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Introduction Fracture-related infection (FRI) is a severe post-traumatic complication which is occasionally accompanied by a deficient or even avital soft-tissue envelope. In these cases, a thoroughly planned orthoplastic approach is imperative as a vital and intact soft-tissue envelope is mandatory to achieve fracture union and infection eradication. The aim of this study was, to analyse if soft-tissue reconstruction (STR) without complications is associated with a better long-term outcome compared to FRI patients with STR complications. In particular, it was investigated if primary flap failure represented a risk factor for compromised fracture union and recurrence of infection. Patients and Methods Patients with a lower leg FRI requiring STR (local, pedicled and free flaps) who were treated from 2010-18 at the University Hospital Basel were included in this retrospective analysis. The main outcome measure was the success rate of STR, further outcome measures were fracture nonunion and recurrence of infection. Results Overall, 145 patients with lower leg FRI were identified, of whom 58 (40%) received STR (muscle flaps: n��=��38, fascio-cutaneous flaps: n=19; composite osteo-cutaneous flap: n��=��1). In total seven patients required secondary STR due to primary flap failure. All failures and flap-related complications occurred within the first three weeks after surgery. Secondary STR was successful in all cases. A high Charlson Comorbidity Index Score was a significant risk factor for flap failure (p��=��0.011). Out of the 43 patients who completed the 9-month follow-up, 11 patients presented with fracture nonunion and 12 patients with a recurrent infection. Polymicrobial infection was a significant risk factor for fracture nonunion (p��=��0.002). Primary flap failure was neither a risk factor for compromised fracture consolidation (p��=��0.590) nor for recurrence of infection (p��=��0.508). Conclusion: A considerable number of patients with lower-leg FRI required STR. This patient subgroup is complex and rich in complications and the long-term composite outcome demonstrated a high rate of compromised fracture consolidation and recurrent infections. It appears that secondary STR should be performed, as primary flap failure was neither a risk factor for compromised fracture consolidation nor for recurrence of infection. We propose to monitor these patients closely for three weeks after STR.

Pregledni rad o poslijeoperacijskoj rehabilitaciji od velikog je značaja kada je u pitanju bilo kakva vrsta osteosinteze. Najčešći uzroci prijeloma potkoljenice su prometne nesreće, padovi i sportske ozljede. Kada su ekstremiteti u pitanju važnost pridajemo težini s kojim je operirani ekstremiteti opterećeni i njihovim ishodima koji su važni za potpuni oporavak nakon prijeloma, u ovom slučaju potkoljenice, operacije i na kraju rehabilitacije koja vodi do potpunog oporavka. Rehabilitacija u ortopediji i traumatologiji je iznimno važna jer započinje prvog postoperativnog dana, te se obavljaju individualno i u skladu sa stanje, dobi i težini ozljede samog pacijenta. Nakon što se rehabilitacija pacijentima obavi u cijelosti i u potpunosti samostalno obavlja zadane vježbe, bitno je dati naglasak na prevenciju. Prevencija pada je bitna kako ne bi došlo do reoperacije, što bi dodatno otežalo proces ponovne rehabilitacije. Svejedno radi li se o zatvorenim ili otvorenim prijelomima, nakon svake operacije potrebna je rehabilitacija koja zahtjeva multidisciplinarni tim. Review work on postoperative rehabilitation is of great importance when it comes to any type of osteosynthesis. The most common causes of lower leg fractures are falls, traffic accidents and sports injuries. When it comes to the extremities, we attach importance to the weight with which the operated extremities are burdened and their outcomes that are important for complete recovery after a fracture, in this case lower leg, surgery and finally rehabilitation leading to complete recovery. Rehabilitation in orthopedics and traumatology is extremely important because it begins on the first postoperative day, and is performed individually and in accordance with the condition, age and severity of the patient's injury. Once the rehabilitation of the patients is done completely and the given exercises are performed completely independently, it is important to put the emphasis on prevention. Fall prevention is essential to prevent reoperation, which would further complicate the rehabilitation process. Whether it is open or closed fractures, rehabilitation requiring a multidisciplinary team is required after each surgery.

BackgroundTraumatic brain injury (TBI) has been known to accelerate bone healing. Many cells and molecules have been investigated but the exact mechanism is still unknown. We aimed to investigate the effect of TBI on fracture healing regarding accelerated hematoma formation.MethodsWe retrospectively investigated patients who were surgically treated for lower leg fractures and who showed secondary bone healing. Patients with and without TBI were divided for comparative analyses. Radiological parameters were time to bridging callus formation and the largest callus ratio during follow-up. Preoperative levels of complete blood count and chemical battery within 3 days from trauma were measured in all patients. Subgroup division regarding age, gender, open fracture, concomitant fracture and severity of TBI were compared.ResultsWe included 48 patients with a mean age of 44.9 (range, 17 – 78), of whom 35 patients (72.9%) were male. There were 12 patients with TBI (Group 1) and 36 patients without TBI (Group 2). Group 1 showed shorter time to callus formation (P < 0.001), thicker callus ratio (P = 0.015), leukocytosis and lymphocytosis (P ≤ 0.028), and lower red blood cell counts (RBCs), hemoglobin, and hematocrit (P < 0.001). Aging and severity of TBI were correlated with time to callus formation and callus ratio (P ≤ 0.003) while gender, open fracture, and concomitant fracture were unremarkable.ConclusionLower leg fractures with TBI showed accelerated bone healing and superior measurements associated with hematoma formation (lymphocytes, RBCs, hemoglobin, hematocrit). Promoted fracture healing in TBI was correlated with the enhanced proinflammatory state.Level of Evidence: Case control study; III

From today’s perspective, it is hard to imagine how fractures were treated well into the 1950s and even into the 1960s. Upon arrival at the Davos Hospital, a patient with a lower leg fracture from a skiing accident was typically treated by first stabilizing the broken limb, then by placing the limb into a plaster cast, and finally by having the patient rest for many weeks in traction, in a hospital bed, until the bone healed. The traction was a complicated looking system, often with a nail put through the patient’s heel and weights attached with ropes to the extended limb. The plaster cast would have to be kept on for 8–12 weeks, during which time the patient was subject to reduced mobility. After the plaster cast was removed, patients would then have to learn how to walk again.

Background Studies have shown that the ambulatory behavior and amount of weight bearing performed by lower leg fracture patients, increases over time. It is likely that gait features, such as center of pressure (CoP), also change over time. Research Question The purpose of this study was to characterize changes in CoP exhibited by lower leg fracture patients wearing a walking boot during the recovery period. Methods Approximately 2 weeks post-surgery, seven lower leg fracture patients were fitted with a MaxTrax walking boot which was integrated with the Ambulatory Tibia Load Analysis System, an underfoot load monitoring system. Patients wore the walking boot for 2–12 weeks resulting in continuous load data during the recovery period. Ambulation was filtered from the raw data and daily average CoP values were calculated by averaging the CoP vectors from all steps in a given day. Result In general, the CoP vector varied in both the x and y directions during the initial stages of recovery but was more uniform during the later stages of healing. In 6/7 patients, the CoP in the y direction was closer to the forefoot during the initial stages of healing but shifted posteriorly as time post-surgery increased. The single patient that did not exhibit a posterior shift in CoP was also the only patient to develop a non-union. CoP in the x direction show a less clear trend. CoP in the x direction exhibited a medial shift in 5 patients and a lateral shift in 2 patients. Significance During lower leg fracture recovery in a walking boot, the CoP in the y direction shifts posteriorly as time post-surgery increases and CoP monitoring may become a useful tool to monitor individual patient healing progression.

Die demografische Entwicklung zeigt einen uberproportionalen Anstieg der Patienten uber 80 Jahre mit einerseits erhohtem, sturzbedingten Verletzungsrisiko (mind. 1 Sturz pro Jahr bei 50%) und andererseits vermehrten Komorbiditaten einschlieslich der sog. geriatrischen Syndromen ( I ntellektueller Abbau, I nstabilitat, I mmobilitat und I nkontinenz) 1 . Die Behandlung dieser posttraumatischen Weichteilschaden bei geriatrischen und multimorbiden Patienten, insbesondere an der unteren Extremitat, gehort zu den zukunftigen medizinischen Herausforderungen.

Objective To examine the psychological, social, behavioural and injury-related factors impacting functional outcome in patients with ankle or lower limb fracture one year post-operation. Methods In this prospective study 66 patients with ankle or lower leg fracture were recruited and followed up one year post-operation. Possible associations between predictors and functional outcome were explored by regression analyses. Functional outcome was assessed with the American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score. Results Linear regression models revealed that smoking and elevated symptoms of adjustment disorder were associated with lower functional outcome one year post-operation. Fracture type, depressive symptoms and quality of relationship had no effect on functional outcome. A second linear regression revealed that preoccupations were correlated with functional outcome. Conclusion Smoking and symptoms of adjustment disorder, specifically preoccupations, are associated with functional outcome one year post-operation in patients recovering from ankle or lower leg fractures. The results support the notion that differences in functional recovery are attributable to psychological and behavioural factors rather than to fracture type. Psychological, fracture-specific, symptoms play a role in functional recovery rather than general affective symptoms.

以前よりGustiloⅢB 以上の重度下腿開放骨折において，早期（72時間以内）の軟部組織再建により感染率が低下することが認識されてきている。2000年4月から2008年3月までの間に16例のGustiloⅢB 重度下腿開放骨折（男性13例，女性3例，平均年齢41.2歳）に対して，早期軟部組織再建と骨再建を施行した。72時間以内に治療を完了したのが9例で，72時間以上を越えて治療完了したのが7例（平均12.5日）であった。16例のうち深部感染を併発したのは4例25％で全例MRSA 感染であった。軟部組織再建時期による差異は認められなかったが，施行病院での差異を認めた（A 病院10例中1例10％，B 病院6例中3例50％）。初期の広範囲デブリドマンと早期皮弁形成術の有効性は認められているものの，同一術者であっても施行病院にて感染率に大きな差があったことは，この治療が複雑であり多くの要因から影響を受けることを示唆する。

Verletzungen des Unterschenkels und des oberen Sprunggelenks (OSG) mussen insbesondere in Hinsicht auf das Outcome einer exakten Diagnostik und Analyse unterzogen werden. Sie bilden die Grundlage fur die entsprechende Therapie und somit die Vermeidung von Komplikationen. Bei der Versorgung sind der richtige Zugangsweg, die Wahl des richtigen Implantats und die richtige Platzierung unbedingte Voraussetzung zur Minimierung von Problemen. Ebenfalls entscheidend sind beim Eintritt von Komplikationen die Kompetenz und die Bereitschaft, diese zu erkennen und zu therapieren.

Background and Aim: Alpine skiing and snowboarding share the hazards of accidents accounting for tibial fractures. The aim of this study was to evaluate the fracture patterns and mechanisms of injury of tibial fractures taking place in downhill skiing and snowboarding. Materials and methods: All patients with tibial fracture due to alpine skiing or snowboarding accident treated in four trauma centers next to the largest ski resorts in Finland were analyzed between 2006 and 2012. The hospital records were retrospectively reviewed for data collection: equipment used (skis or snowboard), age, gender, and mechanism of injury. Fractures were classified according to AO-classification. Results: There were 342 skiing and 30 snowboarding related tibial fractures in 363 patients. Tibial shaft fracture was the most common fracture among skiers (n = 215, 63%), followed by proximal tibial fractures (n = 92, 27%). Snowboarders were most likely to suffer from proximal tibial fracture (13, 43%) or tibial shaft fracture (11, 37%). Snowboarders were also more likely than skiers to suffer complex AO type C fractures (23% vs 9%, p Conclusion: The most important finding was the relatively high number of the tibial plateau fractures among adult skiers. The fracture patterns between snowboarding and skiing were different; the most common fracture type in skiers was spiral tibial shaft fracture compared to proximal tibial fractures in snowboarders. Children had more simple fractures than adults.

In acute situations, fasciotomy can be done prophylactically or as early therapeutic decompression, the latter being performed as soon as the first symptoms of compartment syndrome are present. Results of fasciotomy after lower leg fracture performed between 1992 and 2001 were reviewed with emphasis on the efficacy of treatment and morbidity of the procedure sec. Patients, divided into a prophylactic group (A) and a therapeutic fasciotomy group (B), were interviewed and examined, focusing on late sequelae of compartment syndrome and of the fasciotomy sec. 52 patients were followed up after a median period of 40 months, 18 in group A and 34 in group B. All fractures in group A were operated within 24 h, one third of patients in group B underwent surgery later. In group A, one short foot syndrome was found. In group B, five amputations were performed for ischemic muscle necrosis, two short foot syndromes were observed, and five legs showed other late compelling signs of manifest compartment syndrome. In the 31 legs without sustained compartment syndrome, only seven had no fasciotomy-related abnormalities besides a scar; reduced endurance and swelling were most frequently found. An iatrogenic superficial peroneal nerve lesion was diagnosed in seven legs. Outcome after prophylactic fasciotomy seems to be superior to that after early therapeutic decompression. Though prophylactic fasciotomy is effective, its morbidity is quite high, with long-term consequences in three quarters of patients.

The Upper Palaeolithic skeleton from Vado all'Arancio (Italy), dated to about 11,330 BP, exhibits a severe ankle fracture healed with residual deformation. Following recovery, this young hunter- gatherer continued to walk for an extended period of time, albeit in a mechanically altered manner. While right-left differences in external lower limb bone measurements are relatively low, biomechanical analysis of femur and tibia indicates unusually pronounced asymmetry in all cross-sectional measures of diaphyseal strength. Asymmetry results primarily from normal side endosteal hypertrophy, and not from hypotrophy of the injured limb, suggesting that this individual resumed active life following recovery. This pattern of asymmetry underscores the role of physical activity in maintaining bone mass. Copyright  2002 John Wiley & Sons, Ltd.

Case 1. A 22 year old male fractured his lower leg when landing on a baseball court. On that day after the diagnosis of open lower leg fracture we executed osteosynthesis with an interlocking nail (Gustilo type II, A0 type A3). Case 2. A 37 year old female fractured her lower leg when falling on a badminton court. On that day we executed irrigation and debridement after the diagnosis of lower leg open fracture (Gustilo type II, A0 type A1). 17 days after the first operation we executed plate osteosynthesis.Discussion. In a gymnasium players occasionally lose their balances. To prevent falling to the court, a strong force between the sole of their sports shoes and the court may be transmitted to the bone causing fracture.This report describes 2 cases of an open fracture of the lower leg due to indirect forces, and a discussion about the generation of indirect forces from the interaction of the sole of a sports shoe with the gymnasium floor.

A 20-year-old previously healthy male presented at the pain clinic with chronic headache of about one year duration. Clinical examination revealed no pathological manifestations. During the consultation the patient was drinking Coca-Cola. On direct questioning he told that drinking Coca-Cola gave partial relief from the headache, and that the headache started after he had received two spinal anaesthetics for treatment of a lower leg fracture. Postural post dural puncture headache was now suspected and an epidural blood patch performed. Despite an interval of nearly 12 months since the dural punctures, a single epidural blood patch completely relieved the headache. This case history demonstrates that an epidural blood patch should be tried if a chronic post dural puncture headache is suspected.

Die beiden Freunde Markus und Andreas rasen mit ihren Mountainbikes auf einem steilen Pfad den Berg hinunter. Es geht uber Steine und Wurzeln. Kurz ist Andreas unkonzentriert und ubersieht einen Ast, der quer auf dem Pfad liegt. Andreas verliert das Gleichgewicht und sturzt. Ein stechender Schmerz schiest ihm ins rechte Bein.

1. The contractile properties of the triceps surae were evaluated in 11 patients after unilateral fracture of the lower leg and subsequent immobilization for 135 ± 68 days. Calf muscle cross-sectional area (plus bone: CSA) was assessed from anthropometric measurement. 2. It was shown that the injured leg had a faster time to peak tension and increased half-relaxation time (1/2RT); twitch force (Pt) was reduced by 25%. Evoked maximal tetanic tensions (P0) at 10 and 20 Hz were reduced by 51% and 46% respectively compared with the uninjured leg. The force of a maximal voluntary contraction (MVC) was also reduced, by 50%, but calf circumference and CSA were only 5% and 16% respectively lower in the injured leg. 3. It was concluded that the changes in contractile speed may indicate a relatively greater atrophy of slow (type I) muscle fibres. 4. The relationship between CSA and tension generation in the injured limb was shown to be poor after immobilization and during recovery. Anthropometric estimation of CSA does not appear to reflect the degree of muscle wasting, as indicated by reduced tension development after immobilization.

Fractures of the distal part of the lower leg are more common in everyday practice and traumatology. In young and active patients these injuries are mainly caused by high energy trauma. They are treated with external fi xator in fi rst step, and in second step, after sanation of the soft tissue, with open reduction and internal fi xation (ORIF). It is very safe and effective method of treatment. Treatment of the infections that occur in the early postoperative period after open reduction and internal fi xation represents a great problem and challenge for surgeons. It is widely accepted that the presence of deep infection can´t be cured in the presence of hardware. However, removal of hardware in the presence of unhealed fractures signifi cantly complicates sanation of infection and fracture itself. We have decided to present a 35-years-old patient with a hardware infection with present chronic wound with hardware exposed eight months after the fi rst operation and six months after second operation. The wound measured one centimeter in diameter with cell detritus and bad granulations tissue inside the wound. Hardwre was exposed in the depth of the wound.The secretion was minimal. Negative Pressure Wound Therapy (NPWT) was applicated after debridemet and lavage performed in ambulatory conditions. The starting therapy was continuously –125 mm Hg of vacuum. After fi ve days of NPWT the defect was partially fi lled with granulation tissue. For another fi ve days we continue with NPWT with the same values of –125 mm Hg pressure but in the intermitent mode. After that period we used transforming powder dressing for covering and protection of the wound with was fi lled with granulation tissue. Five days later, wound was completely healed with epithelisation. After four months of patient follow-up, we found the wound is completely repaired. The patient denies pain and has continued orderly fl ow of fracture healing, with no signs of infection.