Comparison of T-POD and SAM Pelvic Sling II and the influence of attachment level in the initial management of unstable pelvic type C injuries - a cadaveric study.

BACKGROUND: Type C pelvic fractures (AO/OTA) are severe injuries that frequently lead to bleeding and hemodynamic instability. Pelvic binders play a crucial role in their initial management. Placement at the correct level in the prehospital setting is challenging. The aim of this study was to compare two pelvic binders regarding their effectiveness in reducing intrapelvic volume and increasing intrapelvic pressure in patients with type C pelvic fractures (AO/OTA) when applied at three different levels. METHODS: Rotationally and vertically unstable pelvic injuries (AO/OTA classification 61-C1.1) were produced in five fresh-frozen human cadaveric specimens. Intrapelvic volume, vesical pressure and compression pressure within the pubic symphysis and the sacroiliac joint were measured when applying a SAM Pelvic Sling II and a T-POD at the level of the greater trochanter as well as levels higher and lower than recommended. RESULTS: Comparison of the two pelvic binders positioned at the recommended level (greater trochanter) showed no significant difference in volume reduction (13.85 ± 31.37 cm3, p = 0.442), however, increase in vesical pressure was significantly higher when using the T-POD (5.80 ± 3.27 cmH2O, p = 0.017). When positioned at the level of the iliac crest, vesical pressure increase and intrapelvic volume reduction were significantly greater with the T-POD (14.00 ± 8.57 cmH2O, p = 0.022 and 10.45 ± 5.45 cm3, p = 0.031 respectively). Application of the SAM Pelvic Sling II below the greater trochanter led to a significantly greater decrease in volume (-32.26 ± 7.52 cm3, p = 0.003) than the T-POD. Comparison of the recommended attachment level with incorrect positioning led to no significant differences for the T-POD, while the SAM Pelvic Sling II achieved a significantly lower volume reduction when placed at the iliac crest (40.15 ± 14.57 cm3, p = 0.012) and a significantly lower increase in vesical pressure when applied below the greater trochanter (3.40 ± 1.52 cmH2O, p = 0.007). CONCLUSION: Direct comparison of the two pelvic binders showed that the T-POD achieved significantly greater results when applied at the recommended level and was less susceptible to incorrect positioning. These outcomes support the preferred use of the T-POD for prehospital emergency pelvic stabilisation.

Temporary Cast Application in Dislocated Ankle Fractures Leads to High Rates of Secondary Loss of Reduction: Does the Lauge-Hansen Injury Type Matter?

BACKGROUND: For the temporary treatment of ankle fracture dislocations (AFDs), previous studies indicate higher rates of secondary loss of reduction (LOR) with splint immobilization, prompting consideration for expanding indications for external fixation (ExFix). However, these studies did not investigate the influence of fracture morphology to further improve patient selection. The aim of this study was to investigate the influence of Lauge-Hansen injury type on the LOR rate in bimalleolar or trimalleolar AFDs for temporary cast vs ExFix immobilization. METHODS: In this retrospective cohort study, patients with isolated AFD cases treated at our institution from 2011 to 2020 were reviewed. Inclusion criteria required radiographs depicting initial dislocation and appropriate reduction after Cast or ExFix immobilization. Exclusion criteria encompassed concomitant injuries, open fractures, conservative management as well as surgery performed within 48 hours or at a different facility. Patients were grouped by temporary treatment (Cast or ExFix). The primary endpoint was LOR prior to definitive surgery across various Lauge-Hansen types. RESULTS: The LOR rate was significantly higher in the cast group (40/152, 26.3%) compared to the ExFix group (5/191, 2.6%; P < .0001). In the cast group, LOR was associated with an increase in time to definitive surgery by a mean of 3 days (P < .002). During cast treatment, LOR was significantly more likely for pronation abduction (P = .001) and supination external rotation injuries (P < .0001), whereas no significant differences were observed for pronation external rotation (P = .006), supination adduction (P > .99), and fractures not classifiable (P > .99). CONCLUSION: In cases of AFDs resulting from supination external rotation or pronation abduction trauma according to the Lauge-Hansen classification, especially in the setting of an additional posterior malleolar fracture, primary application of external fixation should be considered to reduce the risk for secondary loss of reduction. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Software-based method for automated intraoperative planning of Schoettle Point in surgical medial patellofemoral ligament reconstruction: A comparative validation study.

BACKGROUND: The aim of the study was to validate a software-based planning method for the Schoettle Point and to evaluate precision and time efficiency of its live overlay on the intraoperative X-ray. METHODS: A software-based method was compared with surgeons' manual planning in an inter- and intrarater study. Subsequently, K-wire placement was performed with and without an overlay of the planning. The time used and the precision achieved were statistically compared. RESULTS: The average deviation between the surgeons (1.68 mm; 2.26 mm) was greater than the discrepancy between the surgeons and the software-based planning (1.30 mm; 1.38 mm). In the intrarater comparison, software-based planning provided consistent results. Live overlay showed a significantly lower positioning error (0.9 ± 0.5 mm) compared with that without overlay (3.0 ± 1.4 mm, p = 0.000; 3.1 ± 1.4 mm, p = 0.001). Live overlay did not achieve a significant time gain (p = 0.393; p = 0.678). CONCLUSION: The software-based planning and live overlay of the Schoettle Point improves surgical precision without negatively affecting time efficiency.

Improving Medical Photography in a Level 1 Trauma Center by Implementing a Specialized Smartphone-Based App in Comparison to the Usage of Digital Cameras: Prospective Panel Study.

BACKGROUND: Medical photography plays a pivotal role in modern health care, serving multiple purposes ranging from patient care to medical documentation and education. Specifically, it aids in wound management, surgical planning, and medical training. While digital cameras have traditionally been used, smartphones equipped with specialized apps present an intriguing alternative. Smartphones offer several advantages, including increased usability and efficiency and the capability to uphold medicolegal standards more effectively and consistently. OBJECTIVE: This study aims to assess whether implementing a specialized smartphone app could lead to more frequent and efficient use of medical photography. METHODS: We carried out this study as a comprehensive single-center panel investigation at a level 1 trauma center, encompassing various settings including the emergency department, operating theaters, and surgical wards, over a 6-month period from June to November 2020. Using weekly questionnaires, health care providers were asked about their experiences and preferences with using both digital cameras and smartphones equipped with a specialized medical photography app. Parameters such as the frequency of use, time taken for image upload, and general usability were assessed. RESULTS: A total of 65 questionnaires were assessed for digital camera use and 68 for smartphone use. Usage increased significantly by 5.4 (SD 1.9) times per week (95% CI 1.7-9.2; P=.005) when the smartphone was used. The time it took to upload pictures to the clinical picture and archiving system was significantly shorter for the app (mean 1.8, SD 1.2 min) than for the camera (mean 14.9, SD 24.0 h; P<.001). Smartphone usage also outperformed the digital camera in terms of technical failure (4.4% vs 9.7%; P=.04) and for the technical process of archiving (P<.001) pictures to the picture archiving and communication system (PACS) and display images (P<.001) from it. No difference was found in regard to the photographer's intent (P=.31) or reasoning (P=.94) behind the pictures. Additionally, the study highlighted that potential concerns regarding data security and patient confidentiality were also better addressed through the smartphone app, given its encryption capabilities and password protection. CONCLUSIONS: Specialized smartphone apps provide a secure, rapid, and user-friendly platform for medical photography, showing significant advantages over traditional digital cameras. This study supports the notion that these apps not only have the potential to improve patient care, particularly in the realm of wound management, but also offer substantial medicolegal and economic benefits. Future research should focus on additional aspects such as patient comfort and preference, image resolution, and the quality of photographs, as well as seek to corroborate these findings through a larger sample size.

Intraoperative revision rates due to three-dimensional imaging in orthopedic trauma surgery: results of a case series of 4721 patients.

PURPOSE: Intraoperative 3D imaging has become a valued tool in assessing the quality of reduction and implant placement in orthopedic trauma surgery. In our institution, 3D imaging is used routinely since 2001. To evaluate the intraoperative findings and consequences of this technique, intraoperative revision rates in cases with 3D imaging were analyzed. METHODS: All operative procedures carried out with intraoperative 3D imaging between August 2001 and December 2016 were included. The scans were assessed intraoperatively and documented thereafter. In case of malreduction or misplaced implants, an immediate revision was performed. The number of scans per case as well as the findings and consequences drawn regarding the anatomical region were analyzed. RESULTS: 4721 cases with 7201 3D scans were included in this study. The most common anatomical regions were the ankle (22.3%), the calcaneus (14.8%) and the tibial head (9.5%). In 19.1% of all cases, an intraoperative revision was performed. The highest revision rates were found with 36.0% in calcaneal fractures, 24.8% in fractures of the tibial plateau, 22.3% in injuries of the ankle. In 52.0% of revisions, the reduction was improved regarding intra-articular steps or joint congruency. In 30.5% an implant was corrected. CONCLUSION: Intraoperative revision due to results of 3D imaging was performed in almost one-fifth of cases. This illustrates the improved possibilities to detect malreduction and implant misplacements intraoperatively and thus the abilities to improve surgical outcome. LEVEL OF EVIDENCE: III.

Influence of reduction quality on functional outcome and quality of life in the surgical treatment of tibial plateau fractures: A retrospective cohort study.

BACKGROUND: Despite a substantial improvement in the operative treatment of tibial plateau fractures, the surgical procedure remains controversial and is generally challenging, as patients may develop postoperative arthritis and functional impairment of the knee joint. HYPOTHESIS: In the surgical treatment of tibial plateau fractures the intraoperative reposition quality has the greatest influence on the postoperative outcome, whereby misalignments of≥2mm lead to a worse result. PATIENTS AND METHODS: Forty-one patients with tibial plateau fractures were postoperatively examined. The operative treatment was performed under reduction control using an intraoperative 3D C-arm. The follow-up collective was divided into two groups depending on the intraoperative reduction result. The postoperative results were then evaluated using the following parameters: Lysholm score, Rasmussen score, Tegner score, SF-36 score, range of motion and pain level. RESULTS: Group 1 (articular surface incongruencies<2mm) tended to achieve a better result in all scores than group 2 (articular surface incongruencies≥2mm), in the Lysholm score (p=0.039), in the comparison of the range of motion (p=0.012) and the pain level (p=0.039) this was significant. Group 1 achieved an average of 90.71 points (group 2: 78.74) in the Lysholm score. The average range of motion of the knee joint was 138.93° in group 1 (group 2: 127.78°). The average value of the current pain level in group 1 was 1.14 (group 2: 2.63). DISCUSSION: Both study groups achieved a very good result compared to the available literature. It appears that reduction quality - which can be analyzed with intraoperative 3D imaging - plays the most important role in postoperative quality of life and functional outcome. Intraoperative adjustments of the reduction should therefore be performed on joint surface irregularities with a size above 2mm. LEVEL OF EVIDENCE: III; retrospective case control study.

Design, delivery, and evaluation of seminars and hands-on courses worldwide on intraoperative imaging in orthopedic trauma.

INTRODUCTION: Although intraoperative imaging is important for assessing the quality of several steps during fracture fixation, most trainees and surgeons have received little formal education on this topic and report they learn "on the job" and "through practice". A planning committee of orthopedic trauma surgeons was established to design a curriculum using "backward planning" to identify patient problems, identify gaps in surgeons' knowledge and skills, and define competencies as a framework for education in order to optimize patient care. MATERIALS AND METHODS: The committee defined 8 competencies related to intraoperative imaging, with detailed learning objectives for each one (e.g. select the imaging modality, set up the operating room). An interactive, case-based half-day seminar to deliver these objectives for 2-D and 3-D intraoperative imaging during the fixation of common fractures was designed. The seminar was delivered in several locations worldwide over a 6-year period and evaluation and assessment data were gathered online. A full-day procedures course was added and delivered 6 times to address the skills component of competencies. RESULTS: 17 seminars and 6 courses were delivered and attended by an average of 26 and 17 participants respectively (ranges 13-42 and 13-20). Pre-event gap analysis and assessment question scores confirmed needs and motivation to learn in all events. 97% of the 442 seminar participants and 98% of the 100 course participants would recommend the events to colleagues. An average of 88% and 90% respectively learned something new and plan to use it in their practice (range 63%-100%). Commitment to change (CTC) statements showed intended practice improvements related to all competencies. DISCUSSION: The large percentages of high impact ratings for all events suggest the content met the needs of many participants. Post-event reduction in gap scores and an increase in the desired level of ability for most competencies suggests the content addressed many gaps. CONCLUSIONS: Case-based, interactive seminars and courses addressing knowledge, skills, and attitudes to optimize the use of intraoperative imaging during the fixation of common fractures help address unmet educational needs for trainees and complements existing formal training.

Software-Based Method for Automated Segmentation and Measurement of Wounds on Photographs Using Mask R-CNN: a Validation Study.

In clinical routine, wound documentation is one of the most important contributing factors to treating patients with acute or chronic wounds. The wound documentation process is currently very time-consuming, often examiner-dependent, and therefore imprecise. This study aimed to validate a software-based method for automated segmentation and measurement of wounds on photographic images using the Mask R-CNN (Region-based Convolutional Neural Network). During the validation, five medical experts manually segmented an independent dataset with 35 wound photographs at two different points in time with an interval of 1 month. Simultaneously, the dataset was automatically segmented using the Mask R-CNN. Afterwards, the segmentation results were compared, and intra- and inter-rater analyses performed. In the statistical evaluation, an analysis of variance (ANOVA) was carried out and dice coefficients were calculated. The ANOVA showed no statistically significant differences throughout all raters and the network in the first segmentation round (F = 1.424 and p > 0.228) and the second segmentation round (F = 0.9969 and p > 0.411). The repeated measure analysis demonstrated no statistically significant differences in the segmentation quality of the medical experts over time (F = 6.05 and p > 0.09). However, a certain intra-rater variability was apparent, whereas the Mask R-CNN consistently provided identical segmentations regardless of the point in time. Using the software-based method for segmentation and measurement of wounds on photographs can accelerate the documentation process and improve the consistency of measured values while maintaining quality and precision.

Validation of radiological reduction criteria with intraoperative cone beam CT in unstable syndesmotic injuries.

PURPOSE: Acute unstable syndesmotic lesions are regularly treated with closed or open reduction and fixation with either a positioning screw or tight rope. Conventional fluoroscopy is limited to identify a malreduction of the ankle mortise. The aim of the study was to validate the reduction criteria of intraoperative cone beam CT in unstable syndesmotic injuries by analyzing the clinical outcome. METHODS: Acute unstable syndesmotic injuries were treated with a positioning screw fixation, and the reduction in the ankle mortise was evaluated with intraoperative cone beam CT. The patients were grouped postoperatively according to the radiological reduction criteria in the intraoperative 3D images. The reduction criteria were unknown to the surgeons. Malreduction was assumed if one or more reduction criteria were not fulfilled. RESULTS: Seventy-three of the 127 patients could be included in the study (follow-up rate 57.5%). For 41 patients (56.2%), a radiological optimal reduction was achieved (Group 1), and in 32 patients (43.8%) a radiological adverse reduction was found (Group 2). Group 1 scored significantly higher in the Olerud/Molander score (92.44 ± 10.73 vs. 65.47 ± 28.77) (p = 0.003), revealed a significantly higher range of motion (ROM) (53.44 vs. 24.17°) (p = 0.001) and a significantly reduced Kellgren/Lawrence osteoarthritis score (1.24 vs. 1.79) (p = 0.029). The linear regression analysis revealed a correlation for the two groups with the values scored in the Olerud/Molander score (p < 0.01). CONCLUSION: The reduction criteria in intraoperative cone beam CT applied to unstable syndesmotic injuries could be validated. Patients with an anatomic reduced acute unstable syndesmotic injury according to the criteria have a significantly better clinical outcome.

A standardised computed tomography measurement method for distal fibular rotation.

PURPOSE: The aim of the study is to identify an ideal location to measure fibular rotation in the ankle joint using axial computed tomography (CT) scans. Another objective was to detect the average fibular rotation in the uninjured ankle joint in a large cohort. METHODS: Standardised axial CT with coronal/sagittal reconstructions was performed in healthy ankle joints. Three investigators performed the measurements. In the axial view, each investigator appointed the ideal location to measure the angle of fibular rotation with the use of reference lines either 4, 6, 8 or 10 mm distal from the talar joint line. Inter- and intraobserver reliability, as well as the intraclass correlation coefficient, were determined. RESULTS: CT scans of one hundred individuals-78 males and 22 females-were analysed. The most common locations for measuring the fibular rotation were in 31% of cases 4 mm and in 51% of cases 6 mm distal the talar joint line. The external rotation of the fibula averaged 8.42° ± 4.86° (range 0°-26°). The intraclass coefficient correlations (ICC) for interrater and intrarater reliability were 0.75. CONCLUSIONS: The results of the study demonstrate a reproducible location to measure the fibular rotation in the ankle joint. The most convenient location to measure fibular rotation with a high reliability was 6 mm distal to the talar joint line.

Evaluation of Software-Based Metal Artifact Reduction in Intraoperative 3D Imaging of the Spine Using a Mobile Cone Beam CT.

The aim of our study was to evaluate whether software-based artifact reduction can achieve an improved image quality, using intraoperative 3D imaging in spinal surgery. A total of 49 intraoperative 3D image datasets of patients, who underwent surgery with pedicle screw placement, were retrospectively evaluated. The visibility of anatomical structures and the diameter of the pedicle screws were examined, with and without the application of the artifact reduction software. All software prototypes can improve the visibility of anatomical structures (P < 0.01), except MAR (metal artifact reduction) combined with IRIS (iterative reconstruction in image space) (P = 0.04). The algorithms MAR and MAR-2 can reduce the blooming artifacts significantly (P < 0.01), but SL (Shepp & Logan) cannot (P = 0.08-0.988). In summary, software-based artifact reduction for intraoperative 3D datasets can improve the current image quality. Additional information regarding the implant placement and the fracture reduction is therefore generated for the surgeon.

Minimally invasive surgical treatment of minimally displaced acetabular fractures does not improve pain, mobility or quality of life compared to conservative treatment: a matched-pair analysis of 50 patients.

BACKGROUND: Currently available procedures for the treatment of minimally displaced acetabular fractures include conservative treatment and minimally invasive percutaneous screw fixation. Screw fixation of acetabular fractures allows patients' early full-weight bearing due to improved biomechanic stability. Can the range of motion, pain and mobility and quality of life in patients with acetabular fractures be improved by minimally invasive screw fixation, compared to conservative treatment in the long term? METHODS: Patients treated for a minimally displaced acetabular fracture, either conservatively or by closed reduction percutaneous screw fixation, in the period from 2001 to 2013 were included in this retrospective study. Minimal displacement was considered to be less than 5 mm. As well as the collection and analysis of baseline data, Harris Hip Score, Merle d'Aubigné score and Short Form 12 (SF-12) questionnaire data were recorded in the context of a clinical study. To better account for confounding factors, patients of each group were matched. The matched-pair criteria included age, BMI, Letournel fracture classification and the presence of associated injuries. RESULTS: Twenty-five patients from each group were matched. On the Harris Hip Score, conservatively treated patients obtained 96 points (52-100, SD 17) vs. 89 points (45-100, SD 17, p = 0.624). On the Merle d'Aubigné score, conservatively treated patients obtained 17 points (10-18, SD 2) vs. 17 points (11-18, SD 2, p = 0.342). Patients with acetabular fractures treated by minimally invasive screw fixation did not result in improved quality of life, measured by SF-12 questionnaire, compared to conservatively treated patients (PCS 47, SD 9 vs. 44, SD 10; p = 0.294 and MCS 51, SD 7 vs. 53, SD 7; p = 0.795). CONCLUSIONS: The clinical results of the two groups revealed no statistically significant differences. From the data, it cannot be deduced that minimally invasive surgical therapy is superior to conservative treatment of minimally displaced acetabular fractures. Prospective randomised studies are recommended to allow reliable evaluation of both treatment options. TRIAL REGISTRATION: Retrospectively registered.

Comparison of three different reduction methods of the ankle mortise in unstable syndesmotic injuries.

In order to achieve a clinically satisfying result and to prevent posttraumatic osteoarthritis in the treatment of unstable syndesmotic injuries, anatomically correct reduction is crucial. The objective of the study was to investigate three different reduction methods of the ankle mortise in unstable syndesmotic injuries. In a specimen model with 38 uninjured fresh-frozen lower legs, a complete syndesmotic dissection was performed. The ankle mortise was reduced with either a collinear reduction clamp, a conventional reduction forceps or manually with crossing K-wires. The reduction clamps and the K-wires were placed in a 0°-angle to the leg axis. The clamps were positioned on the posterolateral ridge of the fibula 20 mm proximal to the ankle joint line. A cone beam computed tomography was performed after dissection and after each reduction. Tibio-fibular distances and angles were determined. Despite significant differences in terms of overcompression (0.09-0.33 mm; p = 0.000-0.063) and the slight external rotation (0.29-0.47°; p = 0.014-0.07), the results show a satisfying reduction of the ankle mortise. There were no considerable differences between the reduction methods. It can therefore be concluded that the ankle mortise can be reduced with any of the methods used, but that the positioning and the contact pressure must be considered.

Virtual guidance versus virtual implant planning system in the treatment of distal radius fractures.

BACKGROUND: A virtual guidance framework is used to assist the conventional method of virtual implant planning system (VIPS). The study null hypothesis was that its screw placement accuracy is equal to that of conventional VIPS. METHODS: In 34 distal radius sawbone models, 3D implant planning was performed. A camera attached to the surgical drill was used to support screw positioning. Differences of angles/tip distances between planned and placed screws were identified in intraoperative cone beam Computer tomography (CT) and compared with already existing data from 22 patients treated by conventional VIPS. RESULTS: The virtual guidance group showed tip distances of 1.02 ± 0.56 mm, azimuth of 3.69° ± 4.34°, and inclination of 1.75° ± 1.37°, whereas the VIPS group showed tip distances of 2.23 ± 0.99 mm (P < 0.001), azimuth of 23.17° ± 33.50° (P < 0.001), and inclination angle of 4.18° ± 6.29° (P = 0.001). CONCLUSIONS: The results reveal that using a guidance framework leads to a higher accuracy in screw placement compared with the conventional VIPS itself.

Intraoperative assessment of reduction and implant placement in acetabular fractures-limitations of 3D-imaging compared to computed tomography.

BACKGROUND: In acetabular fractures, the assessment of reduction and implant placement has limitations in conventional 2D intraoperative imaging. 3D imaging offers the opportunity to acquire CT-like images and thus to improve the results. However, clinical experience shows that even 3D imaging has limitations, especially regarding artifacts when implants are placed. The purpose of this study was to assess the difference between intraoperative 3D imaging and postoperative CT regarding reduction and implant placement. METHODS: Twenty consecutive cases of acetabular fractures were selected with a complete set of intraoperative 3D imaging and postoperative CT data. The largest detectable step and the largest detectable gap were measured in all three standard planes. These values were compared between the 3D data sets and CT data sets. Additionally, possible correlations between the possible confounders age and BMI and the difference between 3D and CT values were tested. RESULTS: The mean difference of largest visible step between the 3D imaging and CT scan was 2.0 ± 1.8 mm (0.0-5.8, p = 0.02) in the axial, 1.3 ± 1.4 mm (0.0-3.7, p = 0.15) in the sagittal and 1.9 ± 2.4 mm (0.0-7.4, p = 0.22) in the coronal views. The mean difference of largest visible gap between the 3D imaging and CT scan was 3.1 ± 3.6 mm (0.0-14.1, p = 0.03) in the axial, 4.6 ± 2.7 mm (1.2-8.7, p = 0.001) in the sagittal and 3.5 ± 4.0 mm (0.0-15.4, p = 0.06) in the coronal views. A positive correlation between the age and the difference in gap measurements in the sagittal view was shown (rho = 0.556, p = 0.011). CONCLUSIONS: Intraoperative 3D imaging is a valuable adjunct in assessing reduction and implant placement in acetabular fractures but has limitations due to artifacts caused by implant material. This can lead to missed malreduction and impairment of clinical outcome, so postoperative CT should be considered in these cases.

Long-term results after non-operative and operative treatment of radial neck fractures in adults.

BACKGROUND: The aim of this study is to determine the functional long-term outcome after non-operative and operative treatment of radial neck fractures in adults. METHODS: Thirty-four consecutive patients with a mean age of 46.4 (18.0 to 63.0) years with a fracture of the radial neck who were treated between 2000 and 2014 were examined regarding the clinical and radiological outcome. Twenty patients were treated non-operatively, and 14 patients underwent surgery. RESULTS: After a mean follow-up of 5.7 (2.0 to 15.7) years, the clinical scores showed good results in both groups. The Disabilities of Arm, Shoulder and Hand score was 16.1 (0 to 71.6) in the non-operative group and 8.8 (0 to 50.8) in the operative group, respectively. The Mayo Elbow Performance Score was 80.0 (30 to 95) in the non-operative group and 82.5 (35 to 95) in the non-operative group, respectively. The initial angle of the radial head towards the shaft (RHSA) was significantly higher in the operative group in the anterior-posterior plane (12.8° [2 to 23] vs. 26.3° [1 to 90], p = 0.015). In the follow-up radiographs, the RHSA was significantly lower in the operative group (15.1° [3 to 30] vs. 10.9° [3 to 18], p = 0.043). Five patients developed 7 complications in the non-operative group, and 7 patients developed 12 complications in the operative group. Revision rates were higher in the operative groups as 1 patient received radial head resection in the non-operative (5%) group while 7 patients in the operative group (50%) needed revision surgery. CONCLUSION: A good functional long-term outcome can be expected after operative and non-operative treatment of radial neck fractures in adults. If needed due to major displacement, open reduction is associated with a higher risk of complications and the need for revision surgery but can achieve similar clinical results. TRIAL REGISTRATION: DRKS DRKS00012836 (retrospectively registered).

Wire Placement in the Sustentaculum Tali Using a 2D Projection-Based Software Application for Mobile C-Arms: Cadaveric Study.

BACKGROUND: Indirect screw fixation of the sustentaculum tali in the lateral-medial direction can be challenging due to the complex calcaneal anatomy. A novel 2-dimensional (2D) projection-based software application detects Kirschner wires (K-wires) and visualizes their intended direction as a colored trajectory. The aim of this prospectively randomized cadaver study was to investigate whether the software would facilitate the indirect K-wire placement in the sustentaculum tali. METHODS: In 20 cadaver foot specimens, K-wires were placed indirectly in the sustentaculum tali by an experienced and an inexperienced surgeon, with and without using the application. Number of placement attempts, duration of procedure, fluoroscopy time, and number of individual fluoroscopy images were recorded. Each wire's position was analyzed in a 3-dimensional (3D) C-arm scan by an experienced blinded investigator. RESULTS: Use of the software by the inexperienced surgeon significantly reduced the number of placement attempts from 3.2 to 1.2 ( P = .006). The application also reduced operating time, from 273 s to 199 s ( P = .15), and fluoroscopy time, from 41 s to 29 s ( P = .15). Using the software, the experienced surgeon had a longer operating time (139 s to 183 s; P = .30), longer fluoroscopy time (5.6 s to 9.2 s; P = .17), and more individual fluoroscopy images (11.6 to 14.8; P = .30). Wire position did not show significant differences in both cases. CONCLUSION: During indirect K-wire placement in the sustentaculum tali, the software appeared to be a useful tool for the inexperienced surgeon. In our chosen study setting, the experienced surgeon did not benefit from the software. CLINICAL RELEVANCE: Possible indications for the software would be fractures of the proximal femur, sacrum, sacroiliac instabilities, vertebral bodies, scaphoid, Lisfranc joint, talus and calcaneus.

Intra-operative imaging in trauma surgery.

The reconstruction of anatomical joint surfaces, limb alignment and rotational orientation are crucial in the treatment of fractures in terms of preservation of function and range of motion. To assess reduction and implant position intra-operatively, mobile C-arms are mandatory to immediately and continuously control these parameters.Usually, these devices are operated by OR staff or radiology technicians and assessed by the surgeon who is performing the procedure. Moreover, due to special objectives in the intra-operative setting, the situation cannot be compared with standard radiological image acquisition. Thus, surgeons need to be trained and educated to ensure correct technical conduct and interpretation of radiographs.It is essential to know the standard views of the joints and long bones and how to position the patient and C-arm in order to acquire these views. Additionally, the operating field must remain sterile, and the radiation exposure of the patient and staff must be kept as low as possible.In some situations, especially when reconstructing complex joint fractures or spinal injuries, complete evaluation of critical aspects of the surgical results is limited in two-dimensional views and fluoroscopy. Intra-operative three-dimensional imaging using special C-arms offers a valuable opportunity to improve intra-operative assessment and thus patient outcome.In this article, common fracture situations in trauma surgery as well as special circumstances that the surgeon may encounter are addressed. Cite this article: EFORT Open Rev 2018;3:541-549. DOI: 10.1302/2058-5241.3.170074.

Impact of Intraoperative Cone Beam Computed Tomography on Reduction Quality and Implant Position in Treatment of Tibial Plafond Fractures.

BACKGROUND: The intraoperative assessment of the articular surface in displaced intra-articular distal tibia fractures can be challenging using conventional fluoroscopy. The aim of the study was to determine the frequency and the method of intraoperative corrections of fracture reductions or implant placements during open reduction, internal fixation by using cone beam computed tomography (CT) after conventional fluoroscopy. METHODS: Displaced intra-articular distal tibia fractures were retrospectively analyzed from August 2001 until December 2011. The fractures were classified according to the standards of the AO/OTA as type B or C and treated with open reduction and internal plate fixation. After primary reduction using conventional fluoroscopy, an additional cone beam CT scan was used to determine the alignment of the joint line and the implant position. The number of intraoperative revisions of the primary reduction due to the use of cone beam CT was analyzed. RESULTS: A total of 143 patients with an intra-articular tibial plafond fracture were included in the analysis. In 43 patients (30%), an intraoperative correction was performed after the cone beam CT scan. In 34 (24%) of these cases, intraoperative correction was required because of inadequate joint line reduction. Nine (6%) corrections were required as a result of a malposition of the implant. The revision rate did not differ by fracture classification. CONCLUSION: Despite its acceptance as the standard method of imaging, intraoperative conventional fluoroscopy for the assessment of implant positioning and fracture reduction of tibial plafond fractures is limited. The intraoperative utilization of cone beam CT provided additional information for the surgeon to detect insufficient reduction or implant malposition. LEVEL OF EVIDENCE: Level III, retrospective comparative series.