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Purpose: The 3-category rating of volar plate prominence in relation to the most volar edge of the distal radius (the watershed line) on lateral radiographs was reliable among a small group of surgeons and associated with the probability of flexor tendon irritation and potential rupture. Classifications are often less reliable when tested among a large group of practicing surgeons in different environments. Methods: In this survey-based experiment, an international group of 115 fracture and upper extremity surgeons viewed 1 of 4 sets of 24 lateral radiographs (96 unique lateral radiographs) of patients with distal radius fractures who underwent volar plating in the practice of a single surgeon using 2 types of plates. Surgeons were asked to rate the following metrics: (1) the grade of plate prominence according to Soong, (2) whether the plate was more prominent than the watershed line, (3) whether the plate was separate from the bone distally, and (4) whether there is more than 5° of dorsal angulation of the distal radius articular surface. Results: The interobserver agreement of the classification was “fair” (κ = 0.32; 95% confidence interval [CI] = 0.27–0.36), and grading was more reliable among surgeons who do not supervise trainees. Volar prominence was less reliable (κ = 0.034; 95% CI = 0.013–0.055) than plate separation from bone (κ = 0.50; 95% CI = 0.42–0.59) and more than 5° of dorsal angulation (κ = 0.42; 95% CI = 0.35–0.48). Conclusions: Among a large number of international practicing surgeons, the classification of volar plate prominence in 3 categories was fair. Clinical Relevance: The diagnosis of plate prominence might develop toward criteria with moderate reliability, such as separation of the plate from the bone and residual angulation of the distal radius.

Evidence with regard to antibiotic prophylaxis for patients with open fractures of the extremities is limited. We therefore conducted a systematic survey addressing current practice and recommendations.We included publications from January 2007 to June 2017. We searched Embase, MEDLINE, CINAHL, the Cochrane Central Registry of Controlled Trials (CENTRAL), and the Cochrane Database of Systematic Reviews for clinical studies and surveys of surgeons; WorldCat for textbooks; and web sites for guidelines and institutional protocols.We identified 223 eligible publications that reported 100 clinical practice patterns and 276 recommendations with regard to systemic antibiotic administration, and 3 recommendations regarding local antibiotic administration alone. Most publications of clinical practice patterns used regimens with both gram-positive and gram-negative coverage and continued the administration for 2 to 3 days. Most publications recommended prophylactic systemic antibiotics. Most recommendations suggested gram-positive coverage for less severe injuries and administration duration of 3 days or less. For more severe injuries, most recommendations suggested broad antimicrobial coverage continued for 2 to 3 days. Most publications reported intravenous administration of antibiotics immediately.Current practice and recommendations strongly support early systemic antibiotic prophylaxis for patients with open fractures of the extremities. Differences in antibiotic regimens, doses, and durations of administration remain in both practice and recommendations. Consensus with regard to optimal practice will likely require well-designed randomized controlled trials.The current survey of literature systematically provides surgeons' practice and the available expert recommendations from 2007 to 2017 on the use of prophylactic antibiotics in the management of open fractures of extremities.

Item does not contain fulltext PURPOSE: Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth. METHODS: A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure. RESULTS: The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (kappa = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups. CONCLUSIONS: When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Benefits and harms of tenofovir disoproxil fumarate (TDF) in HIV-infected, antiretroviral treatment (ART)-naïve patients of any age have not been systematically reviewed since recent milestone trials were published.We searched MEDLINE, EMBASE, CENTRAL, SCI, LILACS, WHO GHL, and ClinicalTrials.gov for randomized controlled trials (RCTs) comparing TDF-based treatments with any other ART-regimen (last search 01/2015). Trial characteristics and results were extracted, risks of bias systematically assessed, and treatment effects synthesized in meta-analyses using random-effects models.We included 22 RCTs (8297 patients). We found no differences between groups for mortality, AIDS, fractures, CD4 cell count, and virological failure; and inconclusive information due to inadequate reporting for cardiovascular events, renal failure, proteinuria, rash, and quality of life. Tenofovir disoproxil fumarate-based regimens significantly reduced total cholesterol (mean difference -18.42 mg/dl; 95% confidence interval [CI] -22.80 to -14.0), LDL-cholesterol (-9.53 mg/dl; -12.16 to -6.89), HDL-cholesterol (-2.97 mg/dl; -4.41 to -1.53), and triglycerides (-29.77 mg/dl; -38.61 to -20.92), bone mineral density (BMD) (hip: -1.41%; -1.87 to -0.94), and glomerular filtration rate (eGFR) (-3.47 ml/minute; -5.89 to -1.06) over 48 weeks of follow-up. Effects were similar in trials comparing fixed-dose TDF/FTC-based regimens with ABC/3TC-based regimens. We found no influence of baseline viral load on virological failure.Moderate-quality evidence suggests similar effects of TDF-based treatment regimens and other ART on virological failure. Tenofovir disoproxil fumarate-based regimens are associated with a more favorable lipid profile, but with increased risk of reduced BMD and eGFR. Improved reporting quality is vital to allow assessment of clinical outcomes in future trials.

Background Multiple surgical procedures in a single patient are relatively common and lead to dependent (clustered) data. This dependency needs to be accounted for in study design and data analysis. A systematic review was performed to assess how clustered data were handled in inguinal hernia trials. The impact of ignoring clustered data was estimated using simulations. Methods PubMed, Embase and the Cochrane Library were reviewed systematically for RCTs published between 2004 and 2013, including patients undergoing unilateral or bilateral inguinal hernia repair. Study characteristics determining the appropriateness of handling clustered data were extracted. Using simulations, various statistical methods accounting for clustered data were compared with an analysis ignoring clustering by assuming 100 hernias, with a varying percentage of patients having bilateral hernias. Results Of the 50 eligible trials including patients with bilateral hernias, 20 (40 per cent) did not provide information on how they dealt with clustered data and 18 (36 per cent) avoided clustering by assessing the outcome by patient and not by hernia. None of the remaining 12 trials (24 per cent) considered clustering in the design or analysis. In the simulations, ignoring clustering led to an increased type I error rate of up to 12 per cent and to a loss in power of up to 15 per cent, depending on whether the patient or the hernia was the randomization unit. Conclusion Clustering was rarely considered in inguinal hernia trials. The simulations underline the importance of considering clustering as part of the statistical analysis to avoid false-positive and false-negative results, and hence inappropriate study conclusions.

Background Nicotinic acid (niacin) is known to decrease LDL-cholesterol, and triglycerides, and increase HDL-cholesterol levels. The evidence of benefits with niacin monotherapy or add-on to statin-based therapy is controversial. Objectives To assess the effectiveness of niacin therapy versus placebo, administered as monotherapy or add-on to statin-based therapy in people with or at risk of cardiovascular disease (CVD) in terms of mortality, CVD events, and side effects. Search methods Two reviewers independently and in duplicate screened records and potentially eligible full texts identified through electronic searches of CENTRAL, MEDLINE, Embase, Web of Science, two trial registries, and reference lists of relevant articles (latest search in August 2016). Selection criteria We included all randomised controlled trials (RCTs) that either compared niacin monotherapy to placebo/usual care or niacin in combination with other component versus other component alone. We considered RCTs that administered niacin for at least six months, reported a clinical outcome, and included adults with or without established CVD. Data collection and analysis Two reviewers used pre-piloted forms to independently and in duplicate extract trials characteristics, risk of bias items, and outcomes data. Disagreements were resolved by consensus or third party arbitration. We conducted random-effects meta-analyses, sensitivity analyses based on risk of bias and different assumptions for missing data, and used meta-regression analyses to investigate potential relationships between treatment effects and duration of treatment, proportion of participants with established coronary heart disease and proportion of participants receiving background statin therapy. We used GRADE to assess the quality of evidence. Main results We included 23 RCTs that were published between 1968 and 2015 and included 39,195 participants in total. The mean age ranged from 33 to 71 years. The median duration of treatment was 11.5 months, and the median dose of niacin was 2 g/day. The proportion of participants with prior myocardial infarction ranged from 0% (4 trials) to 100% (2 trials, median proportion 48%); the proportion of participants taking statin ranged from 0% (4 trials) to 100% (12 trials, median proportion 100%). Using available cases, niacin did not reduce overall mortality (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.97 to 1.12; participants = 35,543; studies = 12; I2 = 0%; high-quality evidence), cardiovascular mortality (RR 1.02, 95% CI 0.93 to 1.12; participants = 32,966; studies = 5; I2 = 0%; moderate-quality evidence), non-cardiovascular mortality (RR 1.12, 95% CI 0.98 to 1.28; participants = 32,966; studies = 5; I2 = 0%; high-quality evidence), the number of fatal or non-fatal myocardial infarctions (RR 0.93, 95% CI 0.87 to 1.00; participants = 34,829; studies = 9; I2 = 0%; moderate-quality evidence), nor the number of fatal or non-fatal strokes (RR 0.95, 95% CI 0.74 to 1.22; participants = 33,661; studies = 7; I2 = 42%; low-quality evidence). Participants randomised to niacin were more likely to discontinue treatment due to side effects than participants randomised to control group (RR 2.17, 95% CI 1.70 to 2.77; participants = 33,539; studies = 17; I2 = 77%; moderate-quality evidence). The results were robust to sensitivity analyses using different assumptions for missing data. Authors' conclusions Moderate- to high-quality evidence suggests that niacin does not reduce mortality, cardiovascular mortality, non-cardiovascular mortality, the number of fatal or non-fatal myocardial infarctions, nor the number of fatal or non-fatal strokes but is associated with side effects. Benefits from niacin therapy in the prevention of cardiovascular disease events are unlikely.

Nail, plate and external fixator are since decades the most frequently and stabilizers for the surgical treatment of dia- and metaphyseal fractures. These elements are still present today. However, there were important changes in recent years. Together with better knowledge and understanding of fracture healing, fracture biology, implant metallurgy and mechanics and a more and more specified application of these techniques, this resulted in improved possibilities for the treatment of injured patients. Beside an overview about the current discussion of unreamed and reamed nail insertion new trends, techniques and nails are presented for the different long bones (retrograd nails, spiral blade, flex-nail humerus and a distal aiming device (DAD) for interlocking screws). In addition, new approach techniques for nailing (stab incision) and minimally invasive percutaneous plate osteosynthesis (MIPO) for metaphyseal fractures of the proximal and distal femur and proximal tibia are described including the necessary techniques for control of axes and rotation.

Background Transcatheter aortic valve implantation (TAVI), widely used to treat high-risk patients with severe symptomatic aortic stenosis, has recently been extended to younger patients at lower operative risk in whom long-term durability of TAVI devices is an important concern. Therefore, we conducted a systematic review and meta-analysis of observational studies addressing the frequency of structural valve deterioration (SVD) after TAVI. Methods We searched Medline, Embase, Cochrane Database of Systematic Reviews, and Cochrane CENTRAL from 2002 to September 2016. We included observational studies following patients with TAVI for at least 2 years. Independently and in duplicate, we evaluated study eligibility, extracted data, and assessed risk of bias for SVD post-TAVI. Our review used the GRADE system to assess quality of evidence. We pooled incidence rates using a random effects model. Results Thirteen studies including 8914 patients, with a median follow-up between 1.6 and 5 years, reported an incidence of SVD post-TAVI between 0 to 1.34 per 100 patient years. The pooled incidence of SVD was 28.08 per 10 000 patients/year (95% CI 2.46 to 73.44 per 100 patient years). Of those who developed SVD, 12% underwent valve re-intervention. Confidence in the evidence was moderate due to inconsistency among studies. Conclusion Structural valve deterioration is probably an infrequent event within the first 5 years after TAVI. Ascertaining the impact of SVD and the need for valve-related re-interventions to inform recommendations for patients with a longer life-expectancy will require studies including a large number of patients with longer follow-up (>10 years).

Loss of contact between radial head fracture fragments is strongly associated with other elbow or forearm injuries. If this finding has adequate interobserver reliability, it could help examiners identify and treat associated ligament injuries and fractures (eg, forearm interosseous ligament injury or elbow dislocation). (1) What is the interobserver agreement on radiographic loss of contact between radial head fracture fragments? (2) Are there factors associated with the observer such as location of practice or subspecialization that increase interobserver reliability? Fully trained practicing orthopaedic and trauma surgeons from around the world evaluated 27 anteroposterior and lateral radiographs of radial head fractures on a web-based platform for the following characteristics: (1) loss of contact between at least one radial head fracture fragment and the remaining radial head and neck; (2) a gap between fragments of 2 mm or greater; (3) anticipated fracture instability (mobility) on operative exposure; (4) anticipated associated ligament injuries; and (5) recommendation for treatment. Agreement among observers was measured using the multirater kappa measure. Kappas for various observer characteristics were compared using 95% confidence intervals. The overall interobserver agreement was moderate (range, 0.49-0.55) for each question except associated ligament injury, which was fair (0.33). Shoulder and elbow surgeons had substantial agreement (range, 0.51-0.61) in many areas, but kappas were generally in the moderate range (0.41-0.59) based on number of years in practice, radial head fractures treated per year, and trainee supervision. Radiographic signs of radial head fracture instability such as loss of contact have moderate reliability. This characteristic seems clinically useful, because loss of contact between at least one radial head fracture fragment and the remaining radial head and neck is strongly associated with associated ligament injury or other fractures. Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence

Item does not contain fulltext OBJECTIVES: There is substantial variation in the classification and management of scapula fractures. The first purpose of this study was to analyze the interobserver reliability of the OTA/AO classification and the New International Classification for Scapula Fractures. The second purpose was to assess the proportion of agreement among orthopaedic surgeons on operative or nonoperative treatment. DESIGN: Web-based reliability study. SETTING: Independent orthopaedic surgeons from several countries were invited to classify scapular fractures in an online survey. PARTICIPANTS: One hundred three orthopaedic surgeons evaluated 35 movies of three-dimensional computerized tomography reconstruction of selected scapular fractures, representing a full spectrum of fracture patterns. MAIN OUTCOME MEASUREMENTS: Fleiss kappa (kappa) was used to assess the reliability of agreement between the surgeons. RESULTS: The overall agreement on the OTA/AO classification was moderate for the types (A, B, and C, kappa = 0.54) with a 71% proportion of rater agreement (PA) and for the 9 groups (A1 to C3, kappa = 0.47) with a 57% PA. For the New International Classification, the agreement about the intraarticular extension of the fracture (Fossa (F), kappa = 0.79) was substantial and the agreement about a fractured body (Body (B), kappa = 0.57) or process was moderate (Process (P), kappa = 0.53); however, PAs were more than 81%. The agreement on the treatment recommendation was moderate (kappa = 0.57) with a 73% PA. CONCLUSIONS: The New International Classification was more reliable. Body and process fractures generated more disagreement than intraarticular fractures and need further clear definitions. 01 maart 2014

Current anterior fixators can close a disrupted anterior pelvic ring. However, these anterior constructs cannot create posterior compressive forces across the sacroiliac joint. We explored whether a modified fixator could create such forces.We determined whether (1) an anterior external fixator with a second anterior articulation (X-frame) would provide posterior pelvic compression and (2) full pin insertion would deliver higher posterior compressive forces than half pin insertion.We simulated AP compression Type III instability with plastic pelvis models and tested the following conditions: (1) single-pin supraacetabular external fixator (SAEF) using half pin insertion (60 mm); (2) SAEF using full pin insertion (120 mm); (3) modified fixator with X-frame using half pin insertion; (4) modified fixator using full pin insertion; and (5) C-clamp. Standardized fracture compression in the anterior and posterior compartment was performed as in previous studies by Gardner. A force-sensitive sensor was placed in the symphysis and posterior pelvic ring before fracture reduction and the fractures were reduced. The symphyseal and sacroiliac compression loads of each application were measured.The SAEF exerted mean compressions of 13 N and 14 N to the posterior pelvic ring using half and full pin insertions, respectively. The modified fixator had mean posterior compressions of 174 N and 222 N with half and full pin insertions, respectively. C-clamp application exerted a mean posterior load of 407 N.Posterior compression on the pelvis was improved using an X-frame as an anterior fixation device in a synthetic pelvic fracture model.This additive device may improve the initial anterior and posterior stability in the acute management of unstable and life-threatening pelvic ring injuries.

Tibial plateau fracture classification systems have limited interobserver reliability and new systems emerge. The purpose of this study was to compare the reliability of the Luo classification and the Schatzker classification for two-dimensional computed tomography (2DCT) and to study the effect of adding three-dimensional computed tomography (3DCT). Eighty-one observers, orthopedic surgeons and residents, were randomized to either 2DCT or 2D- and 3DCT evaluation of a spectrum of 15 complex tibial plateau fractures using web-based platforms in order to classify according to the Schatzker and according to Luo's Three Column classification. Reliability was calculated with the use of Siegel and Castellan's multirater kappa measure. Kappa values were interpreted according to the categorical rating by Landis and Koch. Overall interobserver reliability of the Schatzker classification was significantly better compared to the Luo classification (kSchatzker=0.32 and kLuo=0.28, P=0.021), however, 'fair' for both fracture classification systems. For the Schatzker classification observers agreed significantly better on 2DCT compared to 2D- and 3DCT (k2DCT=0.37 and k2D+3DCT=0.29, P

We prospectively followed a case series of 68 patients with 69 AO/ASIF 41-C-type fractures treated with the Less Invasive Stabilization System for the proximal lateral tibia. We assessed malreduction, secondary loss of reduction, and infection rates in patients with a locked screw plate for unilateral fixation of bicondylar fractures. Sixty-two (91%) patients returned for final followup (range, 11-13 months). Malreduction and malalignment were defined as an intraarticular step-off of 2 mm or greater, or as a malalignment in the frontal or sagittal plane greater than 5 degrees . Fourteen fractures were open. Primary bone grafting was done in 13 patients. Significant malreduction was seen in 16 patients. There were four superficial infections and one deep infection. One fracture did not heal, and nine patients had substantial loss of reduction. Unilateral locked screw plating is a good alternative for treatment of problematic fractures of the tibial plateau that are associated with soft tissue damage and metaphyseal comminution. The reduction technique for exact alignment is demanding.

Item does not contain fulltext BACKGROUND: The factors influencing the decision making of operative treatment for fractures of the proximal humerus are debated. We hypothesized that there is no difference in treatment recommendations between surgeons shown radiographs alone and those shown radiographs and patient information. Secondarily, we addressed (1) factors associated with a recommendation for operative treatment, (2) factors associated with recommendation for arthroplasty, (3) concordance with the recommendations of the treating surgeons, and (4) factors affecting the inter-rater reliability of treatment recommendations. METHODS: A total of 238 surgeons of the Science of Variation Group rated 40 radiographs of patients with proximal humerus fractures. Participants were randomized to receive information about the patient and mechanism of injury. The response variables included the choice of treatment (operative vs nonoperative) and the percentage of matches with the actual treatment. RESULTS: Participants who received patient information recommended operative treatment less than those who received no information. The patient information that had the greatest influence on treatment recommendations included age (55%) and fracture mechanism (32%). The only other factor associated with a recommendation for operative treatment was region of practice. There was no significant difference between participants who were and were not provided with information regarding agreement with the actual treatment (operative vs nonoperative) provided by the treating surgeon. CONCLUSION: Patient information-older age in particular-is associated with a higher likelihood of recommending nonoperative treatment than radiographs alone. Clinical information did not improve agreement of the Science of Variation Group with the actual treatment or the generally poor interobserver agreement on treatment recommendations.

Copyright © 2015 Wolters Kluwer Health Inc. All rights reserved. Objective: To investigate the prevalence of discontinuation and nonpublication of surgical versus medical randomized controlled trials (RCTs) and to explore risk factors for discontinuation and nonpublication of surgical RCTs. Background: Trial discontinuation has significant scientific ethical and economic implications. To date the prevalence of discontinuation of surgical RCTs is unknown. Methods: All RCT protocols approved between 2000 and 2003 by 6 ethics committees in Canada Germany and Switzerland were screened. Baseline characteristics were collected and if published full reports retrieved. Risk factors for early discontinuation for slow recruitment and nonpublication were explored using multivariable logistic regression analyses. Results: In total 863 RCT protocols involving adult patients were identified 127 in surgery (15) and 736 in medicine (85). Surgical trials were discontinued for any reason more often than medical trials [43 vs 27 risk difference 16 (95 confidence interval [CI]: 5 26); P = 0.001] and more often discontinued for slow recruitment [18 vs 11 risk difference 8 (95 CI: 0.1 16); P = 0.020]. The percentage of trials not published as full journal article was similar in surgical and medical trials (44 vs 40 risk difference 4 (95 CI: 5 to 14); P = 0.373). Discontinuation of surgical trials was a strong risk factor for nonpublication (odds ratio = 4.18 95 CI: 1.45 12.06; P = 0.008). Conclusions: Discontinuation and nonpublication rates were substantial in surgical RCTs and trial discontinuation was strongly associated with nonpublication. These findings need to be taken into account when interpreting surgical literature. Surgical trialists should consider feasibility studies before embarking on full scale trials.

Supracondylar femoral fractures still present a challenge to the treating surgeon. The incidence of delayed and non-unions is reduced due to the minimally invasive plating techniques, but establishing a correct axis and good function is still a problem. During the last few years new implants have been developed to allow less difficult operative techniques in minimally invasive surgery. The Less Invasive Stabilization System (LISS) is a percutaneous plating system with monocortical self-drilling screws. The screws are inserted with an aiming guide and form a stable angle with the plate. The distal femoral nail allows placement of a spiral blade in the nail, thereby enhancing the interlocking stability.

We describe the results after open reduction and internal fixation of 22 consecutive displaced fractures of the glenoid with a mean follow-up of ten years. A posterior approach was used in 16 patients and an anterior in six, the approach being chosen according to the Ideberg classification of the fractures. The fixation failed in two patients, one of whom required a further operation. There were two cases of deep infection. At follow-up the median Constant score was 94% (mean 79%, range 17 to 100). The score was less than 50% in four patients, including the two who became infected. A further two had an associated complete palsy of the brachial plexus.

Farrar questions the finding of our systematic review—that low intensity pulsed ultrasound (LIPUS) was not effective12—based on two hypotheses. Firstly, that despite being ineffective in fresh fractures, LIPUS may work in non-union fractures and, secondly, that its effectiveness is dose dependent. Our systematic review included three trials that enrolled patients with non-union of a fracture, all of which were at high risk of bias, and none reported outcomes that are important to patients. We …

Objective To determine the efficacy of low intensity pulsed ultrasound (LIPUS) for healing of fracture or osteotomy.Design Systematic review and meta-analysis.Data sources Medline, Embase, CINAHL, Cochrane Central Register of Controlled Trials, and trial registries up to November 2016.Study selection Randomized controlled trials of LIPUS compared with sham device or no device in patients with any kind of fracture or osteotomy.Review methods Two independent reviewers identified studies, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including selection of outcomes important to patients. The GRADE system was used to assess the quality of evidence.Results 26 randomized controlled trials with a median sample size of 30 (range 8-501) were included. The most trustworthy evidence came from four trials at low risk of bias that included patients with tibia or clavicle fractures. Compared with control, LIPUS did not reduce time to return to work (percentage difference: 2.7% later with LIPUS, 95% confidence interval 7.7% earlier to 14.3% later; moderate certainty) or the number of subsequent operations (risk ratio 0.80, 95% confidence interval 0.55 to 1.16; moderate certainty). For pain, days to weight bearing, and radiographic healing, effects varied substantially among studies. For all three outcomes, trials at low risk of bias failed to show a benefit with LIPUS, while trials at high risk of bias suggested a benefit (interaction PConclusions Based on moderate to high quality evidence from studies in patients with fresh fracture, LIPUS does not improve outcomes important to patients and probably has no effect on radiographic bone healing. The applicability to other types of fracture or osteotomy is open to debate.Systematic review registration PROSPERO CRD42016050965

What you need to know #### Linked articles in this BMJ Rapid Recommendations cluster Does low intensity pulsed ultrasound (LIPUS) accelerate recovery in adults and children who have experienced bone fractures or osteotomy (cutting of a bone)? An expert panel rapidly produced these recommendations based on a linked systematic review triggered by a large multicentre randomised trial in adults with tibial fracture. Fracture is common (see box 1). Bones can also be broken for medical reasons; osteotomy is a procedure whereby a bone is cut to shorten, lengthen, or to change its alignment. Following osteotomy, the bone has similar healing problems as traumatic fractures, and may require more extensive recovery.1 #### Box 1: Background information ##### Bone fracture ##### LIPUS

In recent years, the technique of surgical stabilization in the distal femur has changed. This change decreased the number of non unions and the need for bone grafting. Minimally invasive surgical techniques with a submuscular plate placement have replaced the emphasis on anatomical reduction in the shaft area. Reconstruction of complex articular injuries has been simplified by more direct visualization of the articular surface with the lateral peripatellar approach. Problems remaining are surgical technique and implant considerations. The Less Invasive Stabilization System (LISS) simplifies the surgical technique for percutaneous plate osteosynthesis. An insertion guide is used to insert monocortical, self-tapping screws through a stab incision. A thread in the plate provides the angular stability for the anchoring of these screws. In extra-articular fractures and simple intra-articular fractures, the distal femoral nail permits intramedullary stabilization. A spiral blade improves fixation of the distal femoral condylar block. Despite the enhanced surgical technique and implant possibilities, a great number of patients show a functional deficiency. These are particularly patients with complex intra-articular fractures. The 'fatigue failure' of the osteoporotic implant-bone construct is a problem in elderly patients. The LISS represents a good option to avoid the addition of bone cement to an osteosynthesis.

In einer prospektiven, nicht randomisierten Studie wurden zwischen Februar 1997 und September 1998 29 frische distale Femurfrakturen mit dem LIS-System versorgt. In die Nachuntersuchung wurden 29 Frakturen eingeschlossen. Die durchschnittliche Nachuntersuchungszeit betrug 6 Monate (1,5–16 Monate). Postoperativ kam es in 1 Fall zu heterotopen Ossifikationen mit Einschrankung der Kniegelenkbeweglichkeit, in 1 Fall zu einer tiefen Beinvenenthrombose mit Lungenembolie und in 3 Fallen zu tiefen Infekten, davon 2-mal als Folge offener Frakturen. In 2 Fallen kam es zu Schraubenausrissen. Die Zeit bis zur knochernen Durchbauung betrug durchschnittlich 3,1 Monate (2,5–4,5 Monate), die Zeit bis zur Vollbelastung 3 Monate (1,5–5 Monate). Die Kniegelenkbeweglichkeit war in 15 Fallen – mit einer Nachuntersuchungszeit >3 Monate – 121° (mindestens 20°, maximal 140°). Der Lysholm-Score konnte fur 9 Patienten ermittelt werden und ergab im Durchschnitt 67,5 Punkte (48–92 Punkte), der Neer-Score 69,8 Punkte (49–88 Punkte). Die Anwendung des LISS ermoglicht eine komplikationslose Ausheilung ohne Notwendigkeit der Knochentransplantation.

Objective Stable internal fixation of distal femur with an implant resisting angular forces. The technique is minimally invasive, relies on a monocortical screw fixation and obviates the need for bone grafting.

Operationsziel Ubungsstabile Osteosynthese distaler Femurfrakturen in minimal invasiver Technik durch ein winkelstabiles Implantat mit monokortikaler Schraubenverankerung ohne zusatzliche Spongiosaplastik. Indikationen Distale Femurfrakturen vom Typ A und C nach der AO-Klassifikation. Distale Femurschaftfrakturen vom Typ A–C. Periprothetische Femurfrakturen nach Implantation von Knie- und Huftgelenkendoprothesen. Kontraindikationen Lokale Infektion, Osteitis. Operationstechnik Bei intraartikularen Frakturen: Parapatellare, anterolaterale Arthrotomie des Kniegelenks; anatomische Reposition und vorlaufige Fixierung der Gelenkfragmente mit Spickdrahten. Geschlossene achsengerechte Reposition des “Gelenkblocks”. Submuskulares Einschieben der LISS-Platte mit Hilfe eines Zielbugels. Ausrichten des Implantats am Femurkondylus. Die Plattenlocher werden uber Stichinzisionen mit winkelstabil verankerten Schrauben besetzt. Bei extraartikularen Frakturen: Stichinzision uber dem lateralen Femurkondylus, Einschieben der Platte unter die Muskulatur und Platzierung der Schrauben mit Hilfe des Zielbugels uber Stichinzisionen. Ergebnisse Von Februar 1997 bis Februar 2000 konnten 51 Patienten (28 Manner, 23 Frauen) mit 54 frischen Frakturen des distalen Femurschafts und angrenzenden Kondylenmassivs in eine prospektive Studie eingeschlossen werden. Davon verstarben zwei Patienten an den Unfallfolgen, ein Patient unfallunabhangig. Zum Zeitpunkt des Unfalls betrug das durchschnittliche Patientenalter 53 (20–92) Jahre. 48 Patienten wiesen nach der AO-Klassifikation Typ-33-Frakturen auf; viermal handelte es sich dabei um A2-, sechsmal um A3-, zwolfmal um C2-, 25-mal umd C3-Frakturen und einmal um eine B-Fraktur als sog. Zweietagenverletzung. Sechsmal lagen distale Typ-32-Frakturen, eine A1-, eine B1-, drei B2- und eine B3-Fraktur vor. Zehn Frakturen waren offen, drei davon erstgradig, vier zweitgradig und drei drittgradig. Die durchschnittliche Operationsdauer betrug 137 (40–300) min, die Durchleuchtungszeit 127 (31–400) s. Vier Patienten erlitten eine Fraktur oberhalb einer Kniegelenkendoprothese, zwei unterhalb einer Huftgelenkendoprothese. An allgemeinen Komplikationen traten eine heterotope Ossifikation, zwei tiefe Beinvenenthrombosen mit Lungenembolien und drei Infektionen auf. Bei vier Patienten beobachteten wir ein Auslockern proximaler Schrauben. 40 Patienten wurden klinisch und rontgenologisch nachuntersucht, 32 davon nach mehr als 6 Monaten, 27 nach mehr als 1 Jahr. Elf Patienten konnten aus verschiedenen Grunden in der Studie nicht berucksichtigt werden. Der Neer-Score betrug 1 Jahr nach dem Unfall bei 27 Patienten (73,9 (38–88) Punkte mit sechs sehr guten, 14 masigen, sechs unbefriedigenden Resultaten und einem schlechten Ergebnis. Der Lysholm-Score erreichte 80,5 (40–100) Punkte.

A multicenter trial analyzed complications and odds for complications in open and closed tibial fractures stabilized by small diameter nails.Retrospective.Four Level I trauma centers.Four hundred sixty-seven tibial fractures were included in the study. There were fifty-two proximal fractures, 219 midshaft fractures, and 196 distal fractures. Breakdown into different AO/OTA groups showed 135 Type A fractures, 216 Type B fractures, and 116 Type C fractures. Two hundred sixty-five were closed fractures and 202 were open fractures.Clinical and radiographic analysis.467 patients' tibial fractures were stabilized with small diameter tibial nails using an unreamed technique. Indications for the use of small diameter tibial nails using an unreamed technique included all types of open or closed diaphyseal fractures. The operating surgeons decided whether or not to ream based on personal experience, fracture type, and soft-tissue damage. Surgeons of Center 1 preferred to treat AO Type A and B fractures with unreamed nails, and surgeons of Centers 2, 3, and 4 preferred to treat AO Type B and C fractures with unreamed nails. Closed and open fractures were treated in approximately the same ratio.Analysis showed five (1.1 percent) deep infections (with a 5.4 percent rate of deep infections in Gustilo Grade III open fractures), forty-three delayed unions (9.2 percent), and twelve (2.6 percent) nonunions. Compartment syndromes occurred in sixty-two cases (13.3 percent), screw fatigue in forty-seven cases (10 percent), and fatigue failure of the tibial nail in three cases (0.6 percent).Fracture distraction of more than three millimeters should not be tolerated when stabilizing tibial fractures with unreamed, small-diameter nails as this increases the odds of having a delayed union by twelve times (p0.001) and a nonunion by four times (p = 0.057). There was a significant increase of complications in the group of Grade III open fractures (p0.001), AO/OTA Type C fractures (p = 0.002), and to a lesser extent in distal fractures. However, the rate of severe complications resulting in major morbidity was low.

In einer biomechanischen Studie wurde erstmals der Einfluss eines dunnen, unaufgebohrten Titanverriegelungsmarknagels auf das Axial- und Torsionssteifigkeitsverhalten 9 verschiedener Oberschenkeldistraktionssysteme untersucht. Insgesamt wurden 582 biomechanische Testungen an einem neuentwickelten Femurmodell in einer Simulation eines Segmenttransportes durchgefuhrt. Durch die zusatzliche Implantation eines unaufgebohrten Femurnagels (UFN 9×360 mm, Fa. Synthes) konnte die Axialsteifigkeit der Fixateursysteme um bis zu 8108% (durchschnittlich 1673,8–2631,8%), die Torsionssteifigkeit um bis zu 86% (durchschnittlich 47%) des Ausgangswertes gesteigert werden. Die Verwendung von Stahlhalfpins anstelle von Titanhalfpins, sowie Stahlhalfpins anstelle von gespannten Kirschnerdrahten fuhrte zu signifikant hoheren Torsionssteifigkeiten. Die Kombination eines Fixateurs mit einem dunnen, unaufgebohrten UFN erscheint besonders bei Fixateuren mit einer geringen Axial- und hohen Torsionseigensteifigkeit sinnvoll. Der Vergleich zeigte, dass der Hexfix®-Fixateur mit Steelbar und Stahlhalfpins in Verbindung mit einem UFN die besten biomechanischen Eigenschaften, dass heist eine hohe Torsionssteifigkeit und eine axial-zyklische Mikrobewegungen zulassende Axialsteifigkeit aufwies.

Objectives/Hypothesis: Proximal and distal femur fractures have traditionally been treated with open reduction and internal fixation through a standard lateral approach. New, "minimally invasive" internal fixation techniques, however, have been developed in an effort to devascularize the bone less than the traditional method. The purpose of this study was to determine whether a minimally invasive percutaneous plating technique better preserves bone vascularity relative to the traditional method by comparing the effect of the two approaches on the blood supply of the distal femur using silicone arterial dye injection in a cadaveric model. Study Design/Methods: Ten fresh human cadavers underwent lateral conventional plate osteosynthesis (CPO) through a standard lateral approach on one side and minimally invasive plate osteosynthesis (MIPO) through two three-centimeter incisions on the contralateral side. After injection of silicone dye, a dissection was performed bilaterally to identify the femoral perforating and nutrient arteries. Results: All MIPO specimens showed intact perforating and nutrient arteries, whereas the CPO specimens had a variable incidence of vessel disruption. The MIPO group demonstrated better periosteal perfusion in each of the cadavers and improved medullary perfusion in 70 percent of the MIPO specimens compared with the CPO specimens. Conclusion: A percutaneous minimally invasive plating technique disrupts the femoral blood supply less than the traditional open method. Such minimally invasive methods may be more advantageous biologically than the traditional method.

A cadaveric arterial injection study was performed to study the effects of percutaneous and conventional surgical plating techniques on femoral vascularity. Sixteen-hole dynamic condylar screw and condylar buttress plates were applied on the proximal and distal shafts, respectively, of intact femora in ten human cadavers. On one side, the plate was inserted using a lateral conventional plate osteosynthesis (CPO) technique with elevation of the vastus lateralis muscle to expose the shaft. On the contralateral side, the plate was inserted percutaneously beneath the muscle using a minimally invasive plate osteosynthesis (MIPPO) technique. After plating, blue silicone dye was injected through the common femoral artery. A dissection was then performed to identify the femoral perforating arteries (PAs). The pattern of periosteal filling of the injected dye was analyzed. The MIPPO technique maintained the integrity of the PAs and exhibited superior periosteal perfusion. The results of this study indicate that the MIPPO technique maintains femoral vascularity and perfusion better than the CPO technique.

Current methods of distal interlocking of intramedullary femoral nails are dependent on image intensification. However, radiation exposure to the patient, the operating room staff, and the surgeon remains a concern. Proximally mounted, radiation-free aiming systems for distal interlocking of femoral nails have reportedly failed because of nail deformation with insertion. To better understand this deformation, a three-dimensional magnetic motion tracking system was used to determine the position of the distal interlocking hole following nail insertion. The amount and direction of deformation of commercially available small-diameter implants (unslotted 9-mm nails inserted without reaming) and large-diameter implants (slotted 13-mm nails inserted with reaming) from a single manufacturer were analyzed. Measurements of deformation (three translations and three angles), based on the center of the distal transverse locking hole, were performed on 10 paired intact human cadaveric femora before and after insertion. The technique produced the following results for the small and large-diameter nails, respectively: lateral translations of 18.1+/-10.0 mm (mean+/-SD, range: 47.8 mm) and 21.5+/-7.9 mm (range: 26.4 mm), dorsal translations of -3.1+/-4.3 mm (range: 15.2 mm) and 0.4+/-9.8 mm (range: 30.1 mm), and rotation about the longitudinal axes of -0.1+/-0.2 degrees (range: 0.7 degrees) and 10.0+/-3.1 degrees (range: 7.8 degrees). This technique is useful for measuring insertion-related femoral nail deformation. The data for the nails tested suggest that a simple aiming arm, mounted on the proximal end of the femoral nail alone, will not sufficiently provide accurate distal aiming.

Operationsziel Knocherne Heilung von Femurschaftfrakturen in achsengerechter Stellung nach Osteosynthese mit unaufgebohrtem intramedullaren Verriegelungsnagel (UFN).

Purpose To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck fractures with measured fracture angulation would recommend surgery as often as surgeons shown unmarked radiographs. Methods Members of the Science of Variation Group, an international collaboration of fully trained orthopedic and trauma surgeons, were asked to review 20 little finger metacarpal neck fracture cases, which included a vignette and 3 high-quality radiographs. Members were then randomized to review radiographs with or without measured fracture angulation on the lateral view and select operative or nonoperative management. Results Surgeons shown radiographs with measured angulation were more likely to recommend surgery, and there was less variability among these surgeons, particularly for fractures with less angular deformity. Conclusions Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. Copyright (C) 2014 by the American Society for Surgery of the Hand. All rights reserved

Ziel unserer Untersuchung war es, die notwendige Plattenvorbiegung und Vorspannung bei Verwendung des AO-Titan-LC-DCP zusammen mit der AO-4,5-mm-Kortikalisschraube zur Stabilisierung von Frakturen der Unterschenkel zu ermitteln. Zur Ermittlung des Stabilitatsverhaltens wurden folgende Parameter bestimmt: der Aufklaffwinkel in Abhangigkeit von der Vorspannung, das Biegemoment und das Ruckbiegemoment fur bestimmte Vorbiegewinkel und das Stabilitatsverhalten der Titan-LC-DCP fur bestimmte Vorspannkrafte und Vorbiegewinkel unter idealisierten Bedingungen an einem Versuchsmodell aus Hartfaserrohren. Bei der Titian-LC-DCP ergab sich ein Aufklaffwinkel von 0,45°/100 N im Bereich zwischen 100 und 1500 N. Das Plattenruckbiegemoment zeigte bei der Titan-LC-DCP keinen linearen Kurvenverlauf bis 8° wie bei der Stahl-DCP, sondern, bedingt durch die hohere Zahigkeit von Titan, einen exponentiellen Verlauf. Uber einer Vorbiegung von 26° kam es zu einem asymptotischen Verlauf. Die Stabilitat der Modellosteosynthesen wurde anhand der Steifigkeit im elastischen und plastischen Verformungsbereich beurteilt. Die in unserem Versuch erreichte maximale Vorspannung betrug 2400 N und die maximale Vorbiegung 24°. Im Modell fand sich die geringste Verformung bei einem Vorbiegewinkel von 24° und einer Vorspannkraft von 1500 N. Im klinischen Einsatz erschwert eine so grose Vorbiegung die Reposition, deshalb empfehlen wir nur einen Vorbiegewinkel von 9° und eine Vorspannung von 1000 N.

Ziel der Studie war die vergleichende Untersuchung verschiedener Femurverriegelungsnagel auf die Primarstabilitat im Knochen-Implantat Verbund (KIV). Dabei wurden die folgenden Implantate in einer Modellosteosynthese getestet: AO-Universal-Femurnagel (AOU) 11 mm, AO unaufgebohrter Femurnagel Stahl 9 mm, Verriegelung mit 3,2–3,9-mm-Bolzen (SUFN3,9), SUFN 9 mm, mit 4,3–4,9-mm-Bolzen (SUFN4,9), AO unaufgebohrter Femurnagel Titan (12TUFN) 12 mm, mit 4,3–4,9-mm-Bolzen, TUFN 9 mm, Verriegelung mit 4,3–4,9-mm-Bolzen, (TUFN). Die Prufungen wurden mit einer Universalprufmaschine an 40 humanen, gepaarten, kaltekonservierten Kadaverfemora durchgefuhrt. Jeder einzelne Knochen wurde zunachst im intakten Zustand gepruft, dann wurde die Osteotomie durchgefuhrt und das jeweilige Implantat eingesetzt. Ausgewertet wurde die relative Steifigkeit. Es zeigte sich eine signifikant hohere Torsionssteifigkeit der nicht soliden ungeschlitzten Femurnagel im Vergleich zu dem geschlitzten AOU. Die Biegesteifigkeit des KIV des TUFN mit 12 mm Durchmesser war signifikant hoher als die Biegesteifigkeit des KIV der anderen Implantate. Bei der axialen Belastung zeigte der KIV des SUFN4,9 eine signifikant hohere Steifigkeit als der KIV des TUFN. Die Steifigkeitsunterschiede zwischen den verschiedenen KIV waren bei der axialen Belastung und Biegebelastung relativ geringer als bei der Torsion. Fur die Torsionssteifigkeit ist das Nagelprofil (±Schlitz) entscheidender Parameter. Zwischen den soliden Implantaten zeigten sich ebenfalls signifikante Unterschiede fur die Biegung und axiale Belastung.

Rotationplasty, or shortening of the leg with rotation of 180 degrees to allow the ankle to function as a knee joint2, is known to be a dependable and durable alternative to above-the-knee amputation for the treatment of malignant tumors about the knee4-7,12-15,17-19,21,22. Compared with patients who have had an above-the-knee amputation, patients who have had a rotationplasty are more active, participate in higher-demand activities, and are less concerned about the limb4,12,13,15,17,21,22. Despite the low rate of complications associated with this procedure7,12,13,22, rotationplasty is infrequently performed in adults and has not been previously described for post-traumatic limb salvage, to our knowledge. We describe the use of rotationplasty in the treatment of a grade-IIIC open fracture8 of the distal part of the femur complicated by infection and loss of bone. A thirty-one-year-old healthy male laborer sustained bilateral injury of the lower extremity as a passenger in a train accident. After a two-hour extrication, the patient was intubated and resuscitated with intravenous administration of fluids at the site of the accident. He was then transported to the Trauma Department of the Hannover Medical School. On arrival 3.5 hours after the injury, physical examination and radiographs revealed a grade-IIIC open8, AO type-33 C3.316 fracture of the distal portion of the left femur (Fig. 1-A); no pulse in the left foot; and a closed fracture of the right tibial shaft. The mangled extremity severity score for the left lower limb was 9 points (4 points for a massive crush injury; 1 point for transient hypotension that responded to fluid resuscitation; 3 …

Between 1987 and 1993, 41 grade 3B open tibial shaft fractures were treated with the unreamed tibial nail (URTN n = 22) or an external fixator (FIX n = 19). The method of treatment was left to the choice of the operating surgeon. Three below the knee amputations were performed, three patients died, and three were lost to follow-up. In all, 32 patients were followed up to union or at least for 1 year. There were no significant statistical differences between the two groups (P < 0.2, chi-squared, t-test) with respect to fracture type, fracture location, age, gender or accompanying injuries. The URTN group showed significantly better results regarding time to full weight-bearing (URTN 11 +/- 4 weeks; FIX 20 +/- 11 weeks, P < 0.01 M-W) Mann-Whitney Test, number of reoperations (URTN 1.04; FIX 2.89; P < 0.01 M-W), isolated bone grafting (URTN 3/22; FIX 8/19; P < 0.05 chi-squared), and average Karlstrom and Olerud score (URTN 30 +/- 4; FIX 26 +/- 5; P < 0.05 M-W). In all, 15/17 URTN patients and only 6/15 FIX patients achieved unlimited walking distance (P < 0.01 M-W). Time to bony union, infection, and nonunion were not significantly different between groups.

In a prospective study, 14 cases of supracondylar or subtrochanteric fractures or osteotomies were stabilized with a dynamic condylar screw (DCS) inserted using a minimally invasive percutaneous plate osteosynthesis (MIPPO) technique. The technique consisted of 4 major steps: 1) placement of the guide wire under fluoroscopic control and condylar screw insertion through a stab incision; 2) plate insertion beneath the vastus lateral muscle; 3) engagement of the condylar screw to the plate using a modified T-handle and, 4) plate fixation to the shaft using percutaneously inserted self-cutting screws. Between October 1994 and December 1995, 14 cases in 12 patients met the inclusion criteria. There were 11 acute fractures (6 subtrochanteric, 5 supracondylar) and 3 corrective osteotomies. Nine fractures were closed, and 2 were open. One 97-year-old patient died 6 weeks after trauma. There were no infections and 12 of 13 cases healed without a second procedure. There was 1 implant failure (plate screw breakage), which required repeat fracture fixation. At follow-up, there were 2 varus deformities above 5 degrees, 2 shortenings over 20 mm, and 1 rotational deformity of 20 degrees. According to the Neer score, there were 6 excellent, 1 satisfactory, 3 unsatisfactory results and no failures. The results of this technique compare favourably with those of other series of osteosynthesis of subtrochanteric or supracondylar femoral fractures treated with internal fixation without the added morbidity associated with an extensive approach or autogenous bone grafting. However, the surgical technique is demanding, and care must be taken to restore the axial alignment.

In a prospective study conducted between 1992 and 1995, displaced Müller type C2-C3 intraarticular fractures of the distal femur were treated using an indirect plate fixation technique and a lateral parapatellar arthrotomy for the direct reduction of the condylar block. There were 6 closed, and 2 open fractures (1 grade II and 1 grade IIIB). Following reconstruction of the articular block, the block was indirectly reduced and fixed to the shaft by a plate inserted by the retrograde method beneath the vastus lateralis. Transcutaneous/transmuscular screws were used to fix the plate to the shaft. Time to bone healing was 12 weeks (median range 8-17 weeks) after surgery without needing primary or secondary bone grafts. There were no infections or refractures. Except for one case which required a corrective osteotomy for 10 degrees of varus malalignment, there were no revisions. According to the Neer score, there were 6 excellent or satisfactory results, 2 unsatisfactory results, and no failures. At follow-up, there were 2 varus-valgus deformities greater than 5 degrees, 2 leg length discrepancies greater than 10 mm, and 2 rotational deformities of 15 degrees. The treatment results for complex supracondylar/intracondylar fractures of the distal femur obtained with this technique compare favourably with other reported series using different techniques without the added morbidity associated with autogenous bone grafting. However, the surgical technique is demanding and special care must be taken to ensure correct axial alignment.

The clinical methods still in common use for measuring leg length and leg length discrepancy (LLD) cannot always meet the demands of precision and accuracy. A method using ultrasound is presented and shown to be a standardized, non-invasive method allowing accurate determination of leg length and LLD. Once the validity had been proved experimentally, practical handling, precision and accuracy of this method were tested on 50 patients in whom teleradiography of the lower extremity was performed for different reasons. The sonographically determined measures of LLD were compared with the radiographic measurements and in addition clinical measurements were taken by direct (tape measure) and indirect methods ("lengthening" of the shorter leg by wooden blocks of known thickness). Adjustments to the ventral hip joint and to the medial knee joint served as standardized, easily reproducible sonographic reference points. The mean variance of repeated sonographic measurements as a reflection of precision amounted to 3.5 mm2 for leg length measurement, with a maximum of 13.5 mm2. In the case of LLD the mean divergence between sonographically and radiographically determined LLD was 0.9 +/- 2.7 mm, with a maximum of 6.4 mm. The clinical methods with mean divergence of -1.2 +/- 9.6 mm (direct method) and -1.0 +/- 6.1 mm (indirect method) proved to be less accurate. The method examined for measuring leg lengths and LLD by means of ultrasound is easy to manage and non-invasive. Its precision and accuracy make it superior to clinical measuring methods and could even make some radiographical examinations superfluous.

= 10; diameter 9 mm, n = 10) were inserted in paired human cadaver tibiae. The results showed lateral translations of –4.5±3.5 mm (mean and standard deviation, range 14.3 mm) and dorsal translations of –7.8±5.8 mm (mean and standard deviation, range 19.2 mm). Rotational deformations around the longitudinal axis of the nail were 0.3±0.7° (mean and standard deviation, range 2.4°). The results showed, that a simple aiming arm, mounted on the proximal nail end, alone or even in combination with a large working channel (e.g. 10 mm in diameter), was not adequate to the aiming process. A radiographic-morphometric analysis was subsequently performed in 40 tibiae after experimental (n = 20) or clinical (n = 20) implantation of nails 8 mm and 9 mm in diameter. These measurements showed a relatively constant distance between the upper distal transverse hole and the anterior aspect of the tibia (average 12.3 mm and only a narrow range (7.6 mm). These data were the basis for the development of an aiming technique that exploits the relatively constant distance between the distal nail hole and the anterior aspect of the tibia. This aiming device is set at a distance of 12.3 mm from the anterior cortex, and the fine tuning is finally resolved by the use of a `working channel' 10 mm in diameter.

Purpose To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. Methods We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." Results According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. Conclusions Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. Clinical relevance Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.

Materials : Between 1987 and 1991, 114 fresh tibial shaft fractures with severe soft tissue injury, which met the inclusion criteria, were treated and retrospectively reviewed. There were 48 cases in the unreamed nail (unreamed tibial nail (UTN)) group and 66 cases in the external fixation (EF) group. Methods : Soft tissue injury was classified by the Gustilo and Tscherne methods. There were 18 AO type A, 56 type B, and 40 type C fractures. There was no significant difference in fracture type, soft tissue injury, age, and additional injury between the groups. Outcome was assessed using the Karlstrom score after 28 months. Results : There were a significantly higher number of reoperations in the EF group. Mean time to bony healing was 25.8 weeks. In the EF group, there was a 26% rate of pin tract infection, whereas 19% of cases had bolt breakages in the UTN group. In the UTN group, 40% had good results, compared with 27% in the EF group. In the UTN group, there were significantly fewer ante- and recurvatum deformities of more than five degrees. Conclusions : Treatment of tibial fractures by UTN, compared with EF, gave a lower reoperation rate and better functional outcome.

We investigated the effect of BoNT/A injection on hip lateralisation in children with bilateral spastic cerebral palsy and bilateral adductor spasticity. Pelvic radiographs using Reimers' migration index (MI) were evaluated from 27 children (n=9 females, n=18 males; mean age 5.2 ± 1.96 years; range: 2-10 years; initial MI

To compare the vertical subsidence in a bicondylar tibial plateau fracture model stabilized either by a unilateral locked screw plate (LSP) or by double plating.Biomechanical cadaver study.A 41-C1 fracture model was created in eight pairs of fresh-frozen human cadaver tibiae. Stabilization was performed either by open reduction and internal fixation (ORIF) using a lateral L-buttress plate and a medial four-hole, one-third tubular antiglide-plate or by a lateral LSP. Four load levels (400N, 800N, 1200N, 1600N), each with five cycles, were consecutively applied to the medial plateau.The vertical plastic deformation at the end of each cycle was the main parameter of interest. Statistical analysis was performed with the two-way ANOVA test for repeated measurements. Each individual loading level was analyzed separately using Student t test.In one pair, both fixation techniques failed at the first loading cycle of 1200N. One ORIF fixation failed at the first loading cycle of 1600N. The average plastic vertical subsidence was 0.40 mm (LSP) and 0.25 mm (ORIF) at 400N (P = 0.291), 0.83 mm (LSP) and 0.81 mm (ORIF) at 800N (P = 8.82), 1.06 mm (LSP) and 0.96 mm (ORIF) at 1200N (P = 0.98), and 1.54 mm (LSP) and 1.14 mm (ORIF) at 1600N (P = 0.53). Vertical subsidence depended on the applied load (P = 0.002), but not on the method of fixation (P = 0.236).Both fixation techniques have a high resistance to vertical subsidence even with loads exceeding the average body weight. No statistically significant difference was seen between the two methods of fixation.

Es wird der Fall einer 26-jahrigen Patientin berichtet, welche aufgrund einer Femurschaftfraktur mit einem unaufgebohrten und retrograd eingebrachten Verriegelungsnagel versorgt wurde. Zwei Jahre spater wurde nach mittlerweile verheilter Oberschenkelfraktur die Implantatentfernung vorgenommen. Dabei kam es intraoperativ zu einer medialseitigen Kondylenabscherfraktur. Diese Komplikation war bisher in der Literatur noch nicht beschrieben worden. Das entstandene Fragment konnte mittels Schraubenosteosynthese refixiert und so die Gelenkkongruenz erhalten werden, sodass die Patientin nach 6-wochiger Teilbelastung zur Vollbelastung ubergehen konnte. Das Beispiel zeigt, dass die retrograde Entfernung von Marknageln keineswegs als komplikationsfreier Eingriff anzusehen ist. Die Indikationsstellung sollte daher nicht leichtfertig erfolgen.

Avascular necrosis of the femoral head is a frequent complication after osteosynthesis of femoral neck fractures. It is rarely seen after proximal femur fractures with intact trochanteric area. The choice of the implant varies from different blade systems (DHS, DCS and condylar plates) to intramedular nailing systems (gamma nail, classic nail). The complication of avascular necrosis of the femoral head after internal fixation of sub-trochanteric and proximal femur fractures is reported following intramedullary nailing. We report a case of a femoral head necrosis after osteosynthesis of a proximal femur fracture with a 95 degree condylar plate.

From 1987 to 1993, 41 Grade 3B open tibial shaft fractures were treated with the unreamed tibial nail or an external fixator. The method of treatment was left to the choice of the operating surgeon. Three below knee amputations were performed; three patients died; and three were lost to followup. Thirty-two patients were observed until union or for at least 1 year. There were no significant statistical differences between the two groups with respect to fracture type, fracture location, age, gender, or accompanying injuries. The unreamed tibial nail group showed significantly better results regarding time to full weightbearing, number of reoperations, isolated bone grafting, walking range, and average Karlstrom and Olerud score. Time to bony union, infection, and nonunion were not significantly different between the groups.

'Radiation-independent' aiming systems for the placement of interlocking screws in intramedullary tibial nails have failed because of insertional related nail deformation. Prior to the development of these distal aiming systems, the variable position of the nails' interlocking holes after insertion must be known. In this study, the amount and direction of implant deformation of solid stainless-steel tibial nails (diameters of 8 and 9 mm, n = 20) were analyzed. Measurement of implant deflection (three translations, three angles) in the center of distal transverse locking hole was performed with a three-dimensional-magnetic motion tracker system after nail insertion in paired human cadaver tibiae. The results showed combined mean lateral translation of the 8 and 9 mm nails (n = 20) of -4.5 +/- 3.5 mm (range: 14.3 mm) and dorsal translation -7.8 +/- 5.8 mm (range: 19.2 mm). The combined mean rotational deformation about the longitudinal axis of the nail was 0.3 +/- 0.7 degree (range: 2.4 degrees). The authors conclude that a simple aiming arm, mounted on the proximal nail end alone, is not sufficient to provide accurate distal aiming.

An intramedullary nail subjected to cyclical loading will fatigue if stresses on the nail exceed its endurance limit. The factors that influence failure of the nail are the stability of the fracture, a non-union or delayed union, and the rehabilitation program2,3,14,16. The methods to remove the distal fragment of a broken hollow nail rely on the passing of hooks or screws down the center of the nail1,8,10,15. For a solid nail, this technique is not possible. We describe a technique for the removal of the distal segment of a broken solid femoral nail. A twenty-four-year-old man sustained a closed fracture of the left femur, just distal to the isthmus, in a high-velocity motor-vehicle accident. The fracture was classified as B3 according to the AO system11 and as C2 according to the system of Tscherne and Oestern (Fig. 1-A). Other injuries included cerebral contusions, fractures of the right femoral condyle and the right tibial plateau, and dislocations of the right elbow and the right carpometacarpal joint. After initial resuscitation, the left femoral fracture was stabilized with a femoral nail, 420 by nine millimeters, made of titanium alloy (Ti-6Al-7Nb; Synthes, Paoli, Pennsylvania). The nail was inserted without reaming and was locked proximally and distally with two locking screws, each with a core diameter of 4.3 millimeters and an outer diameter of 4.9 millimeters7 (Fig. 1-B). Fig. 1-A: Preoperative radiograph showing the infra-isthmal fracture of the femoral shaft. The screw in the medial femoral condyle had been placed during a previous repair of the posterior cruciate ligament. Fig. 1-B: Radiograph made after insertion of a solid titanium-alloy nail with static locking with screws. The fracture was nailed in slight distraction. At the initial operation, …