Do working length and proximal screw density influence the velocity of callus formation in distal tibia fractures treated with a medial bridge plate?

INTRODUCTION: Aim of our study was to evaluate the influence of working length and screw density on callus formation in distal tibial fractures fixed with a medial bridge plate. MATERIALS AND METHODS: 42 distal tibia fractures treated with a bridge plate were analyzed. Minimum follow-up was 12 months. mRUST score (modified Radiographic Union Scale for Tibial fractures) was used to assess callus formation. Working length and screw density were  measured from post-operative radiographs. RESULTS: 39 (92.9%) fractures healed uneventfully. 32 (76.19%) patients showed signs of early callus formation 3 months post-surgery. In these patients a lower screw density was used compared to patients who didn't show early callus (33.4 vs. 26.6; p = 0.04). No differences was noticed in working length. CONCLUSION: Bridge plate osteosynthesis is a good treatment option in distal tibia fractures. In our series increasing the working length was not associated with a faster callus formation in distal tibia fractures. Conversely, a lower screw density proximally to the fracture site was associated to a faster callus growth.

The risk of infection in open distal tibial fracture: the DANGER score.

INTRODUCTION: Open fractures of the distal tibia can be functionally devastating, and they remain one of the most challenging injuries treated by trauma surgeons usually burdened with a high rate of complications, including surgical site infections (SSI). Our aim is to analyze the most significant risk factors of SSI and propose a new scoring system-called the DANGER scale-potentially able to predict reliably and quantify the infection risk in distal tibia open fractures. METHODS: We identified six variables summarized in the acronym DANGER where D stands for Diabetes, A for Antibiotic, N for Nature of trauma (high- or low-energy trauma), G represents Grade of fracture following the AO/OTA classification, E indicates Exposure of the fracture according to the Gustilo-Anderson classification, and R represents Relative risk of patient, including use of tobacco, alcoholism, and psychiatric disorders. Therefore, total score ranged from 1 to 14, with a lower score indicating less risk to develop SSI. RESULTS: A total of 103 patients with open distal tibial fractures were enrolled, 12 patients (11.6%) developed SSI. Regarding DANGER score, a rating of 8.2 was calculated in SSI group and 4.8 in non-SSI group. Based on Fisher's test, diabetes (odds = 31.8 p < 0.05), grade of articular involvement (p < 0.05), severity of open fracture (p < 0.05), and dangerous behavior such as use of tobacco, alcoholism, and psychiatric disorders (p < 0.05) were significantly correlated with infection. Significant difference between total DANGER scores in SSI and non-SSI groups was found (p < 0.001). ROC curve was calculated founding a potential threshold of 7.5 (p < 0.001). CONCLUSION: Based on the above well-accepted risk factors, DANGER scale represents an advantageous and practical tool in order to readily estimate the risk of surgical site infection of open distal tibial fractures.

A modified anterolateral swashbuckler approach for distal femoral fractures: description and outcomes.

BACKGROUND: The treatment of distal femur fractures represents a challenging task. General and local factors, including bone quality, articular surface involvement, fracture comminution, associated soft tissue injuries and ultimately fixation system, all play a role in the final clinical outcome. Current surgical approaches often undermine patellar vascularization and integrity of the extensor apparatus, not guaranteeing sufficient visualization of the medial condyle. This technical note presents the efficacy and safety a new surgical technique to address distal femoral fractures. METHODS: The original "swashbuckler" surgical approach was modified in order to obtain a better visualization of the lateral and medial femoral condyles without affecting the knee extensor mechanism and the anastomotic arterial supply of the patella. This modified surgical approach was utilized in a consecutive series of patients presenting with an AO Foundation/Orthopaedic Trauma Association (AO/OTA) 33 distal femur or periprosthetic fracture of the knee. The final outcome was recorded according to a functional evaluation scoring system. RESULTS: Twelve patients (2 males and 10 females) with a mean age of 67,8 years were included in this series. The same, modified "swashbuckler" surgical approach was applied in all cases. Multiple internal fixation techniques, including a single lateral plate, a combination of a lateral and medial plate, a single lateral plate associated with lag screws, were used to obtain a satisfactory stabilization of the fracture site. All patients were reviewed at a minimum one-year follow up (median 15 months): all patients regained their level of activities of daily living. No major intraoperative or postoperative complications were recorded. CONCLUSIONS: The modified swashbuckler approach allows anatomical reduction and appropriate fixation without sacrificing the blood supply to the patella and ensures rapid weight bearing resumption thanks to an intact extensor mechanism.

Complex open elbow fracture-dislocation with severe proximal ulna bone loss: a case report of massive osteochondral allograft surgical treatment.

We report a case of a 69-year-old right-dominant man who had an open Monteggia-like lesion of the right elbow (Gustilo-Andersen IIIA) with severe proximal ulna bone loss associated with an ipsilateral ulnar shaft fracture due to a motorcycle accident. The patient underwent two-stage surgery. Wound debridement and bridging external fixation were performed at first. Three months later, a frozen massive osteochondral ulnar allograft was implanted and fixed with a locking compression plate. A superficial wound infection appeared 5 weeks after the second surgery. Superficial wound debridement, negative pressure therapy, and antibiotics were administered for 3 months, achieving infection healing. At 3 years post-surgery, the elbow range of motion was satisfactory with a Disabilities of the Arm, Shoulder and Hand (DASH) score of 16.7. Radiographs and computed tomography scans showed good allograft-bone integration without allograft reabsorption or hardware loosening. Although not complication-free, massive ulna osteochondral allograft implantation can be considered a valid option in cases of open Monteggia-like lesions associated with ulnar shaft fracture and severe bone loss in active patients, whenever osteosynthesis or joint replacement is not a proper solution. This type of bone stock restoration allows for future surgery, if needed.

Detection of Circulating Tumor Cells and Microbial DNA Fragments in Stage III Colorectal Cancer Patients under Three versus Six Months of Adjuvant Treatment.

Oxaliplatin-fluoropyrimidine combination therapy is the gold standard treatment for patients with stage III colorectal cancer (CRC); however, treatment duration is now under re-evaluation. The aim of the study was the evaluation of the non-inferiority of three over six months treatment with FOLFOX or CAPOX, in stage III CRC patients. Peripheral blood samples from 121 patients were collected, at three time points during treatment and evaluated for circulating tumor cells (CTCs) and microbial DNA detection (16S rRNA, Escherichia coli, Bacteroides fragilis, Candida albicans). Of all patients, 41.3% and 58.7% were treated with FOLFOX and CAPOX, respectively. CTCs were significantly decreased and increased after three and six months of treatment, respectively. CAPOX tends to reduce the CTCs after 3 months, whereas there is a statistically significant increase of CTCs in patients under FOLFOX after 6 months. A significant correlation was demonstrated between microbial DNA detection and both CTCs detection at baseline and CTCs increase between baseline and three months of treatment. To conclude, the current study provides additional evidence of non-inferiority of three over 6 months of treatment, mainly in patients under CAPOX.

Management of post-traumatic elbow instability after failed radial head excision: A case report.

Radial head excision has always been a safe commonly used surgical procedure with a satisfactory clinical outcome for isolated comminuted radial head fractures. However, diagnosis of elbow instability is still very challenging and often underestimated in routine orthopaedic evaluation. We present the case of a 21-years old female treated with excision after radial head fracture, resulting in elbow instability. The patient underwent revision surgery after four weeks. We believe that ligament reconstruction without radial head substitution is a safe alternative choice for Mason III radial head fractures accompanied by complex ligament lesions.

Operative management of a shear fracture of the bilateral capitellum: A case report and review of the literature.

Fracture of bilateral capitulum humeri is a very rare injury. We present a case of a 38-year-old woman, affected by a shear fracture of bilateral capitellum after a motorcycle accident. Intervention was carried out through a lateral approach on both sides and direct fixation of the fragment with headless screws. Consolidation was achieved and no signs of avascular necrosis occurred at 24 months of follow-up. The patient returned to her previous activities with no functional limitations. To the best of our knowledge, only four cases are reported describing different types of treatment and postoperative period of cast immobilization. According to our review of the literature regarding capitellar fractures, we preferred an immediate postoperative rehabilitation of the elbow, following the stable osteosynthesis.

Fixation of complex proximal humeral fractures in elderly patients with a locking plate: A retrospective analysis of radiographic and clinical outcome and complications.

PURPOSE: The optimal surgical treatment of displaced type B and C fractures of the proximal humerus in the elderly remains controversial. Good clinical results have been reported by plating these fractures as well as a high rate of complications. Our retrospective study aims to evaluate clinical recovery and complications using the S3 locking plate in elderly patients. METHODS: Fifty-one patients older than 65 years of age, with a complex proximal humeral fracture type B or C (AO classification system), were included. Patients have been followed up for a minimum of 12 months. We assessed callus formation, radiological results, clinical outcome (according to the Constant Shoulder Score System) and complications. Any difference in the clinical recovery among the 2 types of fracture pattern (B and C) was investigated. RESULTS: The mean time of fracture healing was 12.4 weeks. The mean Constant score at 3, 6 and 12 months was 68, 73 and 75 respectively. No statistically significant difference in the clinical outcome was observed between the B and C fracture patterns (p > 0.05). We noticed an overall of 5 complications (9.8%). There was no need to revision any of the implants. CONCLUSION: Anatomic reduction and proper plate positioning are essential for minimizing implantrelated complications. In our experience the S3 angular stability system offers a proper osteosyntesis and a good clinical recovery with a low rate of complications.

A two-choice strategy through a medial tibial approach for the treatment of pilon fractures with posterior or anterior fragmentation.

OBJECTIVE: The anterolateral approach to the tibia has been popularized for the management of tibial pilon fractures. For complex fracture patterns a combined anterolateral/anteromedial approach is suitable but a high rate of complication has been reported. In our retrospective study a two-choice strategy adopting a medial tibial approach was proposed for the treatment of pilon fractures with anterior or posterior fragmentation. METHODS: Based on an anatomic study of tibial pilon fractures, we retrospectively analyzed the fractures with primary posterior, posterior-lateral or anterior, anterior-lateral (Tillaux-Chaput) involvement of the distal tibia. This retrospective study consisted of 18 patients with a closed tibial plafond fracture. The inclusion criteria were: (1) pre- sence of an anterior/anterolateral type fragment or a posterior (Volkmann) type fragment involving larger than 25% of the articular surface, (2) a minimum follow-up of 12 months, (3) a fibula fracture associated with a medial column fracture of the distal tibia, and (4) soft tissue conditions at the time of operation that did not compromise the choice of surgical access (Tscherne classification for closed fractures: grade 0 and grade 1). Tibial plafond fractures were classified into two groups: one presenting anterior and the other with posterior rim (Volkmann) fragments. RESULTS: Most patients achieved a good clinical recovery in terms of range of motion and Olerud-Molander scale scores. Only three patients presented a grade 2 osteoarthritis at the 12 month follow-up. CONCLUSION: Our two-choice strategy highlights concepts which have been previously debated and described in the literature. But a new extended protocol for surgical approach to the distal tibia, including more fracture patterns and their association should be further investigated.

Missed posterior shoulder dislocation and McLaughlin lesion after an electrocution accident.

Posterior shoulder dislocation is a rare event that may occur after a direct trauma, an epileptic seizure, electric shock or electroconvulsive therapy. In more than 50% of the cases, posterior dislocations are missed on initial evaluation and often misdiagnosed as frozen shoulders with unfortunate consequences. We present the case of a missed posterior subluxation and reverse Hill Sachs lesion (McLaughlin lesion) in a 40-year-old woman caused by anelectric shock of 240 V. The patient underwent surgery in our institute two weeks after the injury. The humeral head was reduced and the reverse Hill Sachs lesion was filled by demineralized bone matrix allograft with osteoinductive factors. Tendons were repaired and a temporaneous artrodesis was performed. At the final follow up of 12 months, we obtained a Costant Score of 93 and the patient returned to her previous daily activities.