIENTS AND METHODS: Adult patients with lower limb chronic osteomyelitis treated at our hospital by means of segmental bone resection, antibiotic-loaded calcium sulphate implantation or wound irrigation-suction, followed by bone transport with external fixator from January 2011 to July 2015 were retrospectively evaluated. The clinical presentation, laboratory results, complications, docking obstruction, infection recurrence were compared. RESULTS: There were totally 74 patients met the inclusion criteria. Docking obstruction rate and infection recurrence were higher in the irrigation group with significant difference. The success rate of the first operation was 90.74% in the calcium sulphate group compared with 45% in the irrigation group. Postoperaton leakage of the incision happened more in the calcium sulphate group, but it wasn't a risk factor for docking obstruction and infection recurrence. Patients in the calcium sulphate group had shorter hospital stay and systemic antibiotic treatment, also with less external fixator index. CONCLUSIONS: The findings of our study suggest that antibiotic-loaded calcium sulphate implantation for lower chronic limb osteomyelitis was a more successful method than wound irrigation-suction, it greatly decreased infection recurrence and docking obstruction. Postoperative leakage after implantation didn't worsen patient's outcome.

Accuracy of magnetic resonance imaging in diagnosing lateral ankle ligament injuries: A comparative study with surgical findings and timings of scans.

OBJECTIVE: This study aimed to evaluate the accuracy of magnetic resonance imaging (MRI) in diagnosing lateral ankle ligament injuries and the effect of differences in time duration from injury to MRI. METHODS: Data were collected prospectively from 82 patients who underwent MRI and lateral ligament reconstruction, and were divided into either acute (≤3 months) or chronic (>3 months) group based on injury interval. Findings were classified as normal, partial, or complete tears of the anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). MRI results were compared with intraoperative findings and their accuracies were assessed using descriptive statistics. RESULTS: The accuracy of MRI for partial and complete tears of the ATFL was 74% and 79%, respectively, with sensitivity and specificity of 64% and 86% for partial tears, and 78% and 80% for complete tears, respectively. The accuracy of MRI was 66% and 88% for partial and complete tears of the CFL with a sensitivity and specificity of 41% and 87% for partial tears, and 61% and 95% for complete tears, respectively. A decrease in the MRI accuracy was observed in the chronic group. CONCLUSION: MRI is accurate in diagnosing ATFL injuries. It is specific but not sensitive for CFL tears. The accuracy is higher in the acute setting of 3 months or less from time of injury to MRI.

Prospective study of surgical fixation of radial head fractures using cannulated headless compression screws for simple and complex radial head fractures.

INTRODUCTION: Fixing the two-part Mason II radial head fracture using screws is becoming a popular practice. However, the screw fixation efficacy for three-part Mason III and IV fractures is controversial. The purpose of this study is to determine the effectiveness of using a uniform technique of headless compression screw fixation in simple, isolated Mason II and complex three-part Mason III and IV radial head fractures in terms of functional outcome, treatment efficiency and assessment of complications with the procedure. METHODS: A prospective evaluation were performed on 31 adult patients with closed, non-pathological Mason II, III and IV radial head fractures sustained due to trauma and who underwent fixation using either two or three cannulated headless compression screws of 2.0 to 2.5 mm, and all patients were followed up for 2 years after the injury. They were divided into simple Mason II fracture group and complex three-part Mason III-IV fracture group. Operation time, time to discharge and radiological union were used as parameters for assessment of clinical outcome, while Mayo Elbow Performance Score, range of motion and complications were used to assess the functional outcomes. RESULTS: Twelve cases of two-part simple fracture group and 18 cases of complex fracture group were identified. The mean age of 39 years is comparable between the two groups. Both groups had comparable days to union, mean hospital stay and operation time. In the simple fracture group, the mean Mayo Elbow Score was 97 (80-100), which is better than the complex fracture group score of 89 (75-100), p = 0.035. Both groups had no statistical difference in complication rates. All fractures united in our series. The mean range of motion for the simple fracture group was significant, with 133° ± 17.0° for flexion-extension arc, 85° ± 5° in pronation and supination as compared to the complex fracture group with 120° ± 20° flexion-extension arc, 69° ± 10° in pronation and 70° ± 8° in supination, p = 0.068. CONCLUSION: Overall clinical and functional outcomes of this technique are satisfactory in both simple and complex fracture groups, with simple Mason II fracture group doing better than the complex three-part Mason III and IV fractures in terms of Mayo Elbow Score and range of motion. Screw fixation has the advantage of less periosteal stripping and less impingement compared to other fixation methods and also allows for flexible fixation in constrained areas. Headless compression screw fixation can be considered as a method of fracture fixation for both simple and complex three-part radial head fractures.

Unstable Open Posterior Subtalar Dislocation Treated With a Ring External Fixator: A Case Report and Review of the Literature.

Traumatic dislocation of the subtalar joint is an infrequently occurring injury, with open true posterior dislocation an even rarer injury. We describe our treatment of a young motorcyclist who was brought into hospital after a road traffic accident, having sustained an open posterior subtalar dislocation. After initial reduction and resuscitation in the emergency department, he was taken to the operating theater for emergent wound debridement and external fixation of his ankle using a unilateral external fixator device. After 2 subsequent repeat debridements, this was changed to a ring external fixator device, followed by split-thickness skin grafting of his wound. He was allowed full weightbearing and was discharged from hospital 10 days after his last operation. He continued to improve clinically at his outpatient appointments to the 1-year follow-up point, with his external fixator removed at 6 weeks postoperatively. At the last follow-up appointment, he had successfully returned to his previous employment. To the best of our knowledge, only 1 other description of an open posterior dislocation has been reported, which was managed nonoperatively after wound debridement. Ours is the first reported case of an open posterior dislocation managed surgically using a ring external fixator. We believe the ability to allow immediate weightbearing resulting from the additional stability provided by this type of fixation is advantageous, with a theoretical reduction in the risk of periarticular osteoporosis and calf muscle atrophy. The early mobilization afforded by this treatment is hoped to improve the typically poor long-term outcomes for these patients.

Black bone disease in a healing fracture.

Black bone disease refers to the hyperpigmentation of bone secondary to prolonged usage of minocycline. We present a report of a 34-year-old man who underwent femoral shaft fracture fixation complicated by deep infection requiring debridement. The implants were removed 10 months later after long-term treatment with minocycline and fracture union. A refracture of the femoral shaft occurred 2 days after implant removal and repeat fixation was required. Intraoperatively, abundant heavily pigmented and dark brown bone callus was noted over the old fracture site. There was no evidence of other bony pathology and the appearance was consistent with minocycline-associated pigmentation. As far as we are aware, this is the first case of black bone disease affecting callus within the interval period of bone healing. We also discuss the relevant literature on black bone disease to bring light on this rare entity that is an unwelcomed surprise to operating orthopaedic surgeons.

'How to deal with this, that and the other?' An orthopaedic surgeon's unexpected encounter with a trio of problems in an elderly man.

This is the first clinical report of a psoas abscess encountered during a routine hemiarthroplasty surgery for a femoral neck fracture in a man with a recent urinary tract infection. There were no prior symptoms to suggest a psoas abscess, which was present on the same side as the hip fracture, apart from a history of recurrent urinary tract infection. The surgery had to be altered intraoperatively to that of an excision arthroplasty of the displaced non-viable femoral head along with insertion of an antibiotic-impregnated cement spacer into the hip joint. Relevant microbiological studies confirmed a methicillin-sensitive Staphylococcus aureus psoas abscess with bacteraemia in addition to Staphylococcus bacteriuria, so 6 weeks of intravenous antibiotics were started. A planned second-stage hemiarthroplasty was undertaken and the patient recovered fully without complications. Primary infection of the urinary tract by S. aureus is rare. This case serves to remind clinicians that caution must be exercised in patients with recurrent infections, especially when such infections affect organs or areas close to the intended surgery site. This warrants thorough evaluation for an occult source of infection. A psoas abscess is an unusual cause of hip pain and accurate diagnosis relies on a high index of suspicion. The antibiotic-impregnated articulating cement spacer is a useful surgical adjunct after excision arthroplasty, it not only elutes a high concentration of antibiotics in the infected field, but also facilitates second-stage arthroplasty surgery by preventing muscle and soft tissue contractures from developing.

Predictive factors for recurrence of simple bone cyst of the proximal humerus.

PURPOSE: To evaluate factors predictive of recurrence following curettage of simple bone cysts (SBCs) in the proximal humerus. METHODS: Records of 29 male and 3 female patients aged 3 to 22 (mean, 11) years who underwent curettage with or without bone grafting for a solitary SBC in the proximal humerus were reviewed. The appearance, size, location, activity level, and fracture pattern of each cyst were recorded. The cyst index indicated the risk of refracture. Recurrence was defined as a refracture or enlargement of the cyst. RESULTS: 31 patients presented with a pathological fracture. The main symptoms were pain (n=30), loss of function (n=22), and mass/swelling (n=15). 25 patients gave a history of trauma. The duration of symptoms was less than one month. 10 patients had recurrence after a mean of 10 (range, 4-27) months; 5 were refractures and another 5 were enlargement of the cysts. Six were treated conservatively and eventually healed, whereas 4 underwent further curettage. Factors predictive of recurrence were patient age 5 years or younger (p=0.014), right-sided cyst (p=0.01), larger cyst (p=0.039), multilocular cyst (p=0.004) and unimpacted fracture (p=0.04). Recurrence was not related to gender, cyst location, or cyst activity level. CONCLUSION: Most SBCs heal even if the fracture is treated expectantly. SBCs should be left alone unless symptomatic. If curettage is performed, grafts or bone substitutes should be used. More aggressive treatment might be necessary for unimpacted fractures to minimise the risk of recurrence.

An age- and sex-matched comparative study on both-bone diaphyseal paediatric forearm fracture.

PURPOSE: Intramedullary (IM) nailing and plating are recognised fixation methods for both-bone midshaft forearm fractures. Although both methods are effective, IM nailing has recently been the accepted operative treatment for the paediatric population. The aim of the study was to compare the differences in the radiographic and functional outcomes of an age- and sex-matched cohort of children following treatment by IM fixation or plate fixation with screws for an unstable both-bone diaphyseal fracture. METHODS: A retrospective study was conducted and 17 age- and sex-matched pairs of patients returned for a research review clinic. The average age of our patients was 11.6 years at follow up, with 11 boys and six girls in each group. The mean follow up was similar in both groups (IM 31.5 months, plating 31.8 months). RESULTS: Plating and IM nailing result in good or excellent functional and radiological outcomes. Radiographs at the review clinic showed complete healing in the plating group, with reconstitution of the radial bow. Three patients in the IM group did not regain the natural radial bow radiographically. There were no significant differences between both groups for maximum radial bow and its location (P > 0.05). However, the maximum radial bow was significantly different from normative values in both groups (P = 0.003 plate, P = 0.005 IM). No non-union or malunion was observed. There were no significant differences in the loss of forearm motion and grip strength between both groups. There was no difference in the Pediatric Orthopaedic Society of North America (POSNA) scores between both groups. The plating group had a significantly worse Manchester scar score than the IM group (P = 0.012). One major complication was observed in each group: osteomyelitis for IM fixation and ulnar never palsy for plating. CONCLUSION: Our study suggests that functional outcome is likely to be equivalent, regardless of which method of internal fixation is used.