Innovative strategies for the management of long bone infection: a review of the Masquelet technique

Post-traumatic long bone osteomyelitis (PTOM) is a relatively frequent occurrence in patients with severe open fractures and requires treatment to prevent limb-threatening complications. The Masquelet technique represents a length-independent, two-staged reconstruction that involves the induction of a periosteal membrane and use of an antibiotic-impregnated cement spacer for the treatment of segmental bone loss that result from bone infection. In this review, we summarize recent developments regarding the diagnosis and treatment of long bone PTOM, with a special emphasis on the use of the Masquelet technique for reconstruction of wide diaphyseal defects.     

What's new in hip fractures? Current concepts

Hip fractures have been among the most studied injury patterns in adults. The number of hip fractures is increasing exponentially, and their treatment costs place great economic strain on society. Recently developed hip fracture treatments, emphasizing cost containment, deformity prevention, and evidence-based medicine, are attempts to optimize patient outcomes. In this article, we outline some of these developments with respect to femoral neck and intertrochanteric fractures.     

Closed treatment of pelvic and lower extremity fractures

Many of the advantages of operative fixation of pelvic and lower extremity fractures have been assumed rather than proved. This review illustrates how for some injuries, particularly for pelvic fractures, hip fractures in the senescent patient, distal femoral fractures, and tibial plateau fractures, operative treatment can increase the fracture disease. Because of its consistently high frequency of serious complications, operative treatment of pelvic fractures should still be considered experimental surgery. Despite impressive developments in diagnostic imaging, the axiom that we treat patients, not roentgenograms or computed tomograms still applies. To be effective, fracture treatment must be based on the comprehension of circumstances that indicate surgery as well as those that preclude surgery.     

Operative management of intra-articular distal interphalangeal joint fractures of the hand

The management of intra-articular fractures of the hand represents a challenge. Large articular fragments require reduction and operative fixation. A number of surgical techniques have been described in literature, with variable results. Distal interphalangeal joint fractures have been fixed by various methods including screw, plate and suture techniques. Generally operative fixation is indicated when more than 30% of the articular surface is involved with or without subluxation of the joint. The aim of surgery is to reduce the fracture fragments anatomically whilst providing osseous stability, and to commence early active movement of the joint to prevent stiffness. In this review we aim to summarise the main management options for intra-articular distal interphalangeal fractures, placing particular emphasis on surgical treatment.     

Osteosynthesen bei subtrochanteren Femurfrakturen

The continuous developments in operative techniques and implants have contributed to significant improvements in the outcome of treatment of subtrochanteric fractures and a reduction in the frequency of complications. Nonetheless, there are still problems to be solved. Elderly patients who have low bone quality and limited compliance and strength and are dependent on full weightbearing benefit especially from intramedullary stabilisation of these fractures. The choice of implant and operative technique depends on the degree of instability in the individual fracture type.Subtrochanteric fractures are frequently combined with intertrochanteric fractures.The high degree of instability in such fractures makes their treatment particularly challenging.     

Distal metadiaphyseal tibial fractures

Extra-articular fractures of the distal tibial metaphysis, metadiaphyseal junction and adjacent diaphysis are distinct in their management from impaction derived “pilon”-type fractures and mid-diaphyseal fractures. The optimum management of these metadiaphyseal fractures is controversial, with advocates for intramedullary nail, plate and external fixation. The evolution of treatment options for these fractures has been closely linked to developments in implant technology and surgical technique. Further developments in this area, particularly with respect to minimally invasive plating techniques and nail design are ongoing. The literature suggests that both intramedullary nail fixation and minimally invasive plating are appropriate management options for these fractures, but further studies are required to determine the superiority of one technique over the other.     

Is the rotation of the femural head a potential initiation for cutting out? A theoretical and experimental approach

Background  

Since cut-out still remains one of the major clinical challenges in the field of osteoporotic proximal femur fractures, remarkable developments have been made in improving treatment concepts. However, the mechanics of these complications have not been fully understood.     

Adult fractures and dislocations of the shoulder and elbow

Fractures and dislocations of the shoulder girdle, humerus and elbow are common occurrences that will be dealt with daily in any orthopaedic practice. The aim of this article is to provide an overview of the most common fractures and dislocations of the shoulder and elbow that the junior trauma surgeon will encounter. The article also covers the treatment options for each injury with an emphasis on the senior author's preferred method of fixation. Most fractures around the shoulder girdle, including clavicle fractures, proximal humeral fractures and humeral shaft fractures, have traditionally been treated conservatively. There is still a role for conservative management; however, shoulder surgeons are becoming more aggressive regarding fracture fixation. This is because the initial fixation with modern prostheses is easier and carries less morbidity than dealing with an un-united or a mal-united fracture.     

Management of calcaneal fractures: What have we learnt over the years?

Calcaneal fractures result, in many cases, in, subtalar joint stiffness and severe disability. Diagnosis is usually made by X-ray, but more accurately by a computed tomography (CT) scan. In the last years, much has been known regarding its physiopathology and osteosynthesis. Although new developments in osteosynthesis materials have been made, calcaneus fractures still remains in dispute of those advocating non-operative treatment and those defending open reduction and internal fixation. Less invasive surgery, arthroscopy and three-dimensional (3D) fluoroscopy are very important for reduction accuracy and soft-tissue damage avoidance. In this article, the physiopathology, diagnosis, classification and treatment of calcaneus fractures are updated. Nevertheless, systematic reviews have shown no evidence about what treatment is better.     

Adult fractures and dislocations of the shoulder and elbow

Fractures and dislocations of the shoulder girdle, humerus and elbow are common occurrences that will be encountered daily in any orthopaedic practice. The aim of this article is to provide an overview of the most common fractures and dislocations of the shoulder and elbow that the reader would come across in Accident and Emergency. The article also covers the treatment options for each injury with an emphasis on the senior authors' preferred method of fixation. Most fractures around the shoulder girdle, including clavicle fractures, proximal humeral fractures and humeral shaft fractures, have traditionally been treated conservatively. There is still a role for conservative management, however, shoulder surgeons are becoming more aggressive regarding fracture fixation. This is because the initial fixation with modern prostheses is easier and carries less morbidity than dealing with an un-united or a malunited fracture.     

Schussbruch

The management of gunshot-related fractures is still controversially discussed. Although experiences and developments in military surgical treatment have significantly influenced the treatment of gunshot-related factures over the past centuries, there are now also civilian studies on this special subgroup of open fractures which influence modern treatment concepts. Therefore, this article provides a basic understanding of wound ballistics and summarizes current concepts in the treatment of gunshot-related fractures with respect to administration of antibiotics, principles of surgical debridement and primary mechanical stabilization.     

Functional outcome of patients following open reduction internal fixation for bilateral calcaneus fractures

Treatment of displaced intra-articular calcaneus fractures has historically been controversial, but recent developments have led to resurgence in open reduction internal fixation (ORIF) for displaced calcaneus fractures. Recent functional outcome studies comparing operative to nonoperative treatment of unilateral calcaneus fractures has shown a trend towards improved function with ORIF. No studies have investigated the functional outcome of patients who have required operative treatment of bilateral displaced calcaneus fractures. The purpose of this study was to review our operative experience with bilateral displaced intra-articular calcaneal fractures. A retrospective review of medical charts indicated 13 patients had undergone ORIF for bilateral calcaneus fractures. Nine patients could be contacted and brought to the clinic for functional evaluation and radiographic CT studies. Functional outcome was assessed by the Musculoskeletal Functional Assessment Score (MFA) and the American Orthopaedic Foot and Ankle Hindfoot Score (AOFAS). The average follow-up was 56 months. Over half of the patients required additional surgeries. The average MFA and AOFAS scores were 31.1 and 71.8, respectively. Functional outcome decreased for patients with multiple traumatic fractures and surgical procedures of the calcaneus. Our results show a diminished functional outcome for patients sustaining bilateral calcaneus fractures treated with ORIF when compared to patients managed surgically for unilateral calcaneus fractures, but better functional outcomes than patients who do not undergo ORIF for unilateral calcaneus fractures. This diminished function limits work capacity and ability to perform daily activities that require standing.     

Difficulties and complications of the Ender method of treatment of trochanteric fractures of the femur

The advantages of the Ender technique over the other methods of treatment of trochanteric fractures of the femur have been emphasized by several authors but the difficulties and complications of the method have perhaps not been sufficiently highlighted. With this imbalance in mind, 60 patients treated by the Ender method have been reviewed with particular emphasis on the problems encountered during treatment. The follow-up period ranges from 6 to 28 months.The main technical difficulties were experienced during the reduction and nailing of the comminuted and displaced fracture. The main postoperative complications were the cutting out of the nails from the head and neck fragment with weight bearing, backing down of the nails at the knee, and external rotation deformity. The early mortality, infection, delayed union and non-union rates were low.     

The extended deltoid-splitting approach to the proximal humerus

The recent technological developments in implant design and the wider availability of bone graft substitutes have stimulated a renaissance in the operative treatment of complex proximal humeral fractures. However, one of the remaining problems of the operative treatment of these injuries has been the limited surgical access to the posterior aspect of the shoulder afforded by the deltopectoral approach. In this article, we describe a novel extended deltoid-splitting approach, in which the area traversed by the axillary nerve is identified and protected during the surgery. We feel that this approach provides enhanced surgical exposure and offers a useful alternative to the deltopectoral approach in the operative treatment of 3- and 4-part proximal humeral fractures.     

Introduction to adult posttraumatic osteomyelitis of the tibia

The tibia is the most frequent site of an open fracture, and treatment of adult posttraumatic osteomyelitis of the tibia represents a significant clinical problem that has been recognized for centuries. Ancient modalities such as immobilization and debridement are still mainstays of therapy, and recent developments such as the use of antibiotics and muscle transfer have helped to improve outcome. Osteomyelitis is classified based on the Cierny-Mader system to provide prognostic and therapeutic information. Open fractures can be classified by the Gustilo system, again providing prognostic and therapeutic data. Gustilo Type III fractures have a high likelihood of having infection develop. Treatment principles include immobilization, thorough debridement, control of infection through antibiotic use, control of dead space, and soft tissue coverage.     

Salvage of proximal tibia fracture treated with locked compression plate

The treatment of displaced proximal tibial fractures is challenging. Recent developments in the techniques of internal fixation, including the development of locking plates and minimally invasive surgical techniques have revolutionaries the treatment of such fractures. We present a case of proximal displaced tibial fracture that was treated with anatomical proximal tibial locking plate using minimally invasive percutaneous plate osteosynthesis. Patient made uneventful recovery even after he sustained re-injury and plate bending and was manipulated under anaesthesia for the same.     

Cost-utility analysis in orthopaedic trauma; what pays? A systematic review

BackgroundAs healthcare systems come under ever-increasing pressure to provide more care with fewer resources, emphasis is being placed on value-based systems that maximise quality and minimize cost. The aim of this study was to determine which interventions in fracture care have been demonstrated to be cost effective.MethodsA systemic review of cost-utility studies on the management of fractures from 1976 to 2015 was carried out using a search of the Cost-Effectiveness Analysis Registry, National Health Service Economic Evaluation Database (NHS EED) and MEDLINE.Results20 studies were included with 15 (75%) studies assessing interventions in lower limb trauma and 8 (25%) studies assessing interventions in upper limb trauma. 50% of studies used a decision tree model and 50% used collected data alongside a randomised clinical trial. Interventions which were shown to be cost effective in lower limb trauma were total hip replacement in displaced femoral neck fractures, the SHS in stable (A1 and A2) fractures and IM nailing for unstable (A3) fractures, salvage treatment for grade IIIB and IIIC open tibial fractures and operative treatment of ankle and calcaneal fractures. For systems-based strategies, there is evidence demonstrating cost effectiveness to treating hip fractures in high volume centres and to having resources in place to facilitate fractures being treated within 48 h of injury. In upper limb trauma there was evidence showing operative treatment of displaced proximal humerus fractures to be neither clinically nor cost effective. There was evidence supporting the operative treatment of non-displaced scaphoid fractures. Overall the quality of the studies was poor with only 50% (10) of studies able to make a treatment recommendation. Reasons for this included poor quality primary source data and poor reporting methodological practices.ConclusionCertain aspects of fracture management have been shown to be cost effective. However, there is a paucity of evidence in this area and further research is required so that value-based interventions are chosen by healthcare providers engaged in orthopaedic trauma care.     

桡骨远端骨折的手术治疗进展

本文查阅了手术治疗桡骨远端骨折的最新文献，报告其重点内容，探讨桡骨远端骨折新近的手术治疗进展。桡骨远端骨折有多种不同的手术治疗方法，包括掌、背侧联合切口双侧内固定，掌侧切开复位钢板内固定，锁定加压钢板内固定，背侧Pi形钢板内固定，支架外固定及关节镜下治疗等，治疗效果都较满意。桡骨远端骨折有众多的亚型，应根据不同的骨折类型选择适当的手术方法，以期获得最佳的疗效。     

Posterior instrumentation for thoracolumbar fractures

Thoracolumbar fractures are relatively common injuries. Numerous classification systems have been developed to characterize these fractures and their prognostic and therapeutic implications. Recent emphasis on short, rigid fixation has influenced surgical management. Most compression and stable burst fractures should be treated nonsurgically. Neurologically intact patients with unstable burst fractures that have >25 degrees of kyphosis, >50% loss of vertebral height, or >40% canal compromise often can be treated with short, rigid posterior fusions. Patients with unstable burst fractures and neurologic deficits require direct or indirect decompression. Posterior stabilization can be effective with Chance fractures and flexion-distraction injuries that have marked kyphosis, and in translational or shear injuries. Advances in understanding both biomechanics and types of fixation have influenced the development of reliable systems that can effectively stabilize these fractures and permit early mobilization.     

Triple plating of tibia in a complex bicondylar tibial plateau fracture

High-energy tibial plateau fracture poses a significant challenge and difficulty for orthopaedic surgeons. Fracture of tibial plateau involves major weight bearing joint and may alter knee kinematics. Anatomic reconstruction of the proximal tibial articular surfaces, restoration of the limb axis （limb alignment） and stable fixation permitting early joint motion are the goals of the treatment. In cases of complex bicondylar tibial plateau fractures, isolated lateral plating is frequently associated with varus malalignment and better results have been obtained with bilateral plating through dual incisions. However sometimes a complex type of bicondylar tibialplateau fractures is encountered in which medial plateau has a biplaner fracture in posterior coronal plane as well as sagittal plane. In such fractures it is imperative to fix the medial plateau with buttressing in both planes. One such fracture pattern of the proximal tibia managed by triple plating through dual posteromedial and anterolateral incisions is discussed in this case report with emphasis on mechanisms of this type of injury, surgical approach and management.