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Tibial plateau fractures with significant joint depression and metaphyseal comminution pose a challenge. In order to prevent the collapse of the articular surface, some authors propose filling the subchondral void created during reduction with bone graft/substitute, which can add further complications. We present two cases of tibial plateau fractures with severe joint depression of the lateral condyle; both treated with a periarticular rafting construct, in one caseadditional bone substitute was used and in the other case no bone graft/substitute was used; their final outcomes were reported. The treatment of joint depression in tibial plateau fractures using periarticular rafting constructs without bone graft, may be also a valid option, to achieve good final results without the morbidity associated with the use of bone graft/substitutes., Competing Interests: Declaration of Competing Interest There is no conflict of interest amongst the authors related to the submitted work., (Copyright © 2023. Published by Elsevier Ltd.)

Purpose: Helical plates potentially avoid the medial neurovascular structures of the thigh. Two implant designs for additional medial 90° helical plate in double plate constructs for geriatric patients and 180° helical plate for single plating in young patients are potential alternatives to widely used standard straight plates., Aims: (1) assess the distances to adjacent anatomical structures being at risk when applying medial 90° and 180° helical plates with MIPO technique to the femur, (2) compare these distances with medial straight plates, and (3) correlate measurements performed during surgical dissection with CT angiography., Methods: MIPO was performed in ten human cadaveric femoral pairs using either a 90° helical 14-hole LCP (Group 1) or a 180° helical 15-hole LCP-DF (Group 2). Using CT angiography, distances between femoral arteries and plates as well as distances between plates and perforating vessels were evaluated. Following, specimens were dissected and distances determined again. All plates were removed and measurements were repeated with straight medial plates (Group 3)., Results: Overall closest distances between plates and femoral arteries were 14.5 mm (11-19 mm) in Group 1, 21.6 mm (15-24 mm) in Group 2 and 6.5 mm (5-8 mm) in Group 3, with significant differences between Group 3 and both other groups (p < 0.001). Distances to the nearest perforating vessels were 22.4 mm (15-30 mm) in Group 1 and 1.2 mm (1-2 mm) in Group 2. Measurement techniques (visual after surgical disection and CT angiography) demonstrated a strong correlation (p < 0.010)., Conclusions: Inserting 90° and 180° helical plates with MIPO technique is safe, however, attention must be paid to the medial neurovascular structures with 90° helical plates and to the proximal perforating vessels with 180° helical plates. Helical plates can avoid irritation of medial neurovascular structures - compared with straight plates - although care must be taken during their distal insertion. Measurements during surgical dissection correlate with CT angiography., Competing Interests: Declaration of Competing Interest None., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Reamer-Irrigator-Aspirator (RIA) of long bones is increasingly being used as an alternative to iliac crest harvesting for bone-grafts. This meta-analysis compares both harvesting techniques with regard to donor site morbidity, healing potency and implantation site morbidity., Methods: PubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR) with corresponding 95% confidence interval (95%CI)., Results: A total of 5 studies were included. RIA carries a lower risk for chronic pain (0% versus 14.2%, OR 0.08, 95% CI 0.02 - 0.35) and infection (1% versus 5.9%, OR 0.29, 95% CI 0.09- 0.9) at the donor site compared to iliac crest harvesting. Iliac crest bone-harvesting has an inherent additional risk of neuropraxia of the lateral femoral cutaneous nerve and numbness of the scar which is not encountered in RIA harvesting. Risk for other reported complications such as hematoma and iatrogenic fractures appear equal in both groups. The clinical healing potential of both bone grafts, in terms of union rate (OR 1.53, 95%CI 0.62 - 3.75) at the implantation site and time-to-union (MD 0.44 months, 95%CI -1.72 - 0.83), seems equal., Conclusion: The main difference between RIA and iliac crest bone graft harvesting is the considerable higher risk of chronic pain of the pelvic procedure. Although risk for infection was also higher for the iliac crest group, the absolute difference is relatively small. Evidence suggests an equal healing potential of the grafts themselves irrespective of harvesting method., Competing Interests: Declaration of Competing Interests None., (Copyright © 2021. Published by Elsevier Ltd.)

Objectives: Despite continual improvement in the methods and devices used for treatment of proximal femoral fractures, unacceptably high failure rates remain. Novel screw-blade implant systems, combining a lag screw with a blade - the latter adding rotational stability to the femoral head - offer improvement of osseous purchase, especially in osteoporotic bone. The aim of this study was to compare biomechanically the head element (HE) anchorage of two screw-blade implant systems differing in blade orientation in the femoral head - vertical versus horizontal., Methods: Twenty paired human cadaveric femoral heads were assigned to four groups (n = 10), implanted with either Rotationally Stable Screw-Anchor HE (RoSA-HE, vertical blade orientation) or Gamma3 Rotation Control Lag Screw (Gamma-RC, horizontal blade orientation) in center or off-center position, and biomechanically tested until failure under progressively increasing cyclic loading at 2 Hz., Results: Cycles to failure and failure load were significantly higher for Gamma-RC versus RoSA-HE in center position and not significantly different between them in off-center position, p = 0.03 and p = 0.22, respectively. In center position, the progression of both rotation around implant axis and varus deformation over time demonstrated superiority of the implant with horizontal versus vertical blade orientation. Compared with center positioning, off-center implant placement led to a significant decrease in stiffness, cycles to failure and failure load for Gamma-RC, but not for RoSA-HE, p < 0.01 and p = 0.99, respectively., Conclusion: Horizontal blade orientation of screw-blade implant systems demonstrates better anchorage in the femoral head versus vertical blade orientation in center position. As the stability of the implant system with horizontal blade orientation drops sharply in off-center position, central insertion is its placement of choice., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2021. Published by Elsevier Ltd.)

Background: There is no consensus on the optimal operative technique for humeral shaft fractures. This meta-analysis aims to compare minimal-invasive plate osteosynthesis (MIPO) with open reduction internal fixation (ORIF) for humeral shaft fractures regarding non-union, re-intervention, radial nerve palsy, time to union, operation duration and functional outcomes., Methods: PubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies comparing MIPO with ORIF for humeral shaft fractures. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR), risk difference (RD), mean difference (MD) and standardized mean difference (SMD) with corresponding 95% confidence interval (95%CI). Subgroup analysis was performed stratified by study design (RCTs and observational studies)., Results: A total of two RCT's (98 patients) and seven observational studies (263 patients) were included. The effect estimates obtained from observational studies and RCT's were similar in direction and magnitude. MIPO carries a lower risk for non-union (RD: 5%; OR 0.3, 95% CI 0.1-0.9) and secondary radial nerve palsy (RD 5%; OR 0.3, 95%CI 0.1- 0.9). Nerve function eventually restored spontaneously in all patients in both groups. Results were inconclusive regarding re-intervention (RD 7%; OR: 0.7, 95%CI 0.2-1.9), infection (RD 4%; OR 0.4, 95%CI 0.1-1.5), time to union (MD -1 week, 95%CI -3 - 1) and operation duration (MD -13 minutes, 95%CI -38.9 - 11.9). Functional shoulder scores (SMD 0.01, 95%CI -0.3 - 0.3) and elbow scores (SMD 0.01, 95%CI -0.3 - 0.3) were similar for the different operative techniques., Conclusion: MIPO has a lower risk for non-union than ORIF for the treatment of humeral shaft fractures. Radial nerve palsy secondary to operation is a temporary issue resolving in all patients in both treatment groups. Although both treatment options are viable, the general balance leans towards MIPO having more favorable outcomes., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Since its conception in 1989, minimally invasive plate osteosynthesis (MIPO) has gained widespread popularity. It has been studied in over forty countries with most of the publications originating from Asia, Europe and North America. This review aims to describe the scientific path of MIPO from the very beginning to where it stands in current day times; study the pattern and contributing factors influencing its global spread. Finally, the up to date evidence is discussed with regard to several anatomical regions in which MIPO is mostly used. In the meantime, MIPO treads steadily towards accomplishing the same or better outcomes for more and more indications with the goal to leave a smaller surgical footprint to allow for undisturbed bone healing., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Compartment syndrome is a rare but serious complication of contrast medium extravasation. To avoid permanent damage, it is important to recognize the symptoms quickly and immediately initiate treatment. We report a patient, who developed compartment syndrome of the forearm after extravasation of contrast medium and review the available literature on this subject. To our knowledge this is the first reported case of compartment syndrome of the forearm due to contrast medium application for a trauma CT in a patient that had no direct trauma to the affected limb., Competing Interests: Declaration of competing interest This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors declare that they have no conflict of interests., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: To date, limited evidence exists regarding follow-up imaging during the non-operative management (NOM) of blunt splenic injury (BSI), especially concerning ultrasound as first-line imaging modality. The aim of this study was to investigate the incidence and time to failure of NOM as well as to evaluate the relevance of follow-up imaging., Methods: All adult patients with BSI admitted to our level I trauma center, including two associated hospitals, between 01/01/2010 and 31/12/2017 were retrospectively analyzed. Demographic data, comorbidities, injury pattern, trauma mechanism, Injury Severity Score, splenic injury grade and free intra-abdominal fluid were reviewed. Additional analysis of indication, frequency, modality, results and consequences of follow-up imaging was performed. Risk factors for failure of NOM were evaluated using fisher's exact test., Results: A total of 122 patients with a mean age of 43.8 ± 20.7 years (16-84 years) met inclusion criteria. Twenty patients (16.4%) underwent immediate intervention. One-hundred-and-two patients (83.6%) were treated by NOM. Failure of NOM occurred in 4 patients (3.9%). Failure was significantly associated with active bleeding (3 of 4 [75%] failures vs. 8 of 98 [8.2%] non-failures, OR 33.75, 95% CI 3.1, 363.2, p = 0.004), and liver cirrhosis (2 of 4 [50%] failures vs. 0 of 98 [0%] non-failures, OR 197, 95% CI 7.4, 5265.1, p = 0.001). Eighty patients (78.4%) in the NOM-Group received follow-up imaging by ultrasound (US, n = 51) or computed tomography (CT, n = 29). In 57 cases, routine imaging examinations were conducted (43 US and 14 CT scans) without prior clinical deterioration. Fifty-fife (96.4%) of these imaging results revealed no new significant findings. Every failure of NOM was detected following clinical deterioration in the first 48 h., Conclusion: To our knowledge this study includes the largest single centric patient cohort undergoing ultrasound as first-line follow-up imaging modality in the NOM setting of BSI in adult patients. The results indicate that a routine follow-up imaging, regardless of the modality, has limited therapeutic advantage. Indication for radiological follow-up should be based on clinical findings. If indicated, a CT scan should be used as preferred imaging modality., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Fragility fractures of the pelvis (FFP) show a notable rise in prevalence. Minimally invasive surgical fixation of FFP is increasingly advocated for its obvious advantages with reference to early mobilization and weight bearing. Concerns regarding the holding power of osteosynthetic materials in osteoporotic bone led to the development of cementing techniques. However, the role of cement augmentation in the surgical treatment of FFP has yet to be defined. Therefore, the aim of this study was to conduct a systematic review of the current literature concerning studies that are comparing the performance of cement augmented versus non-augmented sacroiliac (SI) screws., Methods: We conducted a systematic literature review from 01/01/2000 onwards. Inclusion criteria were randomized controlled studies, case series (n>3), biomechanical studies and reviews, comparing augmented and non-augmented SI screws. Only papers in German or English language were included., Results: Out of 1247 initial hits, eleven studies met the inclusion criteria. Out of those, six were biomechanical studies and five were clinical case series. Most biomechanical studies showed cement augmented screws to have a greater mechanical stability, both regarding pull-out force and resistance to cyclic loading. The five case studies reported on a total of 98 patients with 122 screw fixations. Three cases of cement leakage into neuroforamina occurred, however, none of these patients showed clinical symptoms., Conclusion: In clinical case series, cement augmentation of SI screws appears to be a safe surgical technique without relevant complications and biomechanical studies demonstrate greater pull-out forces of augmented SI screws but no advantage in regard of cyclic loading. Hence, applicability of the mechanical testing results on the clinical situation are debatable. So far, there are neither retrospective nor randomized controlled studies comparing the performance of cemented and non-cemented SI screws in FFP. Therefore, the clinical benefit of SI screw cement augmentation is unclear and their use remains experimental., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: New implant designs like the Proximal Femoral Nail Antirotation (PFNA) were developed to reduce failure rates in unstable pertrochanteric fractures in the elderly. Standardized implant augmentation with up to 6 mL of polymethylmethacrylate (PMMA) cement has been introduced to enhance implant anchorage by increasing the implant-bone interface in osteoporotic bone conditions. Biomechanically, loads to failure were significantly higher with augmentation. The primary objective of this study was to compare the mobility of patients with closed unstable trochanteric fractures treated by PFNA either with or without cement augmentation., Patients and Methods: A prospective multicentre, randomized, patient-blinded trial was conducted with ambulatory patients aged 75 or older who sustained a closed, unstable trochanteric fracture. Surgical fixation had to be performed within 72 h after admission. Outcomes were evaluated at baseline, during surgery, 3 to 14 days after surgery, 3 months, 6 months, and 12 months after surgery. To evaluate the primary objective, patients' walking speed was assessed by the Timed Up and Go (TUG) test. Secondary objectives included the analysis of implant migration assessed on radiographs, quality of life measured by the Barthel Index, mobility measured by the Parker Mobility Score, and complications., Results: Of 253 randomized patients, 223 patients were eligible: 105 patients were allocated to the PFNA Augmentation group and 118 to PFNA group. At 3 to 14 days after surgery, there was no statistical significant difference in mean walking speed between the treatment groups. For the secondary objectives, also no statistical significant differences were found. However, no patient in the PFNA Augmentation group had a reoperation due to mechanical failure or symptomatic implant migration compared to 6 patients in the PFNA group., Conclusions: Augmentation of the PFNA blade did not improve patients' walking ability compared to the use of a non-augmented PFNA but might have the potential to prevent reoperations by strengthening the osteosynthesis construct., (Copyright © 2018 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Temporary external fixation is a viable option for numerous conditions and fixations in orthopaedic and trauma surgery. If the external fixator is left in place it is necessary to disinfect it prior to surgery, yet the subsequent risk for bacterial contamination of the surgical site originating from the external fixator remains unknown., Material and Methods: In a prospective study, samples were taken at the time of definitive osteosynthesis to assess bacterial contamination of the surgical site and the external fixator in twenty consecutive patients treated with temporary external fixation for closed fractures from October 2016 until March 2017., Results: Twenty external fixators of twenty patients with complete sampling and a mean follow-up of seven months (range: 3-14) were available for analysis. Ten out of 120 cultures of the surgical site (8.3%) were positive for bacterial growth in a total of seven patients (35%). Pathogen's detected were Propionibacterium acnes (60%) and Staphylococcus epidermidis (30%). No contamination of the external fixator was detected., Conclusion: We conclude that the presented perioperative management to decontaminate external fixators allows for a safe definitive osteosynthesis in a staged protocol without increasing bacterial contamination of the surgical site. It is safe to leave the external fixator in place for definitive osteosynthesis., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: To evaluate whether the dorsal tangential view (DTV) allows for reliable and valid in vivo measurement of the distance between screw tips and the dorsal radial cortex (STCD) during volar plating of distal radius fractures., Methods: Subjects included 22 patients with displaced distal radius fractures who had volar plate osteosynthesis. We performed standardized DTV images intraoperatively. After surgery, we performed computed tomography (CT) scans with reconstructions parallel to the distal screws. Three independent observers blinded to the study protocol measured the STCD on the basis of the DTV images and CT reconstructions. We calculated inter- and intraobserver reliability and the correlation between STCD values measured with DTV images and CT scans., Results: Eleven screws were changed intraoperatively. We observed no cases of postoperative screw perforations. Inter- and intraobserver reliability of STCD measurement was good when measured with DTV images and excellent when measured on the basis of CT reconstructions. Statistical analysis showed a good correlation between mean STCD values measured with DTV and CT., Conclusions: The DTV allowed in vivo evaluation of the dorsal radial cortex and enabled reliable assessment of the distance between the screw tip and the dorsal cortex. It may allow detection of dorsal screw perforation during volar plating of distal radial fractures., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Introduction: The purpose of this study was to evaluate the impact of computed tomography scanning on the inter- and intra-observer reliability of the OTA/AO, the Schatzker, and the Hohl classifications in the assessment of tibial plateau fractures., Methods: Four independent observers classified 45 consecutive fractures of the tibial plateau according to the criteria of the OTA/AO system, the Schatzker classification, and the Hohl classification. Two sessions of readings were compared; first, the use of plain anterior-posterior and lateral X-rays alone was evaluated, then 4 weeks later the combination of plain X-rays and two-dimensional computed tomography scans were evaluated. The readings were repeated 8 weeks later to evaluate intra-observer reliability., Results: The three classification systems showed "moderate" inter-observer reliability and "good" and "moderate" intra-observer reliability when classified solely on the basis of plain radiographs. After the addition of computed tomography scans inter-observer reliability significantly improved to "good" in all classifications. Likewise, intra-observer reliability improved to "good" in all classifications after the addition of CT-scans. Statistical analysis showed no significant difference regarding inter- and intra-observer agreement between the three classifications., Conclusions: Computed tomography scanning improved the inter- and intra-observer reliability of the OTA/AO, the Schatzker, and the Hohl classification. Overall, all three classification systems showed "good" inter- and intra-observer reproducibility when classified with CT-scans., (Copyright 2009 Elsevier Ltd. All rights reserved.)

Purpose: To determine the amount and distribution of forces transmitted across the human radioulnocarpal joint under physiologic conditions in vivo. We performed an in vitro validation of a specifically developed capacitive pressure-sensor device and an in vivo measurement of force transmission and pressure distribution at the radioulnocarpal joint in a healthy volunteer., Methods: A new capacitive pressure-sensor device was adapted for intra-articular pressure measurement in the human radioulnocarpal joint. The technical characteristics of the device were determined and the sensor was validated in fresh-frozen cadaver tests. Force transmission across the radioulnocarpal joint then was measured in healthy volunteers under local anesthesia., Results: The sensor delivered reproducible measurements of forces across the radioulnocarpal joint and their distribution in the cadaver experiment. In vivo, 2 centers of force transmission were identified. None of these centers correlated with previous findings in the literature. More force is transmitted across the ulnar side of the radioulnocarpal joint than previously thought. The results are consistent with clinical findings., Conclusions: The novel sensor device is suitable for intra-articular pressure measurement in the human radioulnocarpal joint in vitro and in vivo.

High Tibial Osteotomy (HTO) is an established treatment for unicompartmental osteoarthritis of the knee with malalignment. The classic procedure for correcting varus deformity is the lateral closed wedge osteotomy of the tibia with osteotomy of the fibula. The disadvantages of this technique are well known. Open wedge osteotomy from the medial side eliminates the risk of compartment syndrome and peroneal nerve injuries. A new fixation device (TomoFix) with an adapted surgical technique allows stable fixation of the osteotomy without the need to fill the osteotomy gap with bone grafts. In a prospective study, 92 consecutive cases were treated with this procedure. Bony healing with remodelling of the medial and posterior cortical bone was observed. Full weight-bearing was possible ten weeks after surgery. There were no implant failures. Complications included one delayed union, two revarisations and one deep infection.