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2.  Technical errors and complications in orthopaedic trauma surgery 
Adverse events and associated morbidity and subsequent costs receive increasing attention in clinical practice and research. As opposed to complications, errors are not described or analysed in literature on fracture surgery. The aim of this study was to provide a description of errors and complications in relation to fracture surgery, as well as the circumstances in which they occur, for example urgency, type of surgeon, and type of fracture.
All errors and complications were recorded prospectively in our hospital’s complication registry, which forms an integral part of the electronic medical patient file. All recorded errors and complications in the complication registry linked to fracture surgery between 1 January, 2000 and 31 December, 2010 were analysed.
During the study period 4310 osteosynthesis procedures were performed. In 78 (1.8 %) procedures an error in osteosynthesis was registered. The number of procedures in which an error occurred was significantly lower (OR = 0.53; p = 0.007) when an orthopaedic trauma surgeon was part of the operating team. Of all 3758 patients who were admitted to the surgical ward for osteosynthesis, 745 (19.8 %) had one or more postoperative complications registered. There was no significant difference in the number of postoperative complications after osteosynthesis procedures in which an orthopaedic trauma surgeon was present or absent (16.7 vs. 19.1 %; p = 0.088; OR 0.85).
In the present study the true error rate after osteosynthesis may have been higher than the rate found. Errors that had no significant consequence may be especially susceptible to underreporting.
The present study suggests that an osteosynthesis procedure performed by or actively assisted by an orthopaedic trauma surgeon decreases the probability of an error in osteosynthesis. Apart from errors in osteosynthesis, the involvement of an orthopaedic trauma surgeon did not lead to a significant reduction in the number of postoperative complications.
PMCID: PMC4724359  PMID: 26690070
Fractures; Surgical error; Complications
3.  Development and initial evaluation of a point-of-care educational app on medical topics in orthogeriatrics 
Research by AOTrauma’s orthogeriatrics education taskforce identified ongoing educational needs for surgeons and trainees worldwide regarding the medical management of older adults with a fracture. To address practicing surgeons’ preference for increased use of mobile learning, a point-of-care educational app was planned by a committee of experienced faculty. The goals were to deliver the app to surgeons, trainees, and other healthcare professionals, to measure usage, and to evaluate the impact on patient care.
Materials and methods
The committee of geriatricians and surgeons designed and developed four modules on osteoporosis, delirium, anticoagulation, and pain based on published evidence and the content was programmed into mobile app formats. A registration form was integrated and a 14-question online evaluation survey was administered to users.
The AOTrauma Orthogeriatrics app was installed by 17,839 users worldwide between September 2014 and October 2015: Android smartphones (44 %), iPhones (32 %), iPads (15 %), Android tablets (9 %). 920 users registered and 100 completed the online evaluation: orthopedic/trauma surgeons (67 %), residents/fellows (20 %), and other professionals (13 %). Ratings for all aspects were 4 or higher on a 1–5 Likert scale (5 = Excellent). 80 % of evaluation respondents found the answer to their question or educational need on their last visit, and 26 of 55 respondents (47 %) reported making a change in an aspect of their management of patients as a result of their learning from the app.
The orthogeriatrics app reached its intended audiences and was rated highly as a method of providing education to help improve patient care. Content input by experienced faculty and app improvements based on user feedback were key contributors to successful implementation.
PMCID: PMC4706575  PMID: 26646844
Fragility fractures; Older adults; Orthogeriatrics; Education; Osteoporosis; Delirium; Anticoagulation; Perioperative pain
4.  The effect of postoperative wound infections on functional outcome following intra-articular calcaneal fractures 
High rates of postoperative wound infections (POWI) are reported following the operative treatment of calcaneal fractures. This leads to additional therapy, prolonged hospital stay, burden for patients and increased costs. The primary aim of this study is to evaluate the effect of POWI following the extended lateral approach of displaced intra-articular calcaneal fractures on functional outcome. Secondary aims are assessment of health-related quality of life and patient satisfaction.
Patients and methods
All consecutive adult patients with a calcaneal fracture treated between 2000 and 2011 with open reduction and internal fixation through an extended lateral approach were retrospectively included and sent a questionnaire. Functional outcome was measured using the Foot Function Index (FFI, best score 0 points) and the American Orthopaedic Foot and Ankle Society (AOFAS, best score 100 points) hindfoot score. The EuroQOL-5D was used for quality of life (QOL) and a Visual Analogue Scale (VAS, best score 10 points) for overall patients satisfaction.
Of 135 eligible patients, 94 returned the questionnaire (response rate 70 %). The median FFI was 12 points (IQR 3–33) and AOFAS 79 points (IQR 61–90). The FFI and AOFAS were, respectively, 17 and 9 points higher in favour of patients without POWI (n = 69) compared to patients with POWI (n = 25). Albeit large differences, they were not statistically significant given the current number of patients. Patients without POWI scored better on all health-related aspects of QOL in the EQ-5D, but this did not reach statistical significance. However, the VAS on overall patient satisfaction did show a statistically significant difference of 1.3 points (9.0 vs 7.7; p = 0.01) in favour of patients without POWI. Importantly, a clinically relevant difference was found with the FFI as the estimated minimal clinical important difference of the FFI is 10 points.
Our results implicate that postoperative wound infection leads lower functional outcome scores following calcaneal fracture surgery, but no statistical significance was reached. In addition, patients do not report significant worse QOL or physical impairment. Overall patient satisfaction measured by a VAS was significantly lower in case of a POWI, reflecting the burden caused by a wound complication.
PMCID: PMC4513207  PMID: 25913906
Calcaneus; Open reduction internal fixation; Extended lateral approach; Postoperative wound infection; POWI; Outcome; AOFAS; FFI; Quality of life
5.  Fracture reduction with positive medial cortical support: a key element in stability reconstruction for the unstable pertrochanteric hip fractures 
To introduce the concept of fracture reduction with positive medial cortical support and its clinical and radiological correlation in geriatric unstable pertrochanteric fractures.
A retrospective analysis of 127 patients (32 men and 95 women, with mean age 78.7 years) with AO/OTA 31A2.2 and 2.3 hip fractures treated with cephalomedullary nail (PFNA-II or Gamma-3) between July 2010 and June 2013 was performed. They were classified into three groups according the grade of medial cortical support in postoperative fracture reduction (positive, neutral, and negative). The positive cortex support was defined that the medial cortex of the head–neck fragment displaced and located a little bit superomedially to the medial cortex of the shaft. If the neck cortex is located laterally to the shaft, it is negative with no cortical buttress, and if the two cortices contact smoothly, it is in neutral position. The demographic baseline, postoperative radiographic femoral neck–shaft angle and neck length, rehabilitation progress and functional recovery scores of each group were recorded and compared.
There were 89 cases (70 %) in positive, 26 in neutral, and 12 in negative support. No statistical differences were found between the three groups among patient age, sex ratio, prefracture score of activity of daily living, walking ability score, ASA physical risk score, number of medical comorbidities, osteoporosis Singh index, fracture reduction quality (Garden alignments), and the position of lag screw or helical blade in femoral head (TAD). In follow-up, patients in positive medial cortical support reduction group had the least loss in neck–shaft angle and neck length, and got ground-walking much earlier than negative reduction group, with good functional outcomes and less hip–thigh pain presence.
Fracture reduction with nonanatomic positive medial cortical support allows limited sliding of the head–neck fragment to contact with the femur shaft and achieve secondary stability, providing a good mechanical environment for fracture healing.
PMCID: PMC4436685  PMID: 25840887
Pertrochanteric fracture; Fracture reduction; Positive medial cortical support; Cephalomedullary nail; Wedge-open effect; Hip–thigh pain; Secondary stability
6.  Pelvic ring reconstruction with a double-barreled free vascularized fibula graft after resection of malignant pelvic bone tumor 
In patients undergoing limb-salvage internal hemipelvectomy, pelvic ring reconstruction is mandatory to maintain the stability of the pelvis and the spinal column, which finally expected to achieve a good functional outcome. However, no optimal reconstruction method has been established. In addition, no previous reports have highlighted the long-term complications of pelvic ring reconstruction after internal hemipelvectomy. We aimed to analyze the outcome of pelvic ring reconstruction using a double-barreled free vascularized fibula graft (VFG) after internal hemipelvectomy with special reference to long-term complications.
Materials and methods
We conducted a retrospective review of 9 consecutive patients (5 male, 4 female; mean age 31 years) who underwent pelvic ring reconstruction using a double-barreled free VFG after internal hemipelvectomy (P1, n = 4; P1 + 4, n = 3; P1 + 2, n = 2) at our institution between 1998 and 2013. The mean follow-up period was 55 months (range 3–131 months).
The mean length of the bone defect was 9 cm. The methods of fixation included a Cotrel-Dubosset rod (n = 4), screw (n = 3), and screw and plate (n = 2). Bone union was achieved in 5 of 8 patients (63 %) over a 1-year follow-up. The mean period required for bone union was 5.4 months (range 3–7 months). There were 3 early postoperative complications: 2 deep infections resulting in graft removal and 1 implant failure resulting in non-union. Among 3 patients, 2 developed scoliosis within 5 years. One patient developed lumbar disc hernia as a result of scoliosis, for which surgical intervention was required. The mean Musculoskeletal Tumor Society score was 57 % at the last follow-up.
In conclusion, this reconstruction method can achieve an early and high rate of bone union and provide good functional outcome. However, follow-up with careful attention to postoperative complications, including deep infection in the early postoperative period and spinal deformity in the long term, is necessary.
PMCID: PMC4544562  PMID: 25795428
Internal hemipelvectomy; Pelvic ring reconstruction; Vascularized fibula graft; Complication
7.  Survey on the management of acute first-time anterior shoulder dislocation amongst Dutch public hospitals 
The primary aim of this study was to record how orthopaedic surgeons are currently managing acute first-time anterior shoulder dislocation (AFASD) 8 years after introduction of the Dutch national guideline: “acute primary shoulder dislocation, diagnostics and treatment” in 2005. The second aim was to evaluate how these surgeons treat recurrent instability after AFASD.
Materials and methods
An online questionnaire regarding the management of AFASD and recurrent shoulder instability was held amongst orthopaedic surgeons of all 98 Dutch hospitals.
The overall response rate was 60 %. Of the respondents, 75 % had a local protocol for managing AFASD, of which 28 % had made changes in their treatment protocol after the introduction of the national guideline. The current survey showed wide variety in the overall treatment policies for AFASD. Twenty-seven percent of the orthopaedic surgeons were currently unaware of the national guideline. The variability in treatment for AFASD was present throughout the whole treatment from which policy at the emergency department; when to operate for recurrent instability; type of surgical technique for stabilization and type of fixation of the labrum. As for the treatment of recurrent instability, the same variability was seen: 36 % of the surgeons perform only arthroscopic procedures, 7 % only open and 57 % perform both open and arthroscopic procedures.
Despite the introduction of the national guideline for the initial management of AFASD in 2005, still great variety among orthopaedic surgeons in the Netherlands was present. As for the surgical stabilization technique, the vast majority of the respondents are performing an arthroscopic shoulder stabilization procedure at the expense of the more traditional open procedure as a first treatment option for post-traumatic shoulder instability.
Electronic supplementary material
The online version of this article (doi:10.1007/s00402-015-2156-3) contains supplementary material, which is available to authorized users.
PMCID: PMC4365281  PMID: 25697813
Shoulder; Dislocation; Survey; Guideline; Implementation; Treatment
8.  [No title available] 
PMCID: PMC4295027  PMID: 25539850
9.  [No title available] 
PMCID: PMC4295024  PMID: 25424753
10.  Arthroscopy-assisted reconstruction of coracoclavicular ligament by Endobutton fixation for treatment of acromioclavicular joint dislocation 
The aim of this study was to evaluate the clinical outcomes of arthroscopy-assisted reconstruction of the coracoclavicular (CC) ligament using Endobutton for treating acromioclavicular (AC) joint dislocation.
From March 2012 to May 2013, a total of 22 patients with fresh AC joint dislocation (Rockwood type III and type V) were treated with arthroscopy-assisted Endobutton reconstruction of the CC ligament. The regular post-operation follow-up was performed. Shoulder joint function was assessed with Constant–Murley scores. Postoperative efficacy of the surgery was evaluated using the Karlsson criterion.
The 22 patients were followed postoperatively for an average of 24 months (16–31 months). Among them, 20 patients achieved good functional recovery with no pain. Two patients had slight pain in the acromion during shoulder joint motion with limited abduction at 3 months, both of whom had recovered at 6 months. Radiography confirmed anatomical reduction of the AC joint in all patients. At 1 year, the Constant–Murley scores were 93.1 ± 2.4 points on the injured side versus 94.2 ± 2.7 points on the uninjured side. The difference did not reach statistical significance (P > 0.05). Postoperative Karlsson evaluation ranked 20 patients (90.9 %) as grade A and 2 as grade B (9.1 %) at the 3-month follow-up. All patients had become grade A at 6 months. None of the patients had brachial plexus or peripheral vascular injuries.
Arthroscopy-assisted reconstruction of the coracoclavicular ligament by Endobutton fixation is a safe, easy method for treating AC joint dislocation. It provides reliable fixation, causes little trauma, and has a fast recovery.
PMCID: PMC4281352  PMID: 25421528
Arthroscopy; Endobutton; Coracoclavicular ligament; Acromioclavicular dislocation; Ligament repair
11.  Risk factors for subsidence in anterior cervical fusion with stand-alone polyetheretherketone (PEEK) cages: a review of 82 cases and 182 levels 
To determine risk factors for subsidence in patients treated with anterior cervical discectomy and fusion (ACDF) and stand-alone polyetheretherketone (PEEK) cages.
Materials and methods
Records of patients with degenerative spondylosis or traumatic disc herniation resulting in radiculopathy or myelopathy between C2 and C7 who underwent ACDF with stand-alone PEEK cages were retrospectively reviewed. Cages were filled with autogenous cancellous bone harvested from iliac crest or hydroxyapatite. Subsidence was defined as a decrease of 3 mm or more of anterior or posterior disc height from that measured on the postoperative radiograph. Eighty-two patients (32 males, 50 females; 182 treatment levels) were included in the analysis.
Most patients had 1–2 treatment levels (62.2 %), and 37.8 % had 3–4 treatment levels. Treatment levels were from C2–7. Of the 82 patients, cage subsidence occurred in 31 patients, and at 39 treatment levels. Multivariable analysis showed that subsidence was more likely to occur in patients with more than two treatment levels, and more likely to occur at treatment levels C5–7 than at levels C2–5. Subsidence was not associated with postoperative alignment change but associated with more disc height change (relatively oversized cage).
Subsidence is associated with a greater number of treatment levels, treatment at C5–7 and relatively oversized cage use.
PMCID: PMC4168225  PMID: 25099076
Anterior cervical discectomy; Fusion; Stand-alone; PEEK cage; Subsidence
12.  Alternative treatment of forearm double fractures: new design intramedullary nail 
This study aims to evaluate the results of intramedullary nail treatment in surgical treatment of adult displaced radius and ulna diaphyseal fractures.
Patients and methods
Eighteen patients (36 forearm fractures) who underwent intramedullary nail treatment due to radius and ulna fractures were retrospectively analyzed. Adult patients with displaced forearm double fractures were included in this study. Patients with open physeal lines, pathological fractures, Monteggia and Galeazzi fractures, distal radioulnar joint instability, bilateral fractures and bone loss were excluded.
Thirteen patients were male (72.2 %) and five were female (27.8 %). Average age of the patients was 35.16 (18–63). Twelve patients (66.7 %) suffered right and six patients (33.3 %) left forearm fractures. Average follow-up period was 77.7 (55–162) weeks, average bleeding amount was 51.11 (15–100) ml, average time to bone union was 11.3 (8–20) weeks, average surgery time was 61.94 (45–80) min and average fluoroscopy time was approximately 2 (1–5) min. According to Grace-Eversman criteria, results were excellent in 14 (77.8 %) patients, good in 3 (16.8 %) and acceptable in 1 (5.6 %). Average DASH questionnaire score was 15.15 (4–38.8). There was no iatrogenic vascular, neural and bone injury during surgery. There was late rupture of extensor pollicis longus tendon in one patient, 4 months after surgery.
Intramedullary fixation method has advantages, such as closed application, short surgery period, good cosmetic results and early return to movement. We think intramedullary fixation method may be used as an alternative treatment method to plate osteosynthesis in surgical treatment of radius and ulna diaphyseal fractures.
PMCID: PMC4168222  PMID: 25069578
Intramedullary nail; Radius; Ulna
13.  MRI does not detect acetabular osteolysis around metal-on-metal Birmingham THA 
Osteolysis has not been recognized as a common failure mode of the Birmingham modular metal-on-metal (MoM) total hip arthroplasty (THA). The clinical value of metal artifact reduction sequence (MARS) magnetic resonance imaging (MRI) to assess the periprosthetic soft tissue is well documented; however, the appropriate image modalities to detect periacetabular osteolysis remain unclear.
Case summary
Eleven patients with periacetabular osteolysis within 3–6 years after uncemented Birmingham modular MoM THA with a synergy stem are presented. All 11 patients received corresponding standardized AP pelvis radiographs, high-quality MARS MRIs and CT scans with a metal artifact reduction sequence. While periacetabular osteolysis around MoM THA was not detected on MARS MRI in ten patients, CT imaging identified osteolysis in all patients. Periacetabular osteolysis appears to be a failure mechanism of the Smith & Nephew Birmingham MoM THA.
There is no evidence in the literature to support the effectiveness of MARS MRI to detect periacetabular osteolysis around cobalt chromium alloy metal-on-metal total hip arthroplasties. Osteolysis due to corrosion-related particles seems to be one of the primary modes of failure in modular MoM THA.
MRI is not a sensitive test to identify periacetabular osteolysis. The authors recommend CT for the screening of implants with this failure mode. Our study suggests that patients with a Birmingham modular MoM THA are at increased risk to develop acetabular osteolysis and should be carefully monitored for this failure mode.
PMCID: PMC4062806  PMID: 24838248
Periacetabular osteolysis; Metal-on-metal; Total hip arthroplasty; Screening; MRI; CT
14.  Characteristics and significance of fever during 4 weeks after primary total knee arthroplasty 
Most previous studies on postoperative fever (POF; ≥38 °C) after total knee arthroplasty (TKA) have reported findings from only the immediate postoperative days (PODs). The hypothesis of the current study is that 4 weeks of follow-up may reveal differences in the characteristics of POF and fever-related factors between a normal inflammatory response and an early acute infection-related response.
A total of 400 consecutive TKAs (314 patients) were retrospectively investigated. Patients were stratified into those who developed an early acute periprosthetic infection that required subsequent surgical treatment (STG; n = 5 TKAs) and those who did not (non-STG; n = 395 TKAs).
Among the 400 knees, 149 (37 %) developed POF, with most reaching a maximum temperature (MT) on POD 0. In 13 TKA patients who had POF with a peak daily temperature ≥38 °C during postoperative weeks 2–4, the causes of POF were respiratory and urinary tract infections (n = 5 for each), superficial infection (n = 2), and periprosthetic infection (n = 1). The STG and non-STG differed significantly with regard to the rate of POF (p = 0.0205) and MT (p = 0.0003), including MTs less than 38 °C, during postoperative weeks 2–4. All five STG patients had elevated C-reactive protein levels and local symptomatic findings before the additional surgery.
The occurrence of POF and MT along with elevated C-reactive protein and local symptomatic findings at 2–4 weeks postoperatively may indicate the need for a positive fever workup to recognize early acute periprosthetic infection.
PMCID: PMC3990857  PMID: 24522863
Total knee arthroplasty; Postoperative fever; Maximum temperature; Periprosthetic infection
15.  Recompression in new levels after percutaneous vertebroplasty and kyphoplasty compared with conservative treatment 
Study design
A prospective clinical study assessing new vertebral compression fracture after previous treatment.
The purpose of this study was to investigate the incidence and associated risk factors of new symptomatic osteoporotic vertebral compression fractures (OVCFs) in patients treated by percutaneous vertebroplasty (PVP) and kyphoplasty (PKP) versus conservative treatment, and to elucidate our findings.
Summary of background data
There are a lot of reports concerning the feasibility and efficacy of this minimally invasive procedure compared with conservative treatment, especially in pain soothing. However, it is still unclear whether the risk of subsequent fracture has increased among operative treatment patients in the long term.
From November 2005 to July 2009, 290 consecutive patients with 363 OVCFs were randomly selected for PVP/PKP or conservative treatment and evaluated with a mean follow-up of 49.4 months (36–80 months). Some parameters were characterized and statistically compared in this study. Telephone questionnaires, clinical reexamine, and plain radiographs were performed in the follow-up.
Thirty-one of 290 (10.7 %) patients had experienced 42 newly developed symptomatic secondary OVCFs. Among 169 operation (53.3 % vertebroplasty, 46.7 % kyphoplasty) and 121 comparison patients, there is no significant statistical difference of new OVCFs incidence between the two groups calculated by patient proportion. However, in separate, the rate of secondary adjacent fractures calculated by vertebral refracture number is significantly higher than non-adjacent levels in PVP/PKP group but no significant statistical difference was observed in conservative group. The time interval of recompression after operative procedure was much shorter than that for comparison group (9.7 ± 17.8 versus 22.4 ± 7.99 months, p = 0.017). In addition, older age, gender, fracture times, location of original fracture segment, the amount of cement, cement leakage, operation modality (PVP or PKP),and initial number of OVCFs were documented, but these were not the influencing factors in this study (p > 0.05).
Patients who had experienced PVP/PKP were not associated with an increased risk of recompression in new levels. However, recompression in new levels of PVP/PKP group occurred much sooner than that of conservative group in the follow-up period. The incidence of new vertebral fractures observed at adjacent levels was substantially higher but no sooner than at distant levels in PVP/PKP group. No major risk factors involving new OVCFs have been found in this study and  augmentation for sandwich situation is not necessary.
PMCID: PMC3889698  PMID: 24287674
Percutaneous vertebroplasty; Kyphoplasty; Adjacent fracture; Conservative treatment
16.  Comparison between posterior lumbar interbody fusion and posterolateral fusion with transpedicular screw fixation for isthmic spondylolithesis: a meta-analysis 
Primary aim of this study was to compare long-term pain relief and quality of life in adults with isthmic spondylolisthesis (IS) who were treated with posterior lumbar interbody fusion (PLIF) and posterolateral fusion (PLF). Secondary aim was to compare the fusion and infection rates of PLIF- or PLF-treated groups.
Materials and methods
We searched four databases and the cited reference lists of the included studies. Inclusion criteria were pain assessment with visual analog scale (VAS), and clinical studies that compared long-term pain relief of PLF and PLIF-treated adults with IS. Exclusion criteria were use of only one treatment and non-English language.
Three of five included studies used VAS to assess the decline in low back pain, radicular pain, or leg pains in PLF- or PLIF-treated patients during the follow-up periods (0.5–6 years). Long-term pain relief significantly improved in both treatment groups. Pooled differences in mean improvement of Oswestry disability index after the operation revealed no significant difference in pain relief between the PLF and PLIF groups (P = 0.856). The five studies together indicated that fusion rate was significantly greater in the PLIF group than that in the PLF group.
The majority of PLIF- and PLF-treated adults with low-grade IS experienced long-term pain relief to a similar extent in most studies. PLIF treatment provided significantly better fusion rates than PLF treatment. This meta-analysis indicates that the use of separate, well-defined scales for pain relief and functional outcomes are needed in studies of PLF or PLIF-treated patients.
PMCID: PMC3828496  PMID: 24136445
Posterior lumbar interbody fusion; PLIF; Posterolateral fusion; PLF; Spondylolisthesis; Pain; Fusion rate; Infection rate; Isthmic
17.  Single-incision technique for the internal fixation of distal fractures of the tibia and fibula: a combined anatomic and clinical study 
To present a novel single anterior-lateral approach for the treatment of distal tibia and fibula fracture via anatomical study and primary clinical application in order to minimize soft tissue complications.
Both a gross anatomic cadaver and retrospective studies of the single-incision technique in patients recruited between June 2004 and January 2010.
Level I trauma center.
Twenty-six legs of 14 adult human cadavers and clinical recruitment of 49 patients (29 males, 20 females) with a mean age of 37.6 years (range 11–68) with fracture of distal 1/3 tibia and fibula.
A single anterior-lateral incision technique for open reduction and internal fixations of distal tibia and fibula fractures.
Main outcome measures
To identify the anatomic structures at risk in the anterolateral aspect of the lower leg and explicit the safe dissection distance from the extensor digitorum longus (EDL) to tibia and fibula, 26 legs of 14 adult human embalmed specimens were recruited in the anatomical study with the distance between the EDL and the anterior edge of the distal thirds of the tibia, as well as the distance between the EDL and the anterior edge of the distal thirds of the fibula were measured, and their mutual relationships to the surrounding anatomical structures described. Mean average standard deviations were also calculated. As for the clinical study, the quality of bone union and soft tissue healing were noted.
The mean distances between the distal tibia and the EDL were measured to be 2.96 ± 0.46 cm (proximal), 1.85 ± 0.25 cm (middle), and 2.15 ± 0.30 cm (distal), and that between the fibula and the EDL were 1.82 ± 0.28 cm (proximal), 2.09 ± 0.31 cm (middle), and 2.30 ± 0.27 cm (distal), which means the safe gap from the distal tibia to EDL was1.6–3.4 cm and from the EDL to fibula was 1.5–2.6 cm. The anterior tibial vein and artery and the deep fibular nerve lie on the anterior interosseous membrane over the lateral surface of the distal tibia were excellently visualized. Review of clinical outcomes in 49 patients with combined distal tibial and fibular fractures who underwent reduction and fixation with the single-incision technique, revealed uneventful fracture healings in 47 patients; and two cases of superficial wound necrosis which were treated and healed in 4 months. There was no case of delayed union or non-union.
Distal fibula fracture occurring with distal tibia fracture poses a challenge for stable fixation. This has necessitated the need for dual incisions on the distal leg to approach each fracture for reduction and fixation. However, a single anterolateral incision enables the safe approach to the lateral aspects of the distal tibia and fibula thus eliminating the need for two separate incisions and minimizing the soft tissue complication to some extent. Meanwhile, the neurovascular bundle at risk during operation, distal tibia and fibula is clearly exposed in the single anterior-lateral incision.
PMCID: PMC3828491  PMID: 24121655
Fracture; Distal tibia; Distal fibula; Anatomy; Incision
18.  Subtrochanteric shortening osteotomy combined with cemented total hip arthroplasty for Crowe group IV hips 
Total hip arthroplasty (THA) is a challenging surgical procedure that can be used to treat severely dislocated hips. There are few reports regarding cemented THAs involving subtrochanteric shortening osteotomy (SSO), even though cemented THAs provide great advantages because the femur is generally hypoplastic with a narrow, deformed canal.
We evaluated the utility of cemented THA with SSO for Crowe group IV hips, and assessed the relationship between leg lengthening and nerve injury. Our goal was to describe surgical techniques for optimizing surgical outcomes while minimizing the risk of nerve injury.
We retrospectively reviewed 34 cases of cemented THAs with transverse SSO for Crowe group IV. Prior to surgery, mean hip flexion was 93.1° (40°–130°). The mean follow-up period was 5.2 years (3–10 years).
Bone union took an average of 7.7 months (3–24 months). Mean leg lengthening was 40.5 mm (15–70 mm) and was greater in patients without hip flexion contracture. None of the patients experienced any nerve injuries associated with leg lengthening, and radiographic evidence of loosening was not observed at the final follow-up.
SSO combined with cemented THA is an effective treatment for severely dislocated hips. Leg lengthening is not necessarily associated with nerve injuries, and the likelihood of this surgical complication may be related to the presence of hip flexion contracture.
PMCID: PMC3886399  PMID: 24121623
Subtrochanteric shortening osteotomy; Cemented total hip arthroplasty; Crowe group IV; Leg lengthening; Nerve injury
19.  Proximal radioulnar translocation associated with elbow dislocation and radial neck fracture in child: a case report and review of literature 
Proximal radioulnar translocation with radial neck fracture and elbow dislocation is extremely rare. We report a case of a 5-year-old boy who was presented with elbow dislocation, and proximal radioulnar translocation was diagnosed a day after the injury. Mini-open technique was used to reduce the translocation and radial neck fracture. The patient finally regained full range of elbow motion and forearm rotation. This case had clinical importance in that the reverse instability of the elbow was observed compared with the previous reports.
PMCID: PMC3776268  PMID: 23884463
Radioulnar translocation; Radial neck fracture; Elbow dislocation; Mini-open reduction; Child
20.  Preoperative radiographic and histopathologic evaluation of central chondrosarcoma 
Distinguishing grade 1 chondrosarcoma from grade 2 chondrosarcoma is critical both for planning the surgical procedure and for predicting the outcome. We aimed to review the preoperative radiographic and histologic findings, and to evaluate the reliability of preoperative grading.
We retrospectively reviewed the medical records of 17 patients diagnosed with central chondrosarcoma at our institution between 1996 and 2011. In these cases, we compared the preoperative and postoperative histologic grades, and evaluated the reliability of the preoperative histologic grading. We also assessed the preoperative radiographic findings obtained using plain radiography, computed tomography (CT), and magnetic resonance imaging (MRI).
Preoperative histologic grade was 1 in 12 patients, 2 in 4 patients, and 3 in 1 patient. However, 6 of the 12 cases classified as grade 1 before surgery were re-classified as grade 2 postoperatively. In the radiographic evaluation, grade 1 was suspected by the presence of a ring-and-arc pattern of calcification on plain radiography and CT and entrapped fat and ring-and-arc enhancement on MRI. Grades 2 and 3 were suspected by the absence of calcification and the presence of cortical penetration and endosteal scalloping on plain radiography and CT, as well as soft-tissue mass formation on MRI.
Although the combination of radiographic interpretation and histologic findings may improve the accuracy of preoperative grading in chondrosarcoma, the establishment of a standard evaluation system with the histologic and radiographic findings and/or the development of new biologic markers are necessary for preoperative discrimination of low-grade chondrosarcoma from high-grade chondrosarcoma.
PMCID: PMC3751216  PMID: 23820853
Chondrosarcoma; Imaging features; Histopathology; Surgical staging
21.  Treatment of acute ankle ligament injuries: a systematic review 
Lateral ankle sprains are common musculoskeletal injuries.
The objective of this study was to perform a systematic literature review of the last 10 years regarding evidence for the treatment and prevention of lateral ankle sprains.
Data source
Pubmed central, Google scholar.
Study eligibility criteria
Meta-analysis, prospective randomized trials, English language articles.
Surgical and non-surgical treatment, immobilization versus functional treatment, different external supports, balance training for rehabilitation, balance training for prevention, braces for prevention.
A systematic search for articles about the treatment of lateral ankle sprains that were published between January 2002 and December 2012.
Three meta-analysis and 19 articles reporting 16 prospective randomized trials could be identified. The main advantage of surgical ankle ligament repair is that objective instability and recurrence rate is less common when compared with non-operative treatment. Balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II and III lateral ankle ligament ruptures can be managed without surgery. For non-surgical treatment, long-term immobilization should be avoided. For grade III injuries, however, a short period of immobilization (max. 10 days) in a below knee cast was shown to be advantageous. After this phase, the ankle is most effectively protected against inversion by a semi-rigid ankle brace. Even grades I and II injuries are most effectively treated with a semi-rigid ankle brace. There is evidence that treatment of acute ankle sprains should be supported by a neuromuscular training. Balance training is also effective for the prevention of ankle sprains in athletes with the previous sprains. There is good evidence from high level randomized trials in the literature that the use of a brace is effective for the prevention of ankle sprains.
Balancing the advantages and disadvantages of surgical and non-surgical treatment, we conclude that the majority of grades I, II and III lateral ankle ligament ruptures can be managed without surgery. The indication for surgical repair should be always made on an individual basis. This systematic review supports a phase adapted non-surgical treatment of acute ankle sprains with a short-term immobilization for grade III injuries followed by a semi-rigid brace. More prospective randomized studies with a longer follow-up are needed to find out what type of non-surgical treatment has the lowest re-sprain rate.
PMCID: PMC3718986  PMID: 23712708
Chronic ankle instability; Ankle brace; External support; Surgical treatment; Balance training
22.  Impact of concomitant injuries on outcomes after traumatic brain injury 
Patients with traumatic brain injury (TBI) frequently have concomitant injuries; we aimed to investigate their impact on outcomes.
Between February 2002 and April 2010, 17 Austrian centers prospectively enrolled 863 patients with moderate and severe TBI into observational studies. Data on accident, treatment, and outcomes were collected. Patients who survived until intensive care unit (ICU) admission and had survivable TBI were selected, and were assigned to “isolated TBI” or “TBI + injury” groups. Six-month outcomes were classified as “favorable” if Glasgow Outcome Scale (GOS) scores were five or four, and were classified as “unfavorable” if GOS scores were three or less. Univariate statistics (Fisher’s exact test, t test, χ2-test) and logistic regression were used to identify factors associated with hospital mortality and unfavorable outcome.
Of the 767 patients, 403 (52.5 %) had isolated TBI, 364 (47.5 %) had concomitant injuries. Patients with isolated TBI had higher mean age (53 vs. 44 years, P = 0.001); hospital mortality (30.0 vs. 27.2 %, P = 0.42) and rate of unfavorable outcome (50.4 vs. 41.8 %, P = 0.02) were higher, too. There were no significant mortality differences for factors like age groups, trauma mechanisms, neurologic status, CT findings, or treatment factors. Concomitant injuries were associated with higher mortality (33.3 vs. 12.5 %, P = 0.05) in patients with moderate TBI, and were significantly associated with more ventilation, ICU, and hospitals days. Logistic regression revealed that age, Glasgow Coma Scale score, pupillary reactivity, severity of TBI and CT score were the main factors that influenced outcomes.
Concomitant injuries have a significant effect upon the mortality of patients with moderate TBI. They do not affect the mortality in patients with severe TBI.
Level of evidence and study type
Evidence level 2; prospective, observational prognostic study.
PMCID: PMC3631113  PMID: 23463257
Traumatic brain injury; Outcome; Concomitant injuries
23.  Meniscus suture provides better clinical and biomechanical results at 1-year follow-up than meniscectomy 
Surgery of meniscus tear results in limitation of function. The aim of study was functional assessment of knee 1 year after surgery with two techniques in cases of the medial meniscus tear followed by the same supervised rehabilitation.
Materials and methods
A total of 30 patients with good KOSS scores constituted two equal groups after partial meniscectomy or meniscus suture. Measurements of knee extensors and flexors muscles peak torques were performed with angular velocities 60, 180, 240 and 300 s−1 using Biodex IV system. One-leg-hop and one-leg-rising tests ascertained the function of operated knee. Results of examinations were compared with reference to healthy volunteers. Results of biomechanical and clinical studies were correlated to create complex and objective method evaluating treatment.
Extensors peak torque values at 60 s−1 angular velocity and H/Q coefficient were decreased after meniscectomy more than meniscus suture in comparison to healthy volunteers (P ≤ 0.001; P ≤ 0.05). Analysis of functional tests revealed that patients after meniscectomy showed difference between operated and non-operated knee (P ≤ 0.01) while patients with meniscus suture differed the least to controls (P ≤ 0.05). Extensors peak torque values at 60 s−1 angular velocity correlated with results of one-leg-rising test.
Results suggest worse functional effects when meniscectomy is applied which implies modification of the rehabilitative methods in a postoperative period.
PMCID: PMC3600124  PMID: 23371398
Meniscectomy; Meniscus suture; Peak torque; One-leg-hop and one-leg-rising tests; H/Q coefficient; Supervised rehabilitation
24.  Shortening spinal column reconstruction through posterior only approach for the treatment of unstable osteoporotic burst lumber fracture: a case report 
Study design
Case report.
Clinical question
This study reports if shortening reconstruction procedure through posterior approach only can be used in osteoporotic unstable fracture as well as post-traumatic burst fracture.
An 80-year-old female patient with unstable burst osteoporotic fracture of L1 underwent posterior approach corpectomy and shortening reconstruction of the spinal column by non-expandable cages.
The surgery was uneventful, with average blood loss. Using of small profile cages has helped us to avoid root injury. Augmentation of the screw with cement and the compressive force applied to the spine column aids in obtaining a rigid construct with good alignment without any neurological complication.
Shortening reconstruction procedure through only posterior approach is a viable option in treating unstable osteoporotic fracture as well as post-traumatic fractures. Using non-expandable cage is advocated to avoid cage subsidence.
PMCID: PMC3550702  PMID: 23179477
Osteoporotic fracture; Posterior corpectomy; Shortening reconstruction; Unstable burst fracture; Thoracolumbar fracture
25.  Outcome of Autologous Matrix Induced Chondrogenesis (AMIC) in cartilage knee surgery: data of the AMIC Registry 
Autologous Matrix-Induced Chondrogenesis (AMIC) is an innovative treatment for localized full-thickness cartilage defects combining the well-known microfracturing with collagen I/III scaffold. The purpose of this analysis was to evaluate the medium-term results of this enhanced microfracture technique for the treatment of chondral lesions of the knee.
Methods and materials
Patients treated with AMIC (Chondro-Gide®, Geistlich Pharma, Switzerland) were followed using the AMIC Registry, an internet-based tool to longitudinally track changes in function and symptoms by the Lysholm score and VAS.
A series of 57 patients was enrolled. The average age of patients (19 females, 38 males) was 37.3 years (range 17–61 years). The mean defect size of the chondral lesions was 3.4 cm2 (range 1.0–12.0 cm2). All defects were classified as grade III (n = 20) or IV (n = 37) according to the Outerbridge classification. Defects were localized at the medial (n = 32) or lateral (n = 6) condyle, at the trochlea (n = 4) and at the patella (n = 15). The follow-up period was 2 years. The majority of patients were satisfied with the postoperative outcome, reporting a significant decrease of pain (mean VAS preop = 7.0; 1 year postop = 2.7; 2 years postop = 2.0). Significant improvement of the mean Lysholm score was observed as early as 1 year after AMIC and further increased values were noted up to 2 years postoperatively (preop. 50.1, 1 year postop. 79.9, 2 year postop. 85.2).
AMIC is an effective and safe method of treating symptomatic chondral defects of the knee. However, further studies with long-term follow-up are needed to determine if the grafted area will maintain structural and functional integrity over time.
Level of evidence
Prognostic study, Level IV.
PMCID: PMC3535369  PMID: 23070222
AMIC; Cartilage; Knee; Surgery; Lysholm score

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