Bosworth-type fibular entrapment fracture of the ankle without dislocation: a rare case report and a review of the literature.

Bosworth fracture-dislocation of ankle is a rare and irreducible type of ankle injury, with a high incidence of complication. This type of fracture was defined originally as entrapment of the proximal fragment of the fibula behind the posterior tubercle of the distal tibia. Recently, many variants of this type of fracture dislocation have been reported, but all of those reports included the syndesmosis ligament injury of ankle. Here, we report a case of a particularly rare variant of Bosworth fracture-dislocation without syndesmosis ligament injury of ankle. A 48-year-old male presented with a Bosworth fracture dislocation with entrapment of proximal fragment behind the tibia. After temporary treatment in emergency department was applied, emergency open reduction and internal fixation with a plate and screws was performed due to irreducibility of the fracture fragment. The fractured lateral malleolus was entrapped behind the tibia and rupture of the interosseous ligament was found intraoperatively. The anterior inferior tibiofibular ligament, a part of syndesmosis ligament of ankle, was grossly intact and no abnormal findings was seen by fluoroscopy with external rotational stress. Moreover, the deltoid ligament was found to be normal in ultrasonography. There were no complications after surgery and the patient showed full functional recovery at 2 years follow up. These fractures will frequently be irreducible and should be considered for open reduction and internal fixation with the careful evaluation of injury mechanisms with syndesmotic stability.

Clinical outcomes of rectangular tunnel technique in posterior cruciate ligament reconstruction were comparable to the results of conventional round tunnel technique.

PURPOSE: To compare clinical outcomes between the conventional round and rectangular tunnel techniques in single-bundle posterior cruciate ligament (PCL) reconstruction. METHODS: Twenty-seven and 108 patients who underwent PCL reconstructions using a rectangular dilator (Group 1) and rounded tunnel reamer (Group 2), respectively, were included. The exclusion criteria were having a concomitant fracture, osteotomy, subtotal or total meniscectomy, and no remnant PCL tissue. A 4:1 propensity score matching was performed. The knee laxity on stress radiography, International Knee Documentation Committee Subjective Knee Evaluation score, Tegner activity score and Orthopädische Arbeitsgruppe Knie score were evaluated. RESULTS: No significant differences were found between the groups in terms of clinical scores. (n.s.) The mean posterior translations were also not significantly different between the Group 1 and 2 (3.6 ± 2.8 and 3.8. ± 3.1 mm, respectively; n.s.). However, 3 patients (11.1%) in Group 1 and 15 patients (13.8%) in Group 2 showed posterior translation of > 5 mm. The combined posterolateral corner sling technique was performed for 27 patients (100%) in Group 1 and for 96 patients (88.9%) in Group 2. We found no significant difference in rotational stability at the final follow-up. One patient was found to have a femoral condyle fracture during rectangular femoral tunnel establishment, which was healed after screw fixation, without laxity, during follow-up. The intra- and inter-observer reliabilities of the radiological measurements ranged from 0.81 to 0.89. CONCLUSION: Arthroscopic anatomical remnant-preserving PCL reconstruction using a rectangular dilator showed satisfactory clinical results and stability as compared with PCL reconstruction using a conventional rounded reamer. Rectangular tunnel technique in PCL reconstruction could be a good treatment option with theoretical advantage to be anatomic. LEVEL OF EVIDENCE: Level IV.

Alarm Services as a Useful Tool for Diagnosis and Management of Osteoporosis in Patients with Hip Fractures: A Prospective Observational Multicenter Study.

BACKGROUND: Alarm services in the Order Communication System improve awareness for related physicians including orthopaedic surgeons, internal medicine doctors, and other relevent doctors. This prospective observational multicenter study was to compare the diagnostic and treatment rates of osteoporosis between an alarm service group and a no alarm service group. METHODS: From January 2017 to december 2017, The subjects included patients aged 50 years or older with hip fractures from 16 hospital-based multicenter cohorts. Among the 16 hospitals, 5 university hospitals established an alarm service for osteoporosis management (i.e., Alarm group) and 11 university hospitals did not set-up alarm services (i.e., Control group). The rate of dual energy X-ray absorptiometry (DXA) test and the initiation rate of antiosteoporosis medications between the 2 groups were compared at enrollment and at 6 months follow-up. RESULTS: During the study period, 1,405 patients were enrolled. The DXA examination rate and initiation rate of osteoporosis treatment between the Alarm group and the Control group were 484 patients (89.8%) vs. 642 patients (74.1%) (P<0.001) and 355 patients (65.9%) versus 294 patients (33.9%) (P<0.001), respectively. At 6 months follow-up, the rate of anti-osteoporosis management between the 2 groups decreased (57.8% vs. 29.4%). CONCLUSIONS: This prospective multicenter study demonstrates that alarm services can improve awareness of physicians, and it resulted in a significantly higher rate of examination of DXA and initiation of anti-osteoporosis medication in the Alram group. Therefore, alarm service is a simple and effective tool to increase anti-osteoporosis management as part of the fractuure liaison service in South Korea.

Clinical Relevance of Classifying Massive Rotator Cuff Tears: Results Based on Functional and Radiological Findings After Arthroscopic Repair.

BACKGROUND: Studies on the results of arthroscopic repair of massive rotator cuff tears have reported widely varied prognoses. Among other factors, the sizable discrepancy can be attributable to the fact that the current definition of massive rotator cuff tears covers an extensive area of tendons. HYPOTHESIS: Functional and radiological results according to subgroups would show significant inter-subgroup differences preoperatively and postoperatively. STUDY DESIGN: Cohort study; Level of evidence, 2. METHODS: A total of 104 patients who required arthroscopic repair for massive rotator cuff tears were prospectively evaluated. The patients were allocated into 3 groups according to tendon involvement as diagnosed by preoperative magnetic resonance imaging: group 1 (anterosuperior type involving the subscapularis and supraspinatus), group 2 (posterosuperior type involving the infraspinatus and supraspinatus), and group 3 (anteroposterior type involving the subscapularis, supraspinatus, and infraspinatus). We compared functional results (at 2 years postoperatively) and radiological findings (at 1 year postoperatively) for each group. RESULTS: There were 34 patients in group 1, 54 in group 2, and 16 in group 3. In all 3 groups, functional results significantly improved after surgery. There were no statistically significant intergroup differences in functional results among the 3 groups. On the radiological evaluations, each group (groups 1, 2, and 3) showed a significantly different result in the preoperative acromiohumeral distance (AHD) (7.19, 5.44, and 5.22 mm, respectively), tear size (38.8, 39.3, and 46.4 mm, respectively), extent of retraction (33.9, 40.0, and 41.4 mm, respectively), postoperative AHD (8.92, 7.37, and 6.71 mm, respectively), and retear rate (23.5%, 51.9%, and 56.2%, respectively) ( P < .001 for all). CONCLUSION: Massive rotator cuff tears can be divided into 3 types: anterosuperior (group 1), posterosuperior (group 2), and anteroposterior (group 3). Each group has distinctive characteristics and shows different results in the preoperative AHD, tear size, extent of retraction, postoperative AHD, and retear rate, which provide a reasonable basis for categorization. So far, massive rotator cuff tears have only been broadly defined, consequently being understood as a single category by many. However, to clearly understand and evaluate this injury, we suggest identifying differences within the category through proper subclassification.

Is Anterior Bridge Plating for Mid-Shaft Humeral Fractures a Suitable Option for Patients Predominantly Involved in Overhead Activities? A Functional Outcome Study in Athletes and Manual Laborers.

BACKGROUND: To assess the functional and radiological outcomes of minimally invasive anterior bridge plating (ABP) for mid-shaft humerus fractures in patients predominantly involved in overhead activities (athletes and manual laborers). METHODS: Forty-eight patients fulfilling inclusion criteria were treated with ABP at a level-I trauma center using a 4.5-mm dynamic/locking compression plate and followed for a period of 1 year. Functional outcome was assessed using the Constant, Mayo elbow, and Disabilities of the Arm, Shoulder and Hand (DASH) scores. Range of motion (ROM), subjective strength, and radiographic union were assessed. A general satisfaction questionnaire was also administered. RESULTS: Most patients achieved excellent functional and radiological outcomes. ROM and strength of the shoulder girdle exhibited clinically nonsignificant loss as compared to the opposite side. The mean time for return to the original activities was 64 days (range, 36 to 182 days) and the mean time for confirmed radiographic union was 45 days (range, 34 to 180 days). The mean Constant, Mayo elbow, DASH scores were 95.73 ± 5.76 (range, 79 to 100), 95.94 ± 6.74 (range, 85 to 100), and 1.56 ± 3.15 (range, 0.0 to 14.0), respectively. The majority of patients (43 patients, 89.6%) who fell in the excellent or very good category according to our questionnaire were extremely satisfied. There were 2 cases (4.17%) of nonunion and 3 patients (6.25%) had to change/modify their original occupation. CONCLUSIONS: ABP is fundamentally different from traditional open posterior plating or conventional intramedullary nailing. It gives relative stability with union taking place by callus formation, and a longer plate on the tensile surface ensures that the humerus can withstand greater amount of rotational and bending stresses. The minimally invasive nature causes minimal soft tissue damage and, if done correctly, causes no damage to the vital structures in proximity. ABP for mid-shaft humerus fractures in patients predominantly engaged in overhead activities is a safe and effective treatment modality yielding high rates of union, excellent functional recovery, minimal biological disruption, better cosmesis, and superior satisfaction rates.