Treatment of two or more metatarsal fractures.

INTRODUCTION: Metatarsal fractures are the most common type of foot fracture. When surgical treatment is needed, pinning is typically used, either percutaneous or open. However, this fixation method has been criticized by some authors who lament residual malunion and prefer to use plate and/or screws. The primary objective of our study was to compare the outcomes of K-wire versus plate and/or screw fixation for the surgical treatment of two or more metatarsal fractures. The secondary objective was to evaluate the factors that contribute to poor outcomes and complications. We hypothesized that plate and/or screw fixation will produce better functional outcomes than K-wire fixation. MATERIALS AND METHODS: This was a prospective and retrospective multicenter study carried out between 1 January 2010 and 1 June 2018 with a minimum follow-up of 12 months. Three functional scores were determined (AOFAS, FAAM and SF12 physical and mental) preoperatively, postoperatively and at the final assessment. We evaluated the outcomes in the entire study population and in four injury type subgroups, including one with isolated metatarsal fractures to control analysis bias. RESULTS: Our analysis compiled data from 165 patients (123 men, 42 women) who had a mean age of 38 years (16-82). The mean follow-up time was 27.9months (10-120). There were no complications in 130 patients (79%). Skin necrosis occurred in 25 patients (15%). The FAAM score was significantly higher in the plate and/or screw group 70.2 (17-84) versus 60.3 (31-84) in the K-wire group (P=0.033). The 78 (19-100) AOFAS was higher, but not significantly, in the plate and/or screw group versus 70 (12-100) in the K-wire group (P=0.144). CONCLUSION: Trauma to the foot that causes a fracture in two or more metatarsals often occurs due to a crush injury (39%). The frequency of associated bone lesions means that a preoperative CT scan should be done routinely to analyze the injury pattern and determine the best treatment. The fixation method should be adapted to the local conditions; when possible, it is preferable to use rigid fixation with plates and/or screws as it yields better functional outcomes. LEVEL OF EVIDENCE: IV; study with retrospective component.

Talar fracture: Epidemiology, treatment and results in a multicenter series.

INTRODUCTION: Talar fracture is rare. Treatment is surgical for neck and/or body fractures with displacement. The aims of the present study were to collect epidemiological data on talar fractures, and to assess the impact of trauma via various functional scores and radiographic impact in the medium term. HYPOTHESIS: Displaced talar fracture shows negative medium-term functional and radiological/clinical impact. MATERIAL AND METHODS: A multicenter retrospective study was performed with a minimum follow-up of 12 months post-trauma. Inclusion criteria included radiographic assessment at a minimum 12 months post-trauma and data on 3 functional scores: SF12, AOFAS and FAAM. 225 patients were initially included, 81 of whom had follow-up with functional and radiological/clinical assessment. RESULTS: Fracture reduction was anatomic in 61% of cases when CT was performed; reduction quality was independent of approach (p>0.05). 45% of patients showed subtalar osteoarthritis at a mean 2 years, significantly related to reduction defect (p<0.05). Mean AOFAS score was acceptable, at 74/100. Factors for functional prognosis comprised: reduction quality, hindfoot alignment, subtalar osteoarthritis, and talar osteonecrosis with dome collapse. DISCUSSION: Talar fracture led to late complications with socioeconomic impact. Subtalar osteoarthritis affects almost half of patients within some months of trauma. Optimal reduction is the key to fair progression. Postoperative CT assessment now seems mandatory. LEVEL OF EVIDENCE: IV; multicenter retrospective study.

Does comparison of performance lead to better care? A pilot observational study in patients admitted for hip fracture in three French public hospitals.

OBJECTIVE: To assess whether comparison of quality of hip fracture care among three teams located in different hospitals is associated with improvement in process and outcomes. DESIGN: A baseline assessment was performed using quality indicators selected by professionals. RESULTS: were discussed among the three teams followed by a post-comparison assessment of the same indicators. SETTING: Three hospitals in North Western France. PARTICIPANTS: Professionals caring for patients operated on for a low-impact hip fracture. INTERVENTION: Review and discussion of comparative performance results by three teams followed by implementation of quality improvement as deemed necessary by each team. MAIN OUTCOME MEASURES: Fifteen quality indicators of health care during orthopedic and rehabilitation stay, mobility, dependence and place of residence before hip fracture and 3 months after discharge, 3 month post-surgery mortality and readmission rates. RESULTS: Major differences were observed among hospitals throughout the care process during baseline period. Comparison of performance and discussion among the three teams were followed by corrective action in 11 areas. After comparison, a significant improvement was observed in 10 areas, seven of which corresponded to quality improvement areas chosen for improvement action by professionals. A significant decrease in readmission rate (6.7% vs. 15.7%, P < 0.001) was observed but there was no change in mortality, functional outcome or length of stay. CONCLUSIONS: Comparison of performance among voluntary teams, on fields selected by health-care professionals, was associated with improvement in the care process and with improvement of some related outcomes.