Rotational Malalignment After Intramedullary Nailing of Tibial Shaft Fractures Is Predictable.

OBJECTIVES: Intramedullary nailing is the treatment of choice for most tibial shaft fractures (TSF). However, an iatrogenic pitfall may be rotational malalignment. The aim of this retrospective analysis was to determine predictors of rotational malalignment following intramedullary nailing of TSF. DESIGN: Retrospective study. SETTING: Single level 1 trauma center. PATIENT SELECTION CRITERIA: Patients who had a unilateral intramedullary nailing for TSF with a low-dose bilateral postoperative CT to assess rotational malalignment. OUTCOME MEASURES AND COMPARISONS: Bivariable analysis followed by multivariable analysis was then undertaken to assess for any independent predictors, such as fracture type/sight, surgeon experience, and side of fracture, predictive of rotational malalignment. RESULTS: In total, 154 patients (71% male, median age 37 years) were included in this study. Thirty-nine percent of variability in postoperative rotational malalignment could be explained using a model including (increased) tibial torsion of the noninjured side (mean [38.9 degrees ± 9.02 degrees] considered normal tibial torsion), side of tibial fracture, and spiral-type tibial fracture (R2 = 0.39, P ≤ 0.001, F = 31.40). In this model, there was a negative linear association between degrees of torsion on the noninjured side and rotational malalignment (-0.45, P < 0.001)-as baseline torsion increased from mean by 1 degree, malrotation in the opposite direction of 0.54 degrees seen. Positive linear associations between right-sided TSF and rotational malalignment (8.59 P < 0.001) as well as spiral fractures and rotational malalignment (5.03, P < 0.01) were seen. CONCLUSIONS: This study demonstrates that baseline reduced (internal) tibial torsion of the noninjured limb, spiral fractures, and right-sided TSF are predictive of postoperative external rotational malalignment. Conversely, increased baseline (external) tibial torsion of the noninjured limb and left-sided TSF are predictive of postoperative internal rotational malalignment. Surgeons may use this regression model preoperatively to predict what sort of postoperative rotational difference their patient may be prone to. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Triplane ankle fracture patterns in paediatric patients.

Aims: Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age. Methods: A fracture mapping study was performed in 83 paediatric patients with a triplane ankle fracture treated in three trauma centres between January 2010 and June 2020. Patients aged younger than 18 years who had CT scans available were included. An independent Paediatric Orthopaedic Trauma Surgeon assessed all CT scans and classified the injuries as n-part triplane fractures. Qualitative analysis of the fracture pattern was performed using the modified Cole fracture mapping technique. The maps were assessed for both patterns and correlation with the closing of the physis until consensus was reached by a panel of six surgeons. Results: Fracture map grouped by age demonstrates that, regardless of age (even at the extremes of the spectrum), the fracture lines consolidate in a characteristic Y-pattern, and no shift with closure of the physis was observed. A second fracture map with two years added to female age also did not show a shift. The fracture map, grouped by both age and sex, shows a Y-pattern in all different groups. The fracture lines appear to occur between the anterior and posterior inferior tibiofibular ligaments, and the medially fused physis or deltoid ligament. Conclusion: This fracture mapping study reveals that triplane ankle fractures have a characteristic Y-pattern, and acknowledges the weakness created by the physis, however it also challenges classic teaching that the specific fracture pattern at the level of the joint of these injuries relies on advancing closure of the physis with age. Instead, this study observes the importance of ligament attachment in the fracture patterns of these injuries.

Clockwise torque results in higher reoperation rates in left-sided femur fractures.

PURPOSE: Effects of clockwise torque rotation onto proximal femoral fracture fixation have been subject of ongoing debate: fixated right-sided trochanteric fractures seem more rotationally stable than left-sided fractures in the biomechanical setting, but this theoretical advantage has not been demonstrated in the clinical setting to date. The purpose of this study was to identify a difference in early reoperation rate between patients undergoing surgery for left- versus right-sided proximal femur fractures using cephalomedullary nailing (CMN). MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program was queried from 2016-2019 to identify patients aged 50 years and older undergoing CMN for a proximal femoral fracture. The primary outcome was any unplanned reoperation within 30 days following surgery. The difference was calculated using a Chi-square test, and observed power calculated using post-hoc power analysis. RESULTS: In total, of 20,122 patients undergoing CMN for proximal femoral fracture management, 1.8% (n=371) had to undergo an unplanned reoperation within 30 days after surgery. Overall, 208 (2.0%) were left-sided and 163 (1.7%) right-sided fractures (p=0.052, risk ratio [RR] 1.22, 95% confidence interval [CI] 1.00-1.50), odds ratio [OR] 1.23 (95%CI 1.00-1.51), power 49.2% (α=0.05). CONCLUSION: This study shows a higher risk of reoperation for left-sided compared to right-sided proximal femur fractures after CMN in a large sample size. Although results may be underpowered and statistically insignificant, this finding might substantiate the hypothesis that clockwise rotation during implant insertion and (postoperative) weightbearing may lead to higher reoperation rates. LEVEL OF EVIDENCE: Therapeutic level II.

Incidence, Predictors, and Fracture Mapping of (Occult) Posterior Malleolar Fractures Associated With Tibial Shaft Fractures.

OBJECTIVES: To (1) evaluate the incidence of posterior malleolar fractures (PMFs) in patients with tibial shaft fractures (TSFs) using advanced imaging; (2) identify predictors for patients at risk of an (occult) PMF; and (3) describe PMF characteristics to guide "malleolus-first" fixation. DESIGN: Retrospective diagnostic imaging study. SETTING: Level-I trauma center. PATIENTS: One hundred sixty-four patients treated with intramedullary nailing for TSFs who underwent low-dose postoperative computed tomography (CT) scans to assess (mal)rotational alignment. INTERVENTION: Analysis of advanced imaging for the presence of PMFs. Univariate and multivariate analyses to identify predictors. Qualitative analysis of PMFs by fracture mapping. MAIN OUTCOME MEASURES: (1) Incidence of PMFs in patients with TSFs as diagnosed on post-op CT scans; (2) independent predictors for the presence of PMFs; and (3) PMF patterns. RESULTS: One in five patients with a TSF has an associated PMF (22%), increasing to one-in-two in patients with simple spiral fractures (56%). In 25% of patients, these fractures were occult. Univariate analysis identified simple spiral and distal third TSFs, proximal third and spiral fibula fractures, and low-energy trauma as predictors for PMFs. Multivariate analysis demonstrated that distal third and simple spiral TSFs were the only independent predictors. Haraguchi type I is the pattern specific to PMFs associated with TSF. CONCLUSIONS: Half of patients presenting with a simple spiral TSF have an associated PMF. In one in four patients, these are occult. Additional preoperative CT scan imaging may be considered in patients presenting with simple spiral distal third TSFs, despite negative lateral radiographs, so that PMFs can be identified and managed with "malleolus-first" fixation. LEVEL OF EVIDENCE: Diagnostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Distal Radius Volar Plate Design and Volar Prominence to the Watershed Line in Clinical Practice: Comparison of Soong Grading of 2 Common Plates in 400 Patients.

PURPOSE: To compare plate positioning in clinical practice of 2 commonly used volar locking plate designs with respect to the watershed line as classified by the Soong grading system. METHODS: For this retrospective study, we included a total of 400 patients who underwent open reduction and internal fixation between May 2013 and February 2018. Cohort 1 was defined as patients treated with distal volar radius (DVR) plates during this period. Cohort 2 comprised 200 patients who had volar plate fixation with variable angle locking compression plates (LCP) during the same period. Standardized lateral wrist radiographs were categorized into Soong grade 0, 1, or 2. RESULTS: In cohort 1, 87 plates (43.5%) were not prominent volar to the watershed line, grade 0; 95 plates (47.5%) demonstrated grade 1 prominence; and 18 plates (9.0%) demonstrated grade 2 prominence. In cohort 2, 63 plates (31.5%) were grade 0; 103 plates (51.5%) were grade 1; and 34 plates (17%) had grade 2 prominence on, and volar to, the watershed line. These radiographic results show a greater incidence of volar plate prominence with respect to the watershed line, as defined as Soong grading, in cohort 2. CONCLUSION: This study shows that the use of the variable angle LCP plate is associated with more prominent volar positioning with respect to the watershed line compared with the DVR plate. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

High incidence of screw penetration in the proximal and distal tibiofibular joints after intramedullary nailing of tibial fractures-A prospective cohort and mapping study.

BACKGROUND: Intramedullary-nails (IMN) are the treatment of choice for most tibial shaft fractures due to their minimally-invasive nature and non-demanding surgical technique. However, a potential iatrogenic pitfall is intra-articular interlocking screw positioning within the proximal (PTFJ) and distal (DTFJ) tibiofibular joints that may go unrecognized. OBJECTIVE: To evaluate the incidence of intra-articular screw penetration of the PTFJ and DTFJs after interlocking of IMN for tibial fractures. INTERVENTION: Reamed IMN using modern techniques, including proximal interlocking via standard aiming jig and distal interlocking either freehand or using SureShot®. METHODS: Prospective series of 165 consecutive patients with a tibial shaft fracture managed with an IMN. Diagnosis and incidence of penetration of the PTFJ and DTFJ was assessed on protocolled low-dose postoperative CT-scans (standardized clinical practice for assessing rotational alignment). The degree of penetration of the TFJ's was graded as: Grade 1-slight breach of the tibial cortex; Grade 2-clear penetration of the tibial cortex with intra-articular screw tip; and Grade 3-penetration of both tibial- and fibular cortices with screw tip in fibula. RESULTS: Of the 165 tibial shaft fractures, using the AO/OTA classification, 69% were simple, 16% wedge and 15% complex fractures. Following IMN 42% of patients had intra-articular screw penetration of their PTFJ whilst 39% had penetration of their DTFJ. 66% of patients had penetration of either one- or both of their TFJs. The grading of PTFJ violation was distributed as follows: Grade 1 in 24 patients; Grade 2 in 26 patients and Grade 3 in 19 patients. DTFJ violation was graded as: Grade 1 in 21 patients; 40 patients had Grade 2 violation; and four patients had a Grade 3 penetration. CONCLUSIONS: This diagnostic imaging study reports a high rate of intra-articular screw penetration of the PTFJ and DTFJ after interlocking of IMN for tibia shaft fractures. A prospective cohort study is underway to evaluate its clinical significance. Changes to enable alteration in forced angle of interlocking screw trajectory and avoidance of the anteromedial to posterolateral locking screw may reduce the incidence of TJF violation. LEVEL OF EVIDENCE: Level II - Diagnostic Imaging Study.

Tuberculosis of lower cervical spine--a prospective study.

Tuberculosis was a leading cause of mortality in the beginning of the twentieth century. Tuberculosis of the spine is one of the oldest diseases afflicting humans. A prospective study was carried out among 45 cases of tuberculosis of lower cervical spine and an attempt was made to highlight some of its features. Pain and stiffness were important and dominant complaints. Commonest level affected was C5-C6 vertebrae. The overall incidence of cord compression was 37.8 per cent. The commonest modality of treatment was antituberculous drugs, anterior excision of diseased bone and tricortical bone grafting. This regime rapidly relieves pain, compressive respiratory symptoms due to large abscess and neurological deficit.

Spinal hydatid disease: a case series.

BACKGROUND: Over the past 10 years, 4 cases of spinal hydatid disease (3 men, 1 woman) were diagnosed and treated at our institution, with an average follow-up of 4 years. Hydatid disease of the spine is a rare condition with a poor prognosis that presents diagnostic and therapeutic challenges. METHODS: The patients were evaluated clinically, using the latest imaging modalities available in our institution. Decompressive surgeries were performed and the diagnosis was confirmed by histopathologic examination. All patients received long-term antihelminthic therapy with 400 mg of albendazole 3 times daily for 1 year. RESULTS: After surgery, all patients improved; however, over time, recurrence and residual disease were observed. Two patients had complete neurologic recovery at follow-up at 2 to 3 years, although there were radiographic signs of recurrence. The other 2 patients did not achieve complete neurologic recovery despite anterior decompression; they developed recurrent disease and the neurologic status deteriorated to spastic paraplegia. All patients refused further surgeries for recurrences and 2 patients died of complications of paraplegia. CONCLUSION: Diagnosis was challenging, eradication was difficult, and hydatid disease recurred in all 4 patients. In our experience, morbidity and mortality were high and prognosis was poor.