Search

Aims: To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years., Methods: A total of 100 patients were randomized in this non-inferiority trial, comparing cast immobilization with operation with a volar locking plate. Patients with displaced AO/OTA A and C fractures were eligible if one of the following were found after initial closed reduction: 1) dorsal angulation > 10°; 2) ulnar variance > 3 mm; or 3) intra-articular step-off > 2 mm. Primary outcome measure was the abbreviated version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH) after 12 months. Secondary outcome measures were the Patient-Rated Wrist and Hand Evaluation (PRWHE), EuroQol-5 dimensions 5-level questionnaire (EQ-5D-5L), range of motion (ROM), grip strength, "satisfaction with wrist function" (score 0 to 10), and complications., Results: In all, 89 women and 11 men were included. Mean age was 74 years (65 to 91). Nonoperative treatment was non-inferior to operation with a five-point difference in median QuickDASH after 12 months (p = 0.206). After three and six months QuickDASH favoured the operative group (p = 0.010 and 0.030). Median values for PRWHE were 19 (interquartile range (IRQ) 10 to 32) in the operative group versus ten (IQR 1 to 31) in the nonoperative group at three months (p = 0.064), nine (IQR 2 to 20) versus five (IQR 0 to 13) (p = 0.020) at six months, and two (IQR 0 to 12) versus zero (IQR 0 to 8) (p = 0.019) after 12 months. Range of motion was similar between the groups. The EQ-5D-5L index score was better (mean difference 0.07) in the operative group at three and 12 months (p = 0.008 and 0.020). The complication rate was similar (p = 0.220). The operated patients were more satisfied with wrist function (median 8 (IQR 6 to 9) vs 6 (IQR 5 to 7) at three months, p = 0.002; 9 (IQR 7 to 9) vs 8 (IQR 6 to 8) at six months, p = 0.002; and 10 (IQR 8 to 10) vs 8 (IQR 7 to 9) at 12 months, p < 0.001)., Conclusion: Nonoperative treatment was non-inferior to operative treatment based on QuickDASH after one year. Patients in the operative group had a faster recovery and were more satisfied with wrist function. Results from previous trials comparing operative and nonoperative treatment for displaced distal radius fractures in the elderly vary between favouring the operative group and showing similar results between the treatments. This randomized trial suggests that most elderly patients may be treated nonoperatively. Cite this article: Bone Joint J 2021;103-B(2):247-255.

Background and purpose - Better outcomes are reported for suture button (SB) compared with syndesmotic screws (SS) in patients treated for an acute ankle syndesmotic injury. One reason could be that screws are more rigid than an SB. A single tricortical 3.5 mm syndesmotic screw (TS) is the most dynamic screw option. Our hypothesis is that 1 SB and 1 TS provide similar results. Therefore, in randomized controlled trial, we compared the results between SB and TS for syndesmotic stabilization in patients with acute syndesmosis injury. Patients and methods - 113 patients with acute syndesmotic injury were randomized to SB (n = 55) or TS (n = 58). The American Orthopedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score was the primary outcome measure. Secondary outcome measures included Manchester Oxford Foot Questionnaire (MOXFQ), Olerud-Molander Ankle score (OMA), visual analogue scale (VAS), EuroQol- 5D (EQ-5D), radiologic results, range of motion, complications, and reoperations (no implants were routinely removed). CT scans of both ankles were obtained after surgery, and after 1 and 2 years. Results - The 2-year follow-up rate was 84%. At 2 years, median AOFAS score was 97 in both groups (IQR SB 87-100, IQR TS 90-100, p = 0.7), median MOXFQ index was 5 in the SB group and 3 in the TS group (IQR 0-18 vs. 0-8, p = 0.2), and median OMA score was 90 in the SB group and 100 in the TS group (IQR 75-100 vs. 83-100, p = 0.2). The syndesmotic reduction was similar 2 years after surgery; 19/55 patients in the SB group and 13/58 in the TS group had a difference in anterior syndesmotic width ≥ 2 mm (p = 0.3). 0 patients in the SB group and 5 patients in the TS group had complete tibiofibular synostosis (p = 0.03). At 2 years, 10 TS were broken. Complications and reoperations were similar between the groups. Interpretation - We found no clinically relevant differences regarding outcome scores between the groups. TS is an inexpensive alternative to SB.

Background: The aim of the study was to compare the functional outcomes following fixation with a volar locking plate (VLP) with those outcomes after augmented external fixation (EF) of displaced, intra-articular distal radial fractures in patients 18 to 70 years of age., Methods: Following inclusion, randomization, and surgery, clinical examination and outcome assessments were conducted at 6 weeks, 12 weeks, 6 months, 1 year, and 2 years. The primary outcome was the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, and secondary outcomes included wrist range of motion, grip strength, and pain assessed with a visual analog scale (VAS)., Results: Over a span of 3 years, 166 patients were included in the study. The mean age was 55.0 years (standard deviation [SD] = 11.5 years), with the ages distributed evenly in each treatment group by block randomization (84 patients in the VLP group and 82 in the EF group). The patients in the VLP group had a significantly better mean QuickDASH score, range of motion, and grip strength at 6 weeks, 12 weeks, 6 months, and 1 year. There were no significant differences between the groups at 2 years. On the basis of the minimal clinically important difference, the difference in the QuickDASH score was clinically relevant only at 6 weeks and arguably at 3 months (9.2 and 8.5 points, respectively). Therefore, the statistically significant improvement in the functional outcome of VLP compared with that of EF cannot be safely said to have clinical relevance beyond 12 weeks. The overall complication rate was comparable between the 2 groups. The rate of follow-up at 2 years was 97.0%., Conclusions: VLP fixation resulted in faster recovery of function compared with EF, but no functional advantage was demonstrated at 2 years., Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background: Displaced femoral neck fractures usually are treated with hemiarthroplasty. However, the degree to which the design of the implant used (cemented or uncemented) affects the outcome is not known and may be therapeutically important., Questions/purposes: In this randomized controlled trial, we sought to compare cemented with cementless fixation in bipolar hemiarthroplasties at 5 years in terms of (1) Harris hip scores; (2) femoral fractures; (3) overall health outcomes using the Barthel Index and EQ-5D scores; and (4) complications, reoperations, and mortality since our earlier report on this cohort at 1-year followup., Methods: We present followup at a median of 5 years after surgery (range, 56-65 months) from a randomized trial comparing a cemented hemiarthroplasty (112 hips) with an uncemented, hydroxyapatite-coated hemiarthroplasty (108 hips), both with a bipolar head. Results were previously reported at 1-year followup. Harris hip scores, Barthel Index, and EQ-5D scores were assessed by one research nurse and one orthopaedic surgeon. Complications and reoperations were determined by chart review and radiographs examined by three orthopaedic surgeons. Sixty patients (56%) had died in the cemented group and 63 (60%) in the uncemented group. Respectively, three and two patients (2.7% and 1.9%) were completely lost to followup., Results: Harris hip scores at 5 years were higher in the uncemented group than in the cemented group (86.2 versus 76.3; mean difference 9.9; 95% confidence interval [CI], 1.9-17.9). The prevalence of postoperative periprosthetic femoral fractures was 7.4% in the uncemented group and 0.9% in the cemented group (hazard ratio [HR], 9.3; 95% CI, 1.16-74.5). Barthel Index and EQ-5D scores were not different between the groups. Between 1 and 5 years, we found no additional infections or dislocations. The mortality rate was not different between the groups (HR, 1.2; 95% CI, 0.82-1.7)., Conclusions: Both arthroplasties may be used with good medium-term results after displaced femoral neck fractures. The uncemented hemiarthroplasty may result in higher hip scores but appears to carry an unacceptably high risk of later femoral fractures., Level of Evidence: Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

The treatment of proximal humeral fractures is controversial, and operative treatment is increasing despite sparse evidence to support any surgical method over another. We present the 5-year results of the DelPhi (Delta-PHILOS) trial, in which the hypothesis was that reverse total shoulder arthroplasty (RTSA) yields better clinical results compared with open reduction and internal fixation (ORIF). The DelPhi trial was a multicenter single-blinded randomized controlled trial comparing RTSA versus ORIF for the treatment of displaced AO/OTA type-B2 and C2 proximal humeral fractures in patients 65 to 85 years of age. One hundred and twenty-four patients were allocated to RTSA (64 patients) or ORIF (60 patients). The primary outcome was the Constant score, and secondary outcomes included the Oxford Shoulder Score, radiographic measurements, and quality of life. The results were reported as the mean difference between the groups, with the 95% confidence interval (CI). The mean age was 75 years, and 90% of the patients were female. Overall, 65 of the 124 patients were available at a minimum of 5 years. The mean Constant score was 71.7 (95% CI, 67.1 to 76.3) for the RTSA group, compared with 58.3 (95% CI, 50.6 to 65.9) for the ORIF group, representing a significant difference of 13.4 (95% CI, 5.2 to 21.7) in favor of RTSA (p = 0.002). Among patients with type-C2 fractures, the mean Constant score was 73.3 (95% CI, 67.5 to 79.2) for the RTSA group and 56.0 (95% CI, 47.4 to 64.7) for the ORIF group, representing a significant difference of 17.3 (95% CI, 7.5 to 27.0) in favor of RTSA (p = 0.001). Patients with type-B2 fractures demonstrated a nonsignificant difference of 8.1 (95% CI, −7.3 to 23.3) in favor of RTSA (p = 0.29). Patients 65 to 74 years of age showed a significant mean difference of 15.7 (95% CI, 4.9 to 26.7) in favor of RTSA (p = 0.006), whereas patients 75 to 85 years of age showed a nonsignificant difference of 10.8 (95% CI, −3.0 to 24.6) in favor of RTSA. In the present study, RTSA was superior to plate fixation for displaced AO/OTA type-B2 and C2 fractures in elderly patients at 5 years. Patients 65 to 74 years of age and patients with type-C2 fractures benefited the most. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Recent guidelines recommend non-operative treatment as primary treatment in elderly patients with displaced distal radius fractures. Most of these fractures are closely reduced. We aimed to evaluate the radiological results of closed reduction and casting of dorsally displaced distal radius fractures in patients 65 years or older. Methods: A total of 290 patients treated during the years 2015, 2018 and 2019 in an urban outpatient fracture clinic with complete follow-up at least 5 weeks post-reduction were available for analysis. Closed fracture reduction was performed by manual traction under hematoma block. A circular plaster of Paris cast was used. Radiographs pre- and post-reduction and at final follow-up were analyzed. Results: Mean age was 77 years (SD 8) and 258 (89%) were women. Dorsal tilt improved from mean 111° (range 83–139) to 89° (71–116) post-reduction and fell back to mean 98° (range 64–131) at final follow-up. Ulnar variance was 2 mm ((-1)-12) pre-reduction, 0 mm ((-3)-5) post-reduction and ended at mean 2 mm (0–8). Radial inclination went from 17° ((-6)-30) to 23° (SD 7–33), and then back to 18° (0–32) at final follow-up. 41 (14%) patients had worse alignment at final follow-up compared to pre-reduction. 48 (17%) obtained a position similar to the starting point, while 201 (69%) improved. Fractures with the volar cortex aligned after reduction retained 0.4 mm (95% Confidence Interval (CI) 0.1 to 0.7; p = 0,022) more radius length during immobilization. In a regression analysis, less ulnar variance in initial radiographs (OR 1.8 (95% CI 1.4 to 2.3) per mm, p < 0.001) and lower age (OR 1.06 (95% CI 1.02 to 1.09) per year, p < 0.003) protected against loss of reduction. Conclusion: Subsequent loss of reduction after initial closed reduction was seen in most distal radius fractures. Reduction improved overall alignment in 2/3 of the patients at final follow-up. An aligned volar cortex seemed to protect partially against loss of radial length. [ABSTRACT FROM AUTHOR]

Background: Transsyndesmotic fixation with suture buttons (SBs), posterior malleolar fixation with screws, and anterior inferior tibiofibular ligament (AITFL) augmentation using suture tape (ST) have all been suggested as potential treatments in the setting of a posterior malleolar fracture (PMF). However, there is no consensus on the optimal treatment for PMFs. Purpose: To determine which combination of (1) transsyndesmotic SBs, (2) posterior malleolar screws, and (3) AITFL augmentation using ST best restored native tibiofibular and ankle joint kinematics after 25% and 50% PMF. Study Design: Controlled laboratory study. Methods: Twenty cadaveric lower-leg specimens were divided into 2 groups (25% or 50% PMF) and underwent biomechanical testing using a 6 degrees of freedom robotic arm in 7 states: intact, syndesmosis injury with PMF, transsyndesmotic SBs, transsyndesmotic SBs + AITFL augmentation, transsyndesmotic SBs + AITFL augmentation + posterior malleolar screws, posterior malleolar screws + AITFL augmentation, and posterior malleolar screws. Four biomechanical tests were performed at neutral and 30° of plantarflexion: external rotation, internal rotation, posterior drawer, and lateral drawer. The position of the tibia, fibula, and talus were recorded using a 5-camera motion capture system. Results: With external rotation, posterior malleolar screws with AITFL augmentation resulted in best stability of the fibula and ankle joint. With internal rotation, all repairs that included posterior malleolar screws stabilized the fibula and ankle joint. Posterior and lateral drawer resulted in only small differences between the intact and injured states. No differences were found in the efficacy of treatments between 25% and 50% PMFs. Conclusion: Posterior malleolar screws resulted in higher syndesmotic stability when compared with transsyndesmotic SBs. AITFL augmentation provided additional external rotational stability when combined with posterior malleolar screws. Transsyndesmotic SBs did not provide any additional stability and tended to translate the fibula medially. Clinical Relevance: Posterior malleolar fixation with AITFL augmentation using ST may be the preferred surgical method when treating patients with acute ankle injury involving an unstable syndesmosis and a PMF ≥25%. [ABSTRACT FROM AUTHOR]

Background: Angular stable plates were introduced two decades ago as a promising treatment for fixation of displaced fractures of the proximal humerus (PHF). However, high rates of adverse events and reoperations have been reported. One frequent reason is secondary penetration of screws into the glenohumeral joint, due to sinking of the fracture or avascular head necrosis. To prevent joint penetrations angular stable plates with smooth locking pegs instead of locking screws have been developed. The aim of the present study was to investigate whether blunt pegs instead of pointed screws reduced the risk of secondary penetration into the glenohumeral joint during fracture healing after operatively treated PHFs. Methods: From two different patient cohorts with displaced PHFs (60 treated with PHILOS plate with screws and 50 with ALPS-PHP plate with pegs), two groups were matched according to fracture type AO/OTA 11-B2 and 11-C2 and age (55–85 years). They were followed up at 3, 6 and 12 months. Primary outcome was radiographic signs of peg or screw penetrations into the glenohumeral joint at 12 months. Secondary outcomes were Oxford shoulder score (OSS) and Constant Score (CS) and radiographic signs of avascular humeral head necrosis (AVN). Results: Eighteen PHILOS patients with B2 and C2 fractures could be matched with a corresponding group of 18 operated with ALPS-PHP with pegs. The number of penetrations of pegs and screws were equal between the two groups and the development of avascular head necrosis did not differ either. The functional outcomes for both OSS and CS at 12 months was clearly in favor of patients without joint penetrations in both groups. Conclusion: We found no differences in the number of screw or peg penetrations in the PHILOS and ALPS-PHP group and the occurrence of AVN was equal. Joint penetrations led to inferior functional outcomes at 1 year. The ClinicalTrials.gov identifier 20/11/12 prospectively for the Philos Group is NCT01737060, and for the ALPS group 11/03/20 retrospectively is NCT04622852. [ABSTRACT FROM AUTHOR]

Background and purpose — The trochanteric stabilizing plate (TSP) may be used as an adjunct to a sliding hip screw (SHS) in the treatment of trochanteric fractures to increase construct stability. We performed a scoping review of the literature to clarify when and how the TSP may be useful. Methods — A systematic search was performed in 5 databases and followed by a backwards-and-forwards citation search of the identified papers. 24 studies were included. Results — 6 biomechanical studies and 18 clinical studies were included in the review. The studies presented mainly low-level evidence. All studies were on unstable trochanteric fractures or fracture models. Due to the heterogeneity of methods and reporting, we were not able to perform a meta-analysis. In the biomechanical trials, the TSP appeared to increase stability compared with SHS alone, up to a level comparable with intramedullary nails (IMNs). We identified 1,091 clinical cases in the literature where a TSP had been used. There were 82 (8%) reoperations. The rate of complications and reoperations for SHS plus TSP was similar to previous reports on SHS alone and IMN. It was not possible to conclude whether the TSP gave better clinical results, when compared with either SHS alone or with IMN. Interpretation — The heterogeneity of methods and reporting precluded any clear recommendations on when to use the TSP, or if it should be used at all. [ABSTRACT FROM AUTHOR]

Background: The trochanteric stabilizing plate (TSP) is used as an adjunct to the sliding hip screw (SHS) in unstable trochanteric and subtrochanteric fractures. We wanted to describe the choice of implant for trochanteric fractures with a focus on the TSP in Norway. Methods: A total of 20,902 fractures from the Norwegian Hip Fracture Register treated surgically in 43 hospitals from 2011 to 2017 were included. Logistic regression analyses were performed to detect factors potentially influencing implant choice. Results: The mean age was 83 years, and 15,137 (72%) were women. An SHS was used in 13,273 (63%) fractures, of them 4407 (33%) with a TSP. Fracture classification was the most important determinant of TSP. In cases where an SHS was used, the odds ratio (OR) for using a TSP was 14 for AO/OTA 31A2 fractures and 71 for AO/OTA 31A3 and subtrochanteric fractures, compared to AO/OTA 31A1 fractures. The probability of receiving a TSP was higher in urban, academic, and high-volume hospitals (OR 1.2 to 1.3) and lower in Central and Northern Norway (OR 0.3 to 0.7). The use of an intramedullary nail (IMN) (n = 7629 (36%)) was also to a degree decided by fracture classification (OR 1.8 to 5.3). However, hospital factors, with OR 0.1 to 0.4 for IMN in academic, urban, and high-volume hospitals and OR 1.5 to 2.6 outside South-Eastern Norway (all p < 0.001), were also important. Conclusions: Fracture classification was the main determinant for TSP use. Any additional benefit from a TSP on postoperative fracture stability or clinical outcome needs to be clarified. [ABSTRACT FROM AUTHOR]

Background: Almost one-third of patients with proximal humeral fractures are treated surgically, and the number is increasing. When surgical treatment is chosen, there is sparse evidence on the optimum method. The DelPhi (Delta prosthesis-PHILOS plate) trial is a clinical trial comparing 2 surgical treatments. Our hypothesis was that reverse total shoulder arthroplasty (TSA) yields better clinical results compared with open reduction and internal fixation (ORIF) using an angular stable plate.Methods: The DelPhi trial is a randomized controlled trial comparing reverse TSA with ORIF for displaced proximal humeral fractures (OTA/AO types 11-B2 and 11-C2) in elderly patients (65 to 85 years of age). The primary outcome measure was the Constant score at a 2-year follow-up. The secondary outcome measures included the Oxford Shoulder Score and radiographic evaluation. Results were reported as the mean difference with 95% confidence interval (CI). The intention-to-treat principle was applied for crossover patients.Results: There were 124 patients included in the study. At 2 years, the mean Constant score was 68.0 points (95% CI, 63.7 to 72.4 points) for the reverse TSA group compared with 54.6 points (95% CI, 48.5 to 60.7 points) for the ORIF group, resulting in a significant mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p < 0.001) in favor of reverse TSA. When stratified for fracture classification, the mean score was 69.3 points (95% CI, 63.9 to 74.7 points) for the reverse TSA group and 50.6 points (95% CI, 41.9 to 59.2 points) for the ORIF group for type-C2 fractures, which yielded a significant mean difference of 18.7 points (95% CI, 9.3 to 28.2 points; p < 0.001). In the type-B2 fracture group, the mean score was 66.2 points (95% CI, 58.6 to 73.8 points) for the reverse TSA group and 58.5 points (95% CI, 49.6 to 67.4 points) for the ORIF group, resulting in a nonsignificant mean difference of 7.6 points (95% CI, -3.8 to 19.1 points; p = 0.19).Conclusions: At a 2-year follow-up, the data suggested an advantage of reverse TSA over ORIF in the treatment of displaced OTA/AO type-B2 and C2 proximal humeral fractures in elderly patients.Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: This study compared clinical and radiographic results between patients who underwent stabilization of an acutely injured syndesmosis with a suture button (SB) and those treated with 1 quadricortical syndesmotic screw (SS).Methods: Ninety-seven patients, 18 to 70 years old, with an ankle injury that included the syndesmosis were randomized to 2 groups: SB (48 patients) and SS (49). The main outcome measure was the score on the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scale. The secondary outcome measures were the Olerud-Molander Ankle (OMA) score, visual analog scale (VAS), and EuroQol-5D (EQ-5D) Index and VAS. Computed tomography (CT) scans of both ankles were obtained at 2 weeks and 1 and 2 years after surgery. Both groups were allowed partial weight-bearing at 2 weeks and full weight-bearing at 6 weeks. The mean time for SS removal was 85.9 days (range, 39 to 132 days) after surgery. The patients were followed at 6 weeks, 6 months, and 1 and 2 years. Two years of follow-up were completed for 87 (90%) of the patients (46 in the SB group and 41 in the SS group).Results: The SS group had more injuries to the posterior malleolus than the SB group. At 2 years, the median AOFAS score was higher in the SB group than in the SS group (96 [interquartile range, or IQR, 90 to 100] versus 86 [IQR, 80 to 96]; p = 0.001), as was the median OMA score (100 [IQR, 95 to 100] versus 90 [IQR, 75 to 100]; p < 0.001). The SB group reported less pain during walking at 2 years than the SS group (median VAS score, 0 [IQR, 0 to 1] versus 1 [IQR, 0 to 2]; p = 0.008) and less pain during rest (median VAS score, 0 [IQR, 0 to 0] versus 0 [IQR, 0 to 1]; p = 0.04). There was no difference between treatments groups with regard to pain at night or during daily activities at 2 years. The SB group had a higher median EQ-5D Index score at 2 years (1.0 [IQR, 1 to 1] versus 0.88 [IQR, 0.8 to 1.0]; p = 0.005). Twenty of 40 patients in the SS group had a difference in the tibiofibular distance of ≥2 mm between the injured and uninjured ankles at 2 years, compared with 8 of 40 in the SB group (p = 0.009). Seven patients in the SS group had symptomatic recurrent syndesmotic diastasis during the treatment period compared with none in the SB group (p = 0.005).Conclusions: The patients treated with an SB had higher AOFAS scores, OMA scores, and EQ-5D Index scores as well as lower (better) VAS scores for pain during walking and pain during rest. Also, the SB group had less widening seen radiographically at 2 years than did the patients in the SS group. No differences in the scores for pain at night or during daily activities were identified.Level Of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

Background: Talar fractures are associated with a high incidence of avascular necrosis (AVN), osteoarthritis (OA) and malunion. The aim of this study was to evaluate the complications, the functional outcome, and the need for secondary surgery following surgically treated talar fractures.Methods: Fifty patients with 52 talar fractures were included in the study. The health related quality of life was evaluated using visual analogue scale (VAS). The ankle function was scored using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. OA and AVN were evaluated on plain radiographs and computerized tomography (CT) scans.Results: VAS score was 69±18 (mean±SD) and AOFAS ankle-hindfoot score was 73±17 (mean±SD). OA was seen in 98% and AVN in 65% of the talar bones. Secondary surgery had been performed in 38% of the feet.Conclusion: Long-term complications were commonly seen after talar fractures and had a significant impact on daily life activities and quality of life. The need for secondary surgery was high. Prolonged follow-up is necessary to detect long-term complications, and the patients should be offered a low threshold for recontact. [ABSTRACT FROM AUTHOR]

Background and Purpose: Incidence of posterior malleolar fractures (PMFs) associated with ankle fractures is historically based on plain radiographs. Several classification systems for PMF are currently in use, but the reliability of the Haraguchi classification is not reported. The aim of this diagnostic cohort study was to assess incidence of PMF in patients with AO 44-C fractures, and test the reliability of the Haraguchi fracture classification based on CT. In addition, to evaluate the clinical outcome in patients with PMF.Methods: 210 patients with an AO 44-C type fracture treated with syndesmotic fixation between 2011 and 2017 were included. Presence of PMF was registered, morphology was assessed and classified according to the Haraguchi classification. Interobserver agreement for the Haraguchi classification was evaluated. Patient assessment was conducted at 6 weeks, 6 months, 1 and 2 years. The American Orthopaedic Foot & Ankle Society Ankle-Hindfoot Score (AOFAS) was the primary outcome measure. Secondary outcome measures included presence of osteoarthritis.Results: 125 of 210 patients (60%) had a PMF. 34% of the PMFs were missed on plain radiographs compared to CT. The interobserver agreement was 0.797, (95% CI: 0.705 to 0.889, p < 0.001), for the Haraguchi classification. The 2-year follow-up rate was 86%. Haraguchi type II fractures had a lower AOFAS compared with the no-fracture group at 6 weeks (mean difference -7.5 (95% CI; -15.0 to -0.2), p = 0.04) and 6 months (mean difference -8.4 (95% CI; -15.3 to -1.5), p = 0.01). Presence of osteoarthritis was higher in patients with Haraguchi type II PMF compared to the no PMF group, this finding was not significant (relative risk (RR) 1.6(95% CI 1.1 to 2.4, p = 0.059)).Conclusions: Plain radiographs underestimated PMF. Patients with a Haraguchi type II fracture had a poorer outcome measured by the AOFAS score compared to no PMF up until 6 months. Classification of PMF according to the Haraguchi classification was reliable. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to evaluate the outcome after nondisplaced and stable Lisfranc injuries.Methods: 26 patients with injuries to the Lisfranc joint complex detected on CT scans, but without displacement were tested to be stable using a fluoroscopic stress test. The patients were immobilized in a non-weightbearing short leg cast for 6 weeks. The final follow-up was 55 (IQR 53-60) months after injury.Results: All the Lisfranc injuries were confirmed to be stable on follow-up weightbearing radiographs at a minimum of 3 months after injury. Median American Foot and Ankle Society (AOFAS) midfoot score at 1-year follow-up was 89 (IQR 84-97) and at final follow-up 100 (IQR 90-100); The AOFAS score continued to improve after 1-year (P=.005). The median visual analog scale (VAS) for pain was 0 (IQR 0-0) at the final follow-up. One patient had radiological signs of osteoarthritis at 1-year follow-up.Conclusion: Stable Lisfranc injuries treated nonoperatively had an excellent outcome in this study with a median follow-up of 55 months. The AOFAS score continued to improve after 1 year. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective case series.Introduction: Traumatic lumbosacral dissociation (TLSD) is a rare subgroup of sacral fractures caused by high-energy trauma in healthy adults. There are no accepted treatment algorithms for these injuries. Neurologic deficits and pain are commonly associated with these injuries, however, little is known about the long-term functional outcome in patients with TLSD. The objective of this study was to assess long-term functional outcome in patients with traumatic lumbosacral dissociation (TLSD) injuries.Materials and Methods: Thirteen patients with TLSD were retrospectively identified and followed with clinical and radiological examination mean 7.7 (3-12) years after the injury. Five were treated operatively, and eight non-operatively. Sensorimotor impairments in the lower extremities were classified according to ASIA. Urinary function was assessed with uroflowmetry, and bowel- and sexual functions were assessed using a structured interview. Pain was assessed using a visual analogue scale (VAS), and patient-reported health with SF-36. CT images were scrutinized for non-union and kyphotic angulation across the fracture.Results: Eleven patients had neurologic deficits corresponding to L5 and sacral roots. Urinary dysfunction was observed in nine, and bowel dysfunction in three patients. Eight patients reported problems associated with sexual activities, with pain during intercourse and erectile dysfunction being the most common problems. Twelve patients reported pain in the lumbosacral area, in combination with radiating pain in the majority. The overall patient-reported health (SF-36) was significantly lower than the normal population. All sacral fractures were united as seen on CT. Sacral kyphotic angulation was present in 11, which had increased in three patients comparing with the initial radiographs.Conclusion: In this long-term follow-up, functional impairments, pain, and poor patient-reported health were common findings among patients with TLSD. High rates of neurologic, urinary and sexual dysfunctions were reported. Extended follow-up several years after the injury with a special focus on urogenital dysfunctions and pain management may be beneficial to these patients. [ABSTRACT FROM AUTHOR]