No benefit of the trochanteric stabilizing plate on loss of fracture reduction in AO/OTA 31-A2 trochanteric fractures.

Aims: Despite limited clinical scientific backing, an additional trochanteric stabilizing plate (TSP) has been advocated when treating unstable trochanteric fractures with a sliding hip screw (SHS). We aimed to explore whether the TSP would result in less post operative fracture motion, compared to SHS alone. Methods: Overall, 31 patients with AO/OTA 31-A2 trochanteric fractures were randomized to either a SHS alone or a SHS with an additional TSP. To compare postoperative fracture motion, radiostereometric analysis (RSA) was performed before and after weightbearing, and then at four, eight, 12, 26, and 52 weeks. With the "after weightbearing" images as baseline, we calculated translations and rotations, including shortening and medialization of the femoral shaft. Results: Similar migration profiles were observed in all directions during the course of healing. At one year, eight patients in the SHS group and 12 patients in the TSP group were available for analysis, finding a clinically non-relevant, and statistically non-significant, difference in total translation of 1 mm (95% confidence interval -4.7 to 2.9) in favour of the TSP group. In line with the migration data, no significant differences in clinical outcomes were found. Conclusion: The TSP did not influence the course of healing or postoperative fracture motion compared to SHS alone. Based on our results, routine use of the TSP in AO/OTA 31-A2 trochanteric fractures cannot be recommended. The TSP has been shown, in biomechanical studies, to increase stability in sliding hip screw constructs in both unstable and intermediate stable trochanteric fractures, but the clinical evidence is limited. This study showed no advantage of the TSP in unstable (AO 31-A2) fractures in elderly patients when fracture movement was evaluated with radiostereometric analysis.

Higher complication rate after nail compared with plate fixation of ankle fractures in patients aged 60 years or older: a prospective, randomized controlled trial.

AIMS: The aim of this study was to compare the functional and radiological outcomes and the complication rate after nail and plate fixation of unstable fractures of the ankle in elderly patients. METHODS: In this multicentre study, 120 patients aged ≥ 60 years with an acute unstable AO/OTA type 44-B fracture of the ankle were randomized to fixation with either a nail or a plate and followed for 24 months after surgery. The primary outcome measure was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score. Secondary outcome measures were the Manchester-Oxford Foot Questionnaire, the Olerud and Molander Ankle score, the EuroQol five-dimension questionnaire, a visual analogue score for pain, complications, the quality of reduction of the fracture, nonunion, and the development of osteoarthritis. RESULTS: At 24 months, the median AOFAS score was equivalent in the two groups (nail 90 (interquartile range (IQR) 82 to 100), plate 95 (IQR 87 to 100), p = 0.478). There were statistically more complications and secondary operations after nail than plate fixation (p = 0.024 and p = 0.028, respectively). There were no other significant differences in the outcomes between the two groups. CONCLUSION: The functional outcome after nail and plate fixation was equivalent; however, the complication rate and number of secondary operations was significantly higher after nail fixation. These results suggest that plate fixation should usually be the treatment of choice for unstable ankle fractures in the elderly.Cite this article: Bone Joint J 2023;105-B(1):72-81.

The Accuracy of Percutaneous Sacro-Iliac Screw Fixation for Pelvic Ring Injuries using the Lateral view as the Corner Stone for Screw Placement: A Prospective Cohort Study.

This paper has been temporarily removed by the publisher, Wolters-Kluwer, as it may have been published in error. We regret any confusion this may have caused.

Taylor Spatial Frame or Reamed Intramedullary Nailing for Closed Fractures of the Tibial Shaft: A Randomized Controlled Trial.

OBJECTIVES: To compare a modern ring fixator [Taylor Spatial Frame (TSF)] and reamed intramedullary nailing (IMN) for the treatment of closed tibial shaft fractures. DESIGN: Randomized controlled trial. SETTING: Two university hospitals. PATIENTS: Patients between 18 and 70 years of age surgically treated for an acute tibial shaft fracture. INTERVENTION: TSF (n = 31) versus a reamed intramedullary nail (n = 32). The patients were followed up for 2 years. MAIN OUTCOME MEASUREMENTS: The physical component summary of Short Form 36 (SF-36) at 2 years was the primary outcome measure. Secondary outcomes included the other components of the SF-36, pain assessed by a visual analogue scale (VAS), complications, and resource consumption. RESULTS: The mean age was 43 years (SD 14.0), and 42 (67%) were men. The physical component summary at 2 years was 52.4 (SD 6.3) in the TSF group and 53.3 (SD 8.0) in the IMN group (P = 0.35). There were modest differences in the other SF-36 scores during the follow-up period. Up to and including 12 months, the TSF group had less knee pain [at 12 months: VAS 0.5 (SD 1.2) vs. VAS 2.4 (SD 2.2; P < 0.001)], but this was not statistically significant at 24 months [VAS 0.7 (SD 1.4) vs. VAS 1.5 (SD 2.0; P = 0.11)]. Superficial skin infections were more frequent in the TSF group [22 (71%) vs. 4 (13%); P < 0.001]. The number of other complications was similar between the groups. CONCLUSIONS: Both TSF and IMN provided good clinical results. TSF had more pin-track infections but less knee pain the first year. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Better outcome for suture button compared with single syndesmotic screw for syndesmosis injury: five-year results of a randomized controlled trial.

AIMS: In a randomized controlled trial with two-year follow-up, patients treated with suture button (SB) for acute syndesmotic injury had better outcomes than patients treated with syndesmotic screw (SS). The aim of this study was to compare clinical and radiological outcomes for these treatment groups after five years. METHODS: A total of 97 patients with acute syndesmotic injury were randomized to SS or SB. The five-year follow-up rate was 81 patients (84%). The primary outcome was the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale. Secondary outcome measures included Olerud-Molander Ankle (OMA) score, visual analogue scale (VAS), EuroQol five-dimension questionnaire (EQ-5D), range of movement, complications, reoperations, and radiological results. CT scans of both ankles were obtained after surgery, and after one, two, and five years. RESULTS: The SB group had higher median AOFAS score (100 (interquartile range (IQR) 92 to 100) vs 90 (IQR 85 to 100); p = 0.006) and higher median OMA score (100 (IQR 95 to 100) vs 95 (IQR 75 to 100); p = 0.006). The SS group had a higher incidence of ankle osteoarthritis (OA) (24 (65%) vs 14 (35%), odds ratio (OR) 3.4 (95% confidence interval (CI) 1.3 to 8.8); p = 0.009). On axial CT we measured a significantly smaller mean difference in the anterior tibiofibular distance between injured and non-injured ankles in the SB group (-0.1 mm vs 1.2 mm; p = 0.016). CONCLUSION: Five years after syndesmotic injury treated with either SB or SS, we found better AOFAS and OMA scores, and lower incidence of ankle OA, in the SB group. These long-term results favour the use of SB when treating an acute syndesmotic injury. Cite this article: Bone Joint J 2020;102-B(2):212-219.

Importance of Syndesmotic Reduction on Clinical Outcome After Syndesmosis Injuries.

OBJECTIVES: To evaluate the relationship between syndesmosis reduction and outcome. DESIGN: Retrospective cohort study. SETTING: One Level 1 and 1 Level 3 Trauma Center. PATIENTS: Ninety-seven patients with syndesmosis injury. INTERVENTION: Stabilization of syndesmosis injury. Open reduction and internal fixation of malleolar fracture, if present. MAIN OUTCOME MEASUREMENTS: Anterior, central, and posterior measures of syndesmosis width on computed tomography scans, Olerud-Molander Ankle score, American Orthopaedic Foot and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score, and range of motion measurements. RESULTS: Eighty-seven patients completed 2 years of follow-up. The difference in anterior tibiofibular distance (aTFD) between the injured and noninjured ankle postoperatively had a significant effect on the Olerud-Molander Ankle score after 6 weeks [b = -2.6, 95% confidence interval (CI), -4.8 to -0.4; P = 0.02], 1 year (b = -2.7, 95% CI, -4.7 to -0.8; P < 0.001), and 2 years (b = -2.6, 95% CI, -4.6 to -0.6; P = 0.009) and on American Orthopaedic Foot and Ankle Society Ankle-Hindfoot score after 6 weeks (b = -2.2, 95% CI, -3.7 to -0.7; P = 0.004), 1 year (b = -1.7, 95% CI, -3.0 to -0.4; P = 0.04), and 2 years (b = -1.9, 95% CI, -3.2 to -0.5; P = 0.006). The effect of computed tomography measurements on range of motion was inconsistent. Receiver operating characteristic (ROC) curves demonstrated that aTFD had adequate discriminatory performance (area under the ROC curve ≥ 0.7) 1 and 2 years after surgery and the central measurement at only 2 years after surgery. ROC analyses indicate a cutoff value for syndesmosis malreduction of 2 mm. The postoperative rate of malreduction was 32%. CONCLUSIONS: The aTFD correlated with clinical outcome. A 2-mm difference in aTFD seems to predict poorer clinical outcome. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preoperative incipient osteoarthritis predicts failure after periacetabular osteotomy: 69 hips operated through the anterior intrapelvic approach.

BACKGROUND: Untreated developmental hip dysplasia may result in pain, loss of function and is a common cause of osteoarthritis (OA). The periacetabular osteotomy (PAO) was developed to relieve symptoms and postpone further degeneration of the hip. We aimed to assess preoperative clinical and radiographic prognostic factors and evaluate survivorship of PAO after medium-term follow-up of 7.4 (2-15) years. METHODS: 59 patients (69 hips) operated with a PAO through an anterior intrapelvic approach from 1999 to 2011 were retrospectively identified. The patients were evaluated radiographically and clinically with Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index and 15D quality of life questionnaires. Survival analyses identified native hip joint survival predictors. RESULTS: 9 hips (9 patients) were converted to a total hip arthroplasty (THA). Of the 50 remaining patients (60 hips), 44 patients (54 hips) were examined at medium-term follow-up. 3 patients were lost to follow-up or declined participation and 3 were interviewed by telephone. Patient age at time of surgery was 32 (14-44) years. Survival analyses showed 84.3% (95% confidence interval [CI], 68.7-92.5%) survival of the native hip at 8 years follow-up (number at risk 32) (worst case scenario 80% survival at 8 years, 95% CI, 63.9-89.2%, number at risk 32). Cox regression with presence of preoperative OA (Tönnis ⩾1), showed a crude hazard ratio for conversion to THA with preoperative OA of 13.73, p < 0.001. CONCLUSIONS: Periacetabular osteotomy through the anterior intrapelvic approach can be performed safely and with satisfactory results at medium-term follow-up. The presence of preoperative incipient OA (Tönnis ⩾1) is the most important predictor for poor hip joint survival.

Model-based RSA is suitable for clinical trials on the glenoid component of reverse total shoulder arthroplasty.

This study aims to validate model-based radiostereometric analysis (RSA) on the glenoid component of reversed total shoulder arthroplasty. We compared two different modalities of model-based RSA, elementary geometrical shapes and reversed engineering. We also explored two different ways to position the patient to obtain different projections of the implant, the hip-position (transversal) and shoulder-position (sagittal). Phantom accuracy was determined by performing nine translations (x, y, z) and five rotations (x, y, z), and expressed as the mean difference between RSA measurements and micrometer values. Precision was measured using 12 double examinations of the phantom and 19 in patients, and expressed as1.96 × standard deviations of the paired differences between double examinations. The accuracy was high for both modalities, but rotation around the symmetrical axis of the implant could not be measured using reversed engineering. Clinical precision ranged from 0.13 to 0.25 mm for translations, and 0.4° to 0.7° for rotations, using reversed engineering. For elementary geometrical shapes, the precision ranged from 0.18 to 0.34 mm for translations, and 0.8° to 1.8° for rotations. The hip-position was abandoned due to poor implant visualization. Model-based RSA on the glenoid component of reversed total shoulder arthroplasty has a high precision and accuracy, comparable to RSA results on hips and knees. Patient positioning is vital for obtaining adequate results. We found that reversed engineering was the more reliable method, and recommend reversed engineering as the method of choice for further clinical RSA investigation of the glenoid component of reversed total shoulder arthroplasty. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3299-3307, 2018.

Development and validation of the new international classification for scapula fractures.

OBJECTIVES: Multiple scapula classification systems exist in the literature and were developed using a consensus approach with one or several experts agreeing on a classification without stringent validation. None have gained widespread acceptance. A decision was made by the OTA classification committee and the AO Classification Advisory Group to collaborate on the development of a new validated classification system capable of addressing the limitations of the existing systems. METHODS: A feedback validation process through 4 iterations of revised classifications on radiographs and computed tomography (CT) scans was used. Statistical analyses calculated the proportion of agreement among surgeons and kappa statistics for the assessment of coding reliability. Estimates of classification accuracy were obtained using latent class modeling. RESULTS: Fractures of the scapular neck are rare injuries and were difficult to define and diagnose with kappa values ranging from 0.28 to 0.40. Although fossa fractures could be identified on plain radiographs, specific fracture patterns could only be classified with CT scans. The new classification divides the scapula into 3 segments: fossa, body, and processes. The validation has shown that the classification can be reliable using plain radiographs (kappa 0.66), increasing to kappa of 0.78 when CT scans were added. CONCLUSIONS: This basic coding system allows clinicians to describe and classify scapula fractures with a reasonable degree of reliability. This validated classification that has resulted from this process has been accepted by a disparate group of orthopaedic traumatologists as a better option for clinical communication and research documentation.

Radial Head Fractures: Indications and Technique for Primary Arthroplasty.

The treatment of complex radial head fractures remains a challenge for the orthopedic surgeon. Novel implants and improved surgical techniques have made reconstruction of the radial head with open reduction and internal fixation possible in most cases. However, extremely comminuted radial head fractures with associated instabilities still require replacement of the radial head with a prosthesis to allow rehabilitation with early motion of the elbow, and thereby optimizing the functional results of these potentially devastating injuries. In this article we discuss the surgical considerations related to radial head replacement, encompassing the indications for radial head arthroplasty, implant selection, surgical technique, rehabilitation protocols, and complications related to radial head prosthesis.

Experimental osteoporosis induced by ovariectomy and vitamin D deficiency does not markedly affect fracture healing in rats.

BACKGROUND: The question of whether fracture healing and mechanical properties of the callus are influenced by osteoporosis (OP) is still not settled. We therefore studied this issue in vitamin D-depleted ovariectomized (OVX) rats, an OP model previously shown to induce weakening of the femoral neck, and thus thought to be closer to the human condition than the classic OVX rat model. METHODS: 72 female Wistar rats were randomized into two groups: ovariectomy and vitamin D-deficient diet (Ovx-D group) or sham operation and normal rat chow (Sham group). After 12 weeks, a closed tibial midshaft fracture was performed on the right side and fixed with an intramedullary nail. Bone loss and callus formation were monitored with DXA; serum levels of estradiol and vitamin D3 were measured and histomorphometric analyses were performed. Mechanical properties of callus, tibia, femoral shaft, and femoral neck were examined in 3-point cantilever bending 6 weeks after fracture. RESULTS: The Ovx-D group showed reduced BMD in the spine and femoral neck, and reduced trabecular bone volume in the femoral head. There were no differences in BMD and mechanical properties of callus between the groups. Except for reduced stiffness of the right femoral neck in the Ovx-D group (p = 0.02), no differences in the mechanical strength of long bones were detected. INTERPRETATION: Our results suggest that the systemic effects of estrogen and vitamin D deficiency are not crucial for fracture healing or mechanical properties of the callus.