Plasma and tissue concentrations of 2 g prophylactic cefazolin prior to lower extremity surgery.

Surgical site infections (SSIs) are among the most clinically relevant complications and the use of prophylactic cefazolin is common practice. However, the knowledge about the pharmacological aspects of prophylactic cefazolin in the lower extremities remains limited. In this prospective cohort, a sub-study of the WIFI-2 randomized controlled trial, adults between 18 and 75 years of age who were scheduled for implant removal below the level of the knee and randomized for cefazolin, was included. A maximum of two venous plasma, target-site plasma, and target-site tissue samples were taken during surgery. The primary outcomes were the cefazolin concentrations in venous plasma, target-site plasma, and target-site tissue. A total of 27 patients [median (interquartile range) age, 42 (29-59) years; 17 (63%) male] with 138 samples were included in the study. A minimum of 6 weeks follow-up was available for all patients. The mean (SD) venous plasma, target-site plasma, and target-site tissue concentrations were 36 (13) µg/mL, 29 (13) µg/mL, and 28 (13) µg/g, respectively, and the cefazolin concentrations between the different locations of surgery did not differ significantly in both target-site plasma and target-site tissue (P = 0.822 and P = 0.840). In conclusion, 2 g of prophylactic cefazolin demonstrates adequacy in maintaining coverage for a duration of at least 80 minutes of surgery below the level of the knee, significantly surpassing the MIC90 required to combat the most prevalent microorganisms. This study represents the first of its kind to assess cefazolin concentrations in the lower extremities by examining both plasma and tissue samples in this magnitude.

The effectiveness of ambulatory continuous popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia in patients undergoing foot or ankle surgery (CAREFREE trial); a randomized, open label, non-inferiority trial.

STUDY OBJECTIVE: Management of pain after foot and ankle surgery remains a concern for patients and healthcare professionals. This study determined the effectiveness of ambulatory continuous popliteal sciatic nerve blockade, compared to standard of care, on overall benefit of analgesia score (OBAS) in patients undergoing foot or ankle surgery. We hypothesized that usage of ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care. DESIGN: Single center, randomized, non-inferiority trial. SETTING: Tertiary hospital in the Netherlands. PATIENTS: Patients were enrolled if ≥18 years and scheduled for elective inpatient foot or ankle surgery. INTERVENTION: Patients were randomized to ambulatory continuous popliteal sciatic nerve blockade or standard of care. MEASUREMENTS: The primary outcome was the difference in OBAS, which includes pain, side effects of analgesics, and patient satisfaction, measured daily from the first to the third day after surgery. A non-inferiority margin of 2 was set as the upper limit for the 90% confidence interval of the difference in OBAS score. Mixed-effects modeling was employed to analyze differences in OBAS scores over time. Secondary outcome was the difference in opioid consumption. MAIN RESULTS: Patients were randomized to standard of care (n = 22), or ambulatory continuous popliteal sciatic nerve blockade (n = 22). Analyzing the first three postoperative days, the OBAS was significantly lower over time in the ambulatory continuous popliteal sciatic nerve blockade group compared to standard of care, demonstrating non-inferiority (-1.9 points, 90% CI -3.1 to -0.7). During the first five postoperative days, patients with ambulatory continuous popliteal sciatic nerve blockade consumed significantly fewer opioids over time compared to standard of care (-8.7 oral morphine milligram equivalents; 95% CI -16.1 to -1.4). CONCLUSIONS: Ambulatory continuous popliteal sciatic nerve blockade is non-inferior to standard of care with single shot popliteal sciatic nerve blockade on patient-reported overall benefit of analgesia.

Measuring External Rotation of the Fibula and Fibular Length in Bilateral Computed Tomography Scans: How Reliable Is This Method?

OBJECTIVES: During ankle fracture surgery, goals include accurate reduction and fixation of the fibula regarding rotation and fibular length. Bilateral postoperative computed tomography (CT) can be performed to assess fibular rotation using the talar dome angle, and fibular length. The aim of this study was to compare side-to-side differences of the fibular rotation and fibular length using bilateral CT scans of uninjured ankles. DESIGN: Retrospective. SETTING: Single center, Level I Academic Trauma Center. PATIENT SELECTION CRITERIA: Patients with bilateral CT scans of uninjured ankles. OUTCOME MEASURES AND COMPARISONS: External rotation using the Nault talar dome method and fibular length using the coronal method of Prior et al. The average, difference, and ratio (injured side/healthy side) and interobserver variability were calculated. RESULTS: There were 83 patients included (166 ankles, mean age 47 years, 77.1% male). A random set of 66 ankles (33 CT scans) were used to measure interobserver variability. The mean degrees of external rotation ranged from 6.6 to 7.7, mean difference ranged from 1.4 to 3.4 degrees, mean ratio ranged from 1.1 to 1.5, and interobserver variability ranged from 0.27 to 0.65. For fibular length, the mean ranged from 24.6 to 25.8 mm, mean difference in fibular length ranged from 0.5 to 2.1 mm, mean ratio ranged from 1.0 to 1.1 mm, and interobserver variability ranged from 0.45 to 0.73. CONCLUSIONS: Using bilateral ankle CT scans, mean differences in fibular rotation using the Nault talar dome method were 1.4-3.4 degrees. The distal fibular length had a mean difference between both sides of 0.5-2.1 mm. Although the intraclass correlation's were low, the interleg differences between patients were small, making them useful for clinical practice. LEVEL OF EVIDENCE: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Adjunctive hyperbaric oxygen therapy in the management of severe lower limb soft tissue injuries: a systematic review.

PURPOSE: Traumatic crush injuries of the lower limb often accompany severe complications. The incorporation of hyperbaric oxygen therapy to standard trauma care may have the potential to diminish injury-related complications and improve outcome in such cases. This systematic review aims to evaluate the effectiveness of hyperbaric oxygen therapy in the management of severe lower limb soft tissue injuries. METHODS: The electronic databases Medline, Embase and Cochrane Library were searched to identify studies involving patients with crush-associated sever lower limb soft tissue injuries who received hyperbaric oxygen therapy in conjunction with standard trauma care. Relevant data on type of injury, hyperbaric oxygen therapy protocol and outcome related to wound healing were extracted. RESULTS: In total seven studies met the inclusion criteria, involving 229 patients. The studies included two randomized clinical trials, one retrospective cohort study, three case series and one case report. The randomized placebo-controlled clinical trial showed a significant increase in wound healing and decrease in the need for additional surgical interventions in the patient group receiving hyperbaric oxygen therapy when compared to those undergoing sham therapy. The randomized non-placebo-controlled clinical trial revealed that early hyperbaric oxygen therapy reduces tissue necrosis and the likelihood of long-term complications. The retrospective cohort study indicated that hyperbaric oxygen therapy effectively reduces infection rates and the need for additional surgical interventions. The case series and case report presented beneficial results with regard to wound healing when hyperbaric oxygen therapy was added to the treatment regimen. CONCLUSION: Hyperbaric oxygen therapy is generally considered a safe therapeutic intervention and seems to have a beneficial effect on wound healing in severe lower limb soft tissue injuries when implemented as an addition to standard trauma care.

Geographical Differences in Wound Complication Rates Following the Sinus Tarsi Approach in Displaced Intra-articular Calcaneal Fractures: A Systematic Review of the Literature.

Background: The sinus tarsi approach (STA) has gained popularity for the treatment of displaced intra-articular calcaneal fractures. No large studies comparing wound complications worldwide after STA surgery are available. The aim of this systematic review was to compare postoperative wound complication (POWC) and postoperative wound infection (POWI) rates following STA surgery between continents and countries and their differences in climate. Methods: A literature search was performed using the databases of PubMed, Embase, and the Cochrane Library. Studies published before January 1, 2000, including < 10 patients and written in a language other than English were excluded. Results: In total, 86 studies containing 4,392 surgeries via STA from 20 different countries were included. The mean POWC was 5.9% and the mean POWI was 4.4%. The highest median POWC rate was in North America (8.5%) and the lowest in South America (2.0%). No significant differences were found in the POWC and POWI rates between countries (p = 0.178 and p = 0.570, respectively), but significant differences were found between the POWC and POWI rates between continents (p = 0.011 and p = 0.036, respectively). The number of surgeries per year and climate differences, as represented by mean local temperature, were not correlated with both the POWC/POWI rates and functional outcome scores. Conclusions: Significant differences between the POWC and POWI rates were found between continents but not between individual countries. With a mean POWC of 5.9% and a mean POWI rate of 4.4%, STA has an intrinsic low risk for complications given the minimally invasive nature of the approach and is inevitably becoming the gold standard for calcaneal surgery.

Parameters influencing health-related quality of life after severe trauma: a systematic review (part II).

INTRODUCTION: It is increasingly recognized that health-related quality of life (HRQoL) is a relevant outcome to study in populations comprising severely injured patients. Although some studies have readily demonstrated a compromised HRQoL in those patients, evidence regarding factors that predict HRQoL is scarce. This hinders attempts to prepare patient-specific plans that may aid in revalidation and improved life satisfaction. In this review, we present identified predictors of HRQoL in patients that have suffered severe trauma. METHODS: The search strategy included a database search until the 1st of January 2022 in the Cochrane Library, EMBASE, PubMed, and Web of Science, and reference checking. Studies were eligible for inclusion when (HR)QoL was studied in patients with major, multiple, or severe injury and/or polytrauma, as defined by authors by means of an Injury Severity Score (ISS) cut-off value. The results will be discussed in a narrative manner. RESULTS: A total of 1583 articles were reviewed. Of those, 90 were included and used for analysis. In total, 23 possible predictors were identified. The following parameters predicted reduced HRQoL in severely injured patients and came forward in at least more than three studies: higher age, female gender, lower extremity injuries, higher rate of injury severity, lower achieved educational level, presence of (pre-existing) comorbidities and mental illness, longer duration of hospital stay, and high level of disability. CONCLUSION: Age, gender, injured body region, and severity of injury were found to be good predictors of health-related quality of life in severely injured patients. A patient-centered approach, based on individual, demographic, and disease-specific predictors, is highly recommended.

Functional outcome of routine versus on-demand removal of the syndesmotic screw.

Aims: The primary aim of this study was to present the mid-term follow-up of a multicentre randomized controlled trial (RCT) which compared the functional outcome following routine removal (RR) to the outcome following on-demand removal (ODR) of the syndesmotic screw (SS). Methods: All patients included in the 'ROutine vs on DEmand removal Of the syndesmotic screw' (RODEO) trial received the Olerud-Molander Ankle Score (OMAS), American Orthopaedic Foot and Ankle Hindfoot Score (AOFAS), Foot and Ankle Outcome Score (FAOS), and EuroQol five-dimension questionnaire (EQ-5D). Out of the 152 patients, 109 (71.7%) completed the mid-term follow-up questionnaire and were included in this study (53 treated with RR and 56 with ODR). Median follow-up was 50 months (interquartile range 43.0 to 56.0) since the initial surgical treatment of the acute syndesmotic injury. The primary outcome of this study consisted of the OMAS scores of the two groups. Results: The median OMAS score was 85.0 for patients treated with RR, and 90.0 for patients treated with ODR (p = 0.384), indicating no significant difference between ODR and RR. The secondary outcome measures included the AOFAS (88.0 in the RR group and 90.0 for ODR; p = 0.722), FAOS (87.5 in the RR group and 92.9 for ODR; p = 0.399), and EQ-5D (0.87 in the RR group and 0.96 for ODR; p = 0.092). Conclusion: This study demonstrated no functional difference comparing ODR to RR in syndesmotic injuries at a four year follow-up period, which supports the results of the primary RODEO trial. ODR should be the standard practice after syndesmotic screw fixation.

Prehospital analgesia in suspected hip fracture patients: adherence to national prehospital pain management guidelines.

PURPOSE: Patients with hip fractures frequently present at the emergency department (ED). Despite high pain scores, prehospital pain management is often inadequate and insufficient. In the Netherlands, the emergency medical services (EMS) exhibit a high level of training, supported by a comprehensive pain treatment protocol. This study aimed to assess adherence to the protocol and hypothesized that prehospital pain management in hip fracture patients was both sufficient and adequate. METHODS: This was a retrospective observational cohort study of patients with suspected hip fractures. The median differences in numerical rating scale (NRS) pain scores between the initial score in the ambulance and upon arrival at the ED were compared. Furthermore, adherence to the ambulance pain protocol was studied. RESULTS: From September 2016 to March 2021, 436 ambulance-transported hip fracture patients were included, of whom 81% received analgesics by EMS. The median initial pain score measured by EMS was 8; this number decreased to 5 at ED presentation, a significant decrease (ρ < 0.001). In case a prehospital NRS pain score was assessed, 66.5% of the patients were treated according to the protocol. In 80% of patients, the protocol was not followed correctly, primarily due to missing NRS pain scores. CONCLUSION: In suspected hip fracture patients, initial prehospital pain scores were high and most patients received analgesics from EMS. This resulted in a significant decrease in pain. In nearly 67% of patients in whom an NRS pain score was assessed in the prehospital phase, pain management was according to protocol. However, in 80% of the total population the pain protocol was not adhered to, mainly due to missing NRS pain scores.

Rehabilitation after Distal Radius Fractures: Opportunities for Improvement.

Background Exercises are frequently prescribed to regain function; yet there is no consensus on a standardized protocol, and adherence is low. Smart technology innovations, such as mobile applications, may be useful to provide home-based patient support in rehabilitation after distal radius fractures. Purposes Our purpose was to establish the potential of digital innovations for support and monitoring of patients and treatment adherence in rehabilitation programs, and additionally, to compare the current practice among physiotherapists to the various wrist exercise regimens and their effectiveness as described in the literature. Methods Standard practice, including the use of support tools for treatment adherence, was evaluated using a nationwide survey. Then, scientific databases were searched using "distal radius fracture" and "physiotherapy" or "exercise therapy," and related search terms, up until 23 March 2023. Results of the survey and literature review were compared. Results The survey was completed by 92 therapists. Nonstandardized support tools were used by 81.6% of respondents; 53.2% used some form of technology, including taking photos on the patients' smartphone for home reference. In the literature review, 23 studies were included, of which five described an exercise protocol. Treatment adherence was not reported in any of the included studies. Two studies described the use of smart technology or support tools. Conclusions There is no consensus on a standardized exercise protocol for rehabilitation after distal radius fractures, neither from a systematic literature search nor from a nationwide survey. Smart technology may facilitate monitoring of patients and exercise adherence, hereby supporting self-efficacy and improving adherence and outcomes.

The Effectiveness of Three-Dimensional Osteosynthesis Plates versus Conventional Plates for the Treatment of Skeletal Fractures: A Systematic Review and Meta-Analysis.

PURPOSE: To assess the difference between preformed anatomically shaped osteosynthesis plates and patient-specific implants versus conventional flat plates for the treatment of skeletal fractures in terms of anatomical reduction, operation time, approach, patient outcomes, and complications. MATERIAL AND METHODS: MEDLINE (1950 to February 2023), EMBASE (1966 to February 2023), and the Cochrane Central Register of Controlled Trials (inception to February 2023) databases were searched. Eligible studies were randomised clinical trials, prospective controlled clinical trials, and prospective and retrospective cohort studies (n ≥ 10). Inclusion criteria were studies reporting the outcomes of preformed anatomically shaped osteosynthesis plates and patient-specific implants versus conventional flat plates after treating skeletal fractures. Outcome measures included anatomical reduction, stability, operation time, hospitalisation days, patients' outcomes, and complications. Two independent reviewers assessed the abstracts and analysed the complete texts and methodologies of the included studies. RESULTS: In total, 21 out of the 5181 primarily selected articles matched the inclusion criteria. A meta-analysis revealed a significant difference in operation time in favour of the preformed anatomical plates and patient-specific implants versus conventional plates. Significant differences in operation time were found for the orbital (95% CI: -50.70-7.49, p = 0.008), upper limb (95% CI: -17.91-6.13, p < 0.0001), and lower limb extremity groups (95% CI: -20.40-15.11, p < 0.00001). The mean difference in the rate of anatomical reduction in the lower limb extremity group (95% CI: 1.04-7.62, p = 0.04) was also in favour of using preformed anatomical plates and patient-specific implants versus conventional plates. CONCLUSIONS: This systematic review showed a significant mean difference in surgery time favouring the use of preformed anatomical plates and patient-specific implants for orbital, upper, and lower limb extremity fractures. Additionally, preformed anatomical plates and patient-specific implants in the lower limb group result in a significantly higher rate of anatomical reduction versus conventional flat plates.

Accuracy of ultrasound in diagnosing ankle injuries in emergency care.

BACKGROUND: Ankle injuries are one of the most common presentations in the ED. Although fractures can be ruled out using the Ottawa Ankle Rules, the specificity is low, which means many patients may still receive unnecessary radiographs. Even once fractures are ruled out, assessment of ankle stability is recommended to rule out ruptures, but the anterior drawer test has only moderate sensitivity and low specificity and should be performed only after swelling has receded. Ultrasound could be a reliable, cheap and radiation free alternative to diagnose fractures and ligamentous injuries. The purpose of this systematic review was to investigate the accuracy of ultrasound in diagnosing ankle injuries. METHODS: Medline, Embase and the Cochrane Library were searched up to 15 February 2022 to include studies of patients of 16 years or older presenting to the ED with acute ankle or foot injury, who underwent ultrasound and had diagnostic accuracy as outcome. No restrictions were applied for date and language. Risk of bias and quality of evidence using the Grading of Recommendations, Assessment, Development and Evaluations approach were assessed. RESULTS: Thirteen studies evaluating 1455 patients with bony injuries were included. In 10 studies, the reported sensitivity for fracture was >90%, but varied among studies between 76% (95% CI 63% to 86%) and 100% (95% CI 29% to 100%). In nine studies, the reported specificity was at least 91%, but varied between 85% (95% CI 74% to 92%) and 100% (95% CI 88% to 100%).Six studies including 337 patients examined the use of ultrasound for ligamentous injuries and found a sensitivity and specificity >94% and 100%. Overall quality of evidence for both bony and ligamentous injuries was low and very low. CONCLUSION: Ultrasound has the potential to be a reliable method for diagnosing foot and ankle injuries, however, higher grade evidence is needed. PROSPERO REGISTRATION NUMBER: CRD42020215258.

High-Ankle Sprain and Syndesmotic Instability: How Far Have We Come with Diagnosis and Treatment?

Probably one of the most controversial subjects in the orthopedic field is the distal tibiofibular articulation. Even though its most primary knowledge can be a matter of enormous debate, it is in the diagnosis and treatment most of the disagreements reign. Distinguishing between injury and instability remains challenging as well as an optimal clinical decision regarding surgical intervention. The last years presented technology and that was able to bring body to an already well-developed scientifical rationale. In this review article, we aim to demonstrate the current data behind syndesmotic instability in the ligament scenario, whereas using few fracture concepts.

Implant Choice and Outcomes of the Sinus Tarsi Approach for Displaced Intra-articular Calcaneal Fractures.

BACKGROUND: Operative fixation of displaced intra-articular calcaneal fractures is considered the gold standard, for which multiple fixation methods are available. This study compares the (functional) outcome of screw fixation (SF), plate fixation (PF), and anatomical plate fixation (APF) via the sinus tarsi approach (STA). METHODS: A total of 239 patients (265 fractured calcanei) who received surgical treatment of a displaced intra-articular calcaneal fracture via STA between 2011 and 2022 were included. RESULTS: Böhler angle (BA) measured immediately postoperatively (BA post-OR) and the decrease in BA at 1 year (∆BA) differed significantly in favor of PF/APF compared with SF (BA post-OR: SF vs PF P = .010 and SF vs APF P = .001; ∆BA: SF vs PF P = .032 and SF vs APF P = .042). Implant removal surgery was performed significantly less in the APF group as compared to the SF/PF groups (APF vs SF/PF; 9.9% vs 22.9%/23.7%, P = .015). Surgical site infections and secondary arthrodesis of the subtalar joint occurred equally in the 3 groups. Furthermore, the mean American Orthopaedic Foot & Ankle Society ankle-hindfoot scale, Foot Function Index score, and EuroQOL-5D-index / visual analog scale score, did not differ notably between SF, PF, and APF. CONCLUSION: The results show that both PF and APF are favored over SF because of an improved correction of BA measured directly postoperatively, a lower secondary loss of BA and, for APF, a lower implant removal rate. There was no difference in the rate of surgical site infections, need for secondary arthrodesis, nor functional outcome scores between different implants using the STA. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

The minimal clinically important difference (MCID) of the Olerud Molander Ankle Score (OMAS) in patients with unstable ankle fracture.

INTRODUCTION: The Olerud Molander Ankle Score (OMAS) is a widely used validated Patient Reported Outcome Measure (PROM). For clinical research, it is important to determine the Minimal Clinically Important Difference (MCID). The objective of this study was to determine the MCID of the OMAS at several moments in the follow-up, in a cohort of patients that underwent open reduction and internal fixation of unstable ankle fractures with syndesmotic injury. MATERIALS AND METHODS: Data for this descriptive study were extracted from a prospective randomized controlled trial, the RODEO trial. The Dutch version of the OMAS was completed at 3, 6 and 12-month follow-up and estimated at baseline. The used anchor-based methods were: mean change and ROC curve. The distribution-based methods were: 0.5SD and minimal detectable change (MDC). RESULTS: This cohort included 148 patients. The mean OMAS score in the group with minimal improvement between 3 and 6 months was 15.0 (SD 17.5, 95%CI 9.4-20.6) and between 6 and 12 months 9.5 (SD 17.1, 95% CI 3.1-15.9). The ROC curve between 3 and 6 months resulted in a MCID of 12.5 (AUC 0.72) and between 6 and 12 months, the MCID was 7.5 (AUC 0.78). Using 0.5 SD, the MCID was 10.52 (SD 21.04) at 3 months, 11.37 (SD 22.73) at 6 months and 10.47 (SD 20.94) at 12 months. The MDC was 4.72 at 3 months, 5.20 at 6 months and 4.71 at 12 months. CONCLUSIONS: The calculated MCID in patients following surgery for unstable ankle fractures ranges from 10.5 to 15.0 at 3-6-month follow-up and from 7.5 to 11.4 at 6-12-month follow-up, depending on moment and method.

Health-related quality of life after severe trauma and available PROMS: an updated review (part I).

INTRODUCTION: Throughout the years, a decreasing trend in mortality rate has been demonstrated in patients suffering severe trauma. This increases the relevance of documentation of other outcomes for this population, including patient-reported outcome measures (PROMs), such as health-related quality of life (HRQoL). The aim of this review was to summarize the results of the studies that have been conducted regarding HRQoL in severely injured patients (as defined by the articles' authors). Also, we present the instruments that are used most frequently to assess HRQoL in patients suffering severe trauma. METHODS: A literature search was conducted in the Cochrane Library, EMBASE, PubMed, and Web of Science for articles published from inception until the 1st of January 2022. Reference lists of included articles were reviewed as well. Studies were considered eligible when a population of patients with major, multiple or severe injury and/or polytrauma was included, well-defined by means of an ISS-threshold, and the outcome of interest was described in terms of (HR)QoL. A narrative design was chosen for this review. RESULTS: The search strategy identified 1583 articles, which were reduced to 113 after application of the eligibility criteria. In total, nineteen instruments were used to assess HRQoL. The SF-36 was used most frequently, followed by the EQ-5D and SF-12. HRQoL in patients with severe trauma was often compared to normative population norms or pre-injury status, and was found to be reduced in both cases, regardless of the tool used to assess this outcome. Some studies demonstrated higher scoring of the patients over time, suggesting improved HRQoL after considerable time after severe trauma. CONCLUSION: HRQoL in severely injured patients is overall reduced, regardless of the instrument used to assess it. The instruments that were used most frequently to assess HRQoL were the SF-36 and EQ-5D. Future research is needed to shed light on the consequences of the reduced HRQoL in this population. We recommend routine assessment and documentation of HRQoL in severely injured patients.

Complications and Functional Outcome Following Operative Treatment of Talus Neck and Body Fractures: A Systematic Review.

Background: Central talar fractures are rare and often associated with impaired functional outcome. Despite recent advances in diagnosis and management of talus fractures, complications rates remain high and functional outcome is generally poor. This study aims to provide an overview of complication rates and functional outcome following operative treatment of talar neck and body fractures. This may help in clinical decision making by improving patients' expectation management and tailored treatment strategies. Methods: A systematic review of the literature was conducted of studies published from January 2000 to July 2021 reporting functional outcome and/or complications following operative treatment of talar neck, body, or combined neck and body fractures. Keywords used were (Talar fracture) or (Talus fracture). Data on complication rates and functional outcome was extracted from selected articles. Results: A total of 28 articles were included in our analysis reporting 1086 operative treated talar fractures (755 neck [70%], 227 body fractures [21%], and 104 combined body and neck fractures [9%]). The mean follow-up was 48 (range 4-192) months. Complications occurred frequently with; 6% surgical site infection, 8% nonunion, 29% avascular necrosis, 64% osteoarthritis, and in 16% a secondary arthrodesis was necessary. A wide variety in functional outcome was reported; however, there seems to be a correlation between fracture classification and postoperative complications. Conclusion: Operative treatment of central talar fractures is associated with a high incidence of early and late complications and often leads to an impaired functional outcome. Standardization of talar fracture classification and scoring systems in combination with large sample-sized prospective studies are warranted to detect further predictive factors influencing tailormade treatment strategies and patient expectation management. Level of Evidence: Level III, Systematic review of case series and case-control studies.

Utility of Post-Splinting Conventional Radiographs in Adult Patients With Ankle Fractures Presenting to the Emergency Department.

BACKGROUND: Post-splinting radiographs are often performed in patients with ankle fractures to identify displacement that potentially occurs during splinting. The objective of this study was to investigate the significance of post-splinting conventional radiographs, with an emphasis on stable ankle fractures, not requiring reduction. METHODS: A retrospective study in which all adult patients presenting with ankle fractures to the emergency department of a level 1 trauma center were included. The primary outcome was frequency of displacement at post-splinting radiographs. Secondary outcome was the rate of successful reduction attempts. RESULTS: A total of 225 patients were included and the majority had a Supination-External Rotation (SER) type 2 or Weber B ankle fracture. One hundred fifty patients (mainly SER 2 fractures [68%] or Weber B [89%] fractures), were treated with a splint without fracture reduction. Post-splinting radiographs in these patients, as well as in all patients with a Supination-Adduction (SA) type 1 and 2 fractures, did not show loss of alignment. CONCLUSION: Post-splinting radiographs are probably not necessary in any SA and SER type 2 or Weber A/B ankle fractures without medical clear space widening or need for reduction as no loss of alignment occurred when applying a splint. LEVEL OF EVIDENCE: IV-Case Series.