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.

Fragility spinal fractures among cirrhotic liver transplant candidates in Croatia.

INTRODUCTION: Existing data on fragility spinal fractures prevalence in liver transplant candidates are scarce and inconsistent. This may be due to other comorbidities, besides hepatic osteodystrophy (HO), that contribute to bone loss and fragility fracture prevalence in chronic liver disease (CLD). OBJECTIVES: The aim of this study was to investigate the prevalence of spinal thoracic and lumbar fragility fractures among cirrhotic, non-chronic kidney disease (CKD), non-diabetic liver transplant candidates and to explore their relationship with clinical characteristics, laboratory markers and dual-energy x-ray absorptiometry (DXA) results. MATERIAL AND METHODS: This cross-sectional observational study was conducted at Merkur University Hospital, Croatia, between February 2019 and May 2023. Adult patients with liver cirrhosis referred for liver transplantation were included. Patients with acute infection, CKD, diabetes mellitus, malignancies, inflammatory bone diseases and those on corticosteroid or antiresorptive therapy were excluded. Clinical, laboratory and radiological assessment was carried out and patients were accordingly allocated into non-fractured and fractured group for the purpose of statistical analysis. RESULTS: A total of 90 patients were included in the study. There was 123 fractures, 87 (70.7 %) in the thoracic and 36 (29.3 %) in the lumbar region. Eighty-nine (72.4 %) fractures were grade 1, 31 (25.2 %) were grade 2 and 3 (2.4 %) were grade 3. Patients in the fractured group were significantly older (p < 0.001). No significant differences between fractured and non-fractured group according to laboratory and DXA parameters were noted. Subgroup with lumbar fractures had significantly lower bone mineral density values at L1-L4 region. Statistically significant negative correlation between bone specific alkaline phosphatase (BALP) and hip total BMD (rho = -0.414, p < 0.001) and spine total BMD (rho = -0.258, p = 0.014) values was found. CONCLUSION: Present study confirmed detrimental impact of CLD and HO on bone strength. DXA measurement correlated with the presence of lumbar fragility fractures. A combination of standard X-ray imaging and DXA is needed for adequate bone evaluation in pretransplant period and BALP could be useful for detecting HO in CLD. Searching for other risk factors and implementing bone turnover markers and additional imaging techniques for bone loss evaluation in liver transplant candidates is needed.

Association of Gut Lachnospiraceae and Chronic Spontaneous Urticaria.

(1) Background: Chronic spontaneous urticaria (CSU) has been linked to the dysbiosis of the gut microbiota. Furthermore, various studies have highlighted the anti-inflammatory properties of short-chain fatty acids (SCFAs), whose production is primarily regulated by the gut microbiota. However, only a few studies have investigated the role of major SCFA producers, such as Lachnospiraceae, in skin inflammatory diseases. (2) Goal: This study aimed to compare the abundance of Lachnospiraceae between CSU patients and healthy controls (HCs). (3) Material and methods: In this case-control study, 16S rRNA sequencing was performed to compare the composition of the gut microbiome between 22 CSU patients and 23 HCs. (4) Results: Beta-diversity revealed significant clustering (p < 0.05) between the CSU patients and HCs. Alpha diversity in the CSU group was significantly decreased according to the Evenness index (p < 0.05). The linear discriminant analysis effect size (LEfSe) identified the significant depletion of the Lachnospiraceae family in CSU patients. (5) Conclusion: Our study revealed the dysbiosis of the gut microbiota in CSU patients, including decreased levels of Lachnospiraceae members, responsible for SCFA production, suggesting that SCFAs may contribute to immune dysfunction in the pathogenesis of CSU. We speculate that the modulation of SCFAs could serve as a prospective additional option in CSU treatment.

Psychological Stress and Hand Eczema in Physicians and Dentists: A Comparison Based on Surgical Work.

BACKGROUND: This research looks at the connection between psychological stress and the prevalence of hand eczema (HE) among physicians and dentists (surgeons, non-surgeons). METHODS: This cross-sectional field study involved 185 participants: physicians (surgeons, non-surgeons), dentists (surgeons, non-surgeons) and controls. Hand lesions were examined using the Osnabrueck Hand Eczema Severity Index (OHSI), and participants answered the Nordic Occupational Skin Questionnaire (NOSQ) and Perceived Stress Scale (PSS). Patch tests were performed using commercial contact allergens. RESULTS: The estimated prevalence of HE (self-reported) was 43.9% (physicians 44.6%; dentists 43.2%). HE was significantly more reported by surgeons than controls (p < 0.004; V = 0.288). Degrees of perceived stress (PSS) did not differ significantly between the groups, though physicians non-surgeons most exhibited high stress (50%), and physicians surgeons most exhibited low stress (22.5%). High stress was associated with 2.5 higher odds for self-reported HE (p = 0.008). Low stress was greater among physicians/dentists who did not report eczema (41.0% vs. 24.6%); moderate stress was more common among those who reported eczema (72.3% vs. 51.8%; p = 0.038; V = 0.210). CONCLUSIONS: Since high stress levels may negatively influence physicians'/dentists' work and quality of life, measures to decrease stress could be introduced into the treatment of healthcare workers who are prone to it.

Medicinal signaling cells niche in stromal vascular fraction from lipoaspirate and microfragmented counterpart.

AIM: To expand our previous findings by increasing the number of patients in a study characterizing medicinal signaling cells (MSC) of stromal vascular fraction from lipoaspirate (SVF-LA) and from microfragmented lipoaspirate (SVF-MLA) applied for the treatment of osteoarthritis (OA). METHODS: Twenty OA patients, including 8 new patients, acquiring autologous microfragmented adipose tissue were enrolled. In-parallel immunophenotyping of SVF-LA and SVF-MLA was performed. The samples were incubated in a DuraClone SC prototype tube targeting the CD31, CD34, CD45, CD73, CD90, CD105, and CD146 surface markers, stained with the DRAQ7 cell nuclear dye and Live/Dead Yellow Fixable Stain, and analyzed by flow cytometry. RESULTS: The population phenotypes in SVF-LA and SVF-MLA samples included CD31+CD34+CD73±CD90±CD105±CD146± endothelial progenitors (EP), CD31+CD34-CD73±CD90±CD105-CD146± mature endothelial cells, CD31-CD34-CD73±CD90+CD105-CD146+ pericytes, CD31-CD34+CD73±CD90+CD105-CD146+ transitional pericytes, and CD31-CD34+CD73highCD90+CD105-CD146- supra-adventitial-adipose stromal cells. Compared with the autologous SVF-LA samples, the prevailing cell type in SVF-MLA were EP, which outnumbered leukocytes and supra-adventitial-adipose stromal cells (SA-ASC). The ratio of progenitor cells in SVF-MLA samples differed between female and male patients, showing a higher EP-pericyte and pericyte-SA-ASC ratio in men. CONCLUSION: Our results, hallmarked by EP-enriched anti-inflammatory features and indicating a possible sex-specific impact, contribute to defining the cellular composition of the clinically applied MSC serving as a regenerative cell therapy in OA.

Comparison between external locking plate fixation and conventional external fixation for extraarticular proximal tibial fractures: a finite element analysis.

BACKGROUND: Good clinical outcomes for locking plates as an external fixator to treat tibial fractures have been reported. However, external locking plate fixation is still generally rarely performed. This study aimed to compare the stability of an external locking plate fixator with that of a conventional external fixator for extraarticular proximal tibial fractures using finite element analysis. METHODS: Three models were constructed: (1) external locking plate fixation of proximal tibial fracture with lateral proximal tibial locking plate and 5-mm screws (ELP), (2) conventional external fixation of proximal tibial fracture with an 11-mm rod and 5-mm Schanz screws (EF-11), and (3) conventional external fixation of a proximal tibial fracture with a 7-mm rod and 5-mm Schanz screws (EF-7). The stress distribution, displacement at the fracture gap, and stiffness of the three finite element models at 30-, 40-, 50-, and 60-mm plate-rod offsets from the lateral surface of the lateral condyle of the tibia were determined. RESULTS: The conventional external fixator showed higher stiffness than the external locking plate fixator. In all models, the stiffness decreased as the distance of the plate-rod from the bone surface increased. The maximum stiffness was 121.06 N/mm in the EF-11 model with 30-mm tibia-rod offset. In the EF-7 model group, the maximum stiffness was 40.00 N/mm in the model with 30-mm tibia-rod offset. In the ELP model group, the maximum stiffness was 35.79 N/mm in the model with 30-mm tibia-plate offset. CONCLUSIONS: Finite element analysis indicated that external locking plate fixation is more flexible than conventional external fixation and can influence secondary bone healing. External locking plate fixation requires the placement of the plate as close as possible to the skin, which allows for a low-profile design because the increased distance from the plate to the bone can be too flexible for bone healing. Further experimental mechanical model tests are necessary to validate these finite element models, and further biological analysis is necessary to evaluate the effect of external locking plate fixation on fracture healing.

Results of Treating Mild to Moderate Knee Osteoarthritis with Autologous Conditioned Adipose Tissue and Leukocyte-Poor Platelet-Rich Plasma.

Knee osteoarthritis (KOA) is one of the most common musculoskeletal disorders. Much progress has been made in regenerative medicine for the symptomatic treatment of KOA, including products containing stromal vascular fraction (SVF) and platelet-rich plasma (PRP). The aim of this study was to evaluate clinical and radiological findings after the application of autologous conditioned adipose tissue (ACA) and leukocyte-poor PRP (LP-PRP) in patients with mild to moderate KOA. A total of 16 patients (eight male and eight female) with changes related to KOA on the magnetic resonance imaging (MRI), but without severe osteophytosis, full-thickness cartilage loss, or subchondral bone involvement were included in this study. Patients received an intraarticular, ultrasound-guided injection of ACA and LP-PRP. Clinical scores, including a visual analog scale for pain (VAS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were evaluated at baseline and at the three and six month follow-ups showing a statistically significant improvements at three and six months post-intervention. Furthermore, the delayed gadolinium-enhanced MRI of the cartilage (dGEMRIC) indices were evaluated at baseline and at the three and six month follow-ups showing no significant changes after treatment with ACA and LP-PRP, which were actually equal to the dGEMRIC indices measured in the control group (hyaluronic acid applied in contralateral knees without osteoarthritis). ACA with LP-PRP presents a viable minimally invasive therapeutic option for the clinical improvement of mild to moderate KOA. However, MFAT produced by different systems is likely to differ in cellular content, which can directly affect the paracrine effect (cytokine secretion) of mesenchymal stem cells and consequently the regeneration process.

Polychromatic Flow Cytometric Analysis of Stromal Vascular Fraction from Lipoaspirate and Microfragmented Counterparts Reveals Sex-Related Immunophenotype Differences.

Mesenchymal stem/stromal cells or medicinal signaling cells (MSC)-based therapy holds promise as a beneficial strategy for treating knee OA (osteoarthritis), but there is no standardized protocols nor mechanistic understanding. In order to gain a better insight into the human MSC from adipose tissue applied for autologous OA treatment, we performed extensive comparative immunophenotyping of the stromal vascular fraction from lipoaspirate or microfragmented lipoaspirates by polychromatic flow cytometry and investigated the cellular components considered responsible for cartilage regeneration. We found an enrichment of the regenerative cellular niche of the clinically applied microfragmented stromal vascular fraction. Sex-related differences were observed in the MSC marker expression and the ratio of the progenitor cells from fresh lipoaspirate, which, in female patients, contained a higher expression of CD90 on the three progenitor cell types including pericytes, a higher expression of CD105 and CD146 on CD31highCD34high endothelial progenitors as well as of CD73 on supra-adventitialadipose stromal cells. Some of these MSC-expression differences were present after microfragmentation and indicated a differential phenotype pattern of the applied MSC mixture in female and male patients. Our results provide a better insight into the heterogeneity of the adipose MSC subpopulations serving as OA therapeutics, with an emphasis on interesting differences between women and men.

Cytokines and Chemokines Involved in Osteoarthritis Pathogenesis.

Osteoarthritis is a common cause of disability worldwide. Although commonly referred to as a disease of the joint cartilage, osteoarthritis affects all joint tissues equally. The pathogenesis of this degenerative process is not completely understood; however, a low-grade inflammation leading to an imbalance between anabolic and katabolic processes is a well-established factor. The complex network of cytokines regulating these processes and cell communication has a central role in the development and progression of osteoarthritis. Concentrations of both proinflammatory and anti-inflammatory cytokines were found to be altered depending on the osteoarthritis stage and activity. In this review, we analyzed individual cytokines involved in the immune processes with an emphasis on their function in osteoarthritis.

Comprehensive Review of Knee Osteoarthritis Pharmacological Treatment and the Latest Professional Societies' Guidelines.

Osteoarthritis is the most common musculoskeletal progressive disease, with the knee as the most commonly affected joint in the human body. While several new medications are still under research, many symptomatic therapy options, such as analgesics (opioid and non-opioid), nonsteroid anti-inflammatory drugs, symptomatic slow-acting drugs in osteoarthritis, and preparations for topical administration, are being used, with a diverse clinical response and inconsistent conclusions across various professional societies guidelines. The concept of pharmacogenomic-guided therapy, which lies on principles of the right medication for the right patient in the right dose at the right time, can significantly increase the patient's response to symptom relief therapy in knee osteoarthritis. Corticosteroid intra-articular injections and hyaluronic acid injections provoke numerous discussions and disagreements among different guidelines, even though they are currently used in daily clinical practice. Biological options, such as platelet-rich plasma and mesenchymal stem cell injections, have shown good results in the treatment of osteoarthritis symptoms, greatly increasing the patient's quality of life, especially when combined with other therapeutic options. Non-inclusion of the latter therapies in the guidelines, and their inconsistent stance on numerous therapy options, requires larger and well-designed studies to examine the true effects of these therapies and update the existing guidelines.

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.

THE CROATIAN HEALTH INSURANCE FUND DOES NOT RECOGNIZE DIFFERENCES IN THE COST OF DIFFERENT TREATMENTS FOR REVISION TOTAL HIP ARTHROPLASTY.

In recent years, there has been increased interest in the cost of treatment for revision interventions for hip and knee prostheses. In all publications so far, the authors note the high cost of treatment for revision interventions, especially if infection is present. The aim of this study was to compare the cost of treatment and health insurance reimbursements between revision total hip arthroplasty (THA) for infection and revision for aseptic indications (aseptic instability and periprosthetic fracture). Hospital data on 168 patients having undergone revision THA between 2010 and 2018 at the Department of Traumatology, Sestre milosrdnice University Hospital Centre from Zagreb were analyzed. Financial data were collected from the Hospital Information System. Financial analysis included total cost per patient, Croatian Health Insurance Fund reimbursements, cost of implants, and length of hospital stay. The difference between the mean total cost per patient and the mean Croatian Health Insurance Fund reimbursements was -262.83 € (-6.08%) for aseptic instability, -1694.94 € (-17.25%) for infection and -916.49 € (-17.33%) for periprosthetic fracture. The Croatian Health Insurance Fund does not recognize differences in the cost of revision THA for aseptic instability, infection and periprosthetic fracture. Health insurance reimbursement is inadequate for centers that offer revision hip surgery.

TREATMENT OF HUMERAL SHAFT FRACTURES: ANTEGRADE INTERLOCKING INTRAMEDULLARY NAILING WITH ADDITIONAL INTERLOCKING NEUTRALIZATION SCREWS THROUGH FRACTURE SITE.

The aim of this study was to compare union time between two different nail designs for the treatment of humeral shaft fracture, i.e. antegrade interlocking intramedullary nail with and without additional interlocking neutralization screws. The retrospective study included 51 patients treated with antegrade humeral intramedullary nailing between January 2015 and December 2017. The inclusion criteria of the study were proximal and middle third humeral shaft fractures. Fifty-one patients met the inclusion criteria; 23 patients were treated with antegrade intramedullary nail with additional interlocking neutralization screws through fracture site (group A) and 28 patients were treated with antegrade intramedullary nail without additional interlocking neutralization screws (group B). Medical documentation and radiographic images taken preoperatively and postoperatively were reviewed. Radiological union was defined as cortical bridging of at least three of four cortices in two-plane radiographs, with disappearance of the fracture gap. There were no significant differences in union time between the groups (p>0.05). To our knowledge, this is the first report of antegrade interlocking humeral nailing with additional interlocking neutralization screws through fracture site. Hypothetical advantages of fracture gap reduction by additional interlocking neutralization screws to promote union were not confirmed by this first clinical trial.

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.

Tibial plateau fracture management: arthroscopically-assisted versus ORIF procedure - clinical and radiological comparison.

INTRODUCTION: Tibial plateau fractures are articular injuries that may influence final functional outcome of the knee. Although these fractures comprise only 1% of all fractures, the fracture pattern is usually complex and requires anatomical reduction and absolutely stable fixation to achieve satisfactory results. The development of knee osteoarthritis is a common late complication and it can be strongly influenced by additional, underestimated cartilage defects, and meniscal and ligament tears. MATERIALS AND METHODS: Between January 2012 and February 2015, a total of 78 patients with tibial plateau fractures (Schatzker type I-III) were enrolled in the study. Patients were divided into two groups: one group was treated with arthroscopically-assisted reduction and internal fixation (ARIF) and the other with open reduction and internal fixation (ORIF). The final number of patients was 75; 40 in the ARIF group and 35 in the ORIF group. Radiography and computed tomography were used to assess fracture pattern. An immediate postoperative radiograph was performed, and then repeated at 6 weeks, and 3,6 and 12 months after surgery. Demographic data (age and sex), additional intraarticular injuries, hospital stay and complications were noted, and clinical and radiological Rasmunssen score at 3, 6 and 12 months after surgery were evaluated. RESULTS: Additional intraarticular lesions were found in 27 patients; 20 in the ARIF group and 7 in the ORIF group (p = 0.06). There was a statistically significant difference in average duration of hospital stay: 3.10 ± 0.63 days for the ARIF group and 5.51 ± 1.66 days for the ORIF group (p = 0.0001). All fractures healed within 3 months following surgery. The overall complication rate was 12%. There was no statistically significant difference in complication rate between the two groups (p = 0.63). Clinical and radiological scores were excellent in most patients in both groups. There was no statistically significant difference in average clinical and radiological Rasmunssen scores between the two groups. CONCLUSIONS: Both ARIF and ORIF can provide equally good results; however, ARIF seems to offer a more precise evaluation and treatment of associated intraarticular lesions and to reduce the duration of hospital stay.

Posterior fragment in ankle fractures: anteroposterior vs posteroanterior fixation.

INTRODUCTION: The aim of this study was to compare reduction quality and functional outcome of posterior malleolus fractures treated with indirect reduction and anteroposterior (AP) fixation or with direct reduction via a posterolateral approach and posteroanterior (PA) fixation. METHODS: Forty-eight patients with trimalleolar fracture were enrolled in the study. Patients were randomised in two groups: indirect reduction and AP fixation (AP group) and direct reduction and PA fixation (PA group). Inclusion criteria were: posterior fragment involving more than 25% of the articular surface, displacement over 2mm and ankle instability. The quality of reduction was evaluated using postoperative plain radiographs. Residual displacement of the posterior fragment, articular step-off and/or articular surface gap were analysed. The reduction was considered excellent (<1mm), good (1-2mm) or poor (>2mm). Range of motion (ROM) was measured bilaterally, and the difference in dorsiflexion between the injured and uninjured side was considered as dorsiflexion restriction. Demographic data (age, sex), type of fracture (AO/ASIF classification) and complications were noted. RESULTS: Forty-six patients completed all follow-up examinations. There was no statistically significant difference in age (p = 0.41), sex (p = 0.29) or specific type of fracture (p = 0.83) distribution between the AP and PA groups. All fractures completely healed within 3 months. The overall complication rate was 8.7%. There was no statistically significant difference in complication rate between the two groups (p = 0.71). Radiological evaluation of the ankle showed there was significantly better quality of reduction with direct reduction via a posterolateral approach in the PA group. Excellent reduction was achieved in 79.2% and 45.5% of the PA and AP groups, respectively. The quality of reduction was significantly higher in the PA group compared with the AP group (p = 0.04). The mean restriction of dorsiflexion was lower in the PA group (5.96 ± 0.65°) compared with the AP group (6.45 ± 1.06°), but this difference did not reach statistical significance (p = 0.07). CONCLUSIONS: The direct reduction technique via a posterolateral approach and PA fixation enables higher quality of reduction and better functional outcome in the management of the posterior fragment compared with indirect reduction and percutaneous AP fixation.

Internal fixation of patellar apex fractures with the basket plate: 25 years of experience.

INTRODUCTION: Comminution of the patellar apex is amenable to internal fixation by standard techniques and usually requires partial patellectomy. In our institution, multifragmentary fractures of the distal pole are treated with the basket plate, which is shaped to fit the geometry of the patellar apex. This implant has been used in our institution for over 25 years. The aim of this study was to evaluate long-term results of internal fixation of comminuted fractures of the patellar apex with the basket plate. MATERIALS AND METHODS: A total of 142 patients with fracture of the distal pole of the patella were treated with the basket plate between 1988 and 2013. Functional evaluation was conducted using the modified Cincinnati knee rating system. A total of 98 patients were available for late functional evaluation. RESULTS: There were no infections or implant-related problems during the follow-up period. All fractures healed within 8 to 10 weeks. There were three cases of early revision because of improper use of the implant and incorrect indication. Functional outcome following internal fixation with the basket plate was excellent in 80 patients and good in 18; there were no poor results. CONCLUSION: Internal fixation with the basket plate is recommended for management of multifragmentary fractures of the patellar apex because this method enables early, unrestricted knee motion, and provides reliable healing and good functional outcome. This method is an alternative to partial patellectomy and is considered a patella-saving procedure; therefore, the use of the basket plate is strongly recommended for the treatment of distal pole fractures.

Minimally-invasive plate osteosynthesis in distal tibial fractures: Results and complications.

INTRODUCTION: Distal tibial or pilon fractures are usually the result of combined compressive and shear forces, and may result in instability of the metaphysis, with or without articular depression, and injury to the soft tissue. The complexity of injury, lack of muscle cover and poor vascularity make these fractures difficult to treat. Surgical treatment of distal tibial fractures includes several options: external fixation, IM nailing, ORIF and minimally-invasive plate osteosynthesis (MIPO). Management of distal tibial fractures with MIPO enables preservation of soft tissue and remaining blood supply. This is a report of a series of prospectively studied closed distal tibial and pilon fractures treated with MIPO. MATERIALS AND METHODS: A total of 21 patients with closed distal tibial or pilon fractures were enrolled in the study between March 2008 and November 2013 and completed follow-up. Demographic characteristics, mechanism of injury, time required for union, ankle range of motion and complications were recorded. Fractures were classified according to the AO/OTA classification. Nineteen patients were initially managed with an ankle-spanning external fixator. When the status of the soft tissue had improved and swelling had subsided enough, a definitive internal fixation with MIPO was performed. Patients were invited for follow-up examinations at 3 and 6 weeks and then at intervals of 6 to 8 weeks until 12 months. RESULTS: Mean age of the patients was 40.1 years (range 19-67 years). Eighteen cases were the result of high-energy trauma and three were the result of low-energy trauma. According to the AO/OTA classification there were extraarticular and intraarticular fractures, but only simple articular patterns without depression or comminution. The average time for fracture union was 19.7 weeks (range 12-38 weeks). Mean range of motion was 10° of dorsiflexion (range 5-15°) and 28.3° of plantar flexion (range 20-35°). Three cases were metalwork-related complications. Two patients underwent plate removal at 24 weeks because of plate impingement. There was one case of wound breakdown at 11 weeks. One patient had fracture union with tibial recurvatum of approximately 10°, without functional impairment. Two patients had delayed union. CONCLUSION: MIPO is a reliable method of treatment for distal tibial fractures; it provides a high union rate and good functional outcome with minimal soft tissue complications. Skin impingement remains a common complication with MIPO, but this can be solved by timely plate removal.

Regional bone loss following femoral neck fracture: A comparison between cemented and cementless hemiarthroplasty.

The aim of this prospective, randomised study was to measure and evaluate regional bone mineral changes and clinical results following the use of cemented and cementless hemiarthroplasty (HA) for treatment of femoral neck fracture in elderly patients. The study comprised 60 patients, 30 with cemented HA (group A) and 30 with cementless HA (group B). All patients underwent osteodensitometry of the contralateral hip, lumbar spine and bilateral distal femur. Dual-energy x-ray absorptiometry (DEXA) was scheduled at 1 month, 6 months and 1 year after surgery. Harris Hip Score (HHS) was used for functional assessment. Overall mortality rate was 20.3% within 1 year after surgery. There were no significant differences in morbidity, mortality and hospital stay between the two groups of patients. The implantation of cemented prosthesis took statistically significantly longer than that of cementless prosthesis (79.03±3.59 vs 68.02±5.97min; p=0.00). Functional score in patients treated with cemented HA was significantly higher compared with those with cementless HA. There was a trend of less intensive reduction of bone mineral density (BMD) in regions of interest of the lumbar spine and ipsilateral distal femur in patients with cemented HA (group A), whereas bone loss was less pronounced for the contralateral hip and distal femur in patients treated with cementless HA (group B). Management of displaced femoral neck fractures in elderly patients with cemented and cementless HA provides a comparable outcome with regard to morbidity and mortality; however, functional outcome of patients treated with cementless HA tends to be lower. There is less intensive BMD reduction in lumbar spine and ipsilateral distal femur in patients treated with cemented HA, whereas BMD reduction in patients treated with cementless HA is more likely to be less intensive in contralateral hip and distal femur.