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Challenges in minimally invasive surgeries, such as intramedullary nailing for long bone fractures, include radiation overexposure for patients and surgeons, potential malreduction, and physical burden on surgeons in maintaining the reduction status. A robotic bone fracture reduction system was developed in this study to address these problems. The system consists of a hexapod with six degrees of freedom, with a fracture reduction device and a master device. This study aimed to evaluate the novel system in a preclinical setting. The length of the six axes in the system can be adjusted to precisely control the length, angle, and rotation so that no additional traction is required. Fluoroscopic images can be remotely examined to reduce the risk of radiation exposure for surgeons. In this study, alignment accuracy and radiation exposure were measured using 32 bovine bone fracture models, and these surgical outcomes were compared to those of conventional manual surgery to verify the clinical usability and effectiveness of the system. The alignment accuracy was assessed by analyzing length, angulation, and rotation. The four surgeons participating in this study were divided into two groups (expert and novice) according to their clinical experience. All parameters in robotic surgery significantly decreased by approximately 4 mm and 8° on average (p ≤ 0.05) compared to conventional surgery. The mean radiation exposure in robot-assisted surgery was 0.11 mSv, showing a significant decrease compared to conventional surgery (p < 0.05). Reduction accuracy was higher in robotic surgery performed by the novice group than in conventional surgery performed by the expert group; however, standard deviation values were inversed. In conclusion, the bone fracture reduction robot system increased the alignment accuracy through precise control while reducing radiation exposure in surgeons, as the surgery was performed remotely. The use of this system is predicted to improve the accuracy and reproducibility of the surgery and the safety of medical staff. 1 ., Competing Interests: Declaration of competing interest The authors have no conflicts of interest to disclose., (Copyright © 2024 IPEM. Published by Elsevier Ltd. All rights reserved.)

Background: Although the specific relationship between the stress changes in the external fixator during tibial fracture treatment and the bone healing process remains unclear, it is believed that stress variations in the external fixator scaffold can, to a certain extent, reflect the progress of tibial healing., Objective: This study aims to propose a non-invasive method for assessing the degree of fracture healing by monitoring the changes in stress transmission, the locations of stress-sensitive points, and displacement in the external fixator-tibia system during the healing process of tibial fractures., Methods: In this study, finite element models of tibial fractures at various healing stages were developed. Physiological conditions, including axial, torsional, and bending loads on the tibia, were simulated to evaluate stress and strain within the external scaffold-tibia system under normal physiological loading conditions., Results: The results indicate variations in the stress distribution between the external fixator and the tibia during different stages of healing. In the early phase of fracture healing, the external fixator plays a crucial role as the primary load-bearing unit under all three loading conditions. As the fracture healing progresses, the stress on the tibia gradually increases, concentrating on the medial part of the tibia under axial and torsional loading, and at the upper and lower ends, as well as the central part of the anterior and posterior tibia during bending loading. The stress at the callus gradually increases, while micro-movements decrease. The stress within the external bracket gradually decreases, with a tendency for the connecting rod to transfer stress towards the screws. Throughout the fracture healing process, the location of maximum stress in the external fixator remains unchanged. Under axial and torsional loading, the maximum stress is located at the intersection of the lowest screw and the bone cortex, while under bending loading, it is at the intersection of the second screw and the connecting rod., Conclusion: During the bone healing process, stress is transferred between the external fixation frame and the bone. As bone healing advances, the stress on the connecting rods and screws of the external fixation frame decreases, and the amplitude of stress changes diminishes. When complete and robust fusion is achieved, stress variations stabilize, and the location of maximum stress on the external fixation frame remains unchanged. The intersections of the lowest screw and the bone cortex, as well as the second screw and the connecting rod, can serve as sensitive points for monitoring the degree of bone healing., (© 2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Objective: This study aims to evaluate the clinical application efficacy of the ultrasound-guided Joystick technique for percutaneous leverage reduction in conjunction with Kirschner wires and external fixator in the treatment of difficult-to-reduce pediatric Salter-Harris II type proximal humerus fractures., Methods: A retrospective analysis was conducted on children with Salter-Harris II type proximal humerus fractures, who failed manual closed reduction from January 2018 to March 2022. The group consisted of 7 males and 2 females, aged between 10 and 14 years. The surgical method involved percutaneous leverage reduction using the ultrasound-guided Joystick technique, combined with Kirschner wires and external fixation. Throughout the procedure, ultrasound is used for monitoring, with the fracture condition being determined before surgery. An external support screw is inserted into the distal end of the humerus as an operating lever, along with 3.5 mm Kirschner wire for ultrasound-guided reduction and maintenance of position during the operation. Following fixation with Kirschner wire, a combination external fixator is applied. After fixation is completed, ultrasound is used once more to assess the quality of fracture reduction, followed by verification of the reduction status using a C-arm X-ray machine., Results: All surgeries were successfully completed with a 100 % success rate in resetting. Notably, there were no postoperative complications like nerve or vascular injury, malunion, nonunion, or bone bridge formation in the proximal humeral physis. Three cases experienced minor complications (redness and swelling at the screw sites), which improved with conservative management. The follow-up period ranged from 6 to 18 months, averaging 10.6 months, with fracture clinical healing occurring within 6 to 8 weeks (average 6.3 weeks). The final follow-up revealed excellent functional outcomes, with Neer scores ranging from 90 to 100 (average 96.3 points)., Conclusion: The ultrasound-guided Joystick technique for percutaneous leverage reduction in conjunction with Kirschner wires and external fixator can effectively treat difficult-to-reduce Salter-Harris II proximal humeral fractures in children, avoiding open reduction and minimizing intraoperative radiation exposure. This approach offers good stability and facilitates early rehabilitation, aligning with the ERAS (Enhanced Recovery After Surgery) concept in fracture management, thus warranting clinical promotion., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Proximal humerus fractures are usually treated with rigid angle-stable plates or nails. As an alternative, semi-rigid, minimally invasive systems have been developed for supportive fixation. A new system uses this principle with 2.5 mm partially threaded pins and external fixation., Aim: This study aimed to compare the fracture stability of the fixator with an angular stable plate about whether the mechanical stability is sufficient for early postoperative mobilisation., Materials and Methods: Human proximal humeri (paired, female, age ≥ 60, n = 8) were cut to a 3-part fracture and treated with an external fixator (Galaxy Shoulder, Orthofix) or an angular stable plate (Philos, DePuy Synthes). A physiological load was simulated in vitro based on a 45° abduction motion. The load level was continuously increased from 10 to 320 N within 10,000 cycles simulating the loads during rehabilitation. This was followed by another 10,000 cycles at 320 N for fatigue testing. Fracture motion was recorded with a 3D camera. Fracture stability was evaluated at a partial load of 160 N and 240 N (simulating loads during early mobilisation)., Results: The fracture motion at the lateral aspect was significantly (p < 0.034) larger for the fixator compared to the plate both for axial and for shear movements, while at the medial aspects fracture motions were similar. Both fixation systems adequately stabilized the lateral tubercle fragment with no significant differences between fixation techniques. The migration of the fixator pins (1.1 ± 1.0 mm) and valgus rotation of the head fragment were minimal (3.1 ± 2.0°). The maximum load level of 320 N was reached by all plate constructs and 3 fixator constructs., Conclusion: Our results suggest that the external fixator system allows early but gentle postoperative mobilisation. More aggressive rehabilitation measures should be postponed after the healing of the fracture., Competing Interests: Declarations Ethical approval The utilization of the specimens for biomechanical experiments received approval from the responsible ethical committee (BLÄK 2011-058, Ethik-Kommission der Bayerischen Landesärztekammer, Munich, Germany). Consent to biomechanical research The fresh-frozen proximal humeri were provided by the Institute of Legal Medicine at Universitätsklinikum Hamburg-Eppendorf for the purpose of biomechanical research. Consent for publication Not applicable. Competing interests The institution of the authors (M.G., F.M., S.R., R.P. and P.A.) has received financial support from Orthofix. D.B. was involved in the development of the external fixator system., (© 2024. The Author(s).)

Introduction: Staged treatment of high-energy periarticular tibia fractures involves temporization with closed reduction and external fixation, aiming to provide early reduction and stabilization while mitigating soft-tissue complications. Various external fixator configurations exist, including those that use a "multipin" clamp capable of holding multiple pins but limiting pin placement to a single plane. The purpose of this study was to compare clinical and radiographic outcomes and associated costs of standard and multipin outrigger clamp constructs in tibial plateau and pilon fractures treated with temporary external fixation. We hypothesized that use of the multipin clamp may be associated with poorly aligned reductions and increased complication rates., Methods: A retrospective review of 100 patients with periarticular tibial plateau (AO/OTA: 41B/C) or pilon (43B/C) fracture at a Level 1 trauma center from 2014 to 2023 was conducted. Patient, injury, and complication characteristics were collected. Patients were categorized based on the external fixator clamp used: multipin (MP) or standard (S). Clinical outcomes and complication rates were assessed. Radiographic alignment was evaluated by the change in anterior and lateral distal tibial angles, and sagittal plane translation for pilon fractures, and medial and posterior proximal tibial angles for plateau fractures., Results: 70 patients underwent standard (25 pilon, 45 plateau) and 30 multipin (10 pilon, 20 plateau) external fixation. MP and S groups showed no notable differences in demographics or injury characteristics. Both groups demonstrated comparable complication rates and radiological alignment outcomes, with no notable differences observed. MP constructs were more costly than standard systems., Conclusion: In this retrospective study of 100 patients, there was no difference in radiographic or clinical outcomes between the standard frame and multipin frame groups. Typical costs for the multipin frame constructs were $635 to $1249 more than the standard frame constructs., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Incomplete sacroiliac joint injuries are often associated with external rotation and extension deformities on the injured hemipelvis. To appropriately correct this deformity, an oblique reduction force from caudal to cranial and lateral to medial is helpful. These injuries are often associated with traumatic disruption of the pubic symphysis. However, in injuries without traumatic disruption to the pubic symphysis, a two-pin oblique anterior external fixator can be used to obtain and maintain reduction of the sacroiliac joint, while percutaneous fixation is subsequently placed. Through a small case series and three specific patient examples, we demonstrate that the oblique anterior external fixator frame is a simple and effective strategy with the reduction and stabilization process of these multiplanar hemipelvis deformities., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Objectives: To determine if rates of pin site infection and surgical site infection among patients managed with primary closure after external fixator removal were similar to those allowed to heal secondarily., Design: Retrospective cohort., Setting: Urban/Suburban Academic Level I Trauma Center., Patient Selection Criteria: Patients who had received a lower extremity external fixator for provisional management before definitive fixation of lower extremity fractures were included with pin site wounds closed primarily or allowed to heal by secondary intention., Outcome Measures and Comparisons: The rate of pin tract infection and surgical site infection following primary closure of external fixator pin sites relative to patients whose pin sites were allowed to heal through secondary intention., Results: In total, 256 patients were evaluated: 143 patients (406 pin sites) in the primary closure group and 113 patients (340 in sites) in the secondary closure group. The average age was 49 ± 16 years. Sixty-five percent of included patients were male. There was no difference in pin tract infections between cohorts (primary = 0.5%, secondary = 1.5%, P = 0.26). External fixator duration in the primary closure group was 11.5 ± 8.4 days and 13.0 ± 8.1 days in the secondary closure group (P = 0.15). There was a greater rate of surgical site infections in the secondary intention cohort (15.9% vs. 7.7%, P = 0.047)., Conclusions: There was no difference in pin site infection rate after primary pin site closure relative to patients who were allowed to heal through secondary intention. Furthermore, there was a lower rate of surgical site infection after primary closure. These results challenge the dogma of secondary closure for ex fix pin sites, suggesting that debridement and primary closure is a safe option for management of external fixator pin sites and may impart benefit in decreasing infection risk., Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence., Competing Interests: The authors report no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: We aimed to evaluate the safety and effectiveness of three-dimensional (3D)-printed guide plates for assisting in the positioning of the rotation axis of an elbow-hinged external fixator., Methods: Terrible triad (TT) patients, who were screened using the predefined inclusion and exclusion criteria, underwent installation of a hinged external fixator on the basis of internal fixation; 3D-printed guide plates, generated from the patient's imaging data, assisted in positioning the rotation axis. All patients received the same peri-operative management and were followed up at six, 12, 24, and 48 weeks postoperatively. The duration of positioning pin placement, the number of fluoroscopies, pin placement success rate, types and incidence of post-operative complications, and the Mayo elbow performance score (MEPS) of the diseased elbow and range of motion (ROM) of both elbows were assessed., Results: In 25 patients who completed the follow-up, the average time required for positioning pin placement was 329.32 ± 42.38 s (263-443 s), the average number of fluoroscopies was 2.32 ± 0.48 times (2-3 times), and the pin placement success rate was 100%. At the last follow-up, the mean MEPS of the diseased elbow was 97.50 ± 6.92 (75-100), with an excellent and good rate of 100%, and all patients demonstrated stable concentric reduction. The average range of flexion and extension was 135.08° ± 17.10° (77-146°), while the average range of rotation was 169.21° ± 18.14° (108-180°). No significant difference was observed in the average ROM between the both elbows (P > 0.05). Eight (32%) patients developed post-operative complications, including elbow stiffness due to heterotopic ossification in three (12%) patients, all of whom did not require secondary intervention., Conclusion: Utilizing 3D-printed guide plates for positioning the rotation axis of an elbow-hinged external fixator significantly reduced intra-operative positioning pin placement time and the number of fluoroscopies with excellent positioning results. Satisfactory results were also obtained in terms of post-operative complications, elbow ROM, and functional scores., (© 2024. The Author(s) under exclusive licence to SICOT aisbl.)

Aim: to assess the small-scale 3D printing feasibility and cost estimation of a device for controlled dynamization., Materials and Method: The two-part device previously developed by our research group was printed with a carbon fiber-reinforced nylon filament (Gen3 CarbonX™ PA6+CF, 3DXTECH Additive Manufacturing) by a professional 3D printer (FUNMAT HT, Intamsys). Electricity, material, and labor costs for production in a Brazilian city in the Santa Catarina state were calculated., Results: The devices for controlled dynamization were successfully printed in accordance with the planned design and dimensions. Six out of 38 printed devices presented defects in the bolt hole and were discarded. The average printing time per device was 1.9 h. The average electricity, material, and labor costs per printed device were respectively US$0.71, US$13.55, and US$3.04. The total production cost per device reaches approximately US$20 by adding the average cost of defective devices (15 %)., Conclusion: 3D printing of the controlled dynamization device is feasible and its cost seems affordable to most healthcare services, which could optimize the consolidation of diaphyseal fractures and reduce treatment time for patients., Competing Interests: Declaration of competing interest The authors have no competing interests to declare., (Copyright © 2024. Published by Elsevier Ltd.)

Background: Multiple displaced rib fractures often result in a poor prognosis. Open reduction and internal fixation has been shown to provide benefits for patients with displaced rib fractures and flail chest. Nevertheless, for patients who are unwilling or unsuitable for surgery, the therapeutic options are limited. We developed a novel plastic vacuum device for rib fractures external stabilization. This study aims to compare the therapeutic efficacy of this device against a traditional chest strap in polytrauma patients with multiple rib fractures., Methods: A retrospective investigation was conducted on polytrauma patients with multiple rib fractures admitted to our trauma center between March 2020 and March 2023. Patients were categorized into two groups: vacuum external fixation and chest strap. Comparative analysis was conducted on baseline parameters, injury characteristics, and clinical outcomes between the two groups., Results: In this study, 54 patients were included, with 28 receiving chest strap and 26 undergoing vacuum external fixation. Results showed that, at 3 days and 7 days postintervention, the vacuum external fixation group had significantly lower visual analog scale scores during deep breathing and coughing (P < .05). Vacuum external fixation also reduced pleural drainage duration and volume, as well as lowered the risk of pneumonia and other complications (P < .05). Furthermore, the vacuum external fixation group demonstrated notable improvements in vital capacity, tidal volume, blood-gas test results, and a shorter hospital length of stay., Conclusions: According to the study findings, vacuum external fixation appears to offer benefits to patients with multiple rib fractures, potentially reducing the risk of complications and improving overall clinical outcomes., (© The Author(s) 2024. Published by Oxford University Press on behalf of Fellowship of Postgraduate Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Insertion of a skeletal traction pin in the distal femur or proximal tibia can be a painful and unpleasant experience for patients with a lower-extremity fracture. The purpose of this study was to determine whether providing patients with audio distraction (AD) during traction pin insertion can help to improve the patient-reported and the physician-reported experience and decrease pain and/or anxiety during the procedure., Methods: A prospective randomized controlled trial was conducted at 2 level-I trauma centers. Patients ≥18 years of age who were conscious and oriented and had a medical need for skeletal traction were included. Patients were randomized to receive AD or not receive AD during the procedure. All other procedure protocols were standardized and were the same for both groups. Surveys were completed by the patient and the physician immediately following the procedure. Patients rated their overall experience, pain, and anxiety during the procedure, and physicians rated the difficulty of the procedure, both on a 1-to-10 Likert scale., Results: A total of 54 patients met the inclusion criteria. Twenty-eight received AD and 26 did not. Femoral fractures were the most common injury (33 of 55, 60.0%). Baseline demographic characteristics did not differ between the 2 groups. The overall patient-reported procedure experience was similar between the AD and no-AD groups (3.9 ± 2.9 [95% confidence interval (CI), 3.1 to 4.7] versus 3.5 ± 2.2 [95% CI, 2.9 to 4.1], respectively; p = 0.55), as was pain (5.3 ± 3.2 [95% CI, 4.4 to 6.2] versus 6.1 ± 2.4 [95% CI, 5.4 to 6.8]; p = 0.28). However, anxiety levels were lower in the AD group (4.8 ± 3.3 [95% CI, 3.9 to 5.7] versus 7.1 ± 2.8 [95% CI, 6.3 to 7.9]; p = 0.007). Physician-reported procedure difficulty was similar between the groups (2.6 ± 2.0 [95% CI, 2.1 to 3.1] versus 2.8 ± 1.7 [95% CI, 2.3 to 3.3]; p = 0.69)., Conclusions: AD is a practical, low-cost intervention that may reduce patient anxiety during lower-extremity skeletal traction pin insertion., Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: This study received grant funding from the University of Minnesota Department of Orthopaedic Surgery Research Committee, used for the purchase of MP3 players and headphones and for travel expenses between the 2 study sites. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H967 )., (Copyright © 2024 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: In the field of orthopaedics, external fixators are commonly employed for treating extremity fractures and deformities. Computer-assisted systems offer a promising and less error-prone treatment alternative to manual fixation by utilising a software to plan treatments based on radiological and clinical data. Nevertheless, existing computer-assisted systems have limitations and constraints., Methods: This work represents the culmination of a project aimed at developing a new automatised fixation system and a corresponding software to minimise human intervention and associated errors, and the developed system incorporates enhanced functionalities and has fewer constraints compared to existing systems., Results: The automatised fixation system and its graphical user interface (GUI) demonstrate promising results in terms of accuracy, efficiency, and reliability., Conclusion: The developed fixation system and its accompanying GUI represent an improvement in computer-assisted fixation systems. Future research may focus on further refining the system and conducting clinical trials., (© 2024 The Author(s). The International Journal of Medical Robotics and Computer Assisted Surgery published by John Wiley & Sons Ltd.)

Distal radius fractures are one of the most frequent fractures of the upper extremities. The decision for conservative or surgical treatment is made after appropriate diagnostics using conventional radiographic and usually computed tomography imaging examinations. If the indications for surgical treatment are present, various options for reduction and fixation are available. The spectrum ranges from closed to open procedures up to accompanying arthroscopic support. Appropriate preoperative patient education about the procedure and the planned postinterventional treatment is essential. The goal of treatment is to restore wrist function while maintaining mobility and strength with a low risk of complications. All surgical procedures share the principle of reduction to restore anatomical relationship followed by fixation. Closed procedures include fixation with Kirschner wires and the construction of an external fixator. Volar locking plate osteosynthesis has become established in recent years as the method of choice for the majority of the fractures to be treated. For special fracture patterns and the treatment of accompanying injuries, arthroscopic support can be indicated. There is no uniform consensus on the best choice of procedure. This article discusses the possible procedures including the approaches, fixation techniques and specific follow-up treatment., (© 2024. The Author(s).)

Objective: To design and test a device which is capable of accurately measuring and dynamically adjusting the axial pressure at the fracture end in real-time., Methods: Upon completion of the design, the pressure measurement and adjustment device was implemented in a canine tibial fracture external fixation model. A pressure sensor was mounted at the fracture end, and the displayed values of the pressure sensor were used as the standard for comparison. The relationship between the displayed values of the measurement and adjustment device and the pressure sensor under identical conditions was examined., Results: The device was utilized in external fixation models of tibial fractures in five beagles. A linear correlation was observed between the displayed values of the device and the pressure sensor at the fracture end. The measurement values from the device could be transformed into fracture end pressure through the application of coefficients, thereby facilitating accurate measurement and dynamic adjustment of the fracture end pressure., Conclusion: The pressure measurement and adjustment device at the fracture end is easy to operate, enabling precise measurement and dynamic regulation of the pressure at the fracture end. It is well-suited for animal experiments aimed at investigating the impact of axial compression on fracture healing, demonstrating promising potential for experimental applications.

Purpose: The objective of this study was to evaluate and compare the effectiveness and clinical results of trifocal bone transport (TBT) and pentafocal bone transport (PBT) in treating distal tibial defects > 6 cm resulting from posttraumatic osteomyelitis, highlighting the potential advantages and challenges of each method., Methods: A retrospective assessment was conducted on an overall population of 46 eligible patients with distal tibial defects > 6 cm who received treatment between January 2015 and January 2019. Propensity score analysis was used to pair 10 patients who received TBT with 10 patients who received PBT. The outcomes assessed included demographic information, external fixation time (EFT), external fixation index (EFI), bone and functional outcomes assessed using the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, and postoperative complications evaluated using the Paley classification., Results: The demographic and baseline data of the two groups were comparable. Following radical debridement, the average tibial defect was 7.02 ± 0.68 cm. The mean EFT was significantly shorter in the PBT group (130.9 ± 16.0 days) compared to the TBT group (297.3 ± 14.3 days). Similarly, the EFI was lower in the PBT group (20.67 ± 2.75 days/cm) than in the TBT group (35.86 ± 3.69 days/cm). Both groups exhibited satisfactory postoperative bone and functional results. Pin site infection was the most common complication and the rates were significantly different between the groups, with the PBT group demonstrating a higher incidence., Conclusion: Both TBT and PBT effectively treat posttraumatic tibial defects greater than 6 cm, with PBT offering more efficient bone regeneration. However, PBT is associated with a higher rate of pin site infections, highlighting the importance of careful management in these complex procedures and emphasizing the need for expert surgical execution and tailored treatment approaches in orthopedic reconstructive surgery., (© 2024. The Author(s).)

Background: External fixation is widely used in the treatment of traumatic fractures; however, orthopedic surgeons encounter challenges in deciding the optimal time for fixator removal. The axial load-share ratio (LS) of the fixator is a quantitative index to evaluate the stiffness of callus healing. This paper introduces an innovative method for measuring the LS and assesses the method's feasibility and efficacy. Based on a novel hexapod LS-measurement system, the proposed method is to improve the convenience and precision of measuring LS in vivo, hence facilitating the safe removal of external fixators., Methods: A novel hexapod system is introduced, including its composition, theoretical model, and method for LS measurement. We conducted a retrospective study on 82 patients with tibial fractures treated by the Taylor Spatial Frame in our hospital from September 2018 to June 2020, of which 35 took LS measurements with our novel method (Group I), and 47 were with the traditional method (Group II). The external fixator was removed when the measurement outcome (LS < 10%) was consistent with the surgeon's diagnosis based on the clinical and radiological assessment (bone union achieved)., Results: No significant difference was found in the fracture healing time (mean 25.3 weeks vs. 24.9 weeks, P > 0.05), frame-wearing duration (mean 25.5 weeks vs. 25.8 weeks, P > 0.05), or LS measurement frequency (mean 1.1 times vs. 1.2 times, P > 0.05). The measurement system installation time in Group I was significantly shorter compared to Group II (mean 14.8 min vs. 81.3 min, P < 0.001). The LS value of the first measurement in Group I was lower than that of Group II (mean 5.1% vs. 6.9%, P = 0.011). In Group I, the refracture rate was 0, but in Group II it was 4.3% (2/47, P > 0.05)., Conclusion: The novel hexapod LS-measurement system and involved method demonstrated enhanced convenience and precision in measuring the LS of the external fixator in vivo. The LS measurement indicates the callus stiffness of fracture healing, and is applicable to evaluate the safety of removing the fixator. Consequently, it is highly recommended for widespread adoption in clinical practice., (© 2024. The Author(s).)

To compare the biomechanical properties of several anterior pelvic ring external fixators with two new configurations in the treatment of Tile C pelvic fractures, in order to evaluate the effectiveness of the new configurations and provide a reference for their clinical application. A finite element model of a Tile C pelvic ring injury (unilateral longitudinal sacral fracture and ipsilateral pubic fracture) was constructed. The pelvis was fixed with iliac crest external fixator (IC), anterior inferior iliac spine external fixator (AIIS), combination of IC and AIIS, combination of anterior superior iliac spine external fixator (ASIS) and AIIS, and S1 sacroiliac screw in 5 types of models. The stability indices of the anterior and posterior pelvic rings under vertical longitudinal load, left-right compression load and anterior-posterior shear load were quantified and compared. In the simulated bipedal standing position, the results of the vertical displacement of the midpoint on the upper surface of the sacrum are consistent with the displacement of the posterior rotation angle, and the order from largest to smallest is IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. The longitudinal displacement of IC is greater than that of the other models. The displacements of ASIS + AIIS and IC + AIIS are similar and the latter is smaller. In the simulated semi-recumbent position, the vertical displacement and posterior rotation angle displacement of the midpoint on the upper surface of the sacrum are also consistent, ranking from large to small: IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. Under the simulated left-right compression load state, the lateral displacements of the highest point of the lateral sacral fracture end are consistent with the highest point of the lateral pubic fracture end, and the order from large to small is S1 screw, IC, AIIS, ASIS + AIIS and IC + AIIS, among which the displacements of S1 screw and IC are larger, and the displacements of ASIS + AIIS and IC + AIIS are similar and smaller than those of other models. The displacements of IC + AIIS are smaller than those of ASIS + AIIS. Under the simulated anterior-posterior shear load condition, the posterior displacements of the highest point of the lateral sacral fracture end and the highest point of the lateral pubic fracture end are also consistent, ranking from large to small: IC, AIIS, ASIS + AIIS, IC + AIIS and S1 screw. Among them, the displacements of IC and AIIS are larger. The displacements of ASIS + AIIS and IC + AIIS are similar and the latter are smaller. For the unstable pelvic injury represented by Tile C pelvic fracture, the biomechanical various stabilities of the combination of IC and AIIS are superior to those of the external fixators of conventional configurations. The biomechanical stabilities of the combination of ASIS and AIIS are also better than those of the external fixators of conventional configurations, and slightly worse than those of the combination of IC and AIIS. Compared with sacroiliac screw and conventional external fixators, the lateral stabilities of IC + AIIS and ASIS + AIIS are particularly prominent., (© 2024. The Author(s).)

Objective: To evaluate the needle puncture safety and clinical efficacy of manual reduction combined with external fixation of ankle frame in the treatment of trimalleolar fracture under the guidance of Chinese Osteosynthesis (CO) theory., Methods: The clinical data of 118 patients with trimalleolar fractures admitted from December 2010 to December 2021 were retrospectively analyzed. Fifty-three patients were treated with manual reduction combined with external fixation of ankle frame(observation group). Sixty-five patients were treated with open reduction and internal fixation with plate and screws(control group). The operation time, hospitalization days, non-weight-bearing time of the affected limb, clinical healing time of fracture, incidence of complications, visual analogue scale (VAS) before and 1 month after operation, and American Orthopedic Foot and Ankle Society(AOFAS) score of ankle joint before and 1 year after operation were compared between the two groups., Results: Patients in both groups were followed up for more than 1 year. All patients were followed up, and the duration ranged from 14 to 70 months, with an average of(35.28±14.66) months. There were statistically significant in operation time, hospitalization days, non-load-bearing time of affected limbs, clinical healing time of fractures and VAS score one month after operation between the two groups. One month after operation, the VAS score of the observation group was lower than that of the control group( t =3.343, P =0.001). The operation time of the observation group was significantly shorter than that of the control group( t =9.091, P =0.000). The hospitalization days in the observation group were significantly less than those in the control group( t =5.034, P =0.000). The non-load-bearing time of the affected limb in the observation group was significantly shorter than that in the control group( t =11.960, P =0.000). The clinical healing time of fracture in the observation group was significantly shorter than that in the control group( t =4.007, P =0.000). There was no significant difference in AOFAS score between the two groups one year after operation( t =0.417, P =0.678). In the observation group, there were 2 cases of pinhole infection and 3 cases of loss of reduction less than 2 mm. There were 3 cases of surgical incision infection in the control group. There was no significant difference in the incidence of complications between the two groups( χ 2 =0.446, P =0.504)., Conclusion: Manual reduction combined with external fixation is safe and effective in the treatment of trimalleolar fracture under the guidance of CO theory, and the function of ankle joint recovers well after operation. This therapy has good clinical value.

Displaced lateral humeral condyle (LHC) fractures have routinely been treated with open reduction, which has known postoperative complications. Recent reports show that closed reduction and percutaneous pinning (CRPP) is a valid treatment. Five pediatric patients with displaced LHC fractures were included in a retrospective case series. Closed reductions (CRs) were facilitated by Kirschner wire placement into the capitellum through a toothed drill guide. The Kirschner wire and drill guide were used like a joystick to manipulate the fragment and maintain reduction for placement of additional Kirschner wires. Patient records were used to determine the number of patients diagnosed with LHC fractures between 2011 to 2022 among six pediatric orthopaedic surgeons at one institution along with the treatment and associated complications. Satisfactory reduction of displaced LHC fractures was achieved with CRPP in all patients with no complications using the "martini" modification. Of 26 LHC fractures, 16 were treated with CRPP/CRPS and 10 with open reduction and percutaneous pinning/open reduction and internal fixation, with four converted from CR to OR. Complications included one superficial infection in the CR group and four stiff elbows and one nonunion in the OR group option for LHC fractures. CRPP is an effective treatment option with a decreased risk of complications. Our modified reduction technique may help improve the success and results of closed treatment of LHC fractures., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Academy of Orthopaedic Surgeons.)

Computational predictions of stiffness and peri-implant loading of screw-bone constructs are highly relevant to investigate and improve bone fracture fixations. Homogenized finite element (hFE) models have been used for this purpose in the past, but their accuracy has been questioned given the numerous simplifications, such as neglecting screw threads and modelling the trabecular bone structure as a continuum. This study aimed to investigate the accuracy of hFE models of an osseointegrated screw-bone construct when compared to micro-FE models considering the simplified screw geometry and different trabecular bone material models. Micro-FE and hFE models were created from 15 cylindrical bone samples with a virtually inserted, osseointegrated screw (fully bonded interface). Micro-FE models were created including the screw with threads (=reference models) and without threads to quantify the error due to screw geometry simplification. In the hFE models, the screws were modelled without threads and four different trabecular bone material models were used, including orthotropic and isotropic material derived from homogenization with kinematic uniform boundary conditions (KUBC), as well as from periodicity-compatible mixed uniform boundary conditions (PMUBC). Three load cases were simulated (pullout, shear in two directions) and errors in the construct stiffness and the volume average strain energy density (SED) in the peri-implant region were evaluated relative to the micro-FE model with a threaded screw. The pooled error caused by only omitting screw threads was low (max: 8.0%) compared to the pooled error additionally including homogenized trabecular bone material (max: 92.2%). Stiffness was predicted most accurately using PMUBC-derived orthotropic material (error: -0.7 ± 8.0%) and least accurately using KUBC-derived isotropic material (error: +23.1 ± 24.4%). Peri-implant SED averages were generally well correlated (R 2  ≥ 0.76), but slightly over- or underestimated by the hFE models and SED distributions were qualitatively different between hFE and micro-FE models. This study suggests that osseointegrated screw-bone construct stiffness can be predicted accurately using hFE models when compared to micro-FE models and that volume average peri-implant SEDs are well correlated. However, the hFE models are highly sensitive to the choice of trabecular bone material properties. PMUBC-derived isotropic material properties represented the best trade-off between model accuracy and complexity in this study., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dieter H. Pahr is CEO of Dr. Pahr Ingenieurs e.U., which develops and distributes Medtool. All other authors declare no competing interests., (Copyright © 2023 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Supracondylar humerus fractures are the most common upper limb injury in children, but the incidence of flexion-type fractures is relatively low. Herein, we report the clinical results for three children with Gartland type II flexion-type supracondylar humeral fractures treated by closed reduction and percutaneous pinning. From April 2004 to March 2020, 102 children with supracondylar humeral fractures underwent surgery at our hospital and related institutions. Four had a flexion-type supracondylar humeral fracture (3.9%). Three patients (1 boy and 2 girls) with Gartland type II flexion-type supracondylar humeral fractures were followed for more than 12 months. The patients were treated by closed reduction and percutaneous pinning. Age was 7-13 years at the time of injury, and the duration of postoperative follow-up was 12-16 months. In one case, ulnar nerve paresis was observed as a preoperative complication. After performing closed reduction, percutaneous Kirschner wire cross-fixation was performed. Subsequently, long upper limb cast fixation was carried out for 4 weeks postoperatively. One patient developed preoperative nerve paralysis but recovered in approximately 3 months, without postoperative complications such as infection, nerve paralysis, or cubitus varus or valgus deformity. Flynn's criteria results were excellent for two patients and good for one patient. To maintain anatomical reduction of the fracture fragment, closed reduction using a traction table and percutaneous steel wire fixation are useful for treating flexion-type supracondylar humerus fractures in children with Gartland type II fractures.

Purpose: To evaluate the clinical effectiveness and safety of bioresorbable implants for treating paediatric zygomaticomaxillary complex (ZMC) fractures with concomitant orbital floor defects., Methods: A retrospective review of paediatric patients who underwent ZMC repair with concomitant orbital floor fractures with bioresorbable implants in Shanghai Ninth People's Hospital from July 2015 to June 2019 was performed. The primary outcome measures included ocular motility, diplopia, enophthalmos, facial deformities, and restricted mouth opening, as well as complication rates. Pre- and post-operative computed tomography scans were obtained for clinical diagnosis and surgical effectiveness., Results: Twenty two children were included in this study. Facial deformities were corrected in all 22 cases by surgical reconstruction postoperatively, and the average relative distance of Portals point-Zygomaxillare and Anteriornasalspine-Zygomaxillare were 1.3 ± 0.6mm ( P = 0.22) and 1.2 ± 0.5mm ( P = 0.19). The eye movement restored to normal in 13 patients. The mean amount of relative enophthalmos was 1.0 ± 0.4 mm ( P = 0.12). 12 cases had complete resolution of diplopia postoperatively at the extremes of the gaze, and 1 case presented persistent diplopia on the down gaze as before, but from level III to level I. Facial numbness was resolved completely in 6 cases, and 2 cases presented with persistent numbness but relieved significantly. The average Hounsfield units of RapidSorb plates and OrbFloor PI were 154 ± 5 and 99 ± 4 respectively on computed tomography image obtained 1 week postoperatively, which showed no obvious difference compared with 0.5 year postoperatively ( P > 0.1). Hounsfield units of implants gradually declined around 1 year postoperatively. Hounsfield units of RapidSorb plates (20 ± 1) were consistent with periorbital tissue during postoperative 2-year follow-up, and Hounsfield units of OrbFloor PI (19 ± 1) were consistent with periorbital tissue during postoperative 1.5-year follow-up. No patients had severe sequelae or implant related complications postoperatively. None of bone nonunion, malunion, infection or rejection occurred during the follow-up periods., Conclusions: Open reduction and internal fixation for the treatment of ZMC fracture have achieved significant improvement in functional and cosmetic outcomes postoperatively. Bioresorbable materials have been proved to be effective and safe in the treatment of children's ZMC and orbital wall fractures., Competing Interests: The authors report no conflicts of interest., (Copyright © 2022 by Mutaz B. Habal, MD.)

Objectives: To compare the biomechanical performance of proximal femoral nail anti-rotation (PFNA), the "upside-down" less invasive plating system (LISS), and proximal femoral locking plate (PFLP) in fixing different fracture models of subtrochanteric fractures., Methods: Thirty composite femurs were divided into three equal groups (PFNA, PFLP, and reverse LISS). The implant-femur constructs were tested under axial compression load (0-1400 N) from models I to IV, which represented the Seinsheimer type I subtrochanteric fracture, type IIIa subtrochanteric fracture with the posteromedial fragment reduced; type IIIa subtrochanteric fracture with the posteromedial fragment lost; and type IV subtrochanteric fracture, respectively. Axial stiffness was analyzed for each group. Each group was then divided into two subgroups, one of which underwent torsional and axial compression failure testing, while the other subgroup underwent axial compression fatigue testing. The torsional stiffness, failure load, and cycles to failure were analyzed., Results: PFNA had the highest axial stiffness (F = 761.265, p < 0.0001) and failure load (F = 48.801, p < 0.0001) in model IV. The axial stiffness and failure load of the PFLP were significantly higher than those of the LISS (p < 0.0001, p = 0.001). However, no significant difference in axial stiffness was found between models I to III (model I: F = 2.439, p = 0.106; model II: F = 2.745, p = 0.082; model III: F = 0.852, p = 0.438) or torsional stiffness in model IV (F = 1.784, p = 0.187). In fatigue testing, PFNA did not suffer from construct failure after 90,000 cycles of axial compression. PFLP and LISS were damaged within 14,000 cycles, although LISS withstood more cycles than PFLP (t = 3.328, p = 0.01)., Conclusion: The axial stiffness of the three implants was similar in models I to III. The biomechanical properties of PFNA were the best of the three implants in terms of axial stiffness, failure load, and fatigue testing cycles in model IV. The axial stiffness and failure load of the PFLP were better than those of the reverse LISS, but PFLP had fewer cycles in the fatigue tests than the reverse LISS., (© 2022 The Authors. Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.)

Metastatic disease affecting the proximal tibia is rarer than disease affecting the femur; however, it presents unique challenges that the orthopaedic surgeon must address to ensure successful outcomes and return the patient to an ambulatory status. The essential workup for evaluating and treating these patients is addressed briefly in this review as a summary of the information is provided in part 1 of this series. Part 2 of this series will focus on the surgical treatment of these lesions, which can be complex and is not as well described in the literature. Procedures ranging from open reduction internal fixation with cement augmentation to complex endoprosthetic reconstruction can be employed to address proximal tibia metastatic disease. An awareness of these various treatment modalities allows the orthopaedic surgeon to plan the most effective operation for the patients under their care., Competing Interests: None declared., (Thieme. All rights reserved.)

Acrylic columns are commonly used in external skeletal fixators, especially for fracture management or trans-articular fixations. To the authors' knowledge, there are no studies demonstrating if the number or position of the transfixation pins influence the ultimate strength and stiffness of the acrylic column. The objective of this study was to evaluate the effects of the number and position of transfixation pins (concentric versus eccentric) on the strength and stiffness of acrylic columns placed in axial compression. We hypothesized that strength and stiffness of acrylic columns under axial compression would not be affected by the number or position of the transfixation pins through the column. Three different groups of 12 acrylic columns were constructed with 4, 6, and 8 pins. In each group, 6 columns were constructed with the pins placed concentrically and the remaining 6 columns with the pins placed eccentrically. Each column was then placed under axial compression using a biomechanical testing machine. No significant differences were observed in ultimate strength regarding the number or position of transfixation pins ( P = 0.83 and P = 0.27, respectively). However, stiffness was significantly decreased for columns with 4 eccentric pins compared with columns with 6 and 8 eccentric pins ( P < 0.01) and with columns with 4 concentric pins ( P < 0.001). Although the effects of transfixation pins on the rigidity of acrylic columns do not appear to be clinically significant, these tests were performed only in compression and results might differ if complete external fixator systems are used with different models of testing. Future studies are recommended., (Copyright and/or publishing rights held by the Canadian Veterinary Medical Association.)

Background: Surgical rib fixation (SRF) is being used increasingly in trauma centers for stabilization of chest wall injuries, in line with new and evolving surgical techniques. Our institution has developed a pathway for the management of chest wall injuries and SRF, which includes a follow-up low-volume, noncontrast computed tomography (CT) scan at 12 months., Methods: This study was a single-center retrospective study conducted on 25 consecutive patients who underwent SRF between February 2019 and February 2020. All CT measurements were done by a CT radiographer under the supervision of a board-certified radiologist and included the use of three-dimensional volume-rendered images., Results: There were no patients with SRF who experienced hardware failure at 12 months in either flail or nonflail groups. For fractured ribs treated with SRF, complete or partial union occurred in 75 of 76 ribs plated (98.7%). The median ratio for improvement in lung volumes was 1.71 for flail SRF and 1.69 for nonflail SRF in our study., Conclusion: Three-dimensional volume-rendered CT at 12 months post-SRF showed good alignment (no hardware failure) and fracture healing of fixed ribs in both flail and nonflail groups. Lung volumes also improved pre-SRF and post-SRF for both flail and nonflail patients. More studies are needed to define how the pattern of rib fracture healing of fixed and nonfixed ribs affects lung volumes., Level of Evidence: Therapeutic, Level V., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: Major pelvic hemorrhage remains a considerable challenge of modern trauma care associated with mortality in over a third of patients. Efforts to improve outcomes demand continued research into the optimal employment of both traditional and newer hemostatic adjuncts across the full spectrum of emergent care environments. The purpose of this review is to provide a concise description of the rationale for and effective use of currently available adjuncts for the control of pelvic hemorrhage. In addition, the challenges of defining the optimal order and algorithm for employment of these adjuncts will be outlined., Level of Evidence: Review, level IV., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

The work aimed to evaluate the effectiveness of the developed distraction system based on the rod external monolateral fixation mechanisms by comparing it with the classical technique of long tubular bones distraction based on the circular multi-axial system. The study included patients with a genetically confirmed diagnosis of achondroplasia. The experimental group consisted of 14 patients who underwent surgical limb lengthening by the rod monolateral external fixator with a distraction system developed by the authors. The lengthening was performed on 28 segments of tubular bones. The majority of the experimental group patients achieved the lengthening value close to the planned one and the deformation correction. The fixation period was averagely 83.8 ± 3.7 days, the regenerate length was 8.5 ± 0.6 cm, and the mechanical strength of the distraction regenerate was 10.3° ± 2.18°. The rod external fixator with a control distraction system developed by the authors has small dimensions and low weight of the external supporting elements of high durability. It is reported to provide a good psychological tolerance of the treatment process and significantly outperforms the circular multi-axis system. Considering the aforementioned, the proposed apparatus can grant good orthopedic care to patients with achondroplasia., (© 2021. The Author(s).)

Objective: Femoral neck fracture is one of the most common bone types. The effect of reduction quality on hip joint function and complications after screw internal fixation is not fully understood. To investigate the clinical efficacy and mechanical mechanism of positive buttress, anatomical reduction, and negative buttress in the treatment of femoral neck fracture after cannulated screw fixation., Methods: Retrospective analysis of patients with femoral neck fracture treated with three cannulated screws internal fixation in our hospital from January 2013 to December 2018. According to the quality of fracture reduction, the patients were divided into positive buttress group, anatomical reduction group, and negative buttress group. Basic information such as injury mechanism, time from injury to surgery, Garden classification and Pauwels classification was collected, Harris scores were performed at 3 months, 6 months, and 12 months after surgery, and postoperative complications (femoral head necrosis, femoral neck shortening, and femoral neck nonunion) were collected. At the same time, three groups of finite element models with different reduction quality were established for stress analysis, their stress clouds were observed and the average displacement and stress of the three groups of models were compared. P < 0.05 was used to represent a statistically significant difference., Results: A total of 225 cases of unilateral femoral neck fractures were included and followed up for an average of 4.12 ± 0.69 years. There was no significant difference in age, gender, side, injury mechanism, time from injury to surgery, BMI, Garden classification, Pauwels classification, and follow-up time among the three groups (P > 0.05). However, there was significant difference in Harris score at 6 and 12 months after operation among the three groups (P < 0.05), which was higher in the positive buttress group and anatomical reduction group than in the negative buttress group. In addition, the incidence of osteonecrosis of the femoral head in the negative buttress group (32.2%) was greater than that in the anatomical reduction group (13.4%) and the positive buttress group (5.4%) (P < 0.05). In addition, the incidence of femoral neck nonunion and femoral neck shortening in the negative buttress group was also higher than that in the anatomical reduction positive buttress group (P < 0.05). The finite element results showed that the stress and fracture end displacement in the negative buttress group were greater than those in the positive buttress group (P < 0.05)., Conclusion: Both positive buttress and anatomical reduction in the treatment of femoral neck fracture with cannulated screw internal fixation can obtain better clinical effect and lower postoperative complications. Positive brace support and anatomic reduction can limit the restoration of femoral stress conduction. Therefore, it is not necessary to pursue anatomical reduction too deliberately during surgery, while negative buttress reduction should be avoided., (© 2021. The Author(s).)

Background: Fractures of the proximal humerus in skeletally immature patients are rare, and even rarer still in individuals approaching skeletal maturity. Concepts regarding remodeling potential, amount of deformity and functional demands can guide our treatment decision making, but criteria are poorly defined. The purpose of this manuscript is to discuss the issues and the best available evidence., Methods: A search of the English literature was carried out using PubMed to identify papers on the topic of proximal humerus fractures in skeletally immature individuals., Results: The literature available on the topic of pediatric proximal humerus fractures is limited, especially regarding fractures in patients approaching skeletal maturity. Certainly, as the remodeling potential decreases and the amount of deformity and functional demand increase, the need for operative treatment increases. The exact tolerances and criteria have not been established. A variety of surgical techniques exist, and have been shown to be helpful., Conclusions: Operative treatment may be necessary in individuals approaching skeletal maturity. Concepts discussed in this paper regarding remodeling, amount of deformity and functional demand may help the surgeon to make appropriate treatment decisions. Future prospective comparative studies which are pending will hopefully shed further light on this matter., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: In tibial plateau fractures, the posterolateral segment of the tibia plateau is frequently affected and challenging to treat. Although there are many surgical approaches and fixation methods for the treatment of these fractures, all of these methods have limitations. We designed a new rotational support plate (RSP) and a special pressurizer that can fix the fracture directly via the anterolateral approach. This method is advantageous because it leads to little trauma, involves a simple operation, and has a reliable fixation effect. This study details the technique of treating these fractures with the RSP and special pressurizer and provides the outcomes., Methods: From May 2016 to January 2019, the data of 12 patients with posterolateral tibial plateau fractures treated with the RSP and special pressurizer in our hospital were retrospectively analyzed. Postoperative rehabilitation was advised, knee X-rays were taken at follow-ups, and fracture healing, complications, and knee range of motion were assessed. The Hospital for Special Surgery (HSS) knee score and Knee Injury and Osteoarthritis Outcome Score (KOOS) were used to evaluate knee function at the last follow-up., Results: The average follow-up time of all patients was 16.5 months (range, 12-25 months). The average bony union time was 3.2 months (range, 3-4.5 months). At the last follow-up, the average knee range of motion was 138° (range, 107-145°). The average HSS score was 91 (range, 64-98). The average KOOS Symptoms score was 90 (range, 75-96). The average KOOS Pain score was 91 (range, 72-97). The average KOOS ADL score was 91 (range, 74-97). The average KOOS sport/recreation score was 83 (range, 70-90). The average KOOS QOL score was 88 (range, 69-93). Skin necrosis, incision infections, and fixation failure did not occur during the follow-up period., Conclusions: With our newly designed RSP and special pressurizer, posterolateral tibial plateau fractures can be easily and effectively reduced and fixed through the anterolateral approach, which serves as a novel treatment for posterolateral tibial plateau fractures.

Objective: The standard surgical treatment for supracondylar humeral fractures in children is closed reduction and percutaneous pinning. Given the need for greater fixation strength and higher risk of joint stiffness for children older than 8 years, external fixation is often performed for treating supracondylar humeral fractures in older children. The aim of this study was to compare the efficacy of lateral entry pins and Slongo's external fixation for treating supracondylar humeral fractures in older children., Methods: Children older than 8 years who underwent surgery for supracondylar humeral fractures at our hospital for surgery from January 2016 to December 2020 are to be retrospectively assessed. One group (n = 36) underwent internal fixation and percutaneous pinning with three lateral Kirschner wires, and the other group (n = 32) underwent Slongo's external fixator surgery. The demographic data, operation duration, number of fluoroscopies, and fracture healing time were compared between both groups. The elbow joint function was evaluated 6 months after the surgery on the basis of fracture healing time, lifting angle, elbow joint range of motion (ROM), and Flynn score. The incidence of postoperative complications was also recorded., Results: There was no significant difference between the two patient groups in terms of the demographic parameters. Compared to external fixation surgery, Kirschner wire surgery required shorter duration and fewer fluoroscopies (P < 0.05). Nevertheless, the fracture healing time was significantly less (P < 0.05), and the elbow ROM and Flynn scores were higher in the external fixator group compared to the Kirschner wire fixation group (P < 0.05). There was one case of secondary fracture displacement in the Kirschner wire group and one of pin tract infection in the external fixator group. No other iatrogenic injuries or complications were observed., Conclusion: Maybe Slongo's external fixator is a suitable alternative treatment option for supracondylar humeral fractures in children older than 8 years since it can achieve better fixation strength and early restoration of elbow joint movement with a lower risk of joint stiffness.

Background: Although external fixator is standard for managing staged treatment of open tibial fracture, the main disadvantage of this device is too bulky to be tolerated by most patients for longtime use. The purposes of this pilot study were to compare the biomechanical properties of a novel low-profile external fixator (LP-ESF) with a traditional ESF and also to evaluate its performance in patients with Gustilo type IIIb tibial open fractures., Methods: A prospective clinical pilot study started from January 2015 to December 2017, and 18 patients with Gustilo type IIIb open tibial fractures underwent the fixation with a novel LP-ESF system. The biomechanical properties of the LP-ESF were compared with the Synthes External Fixation System according to the standard ASTM F1541-02. These patients were divided into two groups according to the size of bony defect. The postoperative clinical outcomes were subsequently collected., Results: The biomechanical properties of the LP-ESF were comparable with those of Synthes External Fixation System and had an improved the axial/torsional stiffness and ultimate strength. In the clinical study, all patients with LP-ESF had fracture union. The duration of application of LP-ESF was 3.5 to 18 months until fracture union. In 10 of 18 patients, their fractures were immobilized with the LP-ESF until bone union, and no pin tract infection and no chronic osteomyelitis were recorded. The 36-Item Short Form Health Survey life quality and health survey were good to excellent in these patients. Notably, the LP-ESF allowed a patient with severe bone and soft-tissue defects to preserve the leg and joints function., Conclusion: In this study, we found that the novel LP-ESFs had improved clinical outcomes. The long-term LP-ESF application seems to be tolerable in our patients. This novel approach permits better controls in deep infection and faster healing of fractures, and thus may provide a viable alternative treatment for Gustilo type IIIb open tibial fractures., Competing Interests: Conflicts of interest: The authors declare that they have no conflicts of interest related to the subject matter or materials discussed in this article., (Copyright © 2021, the Chinese Medical Association.)

Paediatric facial fractures are relatively rare. The inherent elasticity of the bones with more of the cartilage than that of the mineralised bone accounts for this. The principles involved in the management of facial fractures are the same irrespective of the age of the patient; however, in children, the techniques used are necessarily modified by certain anatomical, physiological, psychological and feeding factors related to childhood and the parents. In an attempt to keep the treatment and fixation technique simple, the case, presented here, describes the management of a mandibular parasymphyseal fracture in a 16-month-old child with the use of a prefabricated adaptable surgical splint., Competing Interests: None

Background: Intertrochanteric fracture is a common injury in seniors. Senior patients taking surgical interventions suffer from prolonged bed-rest complications such as pressure ulcer, thromboembolism, or pneumonia, which may lead to high mortality rate. A treatment using external fixators is, therefore, recommendable, and has shown satisfactory outcomes such as early weight-bearing, short hospitalization time and quick union time. Fracture treatments in Vietnam mainly use metal and imported fixation, raising concerns of compatibility and financial issues from patients., Objective: This study investigated the in vivo effectiveness in treating an intertrochanteric fracture in Vietnamese geriatric patients by a novel prototype carbon composite external fixator (whose shaft screws near the fracture site) and an available stainless steel external fixator (shaft screw far from the fracture site) already used in Vietnam., Methods: Fifty-five patients treated with the metal fixator and 54 patients treated with the composite fixator - all aged 60 - 99 - were monitored for treatment results until one year after surgery., Results: The results demonstrated the external fixator's effectiveness, especially the composite prototype, which minimized blood loss, shortened operation time, reduced pain, and provided stable fixation that promoted proper bone union., Conclusion: The novel composite fixator prototype in this study was also superior to the current metal fixator in many aspects. Proper application of this method could prove its effectiveness in the surgical cure for fracture in older people. It should be a viable choice for intertrochanteric fracture treatment for senile people in Vietnam., Competing Interests: None declared., (© 2021 Quang-Tri Le.)

Aim: Diabetic neuro-osteoarthropathy (Charcot foot) is a serious form of diabetic foot syndrome, often leading to severe deformity of the foot and subsequently to ulcers and osteomyelitis. The aim of this retrospective study was to determine the success rate and long-term outcomes for a Charcot foot operation using external fixation in 115 individuals who underwent surgery between July 2008 and December 2012., Methods: Some 115 consecutive persons, 78 (68%) men and 37 (32%) women, were enrolled in this study. The eligibility criterion for this retrospective study was reconstructive foot surgery using a Hoffmann II external fixator in diabetic and non-diabetic neuro-osteoarthropathy. The main examination parameters in the follow-up were walking ability, amputation and mortality. Average follow-up was 5.7 (± 3.2) years., Results: Ninety-seven per cent of people were able to walk after the operation with bespoke shoes or an orthosis. At follow-up, 77% were able to walk and 51% were fully mobile even outside the home. Subsequent amputations were performed in 29 individuals (26%), with 17 (15%) minor and 12 (11%) major amputations. Forty-seven individuals died before follow-up, the majority (53%) from cardiovascular events. Average survival time post surgery was 4.5 (± 2.9) years., Conclusion: Reconstruction surgery using external fixation is a very useful method for maintaining walking ability in the case of conservatively non-treatable diabetic and non-diabetic neuro-osteoarthropathy. Individuals with severe Charcot foot disease had a low rate of major amputations. Osteomyelitis was the main reason for major amputations., (© 2020 Diabetes UK.)

Background: This study was performed to compare the results of closed reduction percutaneous pinning (CRPP) versus open reduction internal fixation with a volar locking plate (ORIF) in the treatment of intraarticular distal radius fractures (IDRF) average four-year follow-up., Methods: In this study, 43 patients had unilateral intraarticular distal radius fractures (type B and C) treated with CRPP (n=19; 11 males and eight females) and ORIF (n=24; 14 males and 10 females) were retrospectively evaluated. The mean follow-up was 50.3 months (12-74) at the CRPP group and 45.2 months (40-65) at the ORIF group. The mean age was 50.8 years (29-73) in the CRPP group and 51.5 (19-75) in the ORIF group. The patients were evaluated functionally and radiologically at the last follow-up., Results: There was no statistically significant difference between the groups concerning follow-up, age, and gender. However, there was no statistical difference concerning grip power and the range of motion. The Disabilities of the Arm, Shoulder and Hand Score (Q-DASH) was better in the ORIF group. Voler tilt and radial height measurements were statistically significantly better in the ORIF group. Degenerative arthritis was 63% in the CRPP group and 41% in the ORIF group, and there was no statistically significant difference., Conclusion: ORIF with a volar locking plate has better functional and radiological results than CRPP in IDRF patients' average four-year follow-up.

Background: Fractures of the patella (kneecap) account for around 1% of all human fractures. The treatment of these fractures can be surgical or conservative (such as immobilisation with a cast or brace). There are many different surgical and conservative interventions for treating fractures of the patella in adults. This is an update of a Cochrane Review first published in 2015., Objectives: To assess the effects (benefits and harms) of interventions (surgical and conservative) for treating fractures of the patella in adults., Search Methods: We searched CENTRAL (2020, Issue 1), MEDLINE, Embase, LILACS, trial registers and references lists of articles to January 2020., Selection Criteria: We included randomised controlled trials (RCTs) or quasi-RCTs that evaluated any surgical or conservative intervention for treating adults with fractures of the patella. The primary outcomes were patient-rated knee function, knee pain and major adverse outcomes., Data Collection and Analysis: At least two review authors independently selected eligible trials, assessed risk of bias and cross-checked data extraction. Where appropriate, we pooled results of comparable trials., Main Results: We included 11 small trials involving 564 adults (aged 16 to 76 years) with patella fractures. There were 340 men and 212 women; the gender of 12 participants was not reported. Seven trials were conducted in China and one each in Finland, Mexico, Pakistan and Turkey. All 11 trials compared different surgical interventions for patella fractures. All trials had design flaws, such as lack of assessor blinding, which put them at high risk of bias, potentially limiting the reliability of their findings. No trial reported on health-related quality of life, return to previous activity or cosmetic appearance. The trials tested one of seven comparisons. In the following, we report those of the main outcomes for which evidence was available for the three most important comparisons. Four trials (174 participants) compared percutaneous osteosynthesis versus open surgery. Very low-quality evidence means that we are uncertain of the findings of no clinically important difference between the two interventions in patient-rated knee function at 12 months (1 study, 50 participants) or in knee pain at intermediate-term follow-up at eight weeks to three months. Furthermore, very low-quality evidence means we are uncertain whether, compared with open surgery, percutaneous fixation surgery reduces the incidence of major adverse outcomes, such as loss of reduction and hardware complications, or results in better observer-rated knee function scores. Two trials (112 participants) compared cable pin system (open or percutaneous surgery) versus tension band technique. The very low-quality evidence means we are uncertain of the findings at one year in favour of the cable pin system of slightly better patient-rated knee function, fewer adverse events and slightly better observer-rated measures of knee function. There was very low-quality evidence of little clinically important between-group difference in knee pain at three months. Very low-quality evidence from two small trials (47 participants) means that we are uncertain of the findings of little difference between biodegradable versus metallic implants at two-year follow-up in the numbers of participants with occasional knee pain, incurring adverse events or with reduced knee motion. There was very low-quality and incomplete evidence from single trials for four other comparisons. This means we are uncertain of the results of one trial (28 participants) that compared patellectomy with advancement of vastus medialis obliquus surgery with simple patellectomy; of one quasi-RCT (56 participants) that compared a new intraoperative reduction technique compared with a standard technique; of one quasi-RCT (65 participants) that compared a modified tension band technique versus the conventional AO tension band wiring (TBW) technique; and of one trial (57 participants) that compared adjustable patella claws and absorbable suture versus Kirschner wire tension band., Authors' Conclusions: There is very limited evidence from nine RCTs and two quasi-RCTs on the relative effects of different surgical interventions for treating fractures of the patella in adults. There is no evidence from trials evaluating the relative effects of surgical versus conservative treatment or different types of conservative interventions. Given the very low-quality evidence, we are uncertain whether methods of percutaneous osteosynthesis give better results than conventional open surgery; whether cable pin system (open or percutaneous surgery) gives better results than the tension band technique; and whether biodegradable implants are better than metallic implants for displaced patellar fractures. Further randomised trials are needed, but, to optimise research effort, these should be preceded by research that aims to identify priority questions., (Copyright © 2021 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Objective: To explore the effect of a PEEK material-based external fixator in the treatment of distal radius fractures with non-transarticular external fixation., Methods: There were 48 patients in this prospective comparative study. They were divided into two groups according to the materials used: the PEEK group and the titanium group. Wrist dorsiflexion, palmar flexion, pronation, supination, radial deviation, ulnar deviation, grip strength of the palm on the affected side, kneading force, Visual Analogue Scale/Score (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, operation time, frequency of fluoroscopy procedures, and X-ray results were compared between the two groups. Functional recovery was evaluated at the last follow-up according to the wrist joint evaluation criteria., Results: The baseline data were comparable between the two groups, and no significant differences were found in age, sex, fracture types (P > 0.05). There was no significant difference between the two groups in the results of DASH, grip strength, and recovery of pinch force and wrist function (dorsiflexion, clavicle, ulnar deviation, deviation, pronation, and supination) (P > 0.05). Normal limb function was achieved in the two groups of patients at an average of 6 weeks after surgery, and there was no significant difference in X-ray examination radial height (10.60 ± 1.59 vs 11.00 ± 1.53, P = 0.687), radial inclination (1.11 ± 0.24 vs 1.12 ± 0.24, P = 0.798), volar tilt (10.33 ± 2.13 vs 10.00 ± 2.08, P = 0.660), ulnar variance (20.87 ± 3.00 vs 20.38 ± 3.04, P = 0.748), and step-off persistence (1.73 ± 0.69 vs 1.68 ± 0.72, P = 0.425) between the two groups (P > 0.05). However, the operation time (54.80 ± 12.20 vs 85.23 ± 15.14, P = 0.033) and number of fluoroscopy procedures (36.93 ± 6.89 vs 64.77 ± 9.74, P = 0.000) in the PEEK group were significantly reduced compared with those in the titanium group., Conclusion: Compared with the traditional titanium external fixator, the PEEK composite external fixator has advantages, such as a shorter operation time and fewer fluoroscopy procedures when used to treat different types of distal radius fracture., (© 2020 The Authors. Orthopaedic Surgery published by Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd.)

Aims: Pin-site infection remains a significant problem for patients treated by external fixation. A randomized trial was undertaken to compare the weekly use of alcoholic chlorhexidine (CHX) for pin-site care with an emollient skin preparation in patients with a tibial fracture treated with a circular frame., Methods: Patients were randomized to use either 0.5% CHX or Dermol (DML) 500 emollient pin-site care. A skin biopsy was taken from the tibia during surgery to measure the dermal and epidermal thickness and capillary, macrophage, and T-cell counts per high-powered field. The pH and hydration of the skin were measured preoperatively, at follow-up, and if pin-site infection occurred. Pin-site infection was defined using a validated clinical system., Results: Out of 116 patients who were enrolled in the study, 23 patients (40%) in the CHX group and 26 (44%) in the DML group had at least one bad or ugly pin-site infection. This difference was not statistically significant (p = 0.71). There was no significant relationship between pH or hydration of the skin and pin-site infection. The epidermal thickness was found to be significantly greater in patients who had a pin-site infection compared with those who did not (p = 0.01). Skin irritation requiring a change of treatment occurred in four patients (7%) using CHX, and none using DML., Conclusion: We found no significant difference in the incidence of pin-site infection between the CHX and DML treatment groups. Dermol appeared to offer a small but significant advantage in terms of tolerability. We did not find a significant association between patient or treatment related factors and pin-site infection. It is therefore difficult to make specific recommendations based upon these results. The use of either cleaning agent appears to be appropriate. Cite this article: Bone Joint J 2021;103-B(2):279-285.

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

Objective: To report the preoperative evaluation, treatment with transarticular elastic external skeletal fixation (ESF), and outcome of a dog with bilateral medial patellar luxation (MPL) and stifle rotational deformity., Animal: One nonambulatory, 2.5-month-old, 7.5-kg mixed-breed intact female dog., Study Design: Case report METHODS: Complex pelvic limb deformities were assessed with physical examination and computed tomography (CT) and characterized as bilateral grade 4 MPL and 90° internal rotation of the tibia in relation to the femur. Three-dimensional imaging and bone models were used to quantify the deformity and rehearse surgical correction. Transarticular elastic chains between ESF pins in the femur and tibia were used to gradually correct stifle rotational malalignment on each pelvic limb. Soft tissue releases, imbrication, and a transphyseal staple were used to correct the patellar luxation (PL) and femoral varus. The dog was reevaluated for 1 year postoperatively., Results: Short- and long-term management included intensive physical rehabilitation to increase pelvic limb strength and function. Surgical treatment resulted in resolution of the PL and neutral stifle alignment. The dog was able to ambulate with persistent decreased range of motion of the stifle., Conclusion: Transarticular elastic chains and femoral physeal stapling improved the function of a dog with severe bone deformities and PL in a growing dog., (© 2020 American College of Veterinary Surgeons.)

Background: To explore the ideal trajectory of lumbar cortical bone trajectory screws and provide the optimal placement scheme in clinical applications., Methods: Lumbar computed tomography (CT) data of 40 patients in our hospital were selected, and the cortical vertebral bone contour model was reconstructed in three dimensions (3D). Depending on the different regions of the screw through the entrance and exit of the pedicle, 9 trajectories were obtained through combinational design: T-Aa, T-Ab, T-Ac, T-Ba, T-Bb, T-Bc, T-Ca, T-Cb, and T-Cc. Cortical bone trajectory (CBT) screws with appropriate diameters were selected to simulate screw placement and measure the parameters corresponding to each trajectory (screw path diameter, screw trajectory length, cephalad angle, and lateral angle), and then determine the optimal screw according to the screw parameters and screw safety. Then, 23 patients in our hospital were selected, and the navigation template was designed based on the ideal trajectory before operation, CBT screws were placed during the operation to further verify the safety and feasibility of the ideal trajectory., Results: T-Bc and T-Bb are the ideal screw trajectories for L1-L2 and L3-L5, respectively. The screw placement point is located at the intersection of the inner 1/3 vertical line of the superior facet joint and the bottom 1/3 horizontal line of the outer crest of the vertebral lamina (i.e., 2-4 mm inward at the bottom 1/3 of the outer crest of the vertebral lamina). CBT screws were successfully placed based on the ideal screw trajectory in clinical practice. During the operation or the follow-up period, there were no adverse events., Conclusion: CBT screw placement based on the ideal screw trajectory is a safe and reliable method for achieving effective fixation and satisfactory postoperative effects., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

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

Importance: Despite appropriate treatment, many patients who sustain distal radius fractures (DRFs) report persistent wrist pain. Chronic musculoskeletal pain is among the leading health problems in the elderly population associated with significant personal and societal burden., Objective: To identify modifiable preoperative factors that are significantly associated with developing chronic pain., Design, Setting, and Participants: This is a secondary analysis of the Wrist and Radius Injury Surgical Trial (WRIST), a randomized multicenter clinical trial of 24 study sites in the United States, Canada, and Singapore that enrolled patients from April 10, 2012, to December 31, 2016. Adults older than 60 years who sustained closed extra-articular DRFs, were treated operatively, and completed 12-month Michigan Hand Outcomes Questionnaires (MHQs) were included in this study. Analysis was conducted from September to December 2019., Interventions: Volar locking plate internal fixation, external fixation, or percutaneous pinning., Main Outcomes and Measures: 12-month MHQ pain domain score. Inverse probability weighted logistic regression was used to identify factors associated with of chronic pain., Results: A total of 146 patients with DRF who were treated operatively and had 12-month MHQ scores met inclusion criteria. The mean (SD) patient age was 68.9 (7.2) years, 128 (87.6%) were women, and 93 (63.7%) were retired. Chronic pain was present in 87 patients (59.6%) and absent in 59 patients (40.4%) at 1-year follow-up. A 1-week delay in surgery was associated with more than triple the odds of developing chronic pain (odds ratio [OR], 3.65; 95% CI, 1.48-9.00), and each 10-point increase in preoperative pain was associated with a 17% increase in the odds of experiencing chronic pain (OR, 1.17; 95% CI, 1.02-1.34). Internal fixation was associated with decreased odds of developing chronic pain compared with the other 2 procedures (OR, 0.29; 95% CI, 0.10-0.90)., Conclusions and Relevance: In this study, preoperative pain, time to surgery, and procedure type were modifiable factors associated with chronic pain 1 year after DRF treated with surgery. Adequate pain control in patients with acute DRFs even before definitive surgical management and earlier fixation for patients requiring surgery may decrease the risk of developing chronic pain. Internal fixation may decrease the risk of chronic pain after DRF surgery, compared with percutaneous pinning or external fixation., Trial Registration: ClinicalTrials.gov Identifier: NCT01589692.

Background: In the stabilization of femoral fractures in mono- and polytrauma, clinical practice has shown better care through intramedullary nailing. However, the reason why this is the case is not fully understood. In addition to concomitant injuries, the immunological aspect is increasingly coming to the fore. Neutrophil granulocytes (PMNL), in particular next to other immunological cell types, seem to be associated with the fracture healing processes. For this reason, the early phase after fracture (up to 72 h after trauma) near the fracture zone in muscle tissue was investigated in a pig model., Material and Methods: A mono- and polytrauma pig model (sole femur fracture or blunt thoracic trauma, hemorrhagic shock, liver laceration, and femur fracture) was used to demonstrate the immunological situation through muscle biopsies and their analysis by histology and qRT-PCR during a 72 h follow-up phase. Two stabilization methods were used (intramedullary nail vs. external fixator) and compared with a nontraumatized sham group., Results: Monotrauma shows higher PMNL numbers in muscle tissue compared with polytrauma (15.52 ± 5.39 mono vs. 8.23 ± 3.36 poly; p = 0.013), regardless of the treatment strategy. In contrast, polytrauma shows a longer lasting invasion of PMNL (24 h vs. 72 h). At 24 h in the case of monotrauma, the fracture treated with external fixation shows more PMNL than the fracture treated with intramedullary nailing (p = 0.026). This difference cannot be determined in polytrauma probably caused by a generalized immune response. Both monotrauma and polytrauma show a delayed PMNL increase in the muscle tissue of the uninjured side. The use of intramedullary nailing in monotrauma resulted in a significant increase in IL-6 (2 h after trauma) and IL-8 (24 and 48 h after trauma) transcription., Conclusion: The reduction of PMNL invasion into the nearby muscle tissue of a monotrauma femur fracture stabilized by intramedullary nailing supports the advantages found in everyday clinical practice and therefore underlines the usage of nailing. For the polytrauma situation, the fixation seems to play a minor role, possibly due to a generalized immune reaction.

Background: The purpose of this study was to investigate the clinical efficacy of the "suspension bridge" external fixation technique for the treatment of proximal humeral fractures with or without soft tissue defects and infection, as well as postoperative revision., Methods: From August 2013 to June 2018, 9 patients with proximal humeral fractures were selected. There were 5 males and 4 females, with an average age of 55.2 years (range: 32-74 years). Five patients were diagnosed with acute fractures (soft tissue defects in 2 patients). Of these patients, 1 patient was diagnosed with a fracture of the anatomic neck, 2 patients with 3-part fractures, and 2 patients with 4-part fractures. Internal fixation failure occurred in 4 patients, who needed revision surgery. Of these 4 patients, 1 patient was diagnosed with an anatomic neck fracture and 3 patients with 4-part fractures before surgery. Postoperative plate and screw fixation failure was the main cause of revision. One patient had an accompanying skin defect, and 1 had an infection. The "suspension bridge" external fixation technique was used to treat the fractures in the revision surgeries., Results: The operative time was 84.1 minutes (range: 63-120 minutes), and the blood loss was 224.4 mL (range: 140-320 mL). The follow-up period was 35.1 months (range: 16-72 months). All fractures unioned, with an average unioning time of 12.7 weeks (range: 8-16 weeks). At the final follow-up, the flexion was 131.8° (range 108°-152°), extension 39.9° (range 32°-47°), abduction 128.6° (range 110°-150°), internal rotation 43.9° (range 34°-55°), and external rotation 60.7° (range 46°-72°); the mean visual analog scale score for pain was 1.3 (range 0-3), and the mean Neer score was 87.4 points (range 75-98 points). Efficacy was assessed as excellent in 4 patients, good in 3 patients, and acceptable in 2 patients; the excellent or good rate was 77.8%. No adverse events, such as postoperative infection, fixation failure, and nonunion, occurred during the follow-up., Conclusion: The "suspension bridge" external fixation technique is an effective method for the treatment of proximal humerus fractures, and it can also be used for the treatment of skin defects and infections., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)