Lisfranc Fixation Techniques and Postoperative Functional Outcomes: A Systematic Review.

The optimal method of fixation of acute Lisfranc injuries is yet to be established. We aim to systematically review the literature to identify the impact of fixation method on postoperative functional outcomes. A systematic review was undertaken using the PRISMA framework to identify all studies reporting postoperative functional outcomes in patients who underwent open-reduction internal fixation of acute Lisfranc injuries. Studies reporting outcomes of numerous fixation methods were divided into fixation subcohorts. Studies comparing bridge plate with transarticular screw fixation were included for meta-analysis, conducted using a random-effects model. Seventeen studies (20 subcohorts) with 462 patients were included. Mean patient age was 29.6 (rang, 15-81) years. Mean follow-up was 38.7 (range 11 to 287) months. American Academy of Orthopaedic Surgeons midfoot score (AOFAS-MF) was the most frequently reported functional outcome (16/20 subcohorts). Overall weighted mean AOFAS-MF was 76.3 ± 9.4 for all cases, with 74.2 ± 9.4 for transarticular screws and 79.2 ± 8.3 for bridge plates. The mean difference between screw and plate was not statistically significant (mean difference = 5.0, 95% confidence interval, -4.8 - 14.8, p = .3). A single study reported AOFAS-MF mean of 92 using suture button fixation. Meta-analysis of the 2 available comparative studies revealed higher postoperative AOFAS-MF with bridge plate fixation (pooled standardized mean difference, 0.51; 95% confidence interval, 0.15-0.87, p = .006). There is scarcity of literature examining the impact of fixation method on postoperative functional outcomes in acute Lisfranc injuries. A small number of studies have reported superior functional outcomes with use of bridge plate fixation. Further evidence is needed to ascertain which injuries are best managed with each fixation method or whether 1 fixation construct is universally superior.

Proximal Femoral Erosion: A Sequelae of Psuedoaneursym Formation Following Operative Fixation of an Intertrochanteric Neck of Femur Fracture.

A 72-year-old male sustained a left intertrochanteric neck of femur fracture following a fall. He underwent operative fixation with a dynamic hip screw and was discharged home. Fifteen months later, the patient presented again with ongoing left thigh pain and swelling. A pelvic radiograph showed scalloping of the medial proximal femoral cortex. Further investigation revealed a left profunda femoris artery pseudoaneurysm. Vascular injury during operative fixation of intratrochanteric fractures is a rare complication, which may be missed due to a delayed presentation. Treating physicians should be mindful of late presentations of vascular injury following the surgical fixation of proximal femoral fractures.

Epithelial tissue cut-out following needle insertion into a joint: a potential complication during arthroscopy.

BACKGROUND: Knee arthroscopy is a common orthopaedic procedure and often involves insertion of a needle through skin into a joint. This needle insertion can create epithelial tissue cut-outs possibly containing commensal bacteria that can be flushed into the joint, and potentially lead to post-arthroscopy septic arthritis. This study aims to assess the frequency of epithelial tissue cut-out creation on insertion of different needle sizes at different angles to the skin. METHODS: Using an ex-vivo porcine limb tissue model, needles of various gauge (14-23G) were inserted at angles of 90, 60, 45 and 30° to the skin surface. Ten passes were undertaken at each angle. Needle lumen contents were then examined for solid tissue cut-out. RESULTS: Two hundred and eighty needle passes were performed resulting in 70 tissue cut-outs (25%) containing solid material. This was more common amongst lower gauge needles. 8 of the 70 (11.4%) tissue cut-outs contained macroscopic evidence of epithelium. The overall rate of epithelial tissue cut-out was 2.9%. The 23G needle had the lowest rate of tissue cut-out creation, occurring twice out of 40 passes (P = 0.002). Neither of these contained macroscopic epithelial tissue. CONCLUSION: Hypodermic needle insertion through skin into a joint can create epithelial tissue cut-out. Epithelial tissue cut-out occurs more frequently with use of lower gauge needles. This study suggests use of a 23G needle during arthroscopy, inserted either at 60 or 90° to the skin, to reduce epithelial tissue cut-out and any potential contribution to post-arthroscopy septic arthritis.

Orbitofrontal cortical thinning and aggression in mild traumatic brain injury patients.

INTRODUCTION: Although mild traumatic brain injury (mTBI) comprises 80% of all TBI, the morphological examination of the orbitofrontal cortex (OFC) in relation to clinical symptoms such as aggression, anxiety and depression in a strictly mTBI sample has never before been performed. OBJECTIVES: The primary objective of the study was to determine if mTBI patients would show morphological differences in the OFC and if the morphology of this region would relate to clinical symptoms. METHODS: Using structural images acquired in a 3T MRI machine, the cortical thickness and cortical volume (corrected for total brain volume) of the OFC was collected for healthy control (N = 27) subjects and chronic mTBI (N = 55) patients at least one year post injury. Also, during clinical interviews, measures quantifying the severity of clinical symptoms, including aggression, anxiety, and depression, were collected. RESULTS: MTBI subjects displayed increased aggression, anxiety, and depression, and anxiety and depression measures showed a relationship with the number of mTBI in which the subject lost consciousness. The cortical thickness of the right lateral OFC displayed evidence of thinning in the mTBI group; however, after correction for multiple comparisons, this difference was no longer significant. Clinical measures were not significantly related with OFC morphometry. CONCLUSION: This study found increased aggression, anxiety, and depression, in the mTBI group as well as evidence of cortical thinning in the right lateral OFC. The association between clinical symptoms and the number of mTBI with loss of consciousness suggests the number and severity of mTBI may influence clinical symptoms long after injury. Future studies examining other brain regions involved in the production and regulation of affective processes and inclusion of subjects with well-characterized mood disorders could further elucidate the relationship between mTBI, brain morphology, and clinical symptoms.

Enlarged thalamic volumes and increased fractional anisotropy in the thalamic radiations in veterans with suicide behaviors.

Post-mortem studies have suggested a link between the thalamus, psychiatric disorders, and suicide. We evaluated the thalamus and anterior thalamic radiations (ATR) in a group of Veterans with and without a history of suicidal behavior (SB) to determine if thalamic abnormalities were associated with an increased risk of SB. Forty Veterans with mild traumatic brain injury (TBI) and no SB (TBI-SB), 19 Veterans with mild TBI and a history of SB (TB + SB), and 15 healthy controls (HC) underwent magnetic resonance imaging scanning including a structural and diffusion tensor imaging scan. SBs were evaluated utilizing the Columbia Suicide Rating Scale and impulsivity was measured using the Barratt Impulsiveness Scale (BIS). Differences in thalamic volumes and ATR fractional anisotropy (FA) were examined between (1) TBI + SB versus HC and (2) TBI + SB versus combined HC and TBI-SB and (3) between TBI + SB and TBI-SB. Left and right thalamic volumes were significantly increased in those with TBI + SB compared to the HC, TBI-SB, and the combined group. Veterans with TBI + SB had increased FA bilaterally compared to the HC, HC and TBI-SB group, and the TBI-SB only group. Significant positive associations were found for bilateral ATR and BIS in the TBI + SB group. Our findings of thalamic enlargement and increased FA in individuals with TBI + SB suggest that this region may be a biomarker for suicide risk. Our findings are consistent with previous evidence indicating that suicide may be associated with behavioral disinhibition and frontal-thalamic-limbic dysfunction and suggest a neurobiologic mechanism that may increase vulnerability to suicide.