Comparison of percutaneous and open repair of Achilles tendon rupture: results and complications from a single institution.

BACKGROUND: The Achilles tendon is the strongest tendon in the human body, but it is prone to injury, especially in modern times when recreational sports are growing in popularity. As a result, Achilles tendon rupture is becoming an increasingly common medical problem in modern society. The main objective of this study was to compare the outcomes of percutaneous repair and open repair for the treatment of Achilles tendon rupture. METHODS: A retrospective study was conducted involving a total of 316 patients who had undergone surgical treatment for Achilles tendon rupture between 2013 and 2021. The data collected from the medical history of these patients included the type of surgical procedure, the mechanism of injury, the age and sex of the patients, the time spent in the hospital, and any possible complications of the surgical treatment (such as infections, reruptures, or sural nerve injuries). RESULTS: The study revealed that there was no significant difference between percutaneous and open surgical approaches in terms of sural nerve injury. However, there was a statistically significant advantage of the percutaneous method in terms of the number of infections, which was significantly lower than that of the open method. Additionally, the median length of hospital stay was found to be four days longer with the open approach. However, the study noted that a statistically significant advantage of the percutaneous method for rerupture could not be established due to the small number of patients with rerupture and the insufficient ratio of patients with rerupture in relation to the size of the observed population. CONCLUSIONS: Percutaneous repair is an effective treatment option for Achilles tendon rupture and has outcomes equal to or better than those of open repair. Therefore, this approach is recommended as the preferred method of treatment due to the presence of fewer complications, provided that the indications for this technique are appropriate.

The effect of the ankle syndesmosis reduction quality on the short-term functional outcome following ankle fractures.

INTRODUCTION: A few radiographic techniques have been proposed to evaluate ankle syndesmosis reduction. The purpose of this study was to analyze post-operatively with CT-scanning the quality of ankle syndesmotic reduction. Moreover, to assess the impact of quality of syndesmotic reduction to functional outcome. MATERIALS AND METHODS: A prospective cohort study focused on patients older than 17 years with lateral and medial malleolar fracture with verified syndesmotic disruption. EXCLUSION CRITERIA: open fracture, concomitant injury, surgery delayed for more than 24 hours, additional posterior malleolar fracture, ASA score of ≥ 3, complication requiring revision surgery, articular step or gap of ≥ 2mm on the postoperative CT scans. RESULTS: Out of 41 patients, 34 participants completed the follow-up. There was a male predominance (20 patients - 58.82%) and the mean age was 48.46±16.1 years (range (20-72 years). 22 patients (64.71%) have sustained type B fracture, while in 12 patients (35.29%) the fracture was of a type C. The reduction was classified as anatomical in 26 patients (76.50%), while in 8 patients (23.50%) the reduction of the syndesmosis was non-anatomical. In those 26 patients in whom the reduction was anatomical, 17 (65.39%) were males and there were 18 (66.67%) type B fractures. In the patients with non-anatomical reduction, 3 patients (37.5%) were of a male gender and there was the equal number of type B and C fractures. The statistical analysis showed significantly favorable scores for both AOFAS score and VAS scale for the patients with anatomical reduction. CONCLUSION: Functional analysis showed a strong association with the CT observed reduction quality and both the AOFAS score and VAS scale. Further studies are desirable to provide further evidence in relation to the findings of this study.

Modelling the effect of a dedicated hip fracture unit on patient outcomes using segmented robust linear regression techniques.

INTRODUCTION: Typically, a healthcare intervention is evaluated by comparing data before and after its implementation using statistical tests. Comparing group means can miss underlying trends and lead to erroneous conclusions. Segmented linear regression can be used to reveal secular trends but is susceptible to outliers. We described a novel method using segmented robust regression techniques to evaluate the effect of introducing a dedicated hip fracture unit (HFU). METHODS: We retrospectively analysed patient outcomes from a total of 2777 patients sustaining proximal femoral fragility fractures over a 6-year period at a Level 1 Major Trauma Centre. We compared time to surgical intervention and length of hospital stay before and after the implementation of the HFU using group comparison tests, segmented ordinary regression and robust regression techniques to evaluate the effect of the intervention. RESULTS: Group comparison tests did not identify a significant difference in time to surgery pre and post- HFU. Segmented regression revealed that there was a significant reduction in time to surgery but that this predated the introduction of the HFU. Group comparison tests did not identify a significant difference in length of stay pre and post-HFU. Ordinary segmented regression demonstrated that there was a constant reduction in length of stay, which accelerated after the introduction of the HFU. Robust regression identified that this change occurred prior to the HFU. DISCUSSION: There was a significant decrease in time to surgical intervention during the study period that occurred long before the introduction of the HFU, and that cannot be attributed to the HFU itself. Length of stay started dropping early in the study period and was unrelated to the HFU. However, with robust regression we concluded that the HFU was effective in reducing relatively long hospital stays (outliers). Several explanatory factors that may have affected the observed trends in time to surgery and length of stay were identified. CONCLUSION: Robust regression is a useful adjunct to ordinary segmented linear regression techniques in modelling retrospective time-series and dealing with outliers. The changes observed in hip fracture patient outcomes over a 6-year period was likely multifactorial.

Dorsal minimally invasive plate osteosynthesis of the distal tibia with regard to adjacent anatomical characteristics.

INTRODUCTION: The aim of this study was to perform MIPO of the distal tibia from a dorsomedial and dorsolateral approach and to evaluate their feasibility and risk of injury to adjacent anatomical structures. MATERIAL & METHODS: A total of 18 extremities from 9 adult human cadavers was included in the study. In each cadaver, one lower leg underwent application of a 12-hole 3.5 LCP metaphyseal plate from the medial and the further one from the lateral approach. For the medial approach, a 4 cm skin incision was performed at the tibial border of the Achilles tendon, starting from 1 cm proximal to its insertion point at the calcaneal tuberosity. Entrance was gained between the medial border of the flexor hallucis longus tendon and the medial neurovascular bundle. Regarding the lateral approach, the skin was incised over a length of about 4 cm at the lateral border of the Achilles tendon, approximately 1 cm proximal to its insertion point. Entrance was gained between the Achilles tendon and the peroneus brevis muscle. The plates were inserted in direct bone contact in a proximal direction and the proximal and distal ends were fixed. During dissection, the proximal and distal holes beneath the crossing points of the neurovascular bundle and the plate were noted. The distal and proximal intersection points of the neurovascular bundle and the plate were measured with reference to the distal border of the plate. RESULTS: Concerning the medial approach, the neurovascular bundle was on median located between the 6th and 11th plate holes starting from distal. The bundle intersected the plate distally at a mean height of 65.8 mm and proximally at 156.8 mm on average. For the lateral approach, the neurovascular bundle was situated between the 6th and the 12th plate hole from distal. It crossed the plate distally at a mean of 61.0 mm and proximal at a mean height of 153.9 mm. In none of the cases, lacerations of the neurovascular bundle were observed. CONCLUSION: In conclusion, MIPO from the dorsomedial and dorsolateral approach are both safe procedures as indicated by our study.

Medial minimally invasive helical plate osteosynthesis of the distal femur - a new technique.

INTRODUCTION: The goal of this study was to evaluate distal femoral minimally invasive plate osteosynthesis (MIPO) from a distal medial approach by use of a pre-bent helical implant. MATERIAL & METHODS: A total of 18 lower extremities was evaluated. A 29.6 cm steel plate was constructed and pre-bent on bone specimens with a torsion of 55.7° A 5 cm incision was performed from the tip of the medial epicondyle alongside its centre in a proximal direction. The medial border of the vastus medialis was retracted anteriorly. The level of the proximal skin incision was determined using the length of the pre-bent plates. The proximal incision was performed at a length of 4 cm at the described height at a line between the lateral epicondyle and the tip of the greater trochanter. A raspatory was advanced beneath the vastus medialis in a proximal direction to create an extraperiosteal tunnel for plate insertion. The plate was fixed to the bone at its proximal and distal portion via screws. Following dissection, the distance between the nearest perforator to the proximal plate end was evaluated. The vertical distances between the medial border of the plate and the femoral artery and femoral nerve were measured at the level of the proximal plate end and at the level of the proximal margin of the vastoadductor membrane. RESULTS: The most proximal perforating artery was located at a mean distance of 20.15 mm starting from the proximal plate margin. The mean interval between the medial border of the plate at the level of its proximal tip and the femoral artery was 51.9 mm. The average distance between the femoral nerve and the medial border of the proximal part of the plate was 42.3 mm. Regarding the interval between the medial border of the plate and the femoral artery, this was at a mean of 40.5 mm at the level of the proximal margin of the vastoadductor membrane. During dissection, none of the specimens showed any lesions of the adjacent anatomical characteristics. CONCLUSION: Our results indicate MIPO of the distal femur from a medial approach as a safe technique.

Experimental shortening of the radius in the treatment of Kienböck's disease.

AIM: The aim of the research was to determine the smallest amount of loading on the lunate bone obtained by gradually shortening the radius in different ulnar variants as the potential treatment of Kienböck's disease. METHODS: The research was conducted on anatomic preparations of 20 upper extremities using only the distal part of the forearm and hand, placing them in exactly defined positions. A Fuji Prescale film was inserted in the open radiocarpal joint to measure pressure after compressing axially by changing the length of forearm in four stages by the gradual shortening of the radius. RESULTS: The greatest reduction of average pressure on the lunatum achieved by shortening the radius depended on ulnar variant. In ulnar variant 0, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 3 mm (24% reduction). For ulnar variant -1, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 2 mm (37% reduction). For ulnar variants -2, -3 and +1, the greatest reduction of average pressure on lunatum was achieved by shortening the radius for 3 mm (5%, 75% and 9% respectively). CONCLUSIONS: The pressure distribution in the distal radiocarpal joint is vital for healing, and shortening of the radius relieves the pressure on the lunate bone. The exact type of surgery and the amount of radial osteotomy depends on preoperative ulnar variant.

Operative versus non-operative management of blunt pancreatic trauma in children: Systematic review and meta-analysis.

AIM: Blunt abdominal trauma is the major cause of abdominal injury in children. No clear guidelines exist for the initial management of blunt pancreatic trauma in children. The aim of this study was to perform a systematic review and meta-analysis of initially non-operative versus initially operative treatment in children with blunt pancreatic injury. METHODS: Studies including children (<18 years) with blunt pancreatic injuries published in any language after year 1990 were included. Total of 849 studies were identified by searching PubMed, Scopus, CINAHL and Cochrane Database. After review, 42 studies met inclusion criteria and were included in this systematic review. There were 1754 patients, of whom 1095 were initially managed non-operatively (NOM), and 659 operatively (OM). Primary outcome was non-operative management success rate, and secondary outcomes were mortality, complications (including specifically pseudocysts and pancreatic fistulas), percent of patients and days on total parenteral nutrition (TPN), length of hospital stay and readmissions. RESULTS: There was no difference in mortality between NOM and OM groups. The incidence of pseudocysts was significantly higher in NOM group compared to OM (P<0.001), especially for AAST grade III or higher (P<0.00001). Overall incidence of pancreatic fistulas was significantly lower for NOM group (p = 0.02) but no difference was observed for AAST grades III or higher (p = 0.49). There was no difference in the length of hospital stay (P = 0.31). Duration of total parenteral nutrition was not different for all AAST grades (P = 0.35), but was significantly shorter for OM group for AAST grades III and higher (p = 0.0001). There was no overall difference in readmissions (P = 0.94). Overall success rate of initial non-operative treatment was 87%. CONCLUSIONS: Most patients with pancreatic trauma can initially be treated non-operatively, while early surgical treatment may benefit patients with lesions of the main pancreatic duct. ERCP offers both highly accurate diagnosis and potential treatment of ductal injuries.

Evaluation of screw placement in proximal humerus fractures regarding drilling manoeuvre and surgeon's experience.

INTRODUCTION: Following proximal humeral plate osteosynthesis, mechanical complication rates ranging up to 40% have been reported. The study aims to determine the influence of surgeons' experience and the technique of drilling on the complication rate. MATERIALS AND METHODS: The sample involved 45 cadaveric humeri. Six orthopaedic surgeons were divided into two groups with regard to their level of experience (novice versus expert group). On each humerus two different proximal humerus plates were applied. Drillings were performed either with a sharp or worn drill bit (to simulate either sharp or blunt drilling). The respective holes were drilled until the respective participant thought to have placed the drill bit subchondrally, followed by perforation of the cartilage of the humeral head. Both these values and cases of unintended penetration of the articular cavity were evaluated. RESULTS: Fourteen holes (3.6%) were primary penetrated in the joint cavity in the worn-drill-bit-subgroup and 19 holes (5%) in the sharp-drill-bit-group. The latter had an average distance between the chosen subchondral position and the humeral articular surface of 8.3 mm and the worn-drill-bit-subgroup was at 10.6 mm. In the novice group 20 perforations (5.2%) of the joint space occurred and the mean interval between the chosen subchondral point and the humeral articular surface was 4.0 mm. The experienced surgeons showed a perforation rate of 3.4% and were at a mean of 14.9 mm. There were no significant differences regarding drilling manoeuvres and experience. CONCLUSION: Although our results are satisfactory, they can be traced back to the relatively high interval between the respective chosen position of the drill bit and the humeral articular surface which may not guarantee screw stability during ORIF of all fracture patterns.

Screw placement in two different implants for proximal humeral fractures regarding regional differences in bone mineral density: An anatomical study.

BACKGROUND: The aim of this study was to investigate proximal humerus plating regarding drill depth and over penetration of the glenohumeral joint and to find a relation between these findings and different areas of bone mineral density (BMD) in the humeral head. MATERIAL & METHODS: The study sample involved 45 upper extremities from human adult cadavers. Two different plates (HOFER; PHILOS) were applied to the proximal humerus. Each hole was drilled until the respective participant thought to have placed the drill bit subchondral. Next, penetration of the far cortex was conducted to determine the residual bone stock. Additionally, the point of screw penetration of the far cortex was identified for each hole of the plates and allocated to five regions with different bone mineral density as described by Tingart et al. RESULTS: The screw penetration rate and the residual bone stock were compared within the 5 BMD regions. A significantly thicker residual bone stock was found at the central region (SD ± 13.1 mm) than in the anterior region (SD ± 9.5 mm) and in the posterior region (SD ± 8.5 mm). The anterior region revealed a significantly higher penetration rate than the posterior region (p = 0.01) and the central region (p = 0.03). CONCLUSION: The anterior region of the humeral head was associated with a higher over penetration rate of the far cortex into the glenohumeral joint and a decreased bone stock after subchondral drilling representing a reduced bone mineral density (BMD). LEVEL OF EVIDENCE: Cadaver Study.

Surgical treatment of scapular fractures: Results and complications.

INTRODUCTION: The aim of this study was to describe a surgical technique and report on patient-based functional outcomes and complications following open reduction and internal fixation in patients with scapular fractures. METHODS: The study comprised 14 patients who were treated with open reduction and internal fixation (ORIF) of a scapular fractures between September 2010 and July 2018. Surgical indications were as follows: medial/lateral displacement greater than 20 mm; shortening greater than 25 mm; angular deformity greater than 40°; intra-articular step-off greater than 4 mm; and double shoulder suspensory injuries (including fracture of the clavicle, coracoid or acromion with displacement greater than 10 mm). All patients underwent X-ray examination (true AP, Y scapular view) and computed tomography (CT) scans. Fractures were classified according to the revised (AO/OTA) classification system. Functional outcomes were measured using Constant-Murley scores. RESULTS: Seven patients had glenoid fossa fractures, six patients had scapular body fractures and one patient had an acromion process fracture. All glenoid fossa and scapular body fractures were exposed via the Judet approach. Eleven of 14 patients were given Constant-Murley scores at the final follow-up examination; three patients were lost to follow-up. The mean follow-up after injury was 44 months (range, 6-92 months). We found infraspinatus muscle hypotrophy in four patients. The mean Constant-Murley score was 93.45 (±8.93) for the injured arm and 98.36 (±2.91) for the uninjured arm. The mean score between the injured and uninjured arm was 4.91(±6.49), which is an excellent functional outcome according to the Constant-Murley score. CONCLUSIONS: Open reduction and internal fixation of displaced scapular fractures is a safe and effective treatment option that results in a reliable union rate and good-to-excellent functional outcome.

Intramedullary nailing of adult forearm fractures: Results and complications.

INTRODUCTION: The aim of this study was to evaluate the clinical and radiological results of adult forearm fractures treated with interlocking intramedullary nailing. METHODS: This retrospective study included 21 patients who were treated with intramedullary interlocking nailing for forearm fractures between January 2010 and September 2017. All patients were treated with intramedullary forearm nails designed to allow interfragmentary compression. The medical records and radiographs of all patients were evaluated. Fractures were classified according to the AO/OTA classification system by analyzing the radiographs. Union time, union rate, clinical outcome, and complications were evaluated. RESULTS: Primary intramedullary osteosynthesis was performed in 17 patients with forearm shaft fractures. The average union time was 10 weeks (range, 8-16 weeks) in the primary osteosynthesis cohort. Secondary intramedullary osteosynthesis was performed in four patients following the removal of plates and screws due to nonunions. For this group of patients, bone union took an average of 17 weeks (range 8-24 weeks). The overall union rate was 95.24% in the 21 forearm fractures which were treated with an intramedullary interlocking nail with a compression screw that allows interfragmentary compression to be obtained. Overall complications included one nonunion, one postoperative rupture of the extensor pollicis longus tendon, and 1 postoperative transitory radial nerve palsy. CONCLUSIONS: Intramedullary interlocking nailing with a compression screw is an alternative method of fixation for treating adult forearm fractures and provides good clinical outcomes with reliable union rates.

An anatomical study of transpedicular vs. extrapedicular approach for kyphoplasty and vertebroplasty in the thoracic spine.

INTRODUCTION: Percutaneous vertebral augmentation is a common therapeutic approach for osteoporotic or osteolytic vertebral fractures. Due to the variable pedicle anatomy two different approaches, the transpedicular and the extrapedicular approach have been established. In particular, in the middle and upper thoracic spine, percutaneous procedures are challenging because of difficult visualisation of anatomical landmarks and a more unfavourable anatomy with smaller and differently orientated pedicles. MATERIAL AND METHODS: In our cadaveric study we compared the transpedicular and the extrapedicular approach to the thoracic spine. In 26 cadaveric spine specimes, embalmed using Thiel's method, we placed a total of 486 trans- and extrapedicular K-wires through Jamshidi needles in the vertebral bodies T4 - T12 under fluoroscopy. A CT scan was then performed to verify the actual position of the K-wire. Malpositioning was defined as deviation from the planned approach or placement of the K-wire in the spinal canal or outside the vertebral body. Number and direction of malpositionings was recorded. RESULTS: Malpositioning occurred in 68 of 468 K-wires. It was more frequent in the transpedicular (54) than in the extrapedicular (14) approach. Intraspinal malposition was seen more often in the transpedicular approach (n=36) especially in the upper and middle thoracic spine. CONCLUSION: In summary both approaches are relatively safe but in the upper and middle thoracic spine the risk of intraspinal malpositioning seems to be lower when using the extrapedicular approach.

Pilot study: Internally cooled orthopedic drills - standard sterilization is not enough?

Bone drilling causes focal temperature rise due to metal-to-bone contact, which may result in thermal osteonecrosis. Newly constructed internally cooled medical drill of an open type decreases temperature rise at a point of metal-to-bone contact although standard sterilization of such a drill could be inadequate due to bacteria retention within the drill lumen. The aim of this pilot study was to examine the effectiveness of sterilization and to propose sterilization recommendations for internally cooled open type bone drills. Unused internally cooled medical steel bone drills were tested. Drills were contaminated with Pseudomonas aeruginosa, Bacillus sp., beta-hemolytic Streptococcus sp., Enterobacter sp. and methicillin-resistant Staphylococcus pseudintermedius and then incubated for 24 hours at 37 °C. Afterwards, drills were autoclaved for 15, 20 and 30 minutes at 132 °C and 2.6 bar. When 15-minute sterilization was used, one out of 16 drills was contaminated with Pseudomonas aeruginosa, while the other 15 drills were sterile. Extended cycle sterilization in autoclave lasting for 20 and 30 minutes resulted in 100% sterility of all drills tested. In conclusion, lumened drills should be exposed to extended sterilization times in autoclave. Minimal recommended time for sterilization of lumened drills is 20 minutes.

Talocalcaneal Coalition Including Open Comminuted Calcaneal Fracture; A Case Report and Literature Review.

Tarsal coalition is an often unrecognised cause of foot and ankle pain and represents a congenital osseous, cartilaginous or fibrous connection between two or more tarsal bones. Fractures in combination with tarsal coalitions are rarely described in the literature. We report the case of a 43-year-old male patient with a talocalcaneal coalition who sustained an open comminuted calcaneal fracture and a closed transverse cuboid fracture. Due to the asymptomatic tarsal coalition and the already firmly fixed subtalar joint, the patient was treated with open reduction and internal fixation (ORIF) with satisfactory outcomes instead of ORIF in combination with subtalar arthrodesis. Ten months after the trauma, the patient was satisfactory and could return to his regular work. There is currently no evidence for the gold standard treatment of calcaneal fractures with combined tarsal coalitions. Due to the satisfactory results of this case, authors conclude that in case with prior asymptomatic coalitions, singular ORIF without subtalar arthrodesis may be performed.

Frequency and perforin expression of different lymphocyte subpopulations in patients with lower limb fracture and thoracic injury.

INTRODUCTION: Trauma with multiple injuries is associated with a high risk of complications, which may be related to excessive stimulation of inflammatory and anti-inflammatory responses. Although the effects of polytrauma on the immune response have been well established at the cellular and molecular levels, there is little information about the changes in the cytolytic potential of immunocompetent cells, including expression of cytotoxic molecules such as perforin. Therefore, the objective of the present study was to analyse and compare differences in the frequency and perforin expression of leukocyte subpopulations in the peripheral blood of patients with lower limb fracture, thoracic injury, and simultaneous lower limb fracture and thoracic injury. PATIENTS AND METHODS: Forty-five patients with trauma injury (15 patients with lower limb injury, 15 patients with thoracic injury, and 15 patients with simultaneous lower limb and thoracic injury) were included in the study. Peripheral blood of 15 sex- and age-matched healthy volunteers served as the control group. Peripheral blood samples were taken from all subjects included in the study and peripheral blood mononuclear cells were isolated by gradient centrifugation. The frequency of T lymphocytes, natural killer (NK) and NK T cells, and their subsets, as well as their perforin expression levels were simultaneously detected and analysed by flow cytometry. RESULTS: There was a statistically significant decrease in the frequency of T lymphocytes, NK and NK T cells as well as perforin expression in the patients with simultaneous lower limb and thoracic injury compared with the other two groups, with a predominantly marked decrease in NK and NK T cells. CONCLUSION: The decrease in the frequency and cytotoxic potential of peripheral blood lymphocytes is related to the severity of trauma injury, which can explain the underlying mechanism contributing to complication occurrence.

Humeral shaft cerclage wiring: a safe technique to prevent radial nerve injury.

Humeral periprosthetic fractures are a challenging problem and their occurrence has increased, particularly over the last decade. The role of cerclage wires or cables in these fractures includes revisions with longer stems, and augmentation of a plate osteosynthesis in which the stem does not allow additional screw placement or structural bone grafts as supplementary fixation. These procedures are demanding because of the proximity of the radial nerve within the operating field. Placing a cerclage wire or cable around the fractured fragments offers a simple and safe procedure to avoid radial nerve injury or palsy in the treatment of complex humeral shaft fractures. This new technique is a simple and safe procedure to place a cerclage wire or cable around the humeral shaft.

Plate versus intramedullary fixation of two-part and multifragmentary displaced midshaft clavicle fractures - a long-term analysis.

INTRODUCTION: Surgical fixation of displaced midshaft clavicle fractures is predominantly achieved with intramedullary (IM) or plate fixation. Both techniques have potential pitfalls: plate fixation involves greater periosteal stripping and protuberance of the implant, whereas IM fixation may be associated with implant-related complications, such as migration or skin irritation, which may lead to further surgery for implant removal. The aim of this study was to compare these two methods in simple (Robinson 2b.1) and multifragmentary (Robinson 2b.2) displaced midshaft clavicle fractures. METHODS: A total of 133 consecutive patients who underwent surgical fixation for a displaced midshaft clavicle fracture with either IM fixation using a 2.5-mm Kirschner wire or plate fixation using an 8-hole Dynamic Compression Plate (DCP) were retrospectively reviewed. Follow-up was a minimum of 1 year. The patients were allocated into two injury groups: displaced simple 2-part fractures (64 IM vs. 16 DCP) and displaced multifragmentary fractures (27 IM vs. 26 DCP). The major observed outcome measures were: infection rate, non-union rate, reoperation rate and postoperative range of motion (ROM). RESULTS: Rates of non-union for displaced 2-part fractures were 2/64 (3.13%) with IM fixation and 0/16 (0.00%) with plate fixation (p = 0.477). For displaced multifragmentary fractures, rates of non-union were 2/27 (7.41%) with IM fixation and 0/26 (0.00%) with plate fixation (p = 0.161). No significant difference was observed between the two fixation modalities in patient-reported time to regain ROM on the injured side for displaced 2-part fractures (p = 0.129) and displaced multifragmentary fractures (p = 0.070). Deep infection rate was zero (p = 1.000) overall in the study, and reoperation rate for IM and plate fixation, respectively, was 3.13% and 6.25% in the Robinson 2b.1 group (p = 0.559) and 7.41% and 7.69% in the Robinson 2b.2 group (p = 0.969). CONCLUSION: IM fixation of displaced midshaft clavicle fractures (Robinson 2b.1) has an equivalent non-union rate to plate fixation and similarly low complication and reoperation rates. For displaced midshaft multifragmentary clavicle fractures (Robinson 2b.2), the higher non-union rates observed with IM fixation leads us to recommend consideration of plate fixation for Robinson 2b.2 fractures.

Safe intramedullary fixation of displaced midshaft clavicle fractures with 2.5mm Kirschner wires - technique description and a two-part versus multifragmentary fracture fixation outcome comparison.

INTRODUCTION: The aim of this study was to present a modified Murray and Schwarz 2.5-mm Kirschner wire (K-wire) intramedullary (IM) technique for fixation of displaced midshaft clavicle fractures (DMCF), and to compare the differences in treatment outcome of two-part (Robinson 2B.1) and multifragmentary (Robinson 2B.2) DMCF. METHODS: A retrospective analysis of 91 patients who underwent IM fixation with a 2.5-mm K-wire for DMCF and had a 1-year post-operative follow-up between 2000 and 2012 was performed. The patients were allocated into two groups: Robinson 2B.1 (n = 64) and Robinson 2B.2 (n = 27). Assessed outcomes were non-union, reoperation rate, wire migration and infection. RESULTS: There was no statistically significant difference in the rate of non-union (2B.1,2B.2; 3.13%, 7.41%; p = 0.365), reoperation (2B.1, 2B.2; 3.13%, 7.41%; p = 0.365), K-wire migration (2B.1, 2B.2; 0.00%, 0.00%; p = 1.00) and clavicle shortening at 12-months (2B.1, 2B.2; 3.13%, 7.41%; p = 0.365). CONCLUSION: Intramedullary clavicle fixation with a 2.5-mm K-wire is a safe surgical technique. 2B.1 injuries treated with 2.5-mm IM K-wire fixation have relatively improved outcome compared with displaced 2B.2 fractures for both non-union and reoperation rates. There were no occurrences of implant migration with either 2B.1 or 2B.2 injuries, and a non-significant difference in implant irritation was documented with IM K-fixation. The non-union rate with K-wire IM fixation of 2B.1 injuries concords with the published results of other IM devices and thus this technique should be added to the surgeon's armamentarium when considering surgical treatment of such injuries.

Scaphoid screw placement under minimal radiation exposure.

BACKGROUND: Percutaneous scaphoid fixation through either a volar or dorsal approach has the advantage of minor soft tissue damage compared with ORIF, and faster fracture union compared with conservative treatment. However, this technique demands highly intraoperative reliance on X-ray control, including increased radiation exposure and all associated side effects. PURPOSE: To test the possibility and efficacy of volar percutaneous scaphoid screw placement under minimalradiation exposure. METHODS: The sample included 20 hands (seven left, 13 right) from human adult cadavers. For this study, the utilised wrists were assumed to have non-displaced scaphoid fractures. Using a percutaneous approach, a 2-mm Kirschner wire (K-wire) was advanced to the distal pole of the scaphoid and placed in a 45° horizontal and vertical angle under monitoring with the C-arm. The K-wire was inserted blindly alongside the estimated length of the scaphoid. Following K-wire insertion, four X-rays were taken to depict K-wire positioning and to assess positioning alongside the axis of the scaphoid and K-wire protrusion. The rating scale comprised 1 (good), 2 (moderate) or 3 (poor). RESULTS: All tested radiographic views were evaluated with a median of 2 points (moderate position) regardingplacement alongside the scaphoid axis. CONCLUSION: Our results indicate that percutaneous scaphoid fixation with the guide wire placed in a 45° horizontal and vertical angle enables primary moderate positioning, which may lead to quicker adjustment to the ideal position and a decrease of radiation exposure.