Surgical treatment of pilon fracture based on ankle position at the time of injury/initial direction of fracture displacement: a prospective cohort study.

OBJECTIVE: The purpose of this study is to evaluate a surgical strategy for pilon fractures based on ankle position/initial direction of fracture displacement at the time of injury. METHODS: Sixty-nine patients were categorized into groups based on ankle position at the time of the injury: Group I (varus), Group II (valgus), Group III (dorsiflexion), Group IV (plantarflexion), and Group V (neutral). The American Orthopedic Foot and Ankle Society (AOFAS) score was determined at 12 months. RESULTS: More than 90% of participants in Groups I-IV as well as 57.2% of participants in Group V had anatomic/good fracture reduction, respectively. Fracture healing/union was significantly slower in Group V vs Groups I, III, and IV, and in Group II vs Group IV (P < 0.005). AOFAS scores were significantly higher (P < 0.005) in Groups III (96.0, IQR: 90.0-96.0) and IV (95.0, IQR: 90.0-100.0) vs Groups II (86.9, IQR: 75.0-90.0) and V (83.0, IQR: 73.0-86.0). Wound breakdown was the most common complication (n = 11). CONCLUSIONS: Determining the surgical strategy for managing pilon fractures based on ankle position at the time of the injury/initial direction of fracture displacement may be effective.

A comparison of primary and delayed wound closure in severe open tibial fractures initially treated with internal fixation and vacuum-assisted wound coverage: a case-controlled study.

The ideal timing of wound closure for open tibial fractures is debatable. This study aimed to compare outcomes of primary and delayed wound closure in severe open tibial fractures initially treated with internal fixation and vacuum-assisted wound coverage (VAC). Data of 80 patients with Gustilo-Anderson type IIIA and IIIB open tibial fractures treated with primary internal fixation, VAC, either primary wound closure (PWC) or delayed wound closure (DWC), and external fixation were reviewed retrospectively, and outcomes and complications compared. Patients were divided into three groups, including a PWC group (n = 27), DWC group (n = 22), and a control group (n = 31) that had received external fixation. Among all patients, the median age was 38 years (IRQ 32-47 years), and 67.5% were male. Injuries included 33 Gustilo-Anderson type IIIA and 47 type IIIB. Among injuries, 83% (66/80) were high-energy trauma, 63.8% were contaminated and median injury severity score (ISS) was 14 points. Significant differences were found between groups in fixation methods (p < 0.001). No significant differences were observed between groups in rates of deep infection, osteomyelitis, amputation and nonunion at 6 and 12 months (all p > 0.05), although all rates were markedly lower in the PWC group. The outcomes of PWC performed in conjunction with primary internal fixation and VAC for the treatment of Gustilo-Andersen type IIIA and IIIB open tibial fractures are similar to or better than those of DWC with primary internal fixation and VAC.

[Surgical strategy for upper cervical vertebrae instability through the anterior approach].

OBJECTIVE: To explore the choice and effect of internal fixation in treating upper cervical vertebrae instability through anterior approach. METHODS: From March 2000 to September 2010,83 patients with upper cervical vertebrae instability were treated with internal fixation through anterior approach. There were 59 males and 24 females with a mean age of 42 years old (ranged, 20 to 68). Among these patients, 36 patients were treated with odontoid screw fixation, 16 patients with C1,2 transarticular screw fixation, 23 patients with C2,3 steel plate fixation, 5 patients with odontoid screw and transarticular screw fixation,2 patients with odontoid screw and C2.3 steel plate fixation, 1 patient with C1,2 transarticular screw and C2,3 steel plate fixation. RESULTS: One patient with completely cervical vertebrae cord injury died of pulmonary infection after C1,2 transarticular screw fixation. Other patients were followed up from 8 to 36 months with an average of 15 months. Upper cervical vertebrae stability were restored without vertebral artery and spinal cord injury. Thirty-six patients were treated with odontoid screw fixation and 5 patients were treated with screw combined with transarticular screw fixation obtained bone union in the dentations without bone graft. Among the 16 patients treated with C1,2 transarticular screw fixation, 13 patients obtained bone union after bone graft; 1 patient died of pulmonary infection after surgery; 1 patient with comminuted odontoid fracture of type II C and atlantoaxial anterior dislocation did not obtain bone union after bone graft,but the fibrous healing was strong enough to maintain the atlantoaixal joint stability; 1 patient with obsolete atlantoaxial anterior dislocation were re-treated with Brooks stainless steel wire fixation and bone graft through posterior approach, and finally obtained bone union. CONCLUSION: It could obtain satisfactory effects depending on the difference of cervical vertebrae instability to choose the correctly surgical method.