Comparative CT Study on Syndesmosis Mobility after Static or Dynamic Fixation for Ankle Fractures with Syndesmotic Rupture: A Pilot Study.

Background: The objective of this prospective randomized pilot study is to compare, by computed tomography (CT), the mobility of syndesmosis after static fixation (SF) or dynamic fixation (DF) in ankle fractures with syndesmotic rupture (AFSR) in adults, and to compare this mobility with that of healthy ankles. Methods: Forty-two patients with an AFSR were randomized to 2 groups: SF (N=21) or DF (N=21). Seven patients were lost to follow-up. Ultimately, 35 patients (SF, N=20; DF, N=15) were analyzed. The clinical results were assessed with the American Orthopedic Foot and Ankle Society scale. To assess syndesmosis mobility, CT in 30° of plantar flexion (PFlex) and 20° of dorsal flexion (DFlex) was performed on both ankles one year after the fracture. Four parameters were measured: anterior tibiofibular distance, posterior tibiofibular posterior distance, angle of fibular rotation (AFR), and anteroposterior fibular translation. Results: The AFR between DFlex and PFlex was more similar to the non-affected side in the DF group. The other three parameters showed no statistical differences between types of fixation. The mean loss of AFR compared with the non-affected side was 1.2° in the SF group and 0.1° in the DF group. No clinical differences between the SF group and the DF group were found. No correlation between clinical and radiological results was observed. Conclusion: The AFR was more similar to the non-affected side in the DF group. However, this finding did not correlate with a better clinical result.

SARS-CoV-2 outbreak impact on a trauma unit.

BACKGROUND: From February 2020 onwards, our country has been hit by the coronavirus severe acute respiratory syndrome-2 (SARS-CoV-2) infection. At a glance, hospitals became overrun and had to reformulate all the assistance guidelines, focusing on the coronavirus disease 2019. One year after the start of the pandemic, we present the results of a morbimortality study. AIM: To analyze how our department was affected by the outbreak in terms of morbimortality, and to analyze demographic data, admission to hospital-related data, and subgroups analyses for patients with hip fractures and polytrauma. METHODS: We designed a study comparing data from patients who were admitted to our unit due to a lower limb fracture or a high energy trauma during the pandemic (from March to April 2020) to those admitted during the same period in 2019 before the pandemic. during the pandemic situation. Both cohorts completed a minimum of 6 mo of follow-up. RESULTS: The number of patients admitted to hospital in 2020 was nearly half of those in 2019. Hip fractures in the elderly represented 52 out of 73 of the admitted patients. Twenty patients had a positive test result for SARS-CoV-2 infection. Patients with SARS-CoV-2 infection were admitted to the hospital for a longer time than the non-infected (P < 0.001), and had a higher mortality rate during hospitalization and follow-up (P = 0.02). Patients with a hip fracture associated with a severe respiratory syndrome were mostly selected for conservative treatment (P = 0.03). CONCLUSION: Mortality and readmission rates were higher in the 2020 cohort and during follow-up, in comparison with the cohort in 2019.

Factors that Influence Soft-tissue Injury in Fractures of the Distal Tibia.

BACKGROUND: Soft tissue injury associated with fractures of the distal tibia is a predictive factor for a poor prognosis. The purpose of this study was to investigate factors associated with the need for a flap coverage after distal tibial fracture, and whether there was a difference in functional outcomes between patients with flap coverage or no flap coverage for a distal tibial fracture. METHODS: All fractures of the distal tibia treated in our department between 2010 and 2017 were reviewed. The functional result was assessed using the SF-36 Quality of Life Questionnaire, the Visual Analog Scale (VAS) when walking and the AOFAS scale (American Orthopedic Foot and Ankle Society). RESULTS: 132 distal tibia fractures were reviewed, of which 51 required soft tissue flap reconstruction, which was associated with open fractures (P<0.001, OR 5.25), high energy trauma (P<0.001, OR 1.7)), the use of external fixation (p <0.001, OR 12.5) and the presence of vascular alterations on the Angio-CT scan (P<0.001). No significant differences were found in any of the scales that assessed the functional results between the group of patients who required soft tissue flap reconstruction and the group of patients who did not. CONCLUSION: We found that the need for a soft tissue flap was associated with the following parameters: open fracture, high energy of trauma, presence of skin necrosis, the use of external fixation and the existence of vascular injury. In relation to functional results, differences were not found between the group that needed coverage with a flap and the one that did not.

Open reduction and navigated Iliosacral screws for vertically unstable pelvic fractures.

AIMS: To evaluate clinical and radiological results of vertically unstable pelvic fractures managed by open reduction and navigated iliosacral screws. PATIENTS AND METHODS: The study included eleven patients with complex posterior ring fractures with vertical instability admitted to our hospital and managed with CT navigated iliosacral screws. There were 7 type C1, 2 C2 and 2 C3, according to Tile classification. Three patients presented a spino-pelvic dissociation and four a vertical sacral fracture affecting the foramina (Denis 2). Vertical displacement, pelvic deformity and asymmetry were measured. Tornetta and Matta criteria were used to assess the quality of pelvic reduction. RESULTS: An excellent reduction was achieved in 9 fractures and a good reduction in two. Asymmetry index improved from 13.18 to 2.72. Deformity index improved from 0.049 to 0.010. Only two patients with a Denis 2 fracture showed secondary displacement during follow-up. Four patients presented neurological complications due to their initial injuries. Seven patients were able to resume their previous activities. CONCLUSION: CT navigated IS screws provide enough stability after an anatomic reduction of the fracture. There was no complication related to screw insertion and adequate screw positioning was achieved in all the cases.

Limiting spread of COVID-19 in an orthopaedic department-a perspective from Spain.

Besides national and international recommendations, orthopaedic departments face significant changes in daily activity and serious issues to maintain their standards in musculoskeletal care during the pandemic Covid-19 crisis that we are facing. This report retrospectively addresses measures that were progressively put in place to modify in a week time the activity of a busy orthopaedic department in a large tertiary university hospital in face of the pandemic. Surgical priorities and surgical outcomes are key aspects to consider. The experience may offer some insight to areas where the spread of the disease may be slower or delayed. Abrupt stop of scheduled surgery and clinics is useful to adapt an orthopaedic department to the overall hospital resource reorganization. Orthopaedic surgeons need to be aware of the risks to patients and personnel in view of underdiagnosed cases, which make pre-operative Covid-19 evaluation mandatory for all surgical cases.

Validation of a long bone fracture non-union healing score after treatment with mesenchymal stromal cells combined to biomaterials.

The available scores to clinically evaluate fracture consolidation encounter difficulties to interpret progression towards consolidation in long-bone non-union, particularly when incorporating biomaterials in the surgical treatment. The aims of this study were to validate the REBORNE bone healing scale in tibia, humerus and femur non-unions treated by a combination of mesenchymal stromal cells (MSCs) and biomaterials, through the interclass correlation (ICC) among raters, and to define reliability and concordance in anteroposterior and lateral radiographs, compared to computed tomography (CT). METHODS: Twenty-six cases from the EudraCT 2011-005441-13 clinical trial underwent bone healing evaluation, if at least 3 out of 4 cortical views clearly identified. Three senior orthopaedic surgeons evaluated radiographs and CTs at 3 and 6 months FU. All cases included preoperative imaging and radiographs at 12 months. The 4-stage scale score was obtained from each cortical view in orthogonal radiographs or CTs. A score of 0.6875 (11/16) was set as a threshold for bone healing. Statistically, ICC evaluated agreement among raters. Cronbach's alpha coefficient tested reliability. Lin's concordance correlation coefficients (CCC) were estimated between mean CT scores and mean radiographic scores. Bland and Altman graphs provided the limits of agreement between both imaging techniques. Sensitivity and specificity were assessed in radiographs (against CT), and the Area Under the Receiver Operating Characteristics (ROC) Curve was estimated. The probability to predict bone consolidation with REBORNE scores obtained from radiographs was modelled. RESULTS: An ICC of 0.88 and 0.91 (CT and radiographs) confirmed agreement in the REBORNE score for non-union bone healing, with an inter-rater reliability of 0.92 and 0.95. Scores through the radiographic evaluation were found equivalent to the CTs at 6 months FU. A CCC of 0.79 was detected against CT. The radiographic scores in the REBORNE bone healing scale correctly classified bone consolidation in 77%, with an accuracy of 83% based on ROC curves. CONCLUSIONS: The REBORNE score measured with CT or radiographic images was reliable among raters at a follow-up time above 6 months for long bone non-union fractures. The REBORNE scale measured with radiographs proved valid to assess consolidation against CT measurements.

Fractures of the tibial pilon treated by open reduction and internal fixation (locking compression plate-less invasive stabilising system): Complications and sequelae.

BACKGROUND: The aim of this study was to evaluate variables that could be related to complications and sequelae in fractures of the tibial pilon treated by open reduction and internal fixation (ORIF) with a locking compression plate-less invasive stabilising system (LCP-LISS). PATIENTS AND METHODS: A total of 137 fractures treated by ORIF in a 7-year period were analysed. The mean follow-up was 3.3 years. We analysed the following variables: age, sex, side, type of fracture, energy of the injury, use of provisional external fixation (EF), time until ORIF, stages of treatment (one or two), surgical approach, type of bone fixation, quality of reduction, use of bone graft, hardware removal, associated fractures (fibula and others), functional results (AOFAS scale), early complications (infection, skin necrosis) and late complications (nonunion, early post-traumatic ankle osteoarthritis [AOA]). RESULTS: According to the AOFAS scale, 30.5% of the results were excellent, 46.7% good, 13.1% fair and 9.7% poor. The rate of infection was 8.7%, and the rate of skin necrosis requiring flap coverage was 15.2%. Furthermore, type 43C3 fractures of the AO classification had a higher rate of skin necrosis and flap coverage. The rate of nonunion was 16.3% (22 cases, 4 aseptic, 18 infected), and the use of a medial plate was related to a higher rate of nonunion than the use of a lateral plate. The rate of early post-traumatic AOA was 13.1%, and open fractures were related to a higher prevalence of nonunion and flap coverage. Both infection and a suboptimal anatomic reduction were related to a higher prevalence of fair and poor results. The anteromedial approach was associated with a higher prevalence of skin necrosis and early post-traumatic AOA than the anterolateral approach. CONCLUSION: Optimal reduction and stable fixation is paramount to diminishing the rate of complications and sequelae after ORIF (LCP-LISS) of these fractures.

A Multicentric, Open-Label, Randomized, Comparative Clinical Trial of Two Different Doses of Expanded hBM-MSCs Plus Biomaterial versus Iliac Crest Autograft, for Bone Healing in Nonunions after Long Bone Fractures: Study Protocol.

ORTHOUNION is a multicentre, open, comparative, three-arm, randomized clinical trial (EudraCT number 2015-000431-32) to compare the efficacy, at one and two years, of autologous human bone marrow-derived expanded mesenchymal stromal cell (hBM-MSC) treatments versus iliac crest autograft (ICA) to enhance bone healing in patients with diaphyseal and/or metaphysodiaphyseal fracture (femur, tibia, and humerus) status of atrophic or oligotrophic nonunion (more than 9 months after the acute fracture, including recalcitrant cases after failed treatments). The primary objective is to determine if the treatment with hBM-MSCs combined with biomaterial is superior to ICA in obtaining bone healing. If confirmed, a secondary objective is set to determine if the dose of 100 × 106 hBM-MSCs is noninferior to that of 200 × 106 hBM-MSCs. The participants (n = 108) will be randomly assigned to either the experimental low dose (n = 36), the experimental high dose (n = 36), or the comparator arm (n = 36) using a central randomization service. The trial will be conducted in 20 clinical centres in Spain, France, Germany, and Italy under the same clinical protocol. The confirmation of superiority for the proposed ATMP in nonunions may foster the future of bone regenerative medicine in this indication. On the contrary, absence of superiority may underline its limitations in clinical use.

Analysis of the variables affecting outcome in fractures of the tibial pilon treated by open reduction and internal fixation.

OBJECTIVE: To assess variables that could be related to outcomes in fractures of the tibial pilon treated by open reduction and internal fixation (ORIF). DESIGN: Retrospective. SETTING: University Hospital. PATIENTS: A total 92 fractures of the tibial pilon treated by ORIF in a 5-year period. The minimum follow-up was 1 year (mean: 3.3 years; range: 1-5). INTERVENTION: ORIF with LCP-LISS plate. PRIMARY OUTCOME MEASUREMENTS: Age, sex, side, type of fracture, energy of the injury, provisional external fixation (EF), time until ORIF, stages of treatment (one or two), surgical approach, type of bone fixation, quality of reduction, bone graft, hardware removal, associated fractures (fibula and others), functional results (AOFAS scale), rates of infection, skin necrosis, flap coverage, non-union, and early posttraumatic ankle osteoarthritis (AOA). RESULTS: According to AOFAS scale 30.5% of results were excellent, 46.7% good, 13.1% fair and 9.7% poor. Overall, the rate of infection was 13.04%, The rate of non-union was 10.86%. The rate of skin necrosis was 7.6% and the rate of flap coverage was 13.04%. The rate of early posttraumatic AOA was 13.04%. Type 43C3 fractures of the AO classification had a higher rate of skin necrosis and flap coverage. Open fractures were related to a higher prevalence of nonunion and flap coverage. The use of a bone graft was associated with a higher rate of nonunion and poor results. Infection was related to a higher prevalence of fair and poor results. EF was associated with a higher need for flap coverage. A suboptimal anatomic reduction was related to a higher rate of fair and poor results. The anteromedial approach was associated with a higher prevalence of skin necrosis and early posttraumatic AOA than the anterolateral approach. The use of an medial plate was related to a higher rate of nonunion than the use of a lateral plate. CONCLUSIONS: The anteromedial approach was associated with a higher rate of skin necrosis and posttraumatic AOA than the anterolateral approach. Medial plating had a higher prevalence of nonunion than lateral plating. LEVEL OF EVIDENCE: IV (case series).