Talar Neck Fractures: A Systematic Review of the Literature Halvorson, Jason J., MD; Winter, S. Bradley, MD; Teasdall, Robert D., MD ...
Journal of foot and ankle surgery/The Journal of foot and ankle surgery,
2013, January-February 2013, 2013 Jan-Feb, 2013-1-00, 20130101, Letnik:
52, Številka:
1
Journal Article
Recenzirano
Odprti dostop
Abstract Considerable controversy surrounds the management of talar neck fractures regarding the rate of post-traumatic arthrosis, secondary procedures, avascular necrosis, and the effect of the ...interval to surgery on these variables. A data search using PubMed was performed with the keywords “talus” and “fracture.” The search found 1280 studies. Ultimately, 21 reports involving 943 talar neck fractures were analyzed. Data concerning open fractures, the interval to surgery and its relationship to the incidence of avascular necrosis, and the rates of malunion and nonunion, post-traumatic arthrosis, secondary salvage procedures, and functional outcomes were collected and analyzed. The variables examined were not uniformly reported in all studies. The overall rate of avascular necrosis was 33%, with no demonstrated relationship between the interval to surgery and the rate of avascular necrosis. Malunion occurred approximately 17% of the time, with nonunion occurring approximately 5% of the time. Post-traumatic arthrosis occurred in 68% of patients, although secondary salvage procedures were only performed in 19% of patients. Functional outcomes were difficult to assess, given the variability of reported outcomes and unvalidated measures. The optimal management of talar neck fractures has yet to be determined. Although the present review has improved understanding of these difficult fractures, additional studies that use validated outcomes measures are warranted to determine the effect of delayed surgery on final outcomes and optimal treatment methods.
Management of humeral shaft fractures Carroll, Eben A; Schweppe, Mark; Langfitt, Maxwell ...
Journal of the American Academy of Orthopaedic Surgeons
20, Številka:
7
Journal Article
Recenzirano
Humeral shaft fractures account for approximately 3% of all fractures. Nonsurgical management of humeral shaft fractures with functional bracing gained popularity in the 1970s, and this method is ...arguably the standard of care for these fractures. Still, surgical management is indicated in certain situations, including polytraumatic injuries, open fractures, vascular injury, ipsilateral articular fractures, floating elbow injuries, and fractures that fail nonsurgical management. Surgical options include external fixation, open reduction and internal fixation, minimally invasive percutaneous osteosynthesis, and antegrade or retrograde intramedullary nailing. Each of these techniques has advantages and disadvantages, and the rate of fracture union may vary based on the technique used. A relatively high incidence of radial nerve injury has been associated with surgical management of humeral shaft fractures. However, good surgical outcomes can be achieved with proper patient selection.
We performed a systematic review of the current literature to determine the efficacy and duration of intra-articular corticosteroid injection in reducing pain caused by knee osteoarthritis and to ...determine whether the type of corticosteroid used affected these results. Following an electronic search of multiple databases and a review of reference lists from various articles, we found six trials in five papers that compared corticosteroid versus placebo and four papers that compared different corticosteroids. Results of corticosteroid compared with placebo showed both a statistically and clinically significant reduction in pain at 1 week, with an average difference between groups of 22%. Two of four trials showed triamcinolone to be more effective in pain reduction than other corticosteroids. We concluded that intra-articular corticosteroids reduce knee pain for at least 1 week and that intra-articular corticosteroid injection is a short-term treatment of a chronic problem.
Dual implants for distal femur periprosthetic fractures is a growing area of interest for these challenging fractures with dual plating (DP) emerging as a viable construct for these injuries. In the ...current study, an experience with DP constructs is described.
Retrospective case series with comparison group.
Level 1 academic trauma center.
Adults >50 years old sustaining comminuted OTA/AO 33-A2 or 33-A3 DFPF treated with either DP or a single distal femur locking plating (DFLP). Patients with simple 33-A1 fractures were excluded. Prior to 2018, patients underwent DFLP after which the treatment of choice became DP.
Reoperation rate, alignment, and complications.
34 patients treated with DFLP and 38 with DP met inclusion and follow up criteria. Average follow up was 18.2 ± 13.8 months in the DFLP group and 19.8 ± 16.1 months in the DP group ( P = 0.339). The average patient age in the DFLP group was 74.8 ± 7.3 years compared to 75.9 ± 11.3 years in the DP group. There were no statistical differences in demographics, fracture morphology, loss of reduction, or reoperation for any cause ( P >.05). DP patients were more likely to be weight bearing in the twelve-week postoperative period ( P <0.001) and return to their baseline ambulatory status ( P = 0.004) compared to DFLP patients.
Dual plating of distal femoral periprosthetic fractures maintained coronal alignment with a low reoperation rate even with immediate weight bearing and these patients regained baseline level of ambulation more reliably as compared to patients treated with a single distal femoral locking plate.
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Vascular injury associated with extremity trauma occurs in <1% of patients with long bone fracture, although vascular injury may be seen in up to 16% of patients with knee dislocation. In the absence ...of obvious signs of vascular compromise, limb-threatening injuries are easily missed, with potentially devastating consequences. A thorough vascular assessment is essential; an arterial pressure index <0.90 is indicative of potential vascular compromise. Advances in CT and duplex ultrasonography are sensitive and specific in screening for vascular injury. Communication between the orthopaedic surgeon and the vascular or general trauma surgeon is essential in determining whether to address the vascular lesion or the orthopaedic injury first. Quality evidence regarding the optimal fixation method is scarce. Open vascular repair, such as direct repair with or without arteriorrhaphy, interposition replacement, and bypass graft with an autologous vein or polytetrafluoroethylene, remains the standard of care in managing vascular injury associated with extremity trauma. Although surgical technique affects outcome, results are primarily dependent on early detection of vascular injury followed by immediate treatment.
Modern external ring fixation has been hypothesized to reduce complications requiring hospital readmission compared with internal fixation when treating patients with high-energy open tibial shaft ...fractures. In this study, the 1-year probability of a major limb complication was compared between external and internal fixation of severe open tibial fractures.
This multicenter randomized clinical trial included patients 18 to 64 years of age with severe open tibial shaft fractures randomly assigned to either modern external ring fixation (n = 127) or internal fixation (n = 133). The primary outcome was a major limb complication within 365 days after randomization; these complications included amputation, infection, a soft-tissue problem, nonunion, malunion, and a loss of reduction/implant failure.
Of 260 randomized patients, 254 were included in the final analysis. Their mean age (standard deviation) was 39 (13) years; 214 (84%) were men. The probability of at least 1 major limb complication was higher for external fixation (62.1% 95% confidence interval (CI): 53.4% to 70.8%) than internal fixation (43.7% 95% CI: 35.5% to 52.9%), with a risk difference of 18.4% (95% CI: 5.8% to 30.4%); p = 0.005). The most notable difference was in loss of reduction/implant failure, the rate of which was higher for external fixation (risk difference: 14.4% 95% CI: 7.0% to 21.6%; p = 0.002). There was no appreciable difference in the probability of deep infection between external fixation (26.1%) and internal fixation (29.7%) (risk difference: -3.5% 95% CI: -14.8% to 7.8%; p = 0.54). There were also no appreciable differences in the probabilities of amputation, nonunion, soft-tissue problems, malunion, or fracture healing between the groups.
These results argue against routine use of modern external ring fixation for the treatment of these severe open tibial fractures.
Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
Intra-articular Pilon fractures remain therapeutically challenging due to osteochondral fracturing and comminution, marginal impaction, and insult to the soft tissue envelope. The purpose of this ...study was to compare the efficacy of anterolateral distal tibial locking plates in capturing main fracture fragments in tibial plafond fractures.
From May 2011 to Dec 2015, 169 OTA C-type pilon fractures met inclusion and exclusion criteria with computed tomographic (CT) scans performed prior to definitive fixation. For each patient, the fracture lines were mapped, digitized, and graphically superimposed to create a compilation of fracture lines. Based on these average measurements, three distal tibia sawbones had three different anterolateral plates applied. Axial CT scan images were used to determine the efficacy of screw purchase in main fracture fragments in pilon fractures.
The Smith & Nephew PERI-LOC plate secured the largest number of fracture lines (90.1%) but missed the Volkmann fragment with greatest frequency at 3.6%. The Synthes 2.7/3.5 mm VA-LCP captured 87.3% of the fracture lines while missing the Volkmann fragment 3.2% of the time. The Synthes 3.5 mm LCP captured 86.5% of the fracture lines but was the best at securing the Volkmann fragment (1.2% missed). All three implants were deficient in capturing the medial malleolar fragment. The PERI-LOC and 2.7/3.5 mm VA-LCP did not differ with respect to percentage of fragments captured (p = 0.721) but both outperformed the 3.5 mm LCP (p = 0.021 and p = 0.05, respectively).
This study was consistent with prior literature in defining three main fracture fragments: anterior, medial, and posterior. All three plates were deficient in capturing the medial malleolar fragment. The Smith and Nephew PERI-LOC plate secured the most number of fracture lines, while the Synthes 3.5 mm LCP was least likely to miss the Volkmann fragment and most likely to miss the medial malleolar fragment. No plate was found to be superior to the other in capturing all fracture lines of the OTAC3 pilon fragments.
Three.
Negative Pressure Wound Therapy (NPWT) is frequently utilized to manage complex wounds, however its mechanisms of healing remain poorly understood. Changes in growth factor expression, micro- and ...macro-deformation, blood flow, exudate removal, and bacterial concentration within the wound bed are thought to play a role. NPWT is gaining widespread usage in foot and ankle surgery, including the management of traumatic wounds; diabetic and neuropathic ulcers; wounds left open after debridement for infection or dehiscence; high-risk, closed incisions; tissue grafts and free flaps. This article reviews the rationale for NPWT, its proposed mechanisms of action, and the evidence regarding its clinical applications within the field of foot and ankle surgery.
Level of Evidence: Level V, expert opinion.
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