Proximal abduction–supination osteotomy of the first metatarsal for adolescent hallux valgus: a preliminary report

Background

Surgical treatment of adolescent hallux valgus has been a challenging intervention because of high rates of postoperative recurrence. The purposes of this study were to describe a proximal abduction–supination osteotomy of the first metatarsal and prospectively review preliminary results of this procedure for correction of adolescent hallux valgus.

Methods

Eleven patients (12 feet) who had had a proximal abduction–supination osteotomy of the first metatarsal combined with a distal soft-tissue procedure to correct an adolescent hallux valgus deformity were prospectively reviewed clinically and radiologically. The average duration of follow-up was 22 months. The average age at the time of surgery was 17 years.

Results

The mean score on the Japanese Society for Surgery of the Foot standard rating system for hallux improved significantly, from 62.0 points preoperatively to 99.2 points postoperatively (p = 0.002). All patients were satisfied and would choose to have the same procedure again. The mean hallux valgus angle decreased significantly, from 32.3° preoperatively to 12.2° postoperatively (p = 0.002); mean intermetatarsal angle decreased significantly from 14.0° preoperatively to 6.2° postoperatively (p = 0.002). No feet had postoperative recurrence of hallux valgus (a hallux valgus angle ≥20°). There were no occurrences of nonunion or transfer lesions.

Conclusions

The clinical and radiological results of this study demonstrate that a proximal abduction–supination osteotomy with a distal soft-tissue procedure, which described in this study, achieved significant correction of an adolescent hallux valgus deformity, significant improvement in pain and function, and reduction in rate of recurrence.     

Plate osteosynthesis of fractures of the shaft of the humerus: comparison of limited contact dynamic compression plates and locking compression plates

Background

The aim of this retrospective study was to compare outcomes and complications of displaced fractures of the shaft of the humerus treated with limited-contact dynamic compression plates (LCDCPs) and locking compression plates (LCPs).

Materials and methods

Two hundred and twelve patients with displaced fractures of the shaft of the humerus, treated with plate osteosynthesis from January 2005 to December 2009 were reviewed. One hundred and two patients (group A) were treated with LCDCP osteosynthesis and 110 patients (group B) were treated with LCP osteosynthesis. Clinical and radiological assessments were made at monthly intervals for the first 6 months and then at 2-month intervals for the next 6 months. Primary outcome measures like operative time, duration of hospital stay, time to fracture union, union rate and secondary outcome measures (functional outcome and complications such as infection, malunion, delayed union, nonunion, implant failure and iatrogenic radial nerve palsy) were compared between both groups. The ULCA scoring system and Mayo elbow performance index (MEPI) were used to assess shoulder and elbow functions, respectively. Rodriguez-Merchan criteria were used to assess the functional outcomes of the fracture fixation.

Results

There was no significant difference found between the two groups in terms of primary outcome measures. According to Rodriguez-Merchan criteria, comparison of functional outcomes of both groups showed insignificant difference (p = 0.48). There was no significant difference found between the two groups regarding mean ULCA score (p = 0.34) and mean MEPI sore (p = 0.54). In terms of complications, no significant difference was found between the two groups.

Conclusion

This study concludes that the principle of fracture fixation was more important than plate selection in fractures of the shaft of the humerus.

Level of evidence

Level 3.     

Internal fixation of humeral shaft fractures using minimally invasive plating: comparative study of two implants

Purpose

We compared the results of two types of implants, dynamic compression plates (DCPs) and locking compression plates (LCPs), applied to correct mid-distal third humeral shaft fractures using minimally invasive plating osteosynthesis (MIPO).

Methods

Data of 43 patients with mid-distal third humeral shaft fractures treated using MIPO were retrospectively analyzed. Patients were divided into two groups according to the implants applied: group A (n = 26), those whose fractures were fixed with 4.5-mm DCP, and group B (n = 17) fixed with 4.5-mm LCP or metaphyseal LCP. The outcomes of the two groups in terms of operative time, time of fracture union, occurrence of early and late postoperative complications, University of California—Los Angeles (UCLA) End-Result score and the Mayo Elbow Performance Index (MEPI) were compared.

Results

The mean operative time was 107.8 ± 33.1 min in group A and 91.2 ± 40.4 min in group B (p > 0.05). The mean time of fracture union was 16.77 ± 6.01 weeks in group A and 14.59 ± 5.73 weeks in group B (p > 0.05). Seven (26.9 %) patients had postoperative complications in group A and 3 (17.6 %) in group B (p > 0.05). The mean UCLA End-Result score in group A was 34.31 ± 1.26 points and 33.12 ± 2.76 points in group B (p > 0.05). The mean MEPI was 100.00 ± 0.00 points in group A and 97.35 ± 7.52 points in group B (p > 0.05).

Conclusions

In surgical stabilization of mid-distal humeral shaft fractures using MIPO, application of DCP or LCP resulted in good outcomes, there were no significant differences between the outcomes of these two types of implant.     

Bladder injuries after external trauma: 20 years experience report in a population-based cross-sectional view

Objectives

Report 20 years experience of bladder injuries after external trauma.

Methods

Gender, age, mechanism/location of damage, associated injuries, systolic blood pressure (SBP), Revised Trauma Score (RTS), Injury Severity Score (ISS), Trauma Injury Severity Score (TRISS), complications, and length of stay (LOS) were analyzed in a prospective collected bladder injuries AAST-OIS grade ≥II database (American Association for the Surgery of Trauma Organ Injury Scaling) from 1990 to 2009 in a trauma reference center.

Results

Among 2,575 patients experiencing laparotomy for trauma, 111 (4.3 %) presented bladder ruptures grade ≥II, being 83.8 % (n = 93) males, mean age 31.5 years old (±11.2). Blunt mechanism accounted for 50.5 % (n = 56)–motor vehicle crashes 47.3 % (n = 26), pedestrians hit by a car (29.1 %). Gunshot wounds represented 87.3 % of penetrating mechanism. The most frequent injury was grade IV (51 patients, 46 %). The mean ISS was 23.8 (±11.2), TRISS 0.90 (±0.24), and RTS 7.26 (±1.48). Severity (AAST-OIS), mechanism (blunt/penetrating), localization of the bladder injury (intra/extraperitoneal, associated), and neither concomitant rectum lesion were related to complications, LOS, or death. Mortality rate was 10.8 %. ISS > 25 (p = 0.0001), SBP <90 mmHg (p = 0.0001), RTS <7.84 (p = 0.0001), and pelvic fracture (p = 0.0011) were highly associated with grim prognosis and death with hazard ratios of 5.46, 2.70, 2.22, and 2.06, respectively.

Conclusions

Trauma scores and pelvic fractures impact survival in bladder trauma. The mortality rate has remained stable for the last two decades.     

Ilizarov external fixation or locked intramedullary nailing in diaphyseal tibial fractures: a randomized,prospective study of 58 consecutive patients

Purpose

The aim of this study was to compare the Ilizarov circular fixator (IL) and locked intramedullary nailing (IM).

Patients and methods

Patients with isolated tibia shaft fractures were randomly allocated to either the IL (n = 31) or IM (n = 27) method. Conventional radiographs, postoperative pain assessment, self-appraisal scores and complications were evaluated. At the clinical 1-year follow-up, the patients were also evaluated by an independent observer.

Results

The minority of patients had open fractures, two and nine patients in the IM and IL groups, respectively. Eight patients in the IM group and four in the IL group sustained major complications (p = 0.107). In the IM group, two patients developed compartment syndrome, one deep infection, one hardware failure, one delayed union, one pseudarthrosis and two had a malunion. In the IL group, two patients developed pseudarthrosis and two had a malunion. Superficial pin-site infections were observed in 16 patients in the IL group. The fractures had healed radiographically at 12 weeks in both groups. At the 1-year follow-up, there were differences in pain (VAS) and satisfaction (VAS) scores in favor of IL treatment (VAS, p = 0.03 and p = 0.02, respectively). There were no differences between the groups with regard to range of motion (ROM) in the knee and ankle joints. The registration of local tenderness and pain revealed that there were 19 patients with anterior knee pain in the IM group and one in the IL group at the 1-year follow-up (p < 0.001).

Conclusion

The IL is a safe and reliable alternative to IM for the treatment of tibial shaft fractures, with a low complication rate and good clinical outcome. Both treatments were well tolerated, but at the 1-year follow-up the patients in the IM group had more pain and were less satisfied. Finally, there was a high frequency of anterior knee pain in the IM group.     

An Observational Cohort Study of the Adoption of Elastic Stable Intramedullary Nailing for the Treatment of Pediatric Femur Fractures in Kumasi,Ghana

Background

In high- and middle-income countries, elastic stable intramedullary nailing (ESIN) is the commonest treatment of femur fractures in children 5–11 years of age. At Komfo Anokye Teaching hospital (KATH) in Kumasi, Ghana, prior to this study all pediatric femur fractures were treated with skin traction to union. This study was designed to report the early results and costs of the adoption of ESIN at KATH to provide data to other low- and middle-income sites considering adoption of this surgical technique.

Methods

An observational cohort study that included 84 pediatric patients ages 3–14 years presenting with closed femur fractures and treated with either skin traction or ESIN. Multivariate logistic regression was used to compare the rate of treatment success between treatment groups.

Results

Treatment success (coronal and sagittal angulation less than 10 ° and shortening less than 15 mm at osseous union) was achieved in 92 % of the ESIN group versus 67 % of the skin traction group (odds ratio for ESIN group 9.28 (1.6–54.7); p = 0.0138). Average length of stay was significantly lower in the ESIN group (p = 0.001), but charges to patients were higher in the ESIN group (p < 0.001) because of the high cost of implants.

Conclusions

The initial experience of operative treatment of femoral shaft fractures in children using ESIN was positive, with improved rates of treatment success and no surgical complications. Because of the high cost of implants, direct costs of treatment remained higher with ESIN despite reductions in length of hospital stay.     

Posterior fixation of thoracolumbar burst fractures: Is it possible to protect one segment in the lumbar region?

Background

The treatment for thoracolumbar burst fractures is controversial. The aim of this retrospective study was to compare intermediate-segment (IS) and long-segment (LS) instrumentation in the treatment for these fractures.

Methods

IS instrumentation was considered as pedicle fixation two levels above and one level below the fractured vertebra (infra-laminar hooks attached to lower vertebra with pedicle screws). LS instrumentation was done two levels above and two levels below the fractured vertebra. Among a total of 25 consecutive patients, Group 1 included ten patients treated by IS pedicle fixation, whereas Group 2 included fifteen patients treated by LS instrumentation.

Results

The measurements of local kyphosis (p = 0.955), sagittal index (p = 0.128), anterior vertebral height compression (p = 0.230) and canal diameter expansion (p = 0.839) demonstrated similar improvement at the final follow-up between the two groups. However, there was a significant difference (p < 0.05) between Group 1 and Group 2 regarding clinical outcome [Hannover scoring system, Oswestry disability questionnaire and the range of motion of the lumbar region compared to neutral (0°)].

Conclusions

The radiographic parameters were the same between the two groups. However, the clinical parameters demonstrated that IS instrumentation is a more effective management of thoracolumbar burst fractures.     

Clinical outcomes of multiple rib fractures: does age matter?

Purpose

To evaluate the clinical outcomes of multiple rib fracture due to blunt trauma in young patients, a 3-year retrospective study was conducted. Patients with ≥3 rib fractures were divided into two groups (group I: <45 years old and group II: ≥45 years old). Mortality, hospital stay, ventilatory support, chest tubes insertion and associated injuries were studied.

Results

Of the 902 patients admitted with blunt chest trauma, 240 (27 %) met the inclusion criteria and 72.5 % patients were <45 years old. The most common causes of injury were motor vehicle crash (59 %) and fall (29 %). The Injury Severity Score (ISS) was higher in group I (16 ± 9 vs. 13 ± 6; p = 0.04). Hospital mortality was higher in group II (6 vs. 2 %; p = 0.18). Pneumothorax, haemothorax and ventilatory support were comparable. Patients in group II were more likely to undergo chest tubes insertion (26 vs. 14 %; p = 0.04), while group I had a significantly higher incidence of associated abdominal injuries (25 vs. 12 %; p = 0.03).

Conclusion

Old age presenting with rib fractures is associated with higher mortality in comparison to young age; however, this difference becomes statistically insignificant in the presence of multiple rib fracture.     

Position of polyaxial versus monoaxial screws in locked plating for proximal humeral fractures: analysis of a prospective randomized study

Background

Aim of the study was to compare the chosen position of polyaxial locking screws with the position of monoaxial screws in the humeral head of proximal humeral fractures treated by locked plating.

Methods

In a prospective randomized observational study, 124 consecutive patients (mean age 70.9 ± 14.8 years) sustaining a displaced proximal humeral fracture were treated with either monoaxial or polyaxial screw-inserted locking plate fixation. The chosen positions of locking screws were identified from standardized postoperative radiographs in anteroposterior and outlet-view, with regard to a regional mapping of the humeral head.

Results

In monoaxial locking technique, a mean of 6 screws purchased the humeral head (95 % CI 5.1–6.2), and in polyaxial locking technique, a mean of 4 screws (95 % CI 3.3–4.5), respectively. Screws were placed in the regions superolateral: monoaxial 24.8 %, polyaxial 20.7 % (p = 0.49); superomedial: monoaxial 21.9 %, polyaxial 20.0 % (p = 0.433); inferolateral: monoaxial 32.5 %, polyaxial 35.0 % (p = 0.354); inferomedial: monoaxial 20.8 %, polyaxial 24.2 % (p = 0.07), superoposterior: monoaxial 45.5 %, polyaxial 30.8 % (p = 0.57); superoanterior: monoaxial 4.4 %, polyaxial 8.3 % (p = 0.33); inferoposterior: monoaxial 22.5 %, polyaxial 29.8 % (p = 0.49) and inferoanterior: monoaxial 27.5 %, polyaxial: 31.2 % (p = 0.09).

Conclusion

The chosen screws’ position in monoaxial and polyaxial locking plate fixation of displaced proximal humeral fractures do not differ significantly. However, loss of fixation is observed more frequently if the fixation did not include at least one screw within the superoposterior region of the humeral head, suggesting that a screw purchasing the superoposterior region is beneficial in locked plating of proximal humeral fractures.

Level of evidence

Treatment Study, Level II.     

Effect of untreated triangular fibrocartilage complex (TFCC) tears on the clinical outcome of conservatively treated distal radius fractures

Objective

The purpose of this study was to investigate the effect of untreated triangular fibrocartilage complex (TFCC) tear on the clinical outcome of conservatively treated distal radius fractures.

Materials and methods

This prospective study comprised 47 consecutive patients who presented at our clinic between January 2009 and January 2010 with displaced radius distal fracture and were treated with closed reduction and casting. During the first 15 days of treatment, all patients underwent wrist MR imaging to detect traumatic TFCC tears. At the final follow-up, all patients were evaluated with Mayo wrist function score and wrist radiographs. Patients were divided into two groups according to presence of TFCC tear, and two groups were analyzed statistically.

Results

The mean follow-up period was 38.9 ± 3.5 months (range 36–48). TFCC tear was detected in 24 cases, and remaining 23 cases had no TFCC tear. Both groups were statistically similar regarding age (p = 0.574), gender (p = 0.108), dominant side involvement (p = 0.339), fracture type (p = 0.709) and immobilization period (p = 0.514). According to Mayo wrist score, excellent results were obtained in 21 (44.7 %) cases, good in 16 (34.0 %) and satisfactory in 10 (21.3 %). No significant difference was observed between groups in wrist function scores (p = 0.451). Radiographic measurements were similar between groups (radial length p = 0.835, volar til p = 0.464, radial inclination p = 0.795).

Conclusions

Traumatic TFCC tears which are frequently seen together with distal radius fractures do not affect the long-term functional results. Therefore, further diagnostic tests and treatment of TFCC tears in patients with stable distal radius fractures may be unnecessary. However, it should be borne in mind as a reason for continuing wrist pain and instability after distal radius fractures despite proper radiologic recovery.     

Treatment of non-union of humerus diaphyseal fractures: a prospective study comparing interlocking nail and locking compression plate

Background

The aim of this prospective comparative study was to compare outcomes and complications of humeral diaphyseal fracture non-unions managed with humerus interlocking nail (HIL) and locking compression plate (LCP).

Materials and methods

40 patients with non-union of humeral diaphyseal fractures were included in this study and were randomly allocated in two groups; group A had 20 cases treated with HIL and group B had 20 cases treated with LCP. Clinico-radiological assessments were done for each case up to 2-year follow-up period. Primary outcome measures (time to fracture union, union rate) and secondary outcome measures (functional outcome and complication such as infection, malunion, delayed union, implant failure, joint stiffness and iatrogenic radial nerve palsy) were compared between both the groups. Disabilities of the arm, shoulder and hand (DASH) scoring and Steward and Hundley’s scoring system were used to assess functional outcome of the fracture fixation.

Results

There was no significant difference (p = 0.12) in terms of mean fracture union time between group A (15.8 ± 4.2 weeks) and group B (17.2 ± 3.8 weeks). Group A had 95 % union rate and group B had 100 % union rate (p = 0.14). At the 2-year follow-up visit, there was no significant difference found between both the groups regarding range of motion of shoulder and elbow joint. There was no significant difference found in final functional outcomes between both the groups on comparing DASH score (p = 0.14) and Steward and Hundley’s score (p = 0.08). In terms of complications, there was insignificant difference found between both the groups.

Conclusions

This study concludes that both the implants can be used in non-union of humeral shaft fractures with good functional outcomes and acceptable rate of complications.     

Biomechanical testing of rectangular humeral shaft prosthesis: higher torsional stability without increased fracture risk

Background

Rectangular cementless femur shaft prostheses have a higher primary stability than round shafts. A novel rectangular humeral shaft design was tested with two questions: does the rectangular design cause a higher fracture risk during implantation than round designs, and does it increase the torsional stiffness?

Materials and methods

Two series with six paired human humeri (total 24) were tested on one side with the rectangular shaft and on the contralateral side with a round shaft. In the first series, the shaft implantation was carried out with a constant speed of 100 mm/min and the maximum force was measured when the fracture occurred. In the second series, the implants were preloaded with 50 N and then rotated at 2° per second with monitoring of the torsional torque.

Results

The maximum force at fracture showed no significant difference for the two designs (p = 0.34). Higher age and low bone density reduced the force required for fracture. The rectangular shaft showed significant higher torsional moments (p < 0.05).

Conclusions

In biomechanical testing, the rectangular shaft had a significantly higher primary torsional stability than the round shaft without a higher risk of fracture during cementless implantation. Fracture risk and torsional stability are influenced by age and bone density.     

Antegrade intramedullary nailing for fifth metacarpal neck fractures: a systematic review and meta-analysis

Purpose

We investigated the outcomes of the antegrade intramedullary nailing (AIMN) compared to other surgical modalities in the treatment for fifth metacarpal neck fractures via a systematic review.

Methods

Pain, functional scores, grip strength, total active motion (TAM), the range of motion (ROM) of the fifth metacarpal joint, complications and patient satisfaction were set to be the primary outcomes. The data were evaluated using a modified version of the Cochrane Collaboration tool.

Results

We identified four studies, comprising 163 participants, which met the inclusion criteria. Meta-analyses showed that (a) AIMN demonstrated significantly better results in relation to GS at 12 months (p < 0.0001), TAM (p = 0.01) and ROM of the fifth finger (p = 0.0001); (b) AIMN technique yielded significantly lesser residual angulation at the site of fracture (p = 0.05); (c) AIMN significantly demonstrated fewer complications (p = 0.05); (d) there was a trend for better pain scores when using AIMN.

Conclusions

Though the amount of evidence was derived from just four small sample-sized studies, our findings suggested that the AIMN technique could have some advantages over the use of plates or other types of pinning in the treatment for the fifth metacarpal neck fractures. We highlighted the need for a standardization of the outcomes and their corresponding units related to this specific type of fracture. Editors and reviewers should incite authors to provide the standard deviation values for the reported means.

Level of evidence

Therapeutic II.     

Minimally invasive distal linear metatarsal osteotomy for correction of hallux valgus: a preliminary study of clinical outcome and analytical radiographic results via a mapping system

Purposes

To date, actual results of a minimally invasive distal linear metatarsal osteotomy (DLMO) via more explicit radiographic delineation are poorly understood and radiographic findings and clinical results have not been systematically correlated. Purposes of this study were (1) to evaluate the effectiveness of DLMO using a precise radiographic mapping system; and (2) to determine the relationship between radiographic outcomes and clinical results.

Materials and methods

In 2008–2011, DLMO was performed in 30 patients (36 feet) who had reducible symptomatic hallux valgus. Clinical data were assessed using American Orthopaedic Foot and Ankle Society (AOFAS) score. Radiographs were reviewed at preoperative and final follow-up for delineations of first ray construct, hallux valgus angle (HVA), intermetatarsal angle (IMA), distal metatarsal articular angle, and other radiographic profiles. Correlation between postoperative AOFAS score and degree of malalignment was also analyzed.

Results

A total of 36 feet had predominantly moderate hallux valgus (26 feet with HVA: 21–39°; 23 feet with IMA: 12–17°). Mean preoperative and postoperative AOFAS scores were 70.2 ± 11.3 and 95 ± 6.4, respectively (p < 0.001). Mapping system revealed improvements of first ray construct deformity (p < 0.05). Significant reductions in all angular measurements were observed at final follow-up period (p < 0.001) and correlated significantly with changes in AOFAS score (p < 0.001). Nine feet (25 %) were observed with recurrence of deformity which showed HVA >15°. Significant sesamoid lateralization was observed (p < 0.05). Twenty-four feet (66.7 %) showing overall sagittal malunions were found with significant plantar angulation (p = 0.026) and non-significant plantar displacement compared with preoperative reference (p = 0.43). These radiographic abnormalities were not related to clinical outcomes including postoperative AOFAS scores (p > 0.05).

Conclusion

DLMO is an acceptable procedure to correct reducible hallux valgus in most patients with moderate level of severity. Sagittal malunion, recurrence, and sesamoid lateralization are possibly radiographic abnormalities but are not associated with clinical impairments.     

Gelenkerhaltende Korrekturen bei Fehlheilungen im Chopart-Gelenk

Background

Injuries to the mid-tarsal (Chopart) joint are frequently overlooked or misinterpreted and therefore, not adequately treated at initial presentation. Malunion results in a loss of essential joint function and a three-dimensional malalignment leading to considerable impairment of global foot function and a rapid development of painful posttraumatic arthritis.

Methods

If no symptomatic arthritis is present, joint displacement or non-union may be subject to secondary anatomical reconstruction and internal fixation. Bone grafting becomes necessary in cases of non-union or partial avascular necrosis (AVN) of the navicular bone. In most cases joint destruction will have lead to manifest posttraumatic arthritis requiring fusion of the affected joint. Arthrodesis is always combined with axial realignment. Rebalancing of the medial and lateral foot columns is of utmost importance.

Results

We have treated 16 patients with joint-preserving correction of the Chopart joint: 6 of the navicular bone, 3 of the talar head, 3 of the anterior calcaneal process, 2 of the cuboid and 2 with combined malunions. Two female patients aged 50 and 67 years developed AVN of the navicular bone and required talonavicular fusion and one patient with a nonunion of the anterior calcaneal process needed a second revision surgery to achieve union. The average American Orthopaedic Foot and Ankle Society (AOFAS) score of 12 patients increased from 37 preoperatively to 77 at follow-up after an average of 2 years.

Conclusion

Joint-preserving corrections are generally possible for all four bony components of the Chopart joint in carefully selected cases of malunited fractures and fracture dislocations.     

Comparative study of the closed reduction percutaneous cannulated screw fixation and open reduction palmar locking plate fixation in the treatment of AO type A2 distal radius fractures

Introduction

The present study was designed to demonstrate the efficacy of standard 4.0 mm cannulated screw fixation by comparing it with palmar locking plate fixation in the treatment of acute, unstable, simple extra-articular distal radius fractures.

Materials and methods

We prospectively collected and retrospectively analyzed outcomes data for 65 patients aged between 18 and 60 with AO type A2 fractures treated with closed reduction, percutaneous cannulated screw fixation (CRPCS n = 34) or open reduction palmar locking plate fixation (ORPLP n = 31). Range of motion, grip strength, Gartland–Werley and QuickDASH scores were compared at 2 months after surgery, and final follow-up (mean 32 months, range 12–90). Deterioration in radiographic parameters were measured and compared. Operative time and return to preinjury activity were evaluated.

Results

Parameters did not differ significantly between the groups at either time point with respect to grip strength or range of motion, except pronation and supination; they were better in the CRPCS group (p = 0.005 and 0.025, respectively) at 2 month follow-up. The Gartland–Werley and QuickDASH scores obtained at final follow-up were similar for each group and lacked statistical significance. Group comparison for the deterioration of radiologic parameters showed no significant difference. CRPCS group had significantly shorter operative time (p = 0.001) and there was no significant differences between the groups regarding the return to preinjury activity (p = 0.129).

Conclusions

CRPCS group was found to be as successful as ORPLP group and it may be suitable in the case of young, active individuals with AO type A2 distal radius fractures.     

Prospective Assessment of Trocar-Specific Morbidity in Laparoscopy

Background

The purpose of the present study was to challenge the hypothetical advantage of single port laparoscopy (SPL) over conventional laparoscopy by measuring prospectively the morbidity specifically related to conventional trocar sites (TS).

Methods

From November 2010 to December 2011, 300 patients undergoing various laparoscopic procedures were enrolled. Patient, surgery, and trocar characteristics were recorded. We evaluated at three time points (in-hospital and at 1 and 6 months postoperatively) specifically for each TS, pain (Visual Analog Scale), morbidity (infection, hematoma, hernia), and cosmesis (Patient Scar Assessment Score; PSAS). Patients designated their “worst TS,” and a composite endpoint “bad TS” was defined to include any adverse outcome at a TS.

Results

We analyzed 1,074 TS. Follow-up was >90 %. Pain scores of >3/10 at 1 and 6 months postoperatively, were reported by 3 and 1 % of patients at the 5 mm TS and by 9 and 1 % at the larger TS, respectively (5 mm TS vs larger TS; p = 0.001). Pain was significantly lower for TS located in the lower abdomen than for the upper abdomen or the umbilicus (p = 0.001). The overall complication rate was <1 % and significantly lower for the 5 mm TS (hematoma p = 0.046; infection p = 0.0001). No hernia was found. The overall PSAS score was low and significantly lower for the 5 mm TS (p = 0.0001). Significant predictors of “bad TS” were larger TS (p = 0.001), umbilical position (p = 0.0001), emergency surgery (p = 0.0001), accidental trocar exit (p = 0.022), fascia closure (p = 0.006), and specimen extraction site (p = 0.0001).

Conclusions

Specific trocar morbidity is low and almost negligible for 5 mm trocars. The umbilicus appears to be an unfavorable TS.     

Autotransfusion in emergent operative trauma resuscitation

Purpose

Autotransfusion of red cells is common in many surgical specialties. However, this technique is not uniformly used in abdominal trauma. The purpose of this paper is to study the outcomes of patients who were autotransfused during emergency trauma operations in which they sustained full-thickness hollow viscus injury (HVI).

Methods

A total of 179 patients in period 1999–2008 with penetrating and blunt abdominal trauma requiring intraoperative blood transfusion were evaluated. Recipients of autotransfusion and banked blood (autotransfused group) were compared with recipients of banked blood products only (control group). The t-test, Chi-squared, and Fisher’s exact test were used to evaluate the data. Multivariate regression analysis evaluated the primary outcomes, survival and bloodstream infection (BSI).

Results

Of the 179 patients, 108 controls and 71 autotransfused patients were evaluated. The results showed no statistically significant difference between the control and autotransfusion groups regarding age, injury pattern/severity [Injury Severity Score (ISS)], length of stay, postoperative international normalized ratio (INR), and volume of banked blood products. Both groups were also proportional with colon injury. The estimated operative blood loss (EBL) was 2,472 ± 3,261 for controls and 4,056 ± 3,825 for the autotransfused group (p = 0.0001). The total volume of blood transfused was 2,792 and 5,513 for controls and patients in the autotransfusion group, respectively (p = 0.002). Ninety controls (84 %) and 53 autotransfused patients (76 %) survived to discharge (p = 0.21). Twenty controls (49 %) and 17 autotransfused patients (45 %) developed BSI (p = 0.72). Logistic regression analysis revealed that an ISS >25, systolic blood pressure <90, and EBL >2 L predicted mortality. There was also a trend towards decreased survival with age >50 years.

Conclusion

We found no evidence that emergent autotransfusion worsens clinical outcomes in the setting of concomitant HVI.     

Functional outcomes and clinical strength assessment after infraspinatus-sparing surgical approach to scapular fracture: Does it really make a difference?

Background

Surgical treatment of scapular fractures with posterior approach is frequently associated with postoperative infraspinatus hypotrophy and weakness. The aim of this retrospective study is to compare infraspinatus strength and functional outcomes in patients treated with the classic Judet versus modified Judet approach for scapular fracture.

Patients and methods

20 cases with scapular neck and body fracture treated with posterior approach for lateral border plate fixation were reviewed. In 11 of 20 cases, we used the modified Judet approach (MJ group), and in 9 cases we used the classic Judet approach (CJ group). All fractures were classified according to the AO classification system. At follow-up examinations, patients had X-ray assessment with acromiohumeral distance (AHD) measurement, clinical evaluation, active range of motion (ROM) examination, Constant Shoulder Score, and Disability of the Arm, Shoulder and Hand (DASH) Score. Infraspinatus strength assessment was measured using a dynamometer during infraspinatus strength test (IST) and infraspinatus scapular retraction test (ISRT).

Results

Demographic data did not significantly differ between the CJ group and MJ group, except for mean follow-up, which was 4.15 years in the CJ group and 2.33 in the MJ group (p < 0.001). All X-ray examinations showed fracture healing. AHD was significantly decreased in the CJ group (p = 0.006). We did not find significant differences in active ROM between the MJ and CJ groups in the injured arm (p < 0.05). The Constant Score was 75.83 (±14.03) in the CJ group and 82.75 (±10.72) in the MJ group (p = 0.31); DASH Score was 10.16 in the CJ group and 6.25 in the MJ group (p = 0.49). IST showed mean strength of 8.38 kg (±1.75) in the MJ group and 4.61 kg (±1.98) in the CJ group (p = 0.002), ISRT test was 8.7 (±1.64) in the MJ group and 4.95 (±2.1) in the CJ group (p = 0.002). Infraspinatus hypotrophy was detected during inspection in six patients (five in the CJ group and one in the MJ group); it was related to infraspinatus strength weakness in IST and ISRT (p < 0.001).

Conclusions

Infraspinatus-sparing surgical approach for scapular fracture avoids infraspinatus hypotrophy and external-rotation strength weakness. We suggest use of the modified Judet approach for scapular fracture and to restrict the classic Judet approach to only when the surgeon believes that the fracture is not easily reducible with a narrower exposure.

Level of evidence

Level IV.