Missed Tillaux Fracture and Syndesmosis Injury in Adult: Arthroscopic Assisted Reduction and Fixation / Fratura de Tillaux não percebida e lesão por sindesmose em adultos: Redução e fixação artroscópica assistida

Abstract Tillaux fractures are fractures of the lateral margin of the distal tibia, usually reported in children between 12 and 14 years old. As intraarticular fractures, they require anatomic reduction and fixation to avoid posttraumatic complications. Since the injury mechanism is external rotation of the foot on the leg, these injuries are commonly associated with other fractures or ligamentous lesions. Currently, arthroscopy is being increasingly used to assist and improve surgical treatment of ankle fractures. The authors describe a 12-month follow-up of a rare case of a missed Tillaux fracture associated with syndesmosis injury in a 76-year-old polytrauma patient, successfully treated by arthroscopically-assisted reduction and internal fixation.

Resumo As fraturas de Tillaux são fraturas da margem lateral da tíbia distal, geralmente relatadas em crianças entre 12 e 14 anos. Como fraturas intra-articulares, requerem redução e fixação anatômica para evitar complicações pós-traumáticas. Como o mecanismo de lesão é a rotação externa do pé na perna, essas lesões são comumente associadas a outras fraturas ou lesões ligamentares. Atualmente, a artroscopia está sendo cada vez mais utilizada para auxiliar e melhorar o tratamento cirúrgico das fraturas do tornozelo. Os autores descrevem um acompanhamento de 12 meses de um caso raro de uma fratura não percebida de Tillaux associada a lesão por sindesmose em um paciente de politrauma com 76 anos de idade, tratado com sucesso por redução e fixação interna assistida por artroscopia.

Comparative study on curative effect of minimally invasive locking plate for the treatment of intra-articular calcaneal fractures via sinus tarsi approach / 中国骨伤

OBJECTIVE@#To compare clinical efficacy of minimally invasive locking plate and anatomic locking plate in treating intra-articular calcaneal fractures via sinus tarsi approach.@*METHODS@#A retrospective analysis was conducted of 48 patients with intra-articular calcaneal fractures treated with surgery via sinus tarsi approach from July 2016 to June 2017. According to differernt methods of internal fixation, the patients were divided into minimally invasive locking plate group and anatomic locking plate group. In minimally invasive locking plate group, there were 14 males and 10 females, aged from 27 to 46 years old with an average age of (38.70±5.58) years old, 18 patients were typeⅡand 6 patients were type Ⅲ according to Sanders classification. In anatomic locking plate group, there were 17 males and 7 females, aged from 26 to 46 years old with an average age of (37.10±6.44) years old, 16 patients were typeⅡ and 8 patients were type Ⅲ according to Sanders classification. Operative time, visual analogue scale (VAS), postoperative complications between two groups were compared, and Böhler angle, Gissane angal, calcaneal width and height were recorded and compared between two groups at 1 week after operation and final follow up. The functional effect was assessed according to Maryland foot function score at final follow up.@*RESULTS@#All patients were followed up for (14.10±1.94) months (ranged 12 to 18 months). All patients were obtained bone union from 8 to 16 weeks with an average of (10.60±2.25) weeks. Operation time, VAS score and complication rate in minimally invasive locking plate group were (69.50±7.51) min, (2.80±1.07) and 2 cases respectively, and (77.50±7.15) min, (3.80±1.09) and 8 cases in anatomic locking plate group respectively, there were statistical difference between two groups (@*CONCLUSION@#Compare with anatomic locking plate, minimally invasive locking plate via sinus tarsi approach for Sanders typeⅡ and Ⅲ intra-articular calcaneal fractures could obtain similar reliable fixation and functional recovery with more simple operation, shorter operative time, lighter postoperative pain and less complications.

Fracturas intraarticulares de radio distal: reducción bajo fluoroscopía versus asistencia artroscópica. Revisión sistemática / Distal radius intraarticular fractures: fluoroscopy reduction versus arthroscopic assistance. Systematic review

Resumen: Introducción: Las fracturas intraarticulares de radio distal son un desafío terapéutico para el cirujano ortopedista. Hay estudios que avalan el uso de la fluoroscopía y otros promueven la artroscopia. Con este trabajo intentamos resumir la evidencia, para determinar si la asistencia artroscópica aporta beneficios adicionales para evitar incongruencias articulares en comparación con los resultados obtenidos bajo asistencia fluoroscópica. Material y métodos: Búsqueda sistemática de estudios prospectivos, retrospectivos, de cohortes, seguimiento, ensayos clínicos en PubMed, MEDLINE, Scopus, Scielo, Embase, Google Scholar y otras fuentes nacionales, incluyendo como palabras clave los términos: intraarticular distal radius fracture, wrist arthroscopy, arthroscopy, fluoroscopy. Los valores medios y desvíos estándar para cada característica, obtenidos de los trabajos seleccionados fueron analizados usando estadística descriptiva y gráficos ilustrativos. Resultados: Fueron evaluados 463 pacientes (256 mujeres y 207 hombres), con una edad promedio de 48.29 años y rango de 39 a 64 años. Los dos tratamientos (A y F) fueron homogéneos en cuanto a la edad de los pacientes que reportan (p = 0.5820) y el tiempo de seguimiento promedio (p = 0.9597). Sólo la desviación cubital y el DASH, para las cuales el grupo de artroscopía tuvo mejor desempeño, en las variables restantes las diferencias no fueron significativas. Conclusión: La evidencia disponible hasta la fecha es controvertida y no permite hacer recomendaciones a favor o en contra de estas intervenciones, encontrando otros factores que podrían influir en la toma de decisiones.

Abstract: Introduction: Intraarticular distal radius fractures are a therapeutic challenge for the orthopedist surgeon there are studies that support the use of fluoroscopy, and others promote arthroscopy, with this work we try to summarize the evidence, to determine whether arthroscopic assistance provides additional benefits to avoid joint incongruities compared to results obtained under fluoroscopic assistance. Material and methods: Systematic search for prospective, retrospective, cohort, follow-up, clinical trials on PubMed, MEDLINE, Scopus, Scielo, Embase, Google Scholar and other national sources, including as keywords the terms: «intra-articular distal radius fracture¼, «wrist arthroscopy¼, «arthroscopy¼, «fluoroscopy¼. The average values and standard offsets for each characteristic, obtained from the selected works, were analyzed using descriptive statistics and illustrative graphs. Results: 463 patients (256 women and 207 men) were evaluated, with an average age of 48.29 years and range from 39 to 64 years. The two treatments (A and F) were homogeneous in terms of the age of the patients reporting (p = 0.5820) and the average follow-up time (p = 0.9597). Only the ulnar deviation and DASH score, for which the arthroscopy group performed best, in the remaining variables the differences were not significant. Conclusion: The evidence available to date is conflicting, and does not allow recommendations to be made for or against these interventions, finding other factors that could influence decision-making.

Radiographic Analysis of Intra-articular Fractures of the Calcaneus in patients undergoing Minimally Invasive Surgical Treatment in a Tertiary Hospital / Análise radiográfica de fraturas intra-articulares de calcâneo em pacientes submetidos a tratamento cirúrgico minimamente invasivo em hospital terciário

Abstract Objective This paper aims to evaluate patients with articular calcaneal fractures treated with a minimally invasive surgical technique between January 2015 and August 2016, with emphasis on radiographic results. Methods Retrospective study of 49 patients with 64 displaced calcaneal fractures treated with open reduction by minimal lateral access to the subtalar joint and minimal fixation. Pre- and postoperative radiographic studies were performed to measure the angles of Böhler and Gissane. Results The average angle of Böhler before surgery was 2.5º, increasing to an average value of 25.3º after the minimally invasive surgical treatment. The average angle of Gissane before surgery was 136.3º, decreasing to an average value of 114.3º after the procedure. Conclusion The minimally invasive surgical technique improves the radiographic parameters of intra-articular calcaneal fractures, with appropriate anatomical restoration of anatomical shape.

Resumo Objetivo Avaliar pacientes com fraturas intra-articulares de calcâneo tratados entre janeiro de 2015 e agosto de 2016 com técnica cirúrgica minimamente invasiva, com ênfase no resultado radiológico. Métodos Estudo retrospectivo de 49 pacientes com 64 fraturas intra-articulares de calcâneo, submetidos a tratamento cirúrgico minimamente invasivo. As lesões foram tratadas com redução aberta por acesso mínimo lateral à articulação subtalar e fixação mínima. Foi realizado estudo radiográfico no pré- e no pós-operatório para aferição dos ângulos de Böhler e de Gissane. Resultados O ângulo de Böhler médio dos casos antes da cirurgia foi de 2,5º, apresentando aumento da média dos ângulos para 25,3º após o tratamento cirúrgico minimamente invasivo. O ângulo de Gissane médio dos casos antes da cirurgia foi de 136,3º, apresentando diminuição da média dos ângulos para 114,3º na análise após a cirurgia. Conclusão A técnica cirúrgica minimamente invasiva permite melhora dos parâmetros radiográficos (ângulos de Böhler e Gissane) nas fraturas intra-articulares de calcâneo, com sua adequada recuperação da forma anatômica.

Fracturas inestables de radio distal intra y extraarticulares: análisis comparativo de resultados a mediano plazo del tratamiento quirúrgico con placas volares / Intra- and extra-articular distal radius unstable fractures: comparative analysis of the medium-term results of volar plate surgical treatment

Introducción Comparar los resultados radiológicos y recuperación postoperatoria de la función de la muñeca a mediano plazo en las fracturas inestables extra e intra articulares de radio distal, después de la reducción abierta con abordaje palmar y osteosíntesis con placa volar. Materiales y métodos Estudio de casos y controles en 52 pacientes divididos en los grupos de fracturas extra o intra articulares de acuerdo a la clasificación AO. Las radiografías preoperatorias y postoperatorias fueron evaluadas para determinar la restauración anatómica de la longitud radial, ángulo radial e inclinación palmar del radio. Se evaluó además el resultado, seis meses después de la cirugía, del rango activo de movimiento y la fuerza de agarre, a la vez, que se hizo evaluación del puntaje de QuickDASH. Resultados La edad promedio fue 53,7±16,8 (DE) años; el 63% mujeres. Las fracturas extra articulares fueron más frecuentes en las mujeres, pero las intra articulares presentaron distribución similar por sexo (p=0.023). La fuerza de agarre de la mano operada fue 73.7% y 67.5% de la mano opuesta en las fracturas extra e intra articulares, respectivamente. El puntaje QuickDASH promedio fue 2.36 (DE 2.01) y 4.16 (DE 3.82) en fracturas extra e intra articulares respectivamente (p=0.111). Discusión Para fracturas de radio distal la reducción abierta con abordaje palmar y estabilización con placa volar ofrece resultados funcionales satisfactorios tanto para las fracturas extra articulares como para las intra articulares, con una leve, aunque esperada, ventaja en las primeras debido a su menor complejidad.

Background To examine and compare the radiological results and postoperative recovery of the medium-term wrist function in unstable extra- and intra-articular fractures of distal radius, after open reduction with a palmar approach and osteosynthesis with a volar plate. Materials and methods Retrospective case control study in 52 patients, divided into groups according to the Orthopaedic Association (AO) classification as extra- or intra-articular fractures. The pre-operative and post-operative radiographs were evaluated to determine the anatomical restoration of the radial length, radial angle, and palmar inclination of the radius. The medium-term results of the active range of motion and the grip strength, as well as the Quick DASH score, were evaluated six months after surgery. Results The mean age was 53.7±16.8 (SD) years and 63% were women. Extra-articular fractures were more frequent in women, but intra-articular fractures had a similar distribution by gender (P=.023). The grip strength of the operated hand was 73.7% and 67.5% of the opposite hand in the extra- and intra-articular fractures, respectively. The mean Quick DASH score was 2.36 (SD 2.01) and 4.16 (SD 3.82) in extra- and intra-articular fractures, respectively (P=.111). Discussion For unstable distal radius fractures, open reduction with palmar approach and volar plate stabilisation offers satisfactory functional results for both extra-articular and intra-articular fractures, with a slight, but expected, advantage in the former due to its lesser complexity.

Surgical Treatment of Pediatric Intra-Articular Proximal Phalangeal Head Fracture of the Big Toe

PURPOSE: Pediatric intra-articularproximal phalangeal head fractures of the big toe are very rare and few studies on this have been published. The purpose of this study is to present the diagnostic approach and surgical management of these extremely rare fractures, which might be easily underestimated or misdiagnosed.MATERIALS AND METHODS: The study retrospectively reviewed all the patients who were diagnosed as intra-articular proximal phalangeal head fracture of the big toe and who underwent surgical intervention in our institution. The size of the bony fragment and hallux valgus interphalangeus angle were measured on the preoperative X-rays. The size and rotation of the osteochondral fragment, the presence of avascular necrosis, ligamentous injury and soft tissue entrapment were assessed on the preoperative magnetic resonance images (MRIs). The radiologic and functional evaluation were performed at 1 year postoperatively.RESULTS: The average size of the bony fragments measured on the X-rays was 4.1 mm in width and 2.3 mm in length. Two cases showed hallux valgus interphalangeus. Preoperative MRI was performed in four cases and the average size of any osteochondral lesion was 5.3 mm in width, 3.9 mm in length, and 4.7 mm in height. Rotation of the osteochondral fragment was observed in one patient, and soft tissue entrapment was noted in two patients. Postoperatively, successful bony union was achieved in all the patients and the average time to union was 74.4 days.CONCLUSION: Intra-articular proximal phalangeal head fractures of the big toe are very rare and often neglected due to incomplete ossification in the pediatric population. It is important to suspect the presence of this intra-articular fracture and to appropriately implement further evaluation. Nonunion of chronic cases as well as acute fractures can be successfully treated through open reduction and internal fixation using multiple K-wires.

Böhler's Angle-Comparison Between the pre- and Postoperative in Displaced Intra-Articular Calcaneal Fractures / Ângulo de Böhler-comparação entre o pré e pós-operatório nas fraturas intra-articulares desviadas do calcanhar

Abstract Objective To compare pre- and postoperative variation of radiographicmeasurements of the Böhler angle (BA) in fractures with two types of deviations: severe and moderate. Methods Pre- and postoperative BAs in 31 calcaneal fracture radiographs were retrospectively analyzed. A total of 4 patients were female (6.5%) and 26 were male (83.9%), with age ranging from 23 to 72 years old, and a mean age of 44.5 years old. Results The results show that the postoperative BA was significantly larger than the preoperative BA (p = 0.000). At the intraevaluator and overall assessments, the postoperative BA was, on average, 10.6° higher than the preoperative measure. The postoperative angle was, on average, 108% higher than the preoperative angle. In the global assessment, the agreement between evaluatorswas excellent, bothregarding the estimated point value (0.98) and the intraclass correlation (ICC) confidence interval (CI). Conclusion In the global analysis, the postoperative BAs were, on average, significantly higher than the preoperativemeasurements. The farther from the normal range (20° to 40°) the preoperative angle is, the greater the difference after the surgery. When the preoperative angle was normal, the postoperative angle was, on average, 1.28 times the preoperative measurement. If the preoperative BA was abnormal, the postoperative angle was, on average, 17.3 times the preoperativemeasurement. It was demonstrated that more severe fractures present better anatomic results when compared with moderate fractures. The present study also confirms a good interobserver correlation for the BA.

Resumo Objetivo Comparar a variação dos resultados dasmedidas radiográficas do ângulo de Böhler, no pré e pós-operatório, em fraturas com dois tipos de desvio: graves e moderadas. Métodos: O ângulo de Böhler foi analisado retrospectivamente em 31 radiografias pré e pós-operatórias de fraturas do calcâneo. Quatro pacientes eram do sexo feminino (6,5%) e 26 do masculino (83,9%), entre 23 e 72 anos, média de 44,5. Resultados As medidas pré e pós-operatória demonstraram que o ângulo de Böhler após a cirurgia foi significativamente maior do que o ângulo de Böhler pré-operatório (p-valor = 0,000). Nas análises intraobservador e global, o ângulo de Böhler pósoperatório foi, em média, 10,6 graus maior do que no pré-operatório. O ângulo pósoperatório foi, em média, 108% maior do que o ângulo pré-operatório. No global, a concordância entre os avaliadores é excelente, tanto em relação ao valor pontual estimado (0,98) quanto em relação ao intervalo de confiança do ICC. Conclusão Na análise global, verificou-se que asmedidas do ângulo de Böhler no pósoperatório são, em média, significativamente maiores do que as do ângulo préoperatório. Quanto mais distante da faixa de normalidade (20 a 40 graus) estiver o ângulo pré-operatório, maior a diferença no ângulo após a cirurgia. Quando o ângulo pré-operatório está na faixa de normalidade, o ângulo pós-operatório será, em média, 1,28 vez o ângulo pré-operatório; se o ângulo de Böhler pré-operatório estiver fora da

Irreducible Acute Patellar Dislocation due to a New Anatomical Variant - the Notched Patella / Dislocação patelar aguda irredutível devido a uma nova variante anatômica - a patela entalhada

Abstract Irreducible patella dislocations are rare and are usually associated with complex mechanisms. Theauthors report the clinical case of an irreducible lateral patellardislocationdueto an anatomical variant. The authors assisted a 16-year-old patient who presented with a lateral patella dislocation that was impossible to reduceby closedmanipulation, even under general anesthesia. During the imaging study, the computed tomography (CT) exam showed a notch in the medial facet of the patella, impacted in the lateral condyle, which prevented the reduction. This anatomical variant was later confirmed during surgery. In a bilateral follow-up CT, this variant was also present in the contralateral, normal knee, excluding traumatic reshaping as the reason for this patellar notch. The authors used a medial parapatellar approach for open reduction of the dislocation and to repair themedial retinaculum. According to Wiberg, there are three different patella types. The authors describe a variation of type III patellawith a notch inthemedial border that is not included in the previous classification. They emphasize the importance of a CTstudy in the presence of an irreducible dislocation and the recognition of this anatomical variant of the patella, as further aggressive maneuvers have proven to be unsuccessful. Open reduction appears to be the best option in this scenario.

Resumo As luxações irredutíveis da patela são raras e são geralmente associadas a mecanismos complexos. Os autores relatam o caso clínico de uma luxação patelar lateral irredutível devido a uma variante anatômica. Os autores atenderam um paciente de 16 anos que apresentou uma luxação lateral da patela de redução impossível por manipulação fechada, mesmo sob anestesia geral. Durante o estudo de imagem, a tomografia computadorizada (TC) mostrou um entalhe na faceta medial da patela, impactada no côndilo lateral, o que impediu a redução. Esta variante anatômica foi posteriormente confirmada durante a cirurgia. Em uma TC bilateral de acompanhamento, esta variante anatômica também estava presente no joelho contralateral, normal, excluindo o remodelamento traumático como o motivo deste entalhe patelar. Os autores utilizaramuma abordagem parapatelar medial para a redução aberta do deslocamento e para o reparo do retináculo medial. De acordo comWiberg, existem três tipos diferentes de patela. Os autores descrevem uma variação da patela de tipo III com um entalhe na margem medial que não está incluída na classificação anterior. Ressalta-se a importância de um estudo de TC na presença de luxação irredutível e o reconhecimento desta variante anatômica da patela, já quemanobras agressivas foram testadas sem sucesso. A redução aberta parece ser a melhor opção neste cenário. Abstract Irreducible patella dislocations are rare and are usually associated with complex mechanisms. The authors report the clinical case of an irreducible lateral patellar dislocation due to an anatomical variant. The authors assisted a 16-year-old patient

Simulation for Reduction of Transverse Acetabular Fractures in Sawbones Models

PURPOSE: The transversely oriented fracture lines are very difficult to reduce during operations, even after clear exposure of the fracture site, in acetabular fractures. The purpose of this study is to verify the quality of reduction between the different subtypes (transtectal, juxtatectal, and infratectal) of transverse fractures. This study also determined the proper type of clamps to use and the proper zone for achieving accurate reductions in Sawbones models. MATERIALS AND METHODS: Six fractures in 3 different subtypes of transverse fractures were artificially created. Ten different reduction clamps were applied for reduction of the fractures. Twelve holes around the fracture were drilled for the maintenance of the clamps. The fracture displacements were measured at the extra-articular area and the intra-articular joint portion. The pictures of the intra-articular fracture displacements were taken by a camera and these were uploaded and analyzed by the TraumaCad® computer program (Brainlab). RESULTS: The reduction quality was poor in order of transtectal, juxtatectal and infratectal. The intraarticular opening was more prominent in the transtectal subtype. The safe zone, when giving consideration of the neurovascular bundles, was a quadrilateral surface of the ilium. Drill holes are useful for maintenance of the reduction clamps. Reduction clamps with points (Weber clamp) were the best for maintenance and accurate reduction. Regarding the concerns of placement of clamps, the middle to posterior combination was the best. The upper hole among the posterior holes in the ilium was the most likely to well reduce the intra-articular opening. CONCLUSION: Transtectal was the more complicated subtype in the aspect of reduction quality. The Weber type reduction clamp was the best for reduction by centrally located holes in the quadrilateral surface and posteriorly located iliac holes in transverse acetabular fractures. The upper hole, among the posterior holes in the ilium, was the best for reduction of the fracture displacements in the intraarticular portion of acetabulum.

Use of Miniplate for Severe Comminuted Metadiaphyseal Fractures of the Distal Radius

PURPOSE: This study investigated the clinical and radiological outcomes of patients undergoing provisional fixation in conjunction with locking plate fixation. Miniplates were used as the reduction plates for the surgical treatment of severe comminuted metadiaphyseal fractures with an intra-articular fracture of the distal radius. MATERIALS AND METHODS: The radial length, radial inclination, volar tilt, and radial intra-articular step-off were measured preoperatively, postoperatively, and at one year after surgery in 12 patients (eight males, four females, mean age 55.4 years old). The patients underwent volar locking plate fixation with miniplate as a reduction plate for severe comminuted metadiaphyseal fractures with an intra-articular fracture of the distal radius. Clinical evaluations were conducted using the modified Mayo wrist score (MMWS). RESULTS: Bone union was achieved in all cases. The mean MMWS was 81.8 points, including two excellent, three good, and seven fair cases. Radiological improvements were observed in the average radial length (preoperative, 6.4 mm; postoperative, 11.8 mm), average radial inclination (10.2° to 22.4°), average volar tilt (−4.5° to 10.6°), and average radial intra-articular step-off (4.8–0.8 mm) (all, p0.05). CONCLUSION: Miniplate fixation can be an effective treatment option as a reduction plate for the treatment of distal radial fractures, which is challenging to reduce and maintain due to severely comminuted metadiaphysis fractures with the intra-articular fracture.

Paratricipital Approach for AO/OTA Type C2 Intra-Articular Fracture of Distal Humerus

PURPOSE: The aim of this study was to determine the outcomes of fixation of AO/OTA type C2 fractures among intra-articular fractures of the distal humerus using the paratricipital approach (side to side retraction of the triceps). MATERIALS AND METHODS: From June 2008 to January 2018, 12 patients underwent an open reduction and internal fixation with the paratricipital approach and were followed-up for more than 10 months after surgery. According to the AO/OTA classification, type C2 fractures were chosen among the intraarticular distal humerus fractures. An extended posterior incision was used over the olecranon in the prone position, preserving the insertion site of the triceps brachii muscle. The fracture site was exposed by retracting the muscle side-to side through a dissection of the medial and lateral intermuscular septum of the triceps brachii muscle. The therapeutic results were assessed by the anatomical reduction of the articular surface and integrity of the metaphyseal contour in postoperative simple radiographs, complications, such as neuropathy or non-union, and the Mayo elbow performance score (MEPS) were checked to estimate the functional outcome. RESULTS: In the postoperative simple radiographs, no case showed more than 1 mm step-off and the disrupted contour of the distal humerus was recovered to normal alignment in most cases. The range of elbow joint motion in the last follow-up was 133.8° on average with a mean flexion contracture of 5.0°. The clinical results depending on the MEPS were excellent, except for two cases, which were good. Neuropathy of the ulnar nerve was observed in one patient, which was resolved after metal removal. CONCLUSION: The paratricipital approach is useful technique in AO/OTA type C2 intra-articular distal humerus fractures that provides sufficient exposure of the surgical field, without injury to the triceps brachii muscle and postoperative complications associated with the trans-olecranon approach.

Surgical Treatment Strategy for Distal Humerus Intra-articular Fractures

Treating distal humerus fractures, especially those involving intra-articular lesions, is complex and often technically demanding. Although there still exist many controversial issues, the goal of treatment is to establish anatomical stable fixation by restoring the two columns and the articular surface. Universally, a posterior midline incision is applied, and the approach varies according to the further management of the triceps or olecranon. Evidence supports dual plate fixation as the optimal fixation method, and debates regarding appropriate plating configuration are still ongoing. As multiple clinical studies comparing results of parallel and perpendicular plate fixation have shown no actual difference, it is important to place the plates according to the fracture configuration.

Arthroscopically-Assisted Reduction and Internal Fixation of Intra-Articular Fractures of the Lateral Tibial Plateau / 대한정형외과학회잡지

PURPOSE: To evaluate the results of tibial lateral plateau fractures using arthroscopic-assisted reduction and internal fixation without cortical window or bone grafts. MATERIALS AND METHODS: From March 2009 to March 2017, 27 patients with Schatzker type II tibial plateau fractures with articular depression and displacement over 5 mm on a computed tomography (CT) scan, who were treated with arthroscopic reduction and internal fixation and followed-up for at least 18 months, were enrolled in this study. Under arthroscopic guidance, the depressed fracture fragment was reduced using a freer and fixed with 5.0 or 6.5 mm cannulated screws through the inframeniscal portal without a cortical window or bone graft. The clinical and radiological results were evaluated using a Rasmussen system. Second look arthroscopy was performed in thirteen patients during the implant removal operation. RESULTS: All fractures healed completely with a mean union time of 8.7 weeks (range from 8 to 12 weeks). Twenty four patients had good to excellent clinical results and 25 patients had good to excellent radiological results according to the Rasmussen classification. A well-healed articular surface with fibrocartilage was also found in 13 cases with second look arthroscopy. The 8 cases on CT scan at outpatient department follow-up showed bone union without bone grafting. CONCLUSION: Arthroscopic-assisted fixation of tibial lateral plateau fractures is a useful method without a cortical window or bone graft that produces good clinical results.

Results after Less Invasive Locking Plating in Intra-Articular Fractures of the Distal Femur

PURPOSE: The purpose of this study was to determine the clinical outcomes after a less invasive locking plating technique in intra-articular fractures of the distal femur. MATERIALS AND METHODS: This was a retrospective 19 case series of patients with distal femoral intraarticular fractures treated with a less invasive locking plating technique in a single center (Dankook University Hospital) from June 2010 to April 2016. Nineteen patients (11 males and 8 females) with a mean age of 55.9 years were enrolled. The functional outcomes were evaluated using the visual analogue scale (VAS), range of knee joint motion (flexion & extension), and Knee Society score. The radiology outcomes were evaluated with parameters measured in a plain radiograph (deviation angle of alignment axis on coronal and sagittal plane, mechanical lateral distal femur angle). RESULTS: The mean follow-up period was 26.4 months (range, 12–72 months) and the mean duration to union was 15.94 weeks (range, 11–28 weeks). The mean VAS was 1.36 (range, 0–8) and the range of motion of the knee joint was extension 4.73° (range, 0°–30°) and flexion 107.36° (range, 60°–135°). The mean Knee Society score was 85.47 (range, 47–100). The mean deviation angle of the coronal alignment axis was 4.07° (range, 1.3°–8.8°), the mean deviation angle of the sagittal alignment axis was 3.23° (range, 0.7°–7.0°), and the mechanical lateral femoral angle was 87.75° (range, 82.8°–95.5°). Six patients had traumatic osteoarthritis at the final follow-up. CONCLUSION: The purpose of this study was to evaluate the clinical and radiologic outcomes of intraarticular fractures of the distal femur in patients who underwent an anatomical reduction through an open reduction, and converted to an extra-articular fracture with rigid internal fixation. The results were relatively satisfactory.

Distal Humerus Fracture: How to Choose the Approach, Implant, Fixation and Rehabilitation

Distal humerus fractures require stable fixation and early joint motion, similar to other intra-articular fractures, but are difficult to treat adequately because of the anatomical complexity, severe comminution, and accompanying osteoporosis. In most cases, surgical treatment is performed using two supporting plates. Plate fixation can be divided into right angle plate fixation and parallel plate fixation. In addition, depending on the type of fracture, surgical procedures can be performed differently, and autologous bone grafting can be required in the case of severe bone loss. The elbow joint is vulnerable to stiffness, so it is important to start joint movement early after surgery. Postoperative complications, such as nonunion, ulnar nerve compression, and heterotopic ossification, can occur. Therefore, accurate and rigid fixation and meticulous manipulation of soft tissues are required during surgery.

Traitement par fixateur externe des fractures ouvertes des membres type III de Gustilo-Anderson

Introduction : Les fractures ouvertes des membres type III de Gustilo et Anderson relèvent d'un traumatisme à haute énergie. Ces fractures sont stabilisées par un fixateur externe. Le but de cette étude rétrospective était de préciser les caractéristiques épidémio-cliniques des patients et d'évaluer les résultats du traitement. Patients et Méthodes : Cette étude était basée sur 20 patients totalisant 20 fractures ouvertes des membres traitées par fixateur externe entre janvier 2015 et décembre 2017. L'évaluation des résultats tenait compte de la consolidation, le résultat fonctionnel et les complications. Résultats : Il y avait 15 hommes et cinq femmes avec un âge moyen de 26 ans. Le délai moyen de prise en charge était de 21 heures. Les lésions siégeaient au membre inférieur (n=17) et au membre supérieur (n=3). Selon la classification de Gustilo et Anderson les fractures étaient de type IIIa (n= 11), type IIIb (n= 8) et type IIIc(n=1). Il a été réalisé des greffes de peau (n=16) et des lambeaux n=3). Les types de fixateur étaient le Fixateur Externe du Service de Santé des Armées (n=7), le Hoffman (n=7), et l'Orthofix (n=6). La cicatrisation des plaies a été obtenue dans un délai moyen de 31 jours. La consolidation était acquise chez 17 patients dans un délai moyen de 9 mois. Après un recul moyen de 9 mois, le résultat fonctionnel a été jugé excellent (n= 12), bon (n= 5) et mauvais (n=3). Les complications étaient l'infection postopératoire (n=12), le cal vicieux (n= 4), et la pseudarthrose (n=2). Conclusion : Le fixateur externe a été utilisé comme moyen de contention. La cicatrisation dirigée associée à une greffe cutanée a été réalisée dans la majorité des cas. La consolidation a été acquise chez 17 patients avec des résultats fonctionnels excellents et bons

Subtalar Dislocations: Case Series Inclusive of the Rare Anterior Subtalar Dislocation and Review of the Literature / Dislocaciones subtalares: serie de casos con inclusión de la rara dislocación subtalar anterior y revisión de la literatura

ABSTRACT Subtalar dislocations were first described by Judey and Dufaurest in 1811. These dislocations represent only 1-2% of all joint dislocations, making them a rare injury. In this rare injury, there are four variations with differing clinical presentations. The clinical picture may vary from a dramatic deformity (as in medial and lateral dislocations) to a more subtle presentation (as in anterior and posterior dislocations). This case series highlights the variations in clinical presentations and the management difficulties associated with each subtype.

RESUMEN Las dislocaciones subtalares fueron por primera vez descritas por Judey y Dufaurest en 1811. Estas dislocaciones representan solamente el 1-2% de todas las dislocaciones de las articulaciones, por lo que constituye una lesión poco frecuente. Esta rara lesión se caracteriza por cuatro variaciones con presentaciones clínicas que difieren. El cuadro clínico puede variar desde una deformidad dramática (tal cual ocurre en las dislocaciones intermedias y laterales) hasta una presentación más sutil (como en el caso de las dislocaciones anteriores y posteriores). Esta serie de casos destaca las variaciones en las presentaciones clínicas y las dificultades en el tratamiento asociado con cada subtipo.

Surgical exposures of the distal humeral fractures: An anatomical study of the anterior, posterior, medial and lateral approaches / 中华创伤杂志(英文版)

PURPOSE@#Exposure of the articular surface is the key to the successful treatment of intra-articular fractures of distal humerus. Anterior, posterior olecranon osteotomy as well as medial and lateral approaches are the four main approaches to the elbow. The aim of this study was to compare the exposure of distal articular surfaces of these surgical approaches.@*METHODS@#Twelve cadavers were used in this study. Each approach was performed on six elbows according to previously published procedures. After completion of each approach, the exposed articular surfaces were marked by inserting 0.5 mm K-wires along the margins. The elbow was then disarticulated and the exposed articular surfaces were painted. The distal humeral articular surfaces were then closely wrapped using a piece of fibre-glass screen net with meshes. The exposed articular surfaces and the total articular surfaces were calculated by counting the number of meshes, respectively.@*RESULTS@#The average percentages of the exposed articular surfaces for the anterior, posterior olecranon osteotomy, medial and lateral approaches were 45.7% ± 2.0%, 53.9% ± 7.1%, 20.6% ± 4.9% and 28.5% ± 6.3%, respectively.@*CONCLUSION@#The anterior and posterior approaches provide greater exposures of distal humeral articular surface than the medial and lateral ones in the treatment of distal humeral fractures.

Risk Factors for Knee Stiffness in Distal Femoral Fractures

PURPOSE: The aims of this study were to evaluate risk factors for knee stiffness after the fixation of distal femoral fractures, and to analyze the clinical and radiologic outcomes. MATERIALS AND METHODS: This is a retrospective case control study of 104 consecutive patients who have a distal femoral fracture and were treated with a submuscular locking plate. The case group comprised of patients with 12-month postoperative range of motion (ROM) ≤90° or a history of manipulation under anesthesia. The case group was compared with the control group of patients with a 12-month postoperative ROM >90°. The possible risk factors were evaluated by univariate and logistic regression analysis. The postoperative ROM and Knee Society clinical rating system was evaluated for the clinical assessment and the distal femoral angle on a whole-extremity scanogram was measured for radiologic assessments. RESULTS: Fifty-four patients were included in the study (14 in the case group, 40 in the control group). Univariate analysis showed that comminuted fracture, intra-articular fracture, open fracture, temporary external fixation, severe osteoarthritis, and prolonged immobilization placed patients at an increased risk for knee stiffness. On the other hand, multivariate logistic regression showed that an extensor mechanism injury was the only significant predictor (p=0.001; odds ratio, 42.0; 95% confidence interval, 5.0–350.7). The ROM and Knee Society score were significantly lower in the case group; however, the coronal alignment was similar in the case and control group. CONCLUSION: Various factors that delay postoperative knee motion place patients at increased risk of knee stiffness. Understanding these risk factors may help surgeons prevent postoperative knee stiffness after distal femoral fractures. In particular, extensor mechanism injury, such as patella fracture or open quadriceps injury, was found to be an independent predictable factor associated with knee stiffness.

How Difficult Is It to Surgically Treat AO-C Type Distal Humerus Fractures for Inexperienced Orthopedic Surgeons?

PURPOSE: Twenty early surgical management cases of distal humerus type-C fractures were analyzed. MATERIALS AND METHODS: This study analyzed 20 early patients, who received surgical management of distal humerus type-C fractures, and could be followed-ups for more than one year between March of 2013 and May of 2015. The operative time, bone union time, and elbow range of motion were analyzed. The Mayo's functional score was used to evaluate their postoperative function. The primary and secondary complications of each patient immediately after each of their surgery were also reviewed. RESULTS: All patient groups achieved bone union within an average period of 16.4 weeks. Based on the Mayo functional score, 6, 10, and 4 patients scored excellent, good, and fair, respectively. The average range of motion was a flexion contracture of 14.5° with a follow-up improvement averaging 120.7°. Six patients received nine revision operations due to major and minor complications. Two patients received revision fixation from an inadequate fixating power, and another patient received an ulnar nerve transposition. Other complications included olecranon osteotomy site displacement, superficial operational site infection, and pin loosening. CONCLUSION: Distal humerus fractures of the AO-C type can cause a range of complications and has a very high rate of revision due to its difficult nature of surgical manageability. Therefore, it is imperative for a surgeon to expect various complications beforehand and a careful approach to their postoperative rehabilitation is essential.