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Surgical treatment has been established as the standard method for the treatment of intertrochanteric fractures in the elderly. The design of internal fixation devices has become the key to improve surgical outcomes and reduce postoperative complications. Centered on optimizing biomechanical performance and minimally invasive implantation, coupled with continuous material improvements, the design philosophy of internal fixation devices has also been constantly evolving. There have been several milestone advancements, such as the transition from eccentric fixation to central fixation, the adoption of sliding compression fixation, the replacement of traditional screws with spiral blades, and the shift from single to double (combination) nails. However, the incidence of internal fixation-related complications has remained at a relatively high level of 5% to 10%, without significant breakthroughs. Increasing evidence suggests that in-depth analysis of the anatomy, physiological mechanisms, and mechanical transmission characteristics of the proximal femur can help elucidate the root causes of internal fixation failures. Based on this, the proximal femoral bionic nail (PFBN) has emerged as a new design concept. By fully mimicking the anatomical, mechanical, and biological characteristics of the proximal femur, the PFBN can regulate the local mechanical environment, providing a revolutionary solution and a new approach for the treatment of proximal femoral fractures. This innovative design also has the potential to drive the paradigm shift in the treatment strategies of other fractures.

Background: Proximal humeral fractures are a common injury accounting for a significant workload across orthopaedic departments. Though often managed non-operatively, surgical management is indicated for a proportion of patients., Aims: The aim of this study is to examine the trends in the management of proximal humeral fractures within Ireland over the past 13 years., Methods: A retrospective review of Irish Hospital In-Patient Enquiry (HIPE) data was performed between January 2009 and December 2022. Information regarding demographics including age and gender, along with procedure type were collated after patients with proximal humerus fractures, were identified using relevant ICD 10 codes., Results: Demographic details remained stable with females and those within the 55-69 year age bracket accounting for the highest proportion of patients. The mean annual number of procedures performed across the study period was 365 (273-508), with an increase from 288 cases in 2009 to 441 in 2022. Open reduction and internal fixation were the most common procedures accounting for 76.4% of cases. There has been a rising usage of total shoulder arthroplasty for fixation with an increase from < 5 cases in 2016 to 84 in 2022. A decrease in the usage of hemiarthroplasty and closed reduction internal fixation was also observed., Conclusions: There has been an increasing volume of operatively managed proximal humeral fractures in Ireland, which sustained despite the 2015 publication of the highly publicised PROPHER trial. The increasing utilisation of total shoulder arthroplasty in acute trauma management is notable and necessitates appropriate training for trauma theatre personnel., (© 2024. The Author(s).)

Background: Periprosthetic fractures can be devastating complications after total joint arthroplasty (TJA). The management of periprosthetic fractures is complex, spanning expertise in arthroplasty and trauma. The purpose of this study was to examine and project trends in the operative treatment of periprosthetic fractures in the United States., Methods: A large, public and private payer database was queried to capture all International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for periprosthetic femoral and tibial fractures. Statistical models were created to assess trends in treatment for periprosthetic fractures and to predict future surgical rates. An alpha value of 0.05 was used to assess significance. A Bonferroni correction was applied where applicable to account for multiple comparisons., Results: In this study, from 2016 to 2021, 121,298 patients underwent surgical treatment for periprosthetic fractures. There was a significant increase in the total number of periprosthetic fractures. The incidence of periprosthetic hip fractures rose by 38% and that for periprosthetic knee fractures rose by 73%. The number of periprosthetic fractures is predicted to rise 212% from 2016 to 2032. There was a relative increase in open reduction and internal fixation (ORIF) compared with revision arthroplasty for both periprosthetic hip fractures and periprosthetic knee fractures., Conclusions: Periprosthetic fractures are anticipated to impose a substantial health-care burden in the coming decades. Periprosthetic knee fractures are predominantly treated with ORIF rather than revision total knee arthroplasty (TKA), whereas periprosthetic hip fractures are predominantly treated with revision total hip arthroplasty (THA) rather than ORIF. Both periprosthetic knee fractures and periprosthetic hip fractures demonstrated increasing trends in this study. The proportion of periprosthetic hip fractures treated with ORIF relative to revision THA has been increasing., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: No external funding was received for this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/H943)., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Clavicle fractures in children have traditionally been treated non-operatively. In adults, a great increase in operative treatment has been reported. We aimed to analyze the respective trend and potential explanatory factors in children., Methods: This is a single-institution retrospective study in a subregion in Northern Finland. The ICD-code S42.0 was used to identify the cases in the hospital registry. Altogether, 214 children, aged < 16, with consecutive clavicle fractures were first enrolled in the area during 2008-2019. Hospital journals and radiographs were reviewed. After lateral and medial fractures and patients living outside the area were excluded, final study population was 172. The respective population at risk was extracted by Statistics Finland. Predictive factors and annual rates of operative treatment as adjusted for 100,000 children at risk were determined., Results: The rate of the surgical treatment of clavicle fractures increased from zero in 2008 to 10.8 in 2019 per 100,000 age-adjusted children (β = 0.864, 95% confidential intervals (CI) 0.4 to 1.4). There was a rise in the rate of surgery from 2.6% (2014-16) to 16.1% (2017-19) (diff. 13.5, 95% CI 1.7 to 23.3%). A displacement > 15 mm and a shortening of > 15 mm were associated with the increased risk of surgery but did not change during the study period. Age > 9 years increased the risk of surgery; the mean age increased from 5.5 years (2008-10) to 8.5 years (2017-19). There was a 3.6-fold increase in sports-related fractures (95% CI 7.4 to 26.4). The severity of the fractures did not change., Conclusions: There has been an increasing trend in the surgical fixation of pediatric middle shaft clavicle fractures since 2008. The available literature does not support the trend., (© 2022. The Author(s).)

Background: Posterior fixation without fusion can treat thoracolumbar and lumbar traumatic fractures effectively in certain cases. However, whether patients benefit from implant removal and the correlation between the range of motion (ROM) of the involved segments and the removal time have not been determined., Methods: From 2018 to 2020, we retrospectively reviewed data of patients with AO spine type A or B thoracolumbar or lumbar traumatic fractures who underwent implant removal. A total of 17 patients (group A), 21 patients (group B), and 12 patients (group C) underwent implant removal after the index surgery within 12 months, between 12 and 24 months, and over 24 months, respectively. Clinical and radiological outcomes, including visual analog scale for back pain, patient satisfaction, Oswestry disability index, and EuroQol 5 dimensions questionnaire, for quality of life and segmental ROM were analyzed., Results: The average follow-up time was 9.1 ± 5.7 months after implant removal. There were no significant differences in visual analog scale and patient satisfaction among the 3 groups at the same observation time point. Among the 3 groups, patients in group A gained the lowest Oswestry disability index and highest EuroQol 5 dimensions questionnaire scores after removal and at the final follow-up. The best ROM was obtained in group A followed by groups B and C (11.5° ± 6.2°, 5.5° ± 1.6°, and 2.4° ± 0.6°, respectively)., Conclusions: Immobilization of the involved segments over 24 months may lead to loss of ROM. Regained segmental ROM is correlated negatively with implant removal time, and removal within 12 months promises a better ROM and quality of life., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: The ideal management of thoracolumbar burst fracture (TLBF) remains controversial. We conducted this study to compare the effectiveness and safety of trans-Kambin triangle versus transpedicular bone grafting combined with posterior internal fixation (PIF) for TLBF., Methods: Fifty-four patients were retrospectively analyzed and divided into 2 groups: the observation group (PIF combined with bone grafting via the Kambin triangle, n = 28) and the control group (PIF combined with bone grafting via transpedicular, n = 26). The anterior vertebral height ratio, sagittal Cobb angle, visual analog scale score, Oswestry Disability Index, bone healing rate, and neurologic complications were measured., Results: All patients were followed up regularly for a mean period of 17.94 months (12 - 24 months). The anterior vertebral height ratio in the observation group was higher than that in the control group (93.93 ± 2.92 vs. 89.90 ± 5.54%, P = 0.006), and the loss of correction was lower (1.59 ± 1.20 vs. 3.00 ± 1.98%, P = 0.008). The observation group had lower sagittal Cobb angle at final follow-up (8.68 ± 3.75 vs. 11.33 ± 4.77 degrees, P = 0.046) and less correction loss (1.96 ± 1.32 ± 1.15 vs. 3.90 ± 2.39 degrees, P = 0.002). The visual analog scale score and Oswestry Disability Index in the observation group were lower (0.61 ± 0.43 vs. 0.92 ± 0.38, P = 0.016; 15.86 ± 4.11 vs. 19.18 ± 4.04, P = 0.010), while the fracture healing rate showed no significant difference (P > 0.05). No internal fixation failure or neurologic complications occurred in both groups during the follow-up., Conclusions: Bone grafting via the Kambin triangle combined with PIF is a safe and effective technology for thoracolumbar burst fracture., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background and purpose - Clear and acknowledged treatment algorithms for proximal humeral fractures (PHFs) are lacking. Nevertheless, a change in treatment trends, including a change towards more reversed shoulder arthroplasties (RSA), has been observed during recent years. We examined the effect of these changes on reoperation rates.Patients and methods - Between 2011 and 2017, 4,070 PHFs treated at Sahlgrenska University Hospital were registered prospectively in the Swedish Fracture Register (SFR) and followed up until 2019 (mean follow-up of 4.5 years). Data on all reoperations were gathered from the SFR and from medical records.Results - The majority of PHFs were treated non-surgically and the proportion increased slightly, but not statistically significantly, during the study period (from 76% to 79%). Of the surgically treated fractures, the proportion fixed with a plate decreased from 47% to 25%, while the use of RSA increased 9-fold (from 2.0% to 19%). 221 patients underwent 302 reoperations. For those primarily treated surgically, the reoperation rate was 17%. Among treatment modalities, plate fixation was associated with the highest reoperation rate (21%). Rate of reoperations remained constant during the study period, both for the entire study cohort and for the surgically treated patientsInterpretation - During the study period, treatment changes that are in accordance with recently published treatment recommendations were observed. However, these treatment changes did not affect the reoperation rate. Treatment with a plate, intramedullary nail, or hemiarthroplasty was associated with the highest reoperation rates. The fact that almost every 4th surgical procedure was a reoperation indicates a need for further improvement of modern treatment concepts for PHFs.

Introduction: Anterior odontoid screw fixation is a valid surgical option for unstable odontoid fractures, as type II Anderson D'Alonzo fractures. Grauer further divided type II fractures in subtypes according to the fracture line, providing recommendations for implementation of screw fixation techniques., Objective: Primary endpoint of our study is to evaluate the postoperative results of minimally invasive odontoid screw insertion in terms of outcome, fusion rate and stability of cranio-cervical junction. Secondary endpoint was to investigate the influence of age or fractures' features on outcome and fusion rate., Materials and Methods: We report the clinical and radiological features of 32 patients harbouring unstable type II fractures operated by a minimally invasive odontoid screw insertion technique. All patients underwent a high resolution multiplanar CT in order to assess fracture features according to Grauer's classification; the integrity of ligaments was investigated by MRI. In addition, a preoperative neurological performance (modified Rankin Scale, mRS) was evaluated for patients either directly or interviewing their families. Follow-up at one, three and six months and 1 year have been performed (averaging 13.5 months) by cervical CT (fusion rate and stability) and mRS update. In order to investigate the influence of age on postoperative neurological performance, two groups (≤50 yrs, 9 pts/>50 yrs, 23 pts) were separately considered and analysed. Overall, we observed no surgery related complications. We also analysed the fusion rate and its correlation with patient age and Grauer's subtype of fracture., Results: At last available clinical follow-up, the preoperative performance was preserved (mRS 0/1: 24, 75%; mRS 2-4: 9, 15%) although with slight reduction of intact patients (mRS 0: 22 vs. 19; 71.8 vs. 59.3%). Younger patients (≤50 yrs) fared significantly better than older ones, achieving a good clinical outcome (mRS 0/1) in 100% vs. 69.5% (9/9 vs. 16/23 pts). Statistical analysis showed a fair correlation between age and outcome. Other factors such as sex and Grauer's type did not influence significantly the clinical outcome. Nine patients did not complete a full radiological follow-up and were therefore excluded from analysis of radiological outcome. Among the remaining 23 patients, only 25% of those who were followed three months or less showed fusion; conversely, all patients who have been examined from 6 to 48 months fused. Among the non-union patients, two underwent a second surgery by posterior approach., Conclusions: In our recent experience, the minimally invasive AOSF proved safe and effective in treating odontoid peg fractures. Selection based on Grauer's type is mandatory to achieve best results. While in the elderly, an anterior approach is well accepted as the first choice treatment, we recommend that this option should be offered as a suitable alternative to Halo or orthosis also in younger patients since it provides prompt, excellent clinical outcome and high fusion rate especially in this age group., (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Percutaneous reduction and fixation of pelvic ring fractures is now widely accepted as a safe and effective treatment method. The only exception remains reduction and fixation of pubic symphyseal injuries. Several units from China and one from Spain have published clinical and biomechanical studies supporting percutaneous reduction and fixation of the pubic symphysis with various screw configurations. The initial clinical results are promising. Biomechanical data show there is little difference between plate and screw fixation. We review the current literature and also present a case performed by ourselves using this novel technique., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To summarize the progress in treatment of unstable atlas fracture, the existing problems, and the research direction., Methods: Related literature at home and abroad was reviewed. The stability evaluation of atlas fracture and treatment methods were introduced, and the selection of surgical approach and fixation instruments in treatment of unstable atlas fracture were summarized and analyzed., Results: At present, atlas fractures are considered as unstable fractures except single anterior arch fractures with complete transverse ligament or simple posterior arch fractures. The treatment of unstable atlas fracture has been developed from nonsurgical treatment and traditional fusion surgery to single-segment fixation. Nonsurgical treatment is less effective, while traditional fusion surgery has a disadvantage of limited the motion of the upper cervical spine. Single-segment fixation can not only restore and fix the fracture, but also preserve the upper cervical motion function. Single-segment fixation approaches include posterior and transoral approaches, and the fixation instruments are being constantly improved, mainly including screw-rod system, screw-plate system, and plate system., Conclusion: For unstable atlas fracture, single-segment fixation is an ideal surgical method, and has more advantages when compared with nonsurgical treatment and traditional fusion surgery. Single-segment fixation via transoral approach is more direct for atlas anterior arch fracture reduction, but there is a high risk of infection; and single-segment fixation via posterior approach is less effective for the reduction of atlas anterior arch fracture. Therefore, a better reduction method should be explored.

Background: Short-segment internal fixation with intermediate straight-forward monoaxial screws (SSIF-SFM) and long-segment internal fixation (LSIF) are the two major surgical options for thoracolumbar (TL) fracture. However, SSIF-SFM might not provide adequate support to the spine, and LSIF is unnecessarily extensive. SSIF with intermediate inclined-angle polyxial screw (SSIF-IAP) might offer an alternative solution for the treatment of TL fracture., Methods: A retrospective study was conducted. Sixty-nine patients (47 males and 22 females; average 34.5 years) with Denis type B TL fracture who met the criteria for inclusion were enrolled. Sagittal Cobb's angle (SCA), anterior vertebral body height (AVBH), vertebral body index (VBI), and spinal canal encroachment (SCE) were measured and assessed. Visual analogue scale (VAS) and Oswestry disability index (ODI) were also evaluated., Results: The average values of incision length, blood loss, duration of operation, and hospital stay in the SSIF-IAP group and SSIF-SFM group were significantly decreased compared with those in the LSIF group. The AVBH and VBI in the SSIF-IAP group and LSIF group were significantly improved than those in the SSIF-SFM group at 6-month and the latest follow-ups (P < 0.05). The correction losses of AVBH and VBI (calculated by the reduction of AVBH and VBI) in the SSIF-IAP group and LSIF group were also significantly decreased compared with those in the SSIF-SFM group at 6-month and the latest follow-ups (P < 0.05). There was no significant difference of SCE among the three groups postoperatively. The VAS and ODI in the SSIF-IAP group and SSIF-SFM group were significantly decreased compared with those in the LSIF group at 6-month and the latest follow-ups (P < 0.05)., Conclusion: Both SSIF-IAP and LSIF can improve the biomechanical stability as compared with SSIF-SFM. Moreover, SSIF-IAP was less extensive compared to LSIF. SSIF-IAP was an effective and reliable operative technique for patients with Denis type B TL fracture.

Study Design: Nonrandomized, retrospective, comparative, and single-center trial., Objective: The aim of this study is to compare the long-term clinical and radiographic results of thoracolumbar burst fractures in neurologically intact patients, treated surgically or nonsurgically with the aim to optimize their management., Summary of Background Data: There is an ongoing controversy regarding the treatment of thoracolumbar burst fractures (TLBF) (A3, A4) in neurologically intact patients. Surgical treatment as well as conservative treatment methods are advised to this specific group of patients, while contrasting results exist in the literature., Methods: Forty-five neurologically intact patients with TLBF (A3 or A4) (2010-2016) were included. Twenty-one patients with a mean age of 34.3 and a mean follow-up period of 63.1 months were treated surgically with short segment posterior fixation (group 1), while 24 patients with a mean age of 45.7 and a mean follow-up period of 67.1 months were treated conservatively (group 2) with thoracolumbosacral orthesis., Results: At the final follow-up groups 1 and 2 had an average segmental kyphosis of 4.09°/11.65° (P = 0.027), an average loss of kyphosis of 2.04°/4.03° (P = 0.038), an average loss of anterior/posterior vertebral body height of %12.89/%2.84/%17.94/%7.62 (P = 0.027/ P = 0.03), a median JOA score of (16.6/16.75) (P = 0.198), a median ODI score of (11.7/12.1) (P = 0.25), a median VAS score of (1.9/2.3) (P = 0.3), SF-36 PCS of (56.74/56.67) (P = 0.25), SF-36 MCS of (55.47/55.5) (P = 0.3), mean durations of hospital stay of 9-11 days (P = 0.3), respectively., Conclusion: While there is an ongoing controversy regarding the management of stable thoracolumbar burst fractures in neurologically intact patients in the literature, this study concluded that surgical management of stable thoracolumbar burst fractures in neurologically intact patients provided better radiolographic outcomes, despite the result, that the difference between surgically and nonsurgically treated patients in terms of clinical outcome parameters and quality of life was not statistically significant., Level of Evidence: 3.

Introduction: Idiopathic Parkinson's disease (PD) is a progressive neurologic disorder causing postural instability and unsteady gait. These patients are at increased risk for fractures and have inferior outcomes after treatment. Several studies have evaluated the incidence and outcome of PD patients after hip fractures. However, there are limited studies assessing the outcome of upper extremity fractures in these patients. In this study, we evaluated the outcome of PD patients that received surgical intervention for distal radial fractures (DRF). We hypothesize that these patients have an inferior outcome after surgery in comparison with non-PD patients., Methods: Between May 2005 and May 2017, we retrospectively reviewed all of the patients with DRF and subsequently underwent open reduction and internal fixation (ORIF) at a level 1 trauma center. All of the surgeries were performed by fellowship-trained orthopedic surgeons. The inclusion criteria include patients with a definitive diagnosis of PD, non-pathological DRF, and a minimum follow-up of 1 year or up until the time of treatment failure was noted. Each PD patient was matched for age and gender to 3 non-PD patients. The primary objective was to determine the failure rate after surgical fixation for DRF. The secondary outcomes include time to treatment failure, reoperation rate, readmission rate, length of hospital stay, and postoperative complications., Results: A total of 88 patients were included in this study (23 PD, 65 non-PD patients). All underwent ORIF and received standard postoperative follow-ups. The overall treatment failure rate in PD was 39.1% vs. 4.6% in the non-PD group (p < 0.05). The time to treatment failure were 9.11 ± 3.86 weeks and 14.67 ± 5.8 weeks for PD and non-PD, respectively (p < 0.05). PD patients had a significantly higher rate of failure when k-wires and ESF were used (p < 0.05%), while loss of reduction was the most common mode of failure in PD (44.4%). The length of hospital stay for PD was 5.3 ± 4.69 days compared with 3.78 ± 0.96 days for non-PD (p = 0.01). There were 3 PD patients readmitted within 30 days after surgery, and 1 patient had pneumonia after the surgery., Conclusion: This study revealed that patients with PD have a high treatment failure rate despite surgical intervention for DRF. PD patients had a longer hospital stay and had a shorter time to treatment failure. In treating PD patients complicated with DRF, the surgeon must take into consideration the complex disease course of PD and the associated comorbidities such as osteoporosis, frail status, and frequent falls. Rehabilitation and disposition plans should be discussed in advance and longer hospital stays should be expected. Level of evidenceLevel IV, retrospective cohort study.

Background: Currently available procedures for the treatment of minimally displaced acetabular fractures include conservative treatment and minimally invasive percutaneous screw fixation. Screw fixation of acetabular fractures allows patients' early full-weight bearing due to improved biomechanic stability. Can the range of motion, pain and mobility and quality of life in patients with acetabular fractures be improved by minimally invasive screw fixation, compared to conservative treatment in the long term?, Methods: Patients treated for a minimally displaced acetabular fracture, either conservatively or by closed reduction percutaneous screw fixation, in the period from 2001 to 2013 were included in this retrospective study. Minimal displacement was considered to be less than 5 mm. As well as the collection and analysis of baseline data, Harris Hip Score, Merle d'Aubigné score and Short Form 12 (SF-12) questionnaire data were recorded in the context of a clinical study. To better account for confounding factors, patients of each group were matched. The matched-pair criteria included age, BMI, Letournel fracture classification and the presence of associated injuries., Results: Twenty-five patients from each group were matched. On the Harris Hip Score, conservatively treated patients obtained 96 points (52-100, SD 17) vs. 89 points (45-100, SD 17, p = 0.624). On the Merle d'Aubigné score, conservatively treated patients obtained 17 points (10-18, SD 2) vs. 17 points (11-18, SD 2, p = 0.342). Patients with acetabular fractures treated by minimally invasive screw fixation did not result in improved quality of life, measured by SF-12 questionnaire, compared to conservatively treated patients (PCS 47, SD 9 vs. 44, SD 10; p = 0.294 and MCS 51, SD 7 vs. 53, SD 7; p = 0.795)., Conclusions: The clinical results of the two groups revealed no statistically significant differences. From the data, it cannot be deduced that minimally invasive surgical therapy is superior to conservative treatment of minimally displaced acetabular fractures. Prospective randomised studies are recommended to allow reliable evaluation of both treatment options., Trial Registration: Retrospectively registered.

Hallux valgus is an extremely common and often disabling deformity. In addition to valgus deformity of the hallux, varying degrees of varus and supination of the first metatarsal and instability in the metatarsophalangeal and metatarsocuneiform joints are frequently present. Because of the complexity and multiplicity of deformities, surgical techniques and fixation methods continue to be developed to obtain better results. Recent studies have focused on correcting pronation of the first metatarsal as a way of correcting and equalizing the metatarsal sesamoid bones in a more horizontal and stable position, possibly minimizing the chance of recurrence of the deformity., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: The aim was to evaluate postsurgical outcome in elderly patients (> 70 years) after open reduction and internal fixation (ORIF) of proximal humeral fractures and compare the test-retest agreement of scores which are frequently used to assess the outcome of upper extremity disorders., Methods: Ninety patients (78.1 ± 5.2 years) with a minimum follow-up of 2 years (3.7 ± 0.9 years) following angular stable plate fixation of a proximal humeral fracture (2-part: 34, 3-part: 41, 4-part: 12) were enrolled. Two telephone-based interviews assessed Disabilities of the Arm, Shoulder and Hand Score (DASH), Oxford Shoulder Score (OSS), and Constant Score adjusted for interview assessment (CS) by two independent interviewers. Correlations, Bland-Altman analyses, Cross tabulation, and weighted Kappa measure of agreement (k) were calculated to assess differences and the test-retest agreement between the categories of each score., Results: In the first and second interview, we could state fair outcomes: CS 91 (range 40-100) and 65.5 (23-86), DASH 12.5 (0-64.2) and 18.3 (0-66.7), and OSS 58 (33-60) and 55 (25-60) points. The test-retest correlations were r = 0.67, r = 0.77, and r = 0.71 for CS, DASH, and OSS. Bland-Altman analyses showed absolute mean individual score differences of - 22.3, 4.9, and - 3.0 for CS, DASH, and OSS. Limits of agreement represented possible differences of 21.6%, 15.5%, and 9.0% of CS, DASH, and OSS. The category agreements were medium to high: CS 55.9% (k = 0.08), DASH 87.2% (k = 0.62), and OSS 99.3% (k = 0.74)., Conclusion: Patients showed good subjective outcomes. The test-retest agreement of the interview-adjusted CS was low, but telephone-based assessment of OSS and DASH present as an alternative to collect outcomes in elderly patients., Trial Registration: (250/2011BO2).

Aims: The aim of this study was to examine trends in the management of fractures of the distal radius in Ireland over a ten-year period, and to determine if there were any changes in response to the English Distal Radius Acute Fracture Fixation Trial (DRAFFT)., Patients and Methods: Data was grouped into annual intervals from 2008 to 2017. All adult inpatient episodes that involved emergency surgery for fractures of the distal radius were included., Results: In 2008 Kirschner-wire (K-wire) fixation accounted for 59% of operations for fractures of the distal radius, and plate fixation for 21%. In 2017, the rate of K-wire fixation had fallen to 30%, and the proportion of patients who underwent plate fixation had risen to 62%., Conclusion: There is an increasing trend towards open reduction and internal fixation for fractures of the distal radius in Ireland. This has been accompanied by a decrease in popularity for K-wire fixation. DRAFFT did not appear to influence trends in the management of fractures of the distal radius in Ireland. Cite this article: Bone Joint J 2019;101-B:1550-1556.

Introduction: Proximal humeral fractures (PHF) are among the most common adult fractures. However, valid epidemiologic population-based data, including differentiation of treatment modalities, are lacking., Materials and Methods: Using the ICD codes and associated OPS codes for PHF, a retrospective analysis of 2007-2016 Federal Statistical Office of Germany data was performed. Data were evaluated for total incidence of PHF as well as total use, annual utilization rates, age, and sex distributions of all associated surgical procedures. Simple linear regressions were performed to evaluate trends in treatment modalities., Results: There were 642,556 cases of PHF. During the study period, incidence changed substantially from 65.2 to 74.2 per 100,000 inhabitants with a significant rise in elderly (> 70 years) patients (P < 0.001). The number of surgical procedures increased by 39%, with locking plate fixation being the most common procedure (48.3%), followed by intramedullary nailing (IMN) (20.0%), hemiarthroplasty (HA) (7.5%), K-wire fixation (6.4%), and reverse shoulder arthroplasty (RSA) (5.6%). The utilization rate increased for locking plates, K-wires, and RSA and decreased for HA and IMN. Particularly, the utilization of RSA exhibited a  > eightfold increase. Significant linear correlation of procedure and time were found for all surgical treatments., Conclusions: During this period, the number of inpatient PHFs, especially in the elderly, increased. Although locking plate fixation remained the most common treatment method, RSA had the greatest proportional increase over time, supporting its growing popularity in the light of the current scientific evidence. This incline was offset by a corresponding decrease in HA and IMN, which may be related to a growing knowledge of their application limitations., Level of Evidence: Descriptive epidemiology study, large database analysis.

Background: Proximal humeral fractures (PHFs) are the third most commonly occurring fractures in elderly patients. Most of these fractures can be treated with conservative methods, but the optimal surgical treatment strategy for unstable fractures in elderly patients remains controversial. This study aimed to compare the radiological and clinical outcomes between locking compression plate (LCP) fixation and LCP fixation with fibular allograft implantation for the treatment of comminuted PHFs., Methods: We retrospectively reviewed 60 patients (mean age, 72.75 years) with closed 3- or 4-part fractures, and a minimum of 2 years of follow-up. Fracture reduction was quantitatively determined by humeral head height (HHH) and neck-shaft angle (NSA). The clinical outcome was evaluated by Constant-Murley score (CMS) and American Shoulder and Elbow Surgeons (ASES) score., Result: The average radiological changes were higher in the LCP group than in the locking plate with fibular allograft group (HHH of 4.16 mm vs 1.18 mm [p < 0.001] and NSA of 9.94° versus 3.12° [p < 0.001]) . The final average outcome scores were lower in the LCP group than in the FA group (CMS of 73.00 vs 78.96 [p = 0.024] and ASES score of 72.80 vs 78.64 [p = 0.022]). The FA group showed better forward elevation (p = 0.010) and abduction (p = 0.002); however, no significant differences were observed for shoulder external rotation or internal rotation. The number of complications was higher in the LCP group (28.57%) than in the FA group (1.2%) (p < 0.001)., Conclusion: For comminuted PHFs in elderly patients, LCP fixation combined with a fibular allograft is reasonable option to ensure satisfactory radiological and clinical outcomes., Trial Registration: ZDYJLY(2018)New-9 . Name of registry: IEC for clinical Research of Zhongda Hospital, Affiliated to Southeast University. Date of registration: 2018-05-17.

The supracondylar humerus fracture is the most common elbow fracture in children, corresponding to 58% of these cases. The objective of this study is to report a rare postoperative complication, the pseudoaneurysm of the brachial artery. A 9-year-old girl with was admitted with a Gartland III supracondylar fracture of the right humerus, presenting normal neurological and vascular exams. The patient underwent a surgical treatment with percutaneous fixation and immobilization and was re-evaluated after 2 and 4 weeks. In the last evaluation the immobilization and fixation were removed. She returned after 3 months, presenting a progressive palpable, painless mass in the 1/3 distal right arm. The arterial ultrasound showed a mass in the cubital fossa, which presented internal flow and some wall thrombi, compatible with pseudoaneurysm of the brachial artery. After diagnosis, the treatment was a vascular surgery for dissection and reconstruction of the artery. The incidence of vascular involvement in Gartland III fractures ranges from 2% to 38%. False aneurysms originate from arterial hematomas caused by trauma to the arterial lumen, and their developing time can vary. There are few reports of this complication, so there is no consensus about the treatment.

Displaced supracondylar fractures of the humerus (SCFH) require surgical treatment, most commonly closed reduction with pin fixation. Postoperative displacement following pin fixation is uncommon. Routinely, an early follow-up visit with a radiograph was recommended after fixation of SCFH. The aim of this study was to examine the rate of displacement of SCHF treated with pin fixation using objective radiologic measurements and to determine the need for the early follow-up radiographs. We retrospectively reviewed 161 patients with displaced SFCH treated surgically. The primary outcome measure was loss of reduction (LOR). We examined patient and fracture characteristics and postoperative complications. LOR was defined as a change of 5° or more in measurement of Bauman's angle or the lateral capitellohumeral angle. After applying exclusion criteria, the study group consisted of 131 patients; 87 (66.4%) were male; the left limb was involved in 76 patients (58%); 98 were classified as Gartland type 3 (74.8%); 118 patients had extension type fractures (90%); complications included nerve injury in 32 patients (24.4%), mostly involving the ulnar nerve (17, 13%). Pin-tract infection occurred in four patients (3%). LOR was found in five patients (3.8%). In all these patients, there was evidence of inadequate fixation in the intraoperative radiographs. When adequate fixation is obtained intraoperatively, the next follow-up radiograph is recommended after 3 weeks, at the time of pin removal.

Objectives: To determine if level 1 evidence from a landmark trial changed practice patterns for treatment of patients with displaced midshaft clavicle fractures., Design: Retrospective cohort study., Setting: Two level 1 trauma centres., Participants: Displaced midshaft clavicle fractures., Results: 686 patients met inclusion criteria. The pretrial cohort (n=108) was 68.5% male, with a mean age of 37.7 (±13.9) years. The post-trial cohort (n=578) was 76.1% male, with a mean age of 41.9 (±12.7) years. There was nearly a 10-fold increase in the patients treated with openreduction and internal fixation (ORIF) in the post-trial cohort (34.1%) compared with the pretrial cohort (3.7%) (p<0.001). Patients in the post-trial cohort were more likely to undergo ORIF if they were <40 years (OR=2.2; 95% CI 1.53 to 3.10), if their Injury Severity Score was >9 (OR=1.6; 95% CI 0.89 to 2.99) or if they were treated at a centre that participated in the Canadian Orthopaedic Trauma Society ( COTS ) trial (OR=5.2; 95% CI 3.31 to 8.21)., Conclusions: This study demonstrated a significant shift towards more frequent ORIF for displaced midshaft clavicle fractures following the COTS trial. Quantifying changes in practice pattern following publication of level 1 evidence is important to further our understanding of the impact large randomised clinical trails are having on clinical practice., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Exotic animal orthopedics has not incorporated the most recent progress made in small animal surgery or human medicine. Although minimally invasive osteosynthesis has been incorporated as a routinely used alternative in small animals, its use in exotic animals is still in its infancy. This article compliments the reviews of orthopedics in small mammals, birds, and reptiles in the previous issue. It reviews relevant recent studies performed in laboratory animals about new orthopedic materials and techniques showing potential to become incorporated into the routine orthopedic treatment of exotic animals in the coming years., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Tibial plateau fractures remain a clinical challenge due to the complexity of the fracture patterns which have been repeatedly categorized by many researchers. However, limitations do exist in some respects. So we aimed to reclassify tibial plateau fractures based on injury mechanism and morphological characteristics., Methods: Five hundred fourteen cases of tibial plateau fractures were enrolled. The X-rays and CT scans were analyzed., Results: According to our observation and analysis, tibial plateau fractures can be categorized into the following six types: (1) Lateral condylar fractures (axial force applied while knee extending in valgus position). Two hundred fifty-one cases were included (48.83%). (2) Fracture dislocation (multiple forces especially rotational stress while knee extending). Fifty-five out of 514 cases belong to this pattern (10.70%). Correction of the subluxation remains primary and crucial during surgical procedures. (3) Simple medial condylar fractures (axial force applied while knee extending in varus position). One third of which were associated with an avulsion fracture of fibular head. Fifteen cases were included (2.92%). (4) Bicondylar fractures (axial forces applied while knee extending). One hundred twelve cases were included (21.79%). Surgical algorithm greatly depends on soft tissue conditions. (5) Posterior condylar fractures (axial stress applied while knee flexing). Sixty-five cases were seen in our study (12.65%), most of which were associated with an avulsion fracture of the intercondylar eminence (49/65, 75.38%). The fracture of posteromedial part, posterolateral part, and intercondylar eminence forms a unique pattern of injury defined as "Posterior Condylar Triad." (6) Anterior condylar compression fractures (axial, varus, or valgus forces applied while knee overextending). Posterior structural complexes, crucial ligaments, or even popliteal arteries are prone to be damaged. Sixteen cases were identified (3.11%)., Conclusion: Our classification system has instructive significance in overall preoperative evaluation of fracture features and soft tissue problems as well as guiding clinical management for better functional outcomes.

Backgrounds: The aim of our study was to investigate failure rates of reconstruction plate and non-reconstruction plate, and find the best strategy for implant selection for different fracture types for midshaft clavicular fractures., Patients and Methods: Two hundred twenty-six consecutive patients with midshaft clavicular fractures who received open reduction and plate fixation during Jan 2012 to July 2017 were reviewed. The correlations between implant failure rates and risk factors including demographic data, fracture classifications, and implant types were analyzed., Results: AO/OTA fracture classification and plate types are the most important factors affecting implant failure for midshaft clavicular fractures. Reconstruction plate had a significantly higher failure rate (53%) than that of non-reconstruction plates (3%) in comminuted midshaft clavicular (AO/OTA 15-2C) fractures (P value < 0.01). However, the difference was not significant in AO/OTA 15-2A and 2B classifications., Conclusion: Patients with comminuted midshaft clavicular (AO/OTA 15-2C) fractures treated with reconstruction plates had very high implant failure rates compared to non-reconstruction plates. We suggested that patients with comminuted midshaft clavicular (AO/OTA 15-2C) fractures treated with reconstruction plates need more protection and more frequent follow-up in the postoperative period.

Introduction: the diversity of the causes of trauma produces different patterns of fractures depending on sociodemographics, lifestyle, industry, and outdoor activities. Mandibular fractures (MFs) are the commonest facial fractures. Reconstruction aims to restore the preinjury anatomy and function as much as possible., Aim of the Study: to evaluate the demographics, etiologies, patterns, treatment modalities and outcomes of management of MFs in southern Egypt., Patients and Methods: records of 1371 patients with MFs were reviewed to study the incidence, causes, patterns, treatment modalities and outcomes of surgical management., Results: the study included 1152 (84.03%) males and 219 (15.97%) females. The second and third decades were the most vulnerable groups. Isolated MFs appeared in 75.49% of patients while in the others either zygoma and/or maxilla were affected. The commonest causes were road traffic accidents (66.89%) and fall from height (15.1%). The body was the commonest involved region (30.98%), followed by parasymphyseal region (24.33%). In 66.16% of patients, the treatment was open reduction and internal fixation while in 22.17%, closed reduction and intermaxillary fixation were used. 20.24% of the cases had 1 or more postoperative complications, mainly temporomandibular joint dysfunction in 64 cases, malocclusion in 58 cases, and paresthesia in 42 cases., Conclusion: the MFs are common in the youth. The road traffic accidents are the most common etiology. This can be reduced by simple measures like compulsory seat belts and wearing the helmet. Open reduction and internal fixation is the commonest treatment modality.

Distal radius fracture is a very common injury representing 17.5% of all fractures seen in the emergency room. However, the most effective treatment is still unclear and controversially debated. For ten years, we have been facing a true revolution by the increasing use of open reduction and fixation by volar locking plates as an alternative to previous less invasive treatment such as closed reduction and percutaneous k-wire pinning. Several meta-analyses have compared the clinical results after closed reduction and percutaneous pinning and volar locking plate fixation. Volar locking plate fixation achieves better early functional recovery, better radiological outcomes and less minor complications. However, long-term results were similar for both fixation methods. In addition, worse radiological outcomes and more minor complications after closed reduction and percutaneous pinning seem not to be clinically relevant. Interestingly, volar locking plate fixation continues to be a more dominant treatment method compared to percutaneous pinning in operative care of distal radius fractures. Surgeon characteristics such as age, profession as well as location and type of the clinic seem to play a role in the decision for the surgical treatment method. It appears that implant cost plays a minor role in treatment choice between closed reduction and percutaneous pinning and volar locking plate fixation., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: This study aims to explore if the arthroscopically assisted reduction and internal fixation (ARIF) technique is superior to the traditional open reduction and internal fixation (ORIF) technique in the treatment of tibial lateral plateau fractures., Methods: Forty patients with tibial plateau fractures (Schatzker type I-III) treated with ARIF or ORIF from 2012 to 2017 were included in this retrospective study. All patients received pre-operative radiographs and CT scans. The patients were divided into two groups (ARIF or ORIF). All patients had a minimum follow-up of 12 months and an average follow-up of 44.4 months. The clinical and radiographic outcomes were evaluated according to the Knee Society Score (KSS) and the modified Rasmussen radiological score., Results: Satisfactory clinical and radiological results were found in 39 out of 40 (97.5%) patients. KSS and modified Rasmussen radiological score were significantly better in ARIF group. The mean KSS was 92.37 (± 6.3) for the ARIF group and 86.29 (± 11.54) for the ORIF group (p < 0.05). The mean modified Rasmussen radiographic score was 8.42 (± 2.24) for the ARIF group and 7.33 (± 1.83) for the ORIF group (p = 0.104). Worst clinical and radiological results were related to concomitant intra-articular lesions (p < 0.05). Meniscal tears were found and treated in 17 out of 40 (42.5%) patients. The overall complication rate was 10%., Conclusions: Both ARIF and ORIF provided a satisfactory outcome for the treatment of Schatzker I-III tibial plateau fractures. However, ARIF led to better clinical results than ORIF. No statistically significant differences were found in perioperative complications, radiological results, and post-traumatic knee osteoarthritis., Level of Evidence: Level III.

Background: It is known that there are large regional variations in treatment methods for the management of proximal humeral fractures. The objective of this study was to investigate the national surgical trends in elderly patients with proximal humeral fractures in South Korea., Methods: We analyzed the Korean Health Insurance Review and Assessment Service database from 2008 to 2016. International Classification of Diseases, 10th revision codes and procedure codes were used to identify patients aged ≥65 years with proximal humeral fractures., Results: A total of 69,120 proximal humeral fractures were identified from 2008 to 2016. The overall operative rate for proximal humeral fractures increased steadily from 24.6% in 2008 to 36.8% in 2016 (p < 0.001). The rate of cases treated with open reduction and internal fixation tended to increase each year, from 71.5% of the overall surgeries in 2008 to 85.6% in 2016; conversely, the rate of cases treated with closed reduction and internal fixation tended to decrease from 19.9% in 2008 to 4.5% in 2016. In terms of type of arthroplasty procedure, the rate of cases treated with reverse shoulder arthroplasty tended to increase significantly each year, from 8.2% of the overall arthroplasty procedures in 2008 to 52.0% in 2016 (p < 0.001). The proportion of reverse shoulder arthroplasty was shown to increase especially in patients aged 80 years or older., Conclusion: Overall, our findings indicated that surgical treatment of proximal humeral fractures, particularly by open reduction and internal fixation, continues to increase; in terms of type of arthroplasty procedure, the rate of cases treated with reverse shoulder arthroplasty tended to increase.

Background: The extensile lateral approach (ELA) has been widely used to treat displaced intra-articular calcaneal fractures (DIACFs) and remains the gold standard procedure. Orthopedic surgeons are extremely concerned of the high rate of wound complications. This study intended to report a new surgical technique of the lateral wall osteotomy combined with an embedded biodegradable implant for treating DIACFs and assess clinical and radiological results., Methods: From May 2013 to December 2015, a total of 17 patients with 19 calcaneal fractures underwent surgical treatment using our new technique. Radiographic images, computed tomography (CT) scans, and magnetic resonance (MR) images of the operative limb were obtained to assess fracture healing and biodegradable implant degradation. American Orthopaedic Foot and Ankle Society (AOFAS) ankle/hindfoot score at the last follow-up was obtained to assess functional result for all cases. Böhler's and Gissane's angles, width, and height of the injured calcaneus were analyzed using preoperative and last follow-up radiographic images., Results: All radiological parameters were significantly improved at the last follow-up, with an increase of 15.58°, 8.38°, and 7.65 mm in Böhler's angle, Gissane's angle, and calcaneal height, respectively, and a decrease of 2.51 mm in calcaneal width (p < 0.05). Mean AOFAS score at the last follow-up was 84.37 ± 9.98, with 9, 6, and 4 feet, having excellent, good, and fair rates, respectively. None had nonunion, delayed union, or malunion after a mean follow-up of 34.69 ± 5.22 months. One superficial infection occurred 6 days post-surgery., Conclusions: Osteotomy of the lateral wall of the calcaneus allows tension-free suturing and avoids damage to penetrating branches of the lateral calcaneal artery (LCA). Biodegradable implants are easy to reshape and do not require surgical removal. However, they should be limited to Sander's type II and III fractures only., Level of Evidence: Level IV, case series without controls.

Background: Using a larger, more comprehensive sample, and inclusion of the reverse shoulder arthroplasty as a primary surgical approach for proximal humerus fracture, we report on geographic variation in the treatment of proximal humerus fracture in 2011 and comment on whether treatment consensus is being reached., Methods: This was a retrospective cohort study of Medicare patients with an x-ray-confirmed diagnosis of proximal humerus fracture in 2011. Patients receiving reverse shoulder arthroplasty, hemiarthroplasty, or open reduction internal fixation within 60 days of their diagnosis were classified as surgical management patients. Unadjusted observed surgery rates and area treatment ratios adjusted for patient demographic and clinical characteristics were calculated at the hospital referral region level., Results: Among patients with proximal humerus fracture (N = 77,053), 15.4% received surgery and 84.6% received conservative management. Unadjusted surgery rates varied from 1.7 to 33.3% across hospital referral regions. Among patients receiving surgery, 22.3% received hemiarthroplasty, 65.8% received open reduction internal fixation, and 11.8% received reverse shoulder arthroplasty. Patients that were female, were younger, had fewer medical comorbidities, had a lower frailty index, were white, or were not dual-eligible for Medicaid during the month of their index fracture were more likely to receive surgery (p < .0001). Geographic variation in the treatment of proximal humerus fracture persisted after adjustment for patient demographic and clinical differences across local areas. Average surgery rates ranged from 9.9 to 21.2% across area treatment ratio quintiles., Conclusions: Persistent geographic variation in surgery rates for proximal humerus fracture across the USA suggests no treatment consensus has been reached.

Anterior odontoid screw fixation allows for the internal fixation of unstable odontoid fractures with low morbidity, good fusion rates, and preservation of the atlanto-axial range of motion when applied in appropriate clinical cases. Advances in surgical techniques have allowed for safer, more minimally invasive approaches that reduce the risk of injury to vital prevertebral structures and minimize soft tissue retraction. Moreover, improvements in surgical image guidance technology for spinal surgery that have been applied to odontoid screw placement have helped improve surgeon confidence about exact screw trajectories. In this chapter, we review traditional screw placement techniques and highlight the trends in technical improvements that improve the safety and efficacy of these procedures.

Background: Our hospital has recently used the extended anterolateral approach in posterolateral tibial plateau fracture. We compared the clinical effects of this method in Schatzker type II or type V/VI fractures with posterolateral tibial plateau fracture based on our patients., Methods: The patients from January 2013 to December 2015 were summarized, and some of them were assisted with arthroscopy. According to Schatzker classification, patients with Schatzker type II fracture were divided into group A; patients with Schatzker type V/VI fracture were divided into group B. The fracture characteristics, operation statistics, and postoperative functional evaluation of each group were compared., Results: A total of 46 patients were included in the study and were followed up for 23-45 months. There were 24 cases in group A and 22 cases in group B. The operation time and the amount of bleeding were significantly less in group A (P < 0.05). Twelve cases were assisted with arthroscopy including 6 patients in each group. The fracture healing time made no significant difference in the two groups (P > 0.05). All patients experienced no significant influence on daily life. The knee Rasmussen score was 26.8 in group A and 23.5 in group B (P > 0.05), and the knee range motion was 115.5° in group A and 106.6° in group B (P > 0.05). The excellent and good rate of reduction was 91.7% in group A and 81.8% in group B (P > 0.05), but the excellent rate of reduction was 83.3% in group A and 27.3% in group B (P < 0.05). The unfixed rate of posterolateral fracture was 16.7% in group A and 36.4% in group B (P > 0.05). One patient in group B suffered postoperative wound infection., Conclusions: The extended anterolateral approach could obtain similar satisfactory clinical results in simple/complex tibial plateau fracture with posterolateral tibial plateau fracture. It seemed that easier operation, better posterolateral fracture reduction, and fixation occurred in relative simple fracture from our cases., Trial Registration: It was a retrospective study. This study was consistent with the ethical standards of the Second Affiliated Hospital of Zhejiang University Medical College and was approved by the hospital ethics committee and the trial registration number of our hospital was 20170053.

Background: Occurrence of calcaneus fractures is on the up trend. Owing to its unique anatomical morphology and limited soft-tissue envelope, management of calcaneus fractures is a challenge to the orthopaedic surgeon, and surgical site infection (SSI) is one of the serious postoperative complications. In order to decrease the incidence of wound breakdown and improve clinical outcomes, it is necessary to understand which factors were associated with SSI. The aim of this study was to identify predictors of SSI and quantify the incidence of SSI in calcaneus fractures following open reduction and internal fixation (ORIF)., Methods: This retrospective study was performed at a level 1 trauma center from January 2014 to June in 2017. Data of adult patients with calcaneus fractures treated by ORIF were extracted from the electronic medical records. A total of 681 patients were collected. We reviewed the patients' demographics, characteristics of fracture, treatment-related variables, and indexes of laboratory examination. Univariate and multivariate logistic analysis models were performed respectively to determine independent predictors of SSI., Results: Sixty-six patients developed SSI in this study. The overall incidence of SSI after ORIF of calcaneus fracture was 9.7%, with 2.9% for deep infection and 6.8% for superficial SSI. Independent predictors of SSI identified by multivariate analysis were open fracture (odds ratio = 9.48, 95% CI = 4.53-19.85, P = 0.00007), high-energy injury (odds ratio = 2.07, 95% CI = 1.16-3.70, P = 0.01437), ASA class 3 or higher (odds ratio = 3.50, 95% CI = 1.18-10.37, P = 0.02401), and intraoperative temperature < 36.0 °C (odds ratio = 1.69, 95% CI = 1.13-2.28, P = 0.04410)., Conclusion: The SSI incidence was high (9.7%) for calcaneus fractures following ORIF. External fixation plays an important role in the treatment of severely displaced and depressed intra-articular or open calcaneus fractures. Increased ASA class and intraoperative hypothermia were associated with wound breakdown, and elaborative evaluation of fracture and soft-tissue damage was vitally necessary in this at-risk population.

Background: Posterolateral tibial plateau fractures have become more common, and their treatment is of great importance to knee function. Additionally, there is no available literature detailing specialized anatomic locking plate for tibial plateau fractures. Therefore, the aim of the study was to evaluate the safety and clinical efficacy of an innovative anatomic locking plate for treatment of posterolateral tibial plateau fractures., Methods: Between March 2014 and January 2016, 12 patients with posterolateral tibial plateau fracture underwent surgery with the anatomic locking plate for the posterolateral tibial plateau via the posterolateral approach. Relevant operational data for clinical evaluation were collected., Results: The mean follow-up time was 26 months, and the mean age was 35 years for 12 patients. The mean interval between the time of injury and the surgery was 6.1 days. Radiological fracture union was evident in all patients at 12 weeks. During surgery, the blood loss ranged from 100 to 300 mL, and the duration ranged from 55 to 90 min. The Tegner-Lysholm functional score ranged from 85 to 97 at the final follow-up. Moreover, the final Rasmussen functional score ranged from 25 to 29, and Rasmussen anatomical score ranged from 13 to 18., Conclusions: The newly designed anatomic locking plate for the posterolateral tibial plateau provided adequate fixation along the posterolateral tibial plateau. It proved to be safe and effective in a small-sample-size population (12 patients) during a 12- to 34-month follow-up.

The purpose of this study was to examine alterations in national trends managing midshaft clavicle fractures (MCF) and intra-articular distal humerus fractures (DHF) surrounding recent level 1 publications. A retrospective review of the PearlDiver supercomputer for DHF and MCF was performed. Using age limits defined in the original level 1 studies, total use and annual use rates were examined. Nonoperative management and open reduction and internal fixation (ORIF) were reviewed for MCF. ORIF and total elbow arthroplasty (TEA) were reviewed for DHF. A query yielded 4929 MCF and 106,535 DHF patients. A significant increase in ORIF use for MCF following the publication of the level 1 study ( p = .002) and a strong, positive correlation ( p = .007) were evident. Annual TEA ( p = .515) use for DHF was not observed. (Journal of Surgical Orthopaedic Advances 27(3):219-225, 2018).

Fractures of the talus are challenging to manage, with historically poor outcomes and a high rate of complications. The rare nature of this injury limits the number of studies available to guide treatment. Fortunately, a number of advancements have been made in the last decade. There is increased recognition regarding the importance of anatomic reconstruction of the osseous injury. Advanced imaging is used to assess the subtalar joint, where even slight displacement may predispose to arthritis. Increasing use of dual anteromedial and anterolateral approaches, along with plate fixation, has improved our ability to accurately restore the anatomy of the talus. Modification of the original Hawkins classification can both guide treatment and allow us to better predict which patients will develop avascular necrosis. Lastly, improved reconstructive techniques help address the most common complications after talus fracture, including arthritis, avascular necrosis, and malunion., (Copyright © 2017 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.)

Background: There have been many studies regarding nongeriatric femoral neck fractures (FNFs), which included patients of a wide age range (between 20 and 60 years old). We aimed to determine whether internal fixation provided acceptable outcomes for middle-aged patients with displaced FNFs, and identify predictors of successful internal fixation., Methods: A total of 117 patients, aged 50-60 years and who underwent closed reduction and unilateral internal fixation using cannulated screws, were included. The outcomes were classified as either "complications" (varus malunion, femoral neck shortening, non-union/early collapse, avascular necrosis, or arthroplasty during the follow-up) or "optimal outcomes" (no complications). Patients with displaced FNFs (Garden stages III-IV, n = 69) were categorized according to whether they experienced acceptable or unacceptable reduction. We evaluated whether patients' clinical characteristics could predict optimal outcomes., Results: Patients with displaced FNFs generally experienced complications (84.1%). Twenty-two percent of patients experienced optimal outcomes when acceptable reduction was achieved. Patients with unacceptable reductions experienced complications. Optimal outcomes were positively associated with Pauwels' type II fracture (OR: 8.67, p = 0.025) and negatively associated with excessive alcohol consumption (p = 0.045)., Conclusions: Compared with the younger age group, complication rates are higher in middle-aged patients with displaced FNFs treated using cannulated screws. If internal fixation is to be used for a displaced FNF, patient selection is essential. Care must be taken to avoid selecting patients with excessive alcohol consumption, while successful internal fixation may be more likely for patients with Pauwels' type II fracture.

Internal fixation of bone fractures by plate osteosynthesis has continuously evolved for more than 100 years. The aim of internal fracture fixation has always been to restore the functional capacity of the broken bone. The principal requirements of operative fracture management, those being anatomical fracture reduction, durable fixation, preservation of biology, promotion of fracture healing and early patient mobilization, have always been crucial but were accomplished to different extents depending on the focus of the specific fracture fixation principle employed. The first successful approach for internal fracture fixation was anatomic open reduction and interfragmentary compression. This secured the fracture fragments, maintained alignment and enabled direct healing of the fracture fragments. However, the highly invasive approach inflicted an immense amount of biologic stress to the area surrounding the fracture site. Modern preferably anatomically pre-contoured locking plates with relative stability of the bone-implant construct enable durable fixation while allowing a less invasive approach that preserves the biology at the fracture site. In contrast to conventional plating, locked plating provides a certain amount of flexibility, which is required to induce the formation of periosteal callus through interfragmentary motion. Most recently the concept of dynamic plating was introduced, which aims to induce more controlled interfragmentary motion and active stimulation of periosteal callus formation. This review article describes the historic development of plating from conventional plating to locked and dynamic plating., (© 2018 Elsevier Ltd. All rights reserved.)

The surgical approach for open reduction and internal fixation of lateral condyle fractures in children is controversial. Some authors recommend the lateral approach to the elbow over the posterior approach because of theoretical concern for injury to the vascular supply of the distal humerus and potential avascular necrosis (AVN). The purpose of this retrospective case series study is to report the outcomes of open reduction and internal fixation of displaced lateral condyle fractures of the humerus by the posterior approach. Fifteen consecutive cases were reviewed and the posterior approach resulted in minimal postoperative loss of motion, no angular deformity, cosmetic scars, and no AVN. We support that AVN occurs because of stripping of soft tissues from the lateral condyle fragment and not the approach used. Stripping of soft tissues is not required when using the posterior approach because of excellent visualization of the fracture reduction.

The management of neglected fracture of the lateral condyle of the humerus is controversial. Careful neglect and conservative management with early ulnar nerve transposition and ostetomy, in-situ surgical fixation and accurate open reduction and internal fixation are all recommended as treatment options. However, an overgrowth of fractured condyle, highly distorted anatomy, contracted soft tissue and almost unrecognizable fracture ends make open reduction a challenging task. As the functional loss is not severe, in-situ fixation of the fragment provides a good alternative. There have been proponents of both surgeries with very limited data on comparison on both procedures. Here, we present our experience of 45 patients, 22 treated with anatomical reduction and 23 treated with in-situ fixation with no attempts of anatomical restoration, and attempted to evaluate the results of two surgeries with a follow-up of at least 2 years. Neglected fractures of the lateral condyle were surgically treated with two different techniques. In all, 22 patients were treated with open reduction and fixation whereas 23 patients were treated with in-situ fixation to render the elbow stable. Patients were followed for a minimum of 2 years. These patients were studied in terms of functional scores and radiological union. Radiological union was better in the anatomical reduction group with one nonunion compared with five in the in-situ group. However, functional results and elbow range were better in the in-situ fixation group. The surgical time was 57 min in in-situ fixation compared with 73 min in the anatomical reduction group. Complication rates were found to be high in the open reduction group. In-situ fixation of neglected lateral condyle fractures is an effective technique for the treatment of these difficult fractures presenting late compared with anatomical fixation. Radiological union, although less successful compared with open anatomical reduction, leads to better functional outcome, with decreased surgical time and postoperative complications.

Background: The aim of this study is to determine the functional long-term outcome after non-operative and operative treatment of radial neck fractures in adults., Methods: Thirty-four consecutive patients with a mean age of 46.4 (18.0 to 63.0) years with a fracture of the radial neck who were treated between 2000 and 2014 were examined regarding the clinical and radiological outcome. Twenty patients were treated non-operatively, and 14 patients underwent surgery., Results: After a mean follow-up of 5.7 (2.0 to 15.7) years, the clinical scores showed good results in both groups. The Disabilities of Arm, Shoulder and Hand score was 16.1 (0 to 71.6) in the non-operative group and 8.8 (0 to 50.8) in the operative group, respectively. The Mayo Elbow Performance Score was 80.0 (30 to 95) in the non-operative group and 82.5 (35 to 95) in the non-operative group, respectively. The initial angle of the radial head towards the shaft (RHSA) was significantly higher in the operative group in the anterior-posterior plane (12.8° [2 to 23] vs. 26.3° [1 to 90], p = 0.015). In the follow-up radiographs, the RHSA was significantly lower in the operative group (15.1° [3 to 30] vs. 10.9° [3 to 18], p = 0.043). Five patients developed 7 complications in the non-operative group, and 7 patients developed 12 complications in the operative group. Revision rates were higher in the operative groups as 1 patient received radial head resection in the non-operative (5%) group while 7 patients in the operative group (50%) needed revision surgery., Conclusion: A good functional long-term outcome can be expected after operative and non-operative treatment of radial neck fractures in adults. If needed due to major displacement, open reduction is associated with a higher risk of complications and the need for revision surgery but can achieve similar clinical results., Trial Registration: DRKS DRKS00012836 (retrospectively registered).

Aim: We estimate the impact of the FOCUS trial, which concluded that hip surgery patients with hemoglobin values above 8 g/dl do not benefit from routine transfusions, on transfusion rates., Methods: We evaluated trends in transfusion rates using inpatient discharge data from four states., Results: The transfusion rate was 5.2 percentage points lower in the fourth quarter of 2013 than it would have been had pre-FOCUS trends continued. Transfusion rates declined more in hospitals with a low end-of-life treatment intensity index, a general measure of treatment intensity., Conclusion: The FOCUS trial affected practice, but there are additional opportunities to reduce the use of transfusions.

Background: Proximal humeral fracture is a common fracture. Different approaches have been utilized in the surgical intervention of three-part fractures. Our study is to evaluate the clinical outcomes and effectiveness of a modified anterolateral approach and intra-osseous portal in minimally invasive treatment for three-part proximal humeral fractures in comparison to the traditional deltopectoral approach., Methods: From March 2015 to September 2016, 13 patients with three-part proximal humeral fractures were treated with internal fixation through the modified anterolateral minimally invasive approach (MIPO). These cases were compared to 20 additional cases using the deltopectoral approach (DP). Clinical and radiographic evaluations were performed, including the constant score (CS) and range of motion in abduction, flexion/extension and external/internal rotation. Complications were recorded as well., Results: All patients were followed up for a mean time of 12.12 ± 4.01 months. At the latest follow-up, no significant differences (p < 0.05) were observed in terms of length of stay, range of motion for abduction, flexion or internal/external rotation of the shoulder, Constant score or visual analog scors (VAS) for pain. Elbow flexion (142.31 ± 8.32 vs. 123.00 ± 10.18), posterior shoulder extension (41.92 ± 5.22 vs. 35.50 ± 5.83) and postoperative VAS (4.38 ± 1.04 vs. 6.15 ± 0.99) were significantly better in the MIPO group than in the DP group (p < 0.05). No significant differences were detected in the radiographic evaluation, and complications including axillary nerve injury were not present., Conclusion: The use of the modified anterolateral approach and intra-osseous portal is safe and effective for minimally invasive reduction and plating treatment for three-part proximal humeral fractures.

Advancement in orthopedics have been increasing rapidly. The most important advances have been in fixation. With time, metallic hardware will begin to be replaced by materials that become one with the body. This progress will not only aid in the repair process it will allow permanent and improved reinforcement of the fixated region. Biointegrative technology is a promising new generation of materials capable of achieving this goal. Over time, it is expected that plates, screws, pins, interference screws, and even possibly joint replacements will incorporate into patients' bodies, negating the need for hardware removal and adding structure and stability to an iatrogenically weakened area., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose.

Background: Fractures to the base of the fifth metatarsal are common, but their treatment remains controversial. Especially for Lawrence and Botte (L&B) type II fractures, there is conflicting evidence and consequently no consensus. Further, many authors consider displacement, articular involvement, and number of fragments an indication for surgery, although evidence is missing. The aim of this study was to evaluate the outcome of functional treatment for all L&B type I and II fractures. Of special interest were the influence of (1) the fracture location (L&B type I vs. II) and (2) the fracture characteristics (displacement, intra-articular involvement, communition) on the subjective outcome., Methods: Retrospective registry study with a prospective follow-up. Patients with an acute, isolated, epi-metaphyseal fracture to the fifth metatarsal bone (L&B type I and II) treated by full weightbearing with a minimum follow-up of 6 months were included. Fracture location (L&B type I and II) and characteristics (displacement <2 mm or >2 mm, intra-articular involvement, and number of fragments) were assessed. Outcome parameters were return to work, return to sports, VAS-FA, and SF-12. The influence of the fracture (1) location and (2) -characteristics on these parameters was tested., Results: Thirty-nine patients (40 ± 15 years, 56% female) were enrolled with a mean follow-up of 22 ± 10 months. L&B type I fractures occurred in 59%, type II in 41%. Thirty-one percent of all fractures were dislocated, 74% intra-articular, and 41% multi-fragmentary. Patients returned to work after 17 ± 12 days, to sports after 53 ± 22 days. The VAS-FA score at the final follow-up was 96 ± 4, SF-12 PCS score 57 ± 5 and MCS score 51 ± 8. No complications were reported, no patient required surgery. None of the assessed outcome parameters differed significantly between (1) the different fracture locations (L&B type I vs. II) or (2) the different fracture characteristics (displacement, intra-articular involvement, and number of fragments)., Conclusions: (1) Both, L&B I and II fractures featured excellent results with immediate full weightbearing. Consequently, L&B type I and II fractures should be summarized as epi-metaphyseal fractures. (2) Fracture displacement, articular involvement, and number of fragments did not influence the outcome. Therefore, functional treatment should be recommended for all epi-metaphyseal fractures.

Background: Several studies have reported that diabetic persons have an increased risk for fractures than non-diabetes patients. The association between proximal humerus fractures and type 2 diabetes (T2DM) is unclear and some studies point to insulin treatment, hypoglycaemic episodes consequently to inadequate control of diabetes or, more recently, to an alteration of trabecular bone. We examined trends in the incidence of proximal humerus fractures, surgical procedures and outcomes among hospitalized patients aged ≥65 years, with and without T2DM in Spain, 2001-2013., Methods: This retrospective, observational study was conducted using the Spanish National Hospital Discharge Database to select all hospital admissions with proximal humerus fracture. We calculated incidences overall and stratified by diabetes status, year and sex. We analyzed surgical procedures, comorbidities, length of stay, in-hospital complications and in-hospital mortality., Results: We identified 43,872 patients with proximal humerus fracture (18.3% had a T2DM diagnosis). Age-adjusted incidence rates elevated steadily over the study period for men and women with and without T2DM, independently of diabetes status, although we found a stable trend in the later years. Patients with T2DM had lower relative risk of proximal humeral fracture incidence: 0.87 (95%IC 0.82-0.93) for men and 0.97 (95%IC 0.95-1.00) for women. In-hospital complications were 4.0% of diabetic men vs. 2.6% in non-diabetic (p < 0.001) and 2.9% among T2DM women vs. 1.7% in those without (p < 0.05). The use of open reduction of fracture with internal fixation and arthroplasty is increasing overtime and closed reduction with internal fixation is decreasing. Presence of T2DM in women was associated with higher in-hospital mortality (OR 1.67; 95%CI 1.29-2.15). Comorbidities, in-hospital complications and older age were predictors of higher in-hospital mortality in both sexes., Conclusions: The incidence of proximal humerus fractures seems to be increasing in Spain. The incidence is lower among men with than without T2DM. T2DM is associated to higher in-hospital complications in both sexes. The use of open reduction of fracture with internal fixation and arthroplasty is increasing overtime beside diabetes status. Women with T2DM have higher in-hospital mortality than those without the disease.