A New Intraoperative Syndesmosis Instability Classification System: Utility and Medium‐term Results in Closed Displaced Ankle Fractures

Objective

To investigate the utility and medium‐term results of a new intra‐operative classification system for distal tibiofibular syndesmosis injury in ankle fractures.

Methods

Between January 2010 and January 2015, 116 patients diagnosed with displaced closed Weber B and C ankle fractures were treated in our department. The etiology of injury was 56 cases of fall‐sprain, 36 of traffic injury, 14 of fall from a height, and 10 of multiple injuries. After fixation of the fibular fracture, we classify syndesmosis stability as either normal or one of three grades of instability using the fibular hook traction test. This determined further fixation selection and final syndesmosis treatment.

Results

Of 116 cases, 82 (71%) demonstrated a tibiofibular syndesmosis injury and 52 (45%) were unstable. Twenty‐six cases were type I injuries (<4 mm displacement), 41% cases were type II injuries (4–7 mm displacement), and 3% of cases were type III injuries (>7 mm displacement). Types II and III are defined as unstable and require stabilization. Type III injuries have multiplanar instability and require two screws at the syndesmosis. Weber C fractures demonstrate significantly greater degrees of instability than Weber B fractures (χ² = 15.50, P = 0.0014). All patients were followed up for 12–24 months, with no cases of non‐union or broken screws. Good and excellent results were achieved in 93% of cases (according to the American Orthopaedic Foot and Ankle Society scoring system).

Conclusion

The syndesmosis instability classification system provides a rational and efficient basis for managing syndesmosis instability. Our results from application of the algorithm justify its further evaluation in the treatment of patients with closed displaced Weber B and C ankle fractures.

     

新型胸腰椎骨折损伤AO分型系统的可信度和可重复性研究

目的:评价新型胸腰椎骨折损伤AO分型系统的可信度和可重复性,探讨影响分型一致性的主要原因。方法:选取5名医师,根据术前正侧位X线片、CT、MRI影像,用新型AO分型系统独立对收治的70例胸腰椎骨折损伤患者进行分型。对同一例患者,5名医师在一次分型中只要有1名医师分型不同即认定为不一致。6周后,打乱资料顺序再次分型。全部资料均不含与分型有关的任何标记,应用加权Cohen′s Kappa系数(unweighted Cohen Kappa coefficients)评价观察者间可信度和观察者内可重复性。结果:新型AO分型系统的可信度Kappa系数为0.602,可重复性平均Kappa系数为0.782。在3大骨折类型中,压缩型(A型)和分离移位型(C型)损伤的判定具有中、高度的可信度和极好的可重复性,可信度Kappa系数分别为0.604、0.662,可重复性平均Kappa系数分别为0.787、0.761;牵张型损伤(B型)判定的一致性相对较差,可信度Kappa系数为0.362,可重复性平均Kappa系数为0.657。损伤各亚型整体一致性,可信度Kappa系数为0.526,可重复性平均Kappa系数为0.701;其中B2型一致性最差,可信度Kappa系数为0.214,可重复性平均Kappa系数为0.633;其次为A4型,可信度Kappa系数为0.322,可重复性平均Kappa系数为0.685。结论:新型胸腰椎骨折损伤AO分型系统具有中、高度的一致性和极好的可重复性,但对A4和B2型骨折判定的可信度较差。     

后路体位复位联合椎弓根钉撑开复位固定治疗A3、A4型胸腰椎骨折的疗效对比

目的 对比后路体位复位联合椎弓根钉撑开复位固定治疗A3、A4型胸腰椎骨折的疗效。方法 回顾性分析我院2019年1月至2021年12月采用后路体位复位联合椎弓根钉撑开复位固定治疗的66例A3、A4型胸腰椎压缩骨折病人的临床及影像学资料。其中男40例,女26例,（48.14±5.73）岁（26~60岁）。A3型骨折37例纳入A3组,A4型骨折29例纳入A4组。采用疼痛视觉模拟量表（VAS）评分与Oswestry功能障碍指数（ODI）评估手术临床效果,比较两组伤椎前缘高度比、伤椎后凸角及局部后凸Cobb角等。结果 病人随访11~18个月,术后切口均一期愈合,未见感染、神经损伤、内固定失效等并发症。两组术后随访VAS评分、ODI指数均较术前明显改善,差异有统计学意义（P＜0.05）,但组间差异无统计学意义（P＞0.05）。A3组术后3天的伤椎前缘高度比、伤椎后凸角分别为89.14%±4.79%、6.67°±2.13°,均较术前显著改善,且显著优于A4组的85.72%±5.17%、8.36°±2.49°,在随访期内,各项数值均显著优于术前,且组间比较,差异均有统计学意义（P＜0.05）。两组术后及随访期内,局部后凸Cobb角均较术前显著改善,但组间差异并无统计学意义（P＞0.05）。结论 后路体位复位联合椎弓根钉撑开复位固定治疗A3、A4型胸腰椎骨折均能取得良好的临床疗效,且A3型骨折在伤椎前缘高度比、伤椎后凸角改善方面均优于A4型骨折。     

锁骨近端骨折的手术治疗方法及分型探讨

目的：总结不同锁骨近端骨折的手术治疗方法并探讨锁骨近端骨折的分型。方法：2017年1月至2020年12月收治24例移位型锁骨近端骨折患者,男16例,女8例;年龄28~66岁;其中新鲜骨折20例,陈旧性骨折4例。骨折Edinburgh分型,1B1型14例,1B2型10例。根据不同骨折分型选择不同的内固定方式进行内固定治疗。记录手术时间、失血量、术前后移位差异、骨折愈合时间及Rockwood评分结果。结果：24例患者获得随访,时间12~24个月。术后无感染、复位丢失情况发生,有3例患者出现内固定失效断裂退钉情况,取出内固定装置。手术时间30~65 min,失血量15~40 ml。无重要神经血管脏器损伤。影像学愈合时间3~6个月。末次随访Rockwood功能评分（13.50±1.86）分,疼痛（2.57±0.50）分、活动范围（2.78±0.41）分、肌肉强度（2.93±0.28）分、日常活动受限（2.85±0.35）分、主观结果（2.63±0.61）分,其中优20例,良3例,可1例。结论：锁骨近端骨折是一种发生率较低的骨折类型,针对不同的骨折分型可对应选择不同内固定方法及治疗方式,均取得较为满意的手术效果。     

Pediatric button battery ingestion: A single center experience and risk score to predict severe outcomes

PurposeThe purpose of this study was to analyze the management and outcomes of primary button battery ingestions and their sequelae at a single high-volume center, and to propose a risk score to predict the likelihood of a severe outcome.MethodsThe medical record was queried for all patients under 21 years old evaluated at our institution for button battery ingestion from 2008 to 2021. A severe outcome was defined as having at least one of the following: deep/circumferential mucosal erosion, perforation, mediastinitis, vascular or airway injury/fistula, or development of esophageal stricture. From a selection of clinically relevant factors, logistic regression determined predictors of a severe outcome, which were incorporated into a risk model.Results143 patients evaluated for button battery ingestion were analyzed. 24 (17%) had a severe outcome. The independent predictors of a severe outcome in multivariate analysis were location of battery in the esophagus on imaging (96%), battery size >/ = 2 cm (95%), and presence of any symptoms on presentation (96%), with P < 0.001 in all cases. Predicted probability of a severe outcome ranged from 88% when all three risk factors were observed, to 0.3% when none were present.ConclusionWe report the presentation, management, and complication profiles of a large cohort of BB ingestions treated at a single institution. A risk score to predict severe outcomes may be used by providers initially evaluating patients with button battery ingestion in order to allocate resources and expedite transfer to a center with pediatric endoscopic and surgical capabilities.Level of evidenceLevel IV.Type of studyClinical Research Paper.     

Prenatal Sonography in Suspected Proximal Gastrointestinal Obstructions: Diagnostic Accuracy and Neonatal Outcomes

BackgroundThe purpose of this study was to assess diagnostic accuracy and neonatal outcomes in fetuses with a suspected proximal gastrointestinal obstruction (GIO).MethodsAfter IRB approval, a retrospective chart review was conducted on prenatally suspected and/or postnatally confirmed cases of proximal GIO at a tertiary care facility (2012–2022). Maternal-fetal records were queried for presence of a double bubble ± polyhydramnios, and neonatal outcomes were assessed to calculate the diagnostic accuracy of fetal sonography.ResultsAmong 56 confirmed cases, the median birthweight and gestational age at birth were 2550 g [interquartile range (IQR) 2028–3012] and 37 weeks (IQR 34–38), respectively. There was one (2%) false-positive and three (6%) false-negatives by ultrasound. Double bubble had a sensitivity, specificity, positive predictive value, and negative predictive value for proximal GIO of 85%, 98%, 98%, and 83%, respectively. Pathologies included 49 (88%) with duodenal obstruction/annular pancreas, three (5%) with malrotation, and three (5%) with jejunal atresia. The median postoperative length of stay was 27 days (IQR 19–42). Cardiac anomalies were associated with significantly higher complications (45% vs 17%, p = 0.030).ConclusionsIn this contemporary series, fetal sonography has high diagnostic accuracy for detecting proximal gastrointestinal obstruction. These data are informative for pediatric surgeons in prenatal counseling and preoperative discussions with families.Level of EvidenceDiagnostic Study, Level III.     

Contemporary Epidemiology of and Risk Factors Associated with Removal of a Pathologically Normal Appendix in Children with Suspected Appendicitis

BackgroundThe goal of this study was to characterize contemporary performance benchmarks and risk factors associated with negative appendectomy (NA) in children with suspected appendicitis.MethodsA multicenter retrospective cohort analysis of children undergoing appendectomy for suspected appendicitis was performed using data from the 2016–2021 NSQIP-Pediatric Appendectomy Targeted Public Use Files. Multivariable regression was used to evaluate the influence of year, age, sex, and WBC count on NA rate, and to generate rate estimates for NA based on different combinations of demographic characteristics and WBC profiles.Results100,322 patients were included from 140 hospitals. The overall NA rate was 2.4%, and rates decreased significantly during the study period (2016: 3.1% vs. 2021: 2.3%, p < 0.001). In adjusted analyses, the highest risk for NA was associated with a normal WBC (<9000/mm³; OR 5.31 [95% CI: 4.87–5.80]), followed by female sex (OR 1.55 [95% CI: 1.42–1.68]) and age <5 years (OR 1.64 [95% CI 1.39, 1.94]). Model-estimated risk for NA varied significantly across demographic and WBC strata, with a 14.4-fold range in rates between subgroups with the lowest and highest predicted risk (males 13–17 years with elevated WBC [1.1%] vs. females 3–4 years with normal WBC [15.8%]).ConclusionsContemporary NA rates have decreased over time, however NA risk remains high in children without a leukocytosis, particularly for girls and children <5 years of age. These data provide contemporary performance benchmarks for NA in children with suspected appendicitis and identify high-risk populations where further efforts to mitigate NA risk should be targeted.Level of EvidenceIII.     

Validation of the Pelvic Organ Prolapse Quantification Index (POP-Q-I): a novel interpretation of the POP-Q system for optimization of POP research

Even though very precise at describing pelvic organ position, our criticism to the Pelvic Organ Prolapse Quantification (POP-Q) system is its limited ability to quantify the prolapse itself, since it still classifies prolapse into four stages, almost the same way as Baden and Walker (Clin Obstet Gynecol 15(4):1070-1072, 1972) did in 1972. As a result, the same grade can include a wide prolapse intensity range. The objective of this study was to assess inter-observer reliability in the Pelvic Organ Prolapse Quantification Index (POP-Q-I; Lemos et al., Int Urogynecol J 18(6):609-611, 2007) on a prospective randomized trial. Fifty consecutive women were prospectively examined by two members of the urogynecology staff, blinded to each other's results. Spearman's rank correlation was used to assess inter-observer reliability. Excellent correlation coefficients were observed, with an overall coefficient of 96.5% (CI: 0.889-1.042; p < 0.0001). The POP-Q-I is a method that makes POP research more efficient by directly measuring prolapse as a continuous variable, which is statistically more powerful than the categorical variables proposed by the POP-Q system. This study suggests that the POP-Q-I is applicable to clinical POP research.     

Reliability of classification systems for intertrochanteric fractures of the proximal femur in experienced orthopaedic surgeons

INTRODUCTION: The aim of this study was to determine the reliability of currently used classification systems for intertrochanteric fractures of the proximal femur, and to determine the reliability of these systems in experienced orthopaedic surgeons. MATERIALS AND METHODS: Forty intertrochanteric fractures of the proximal femur were classified independently by five experienced observers using the AO, Evans, Kyle, and Boyd classification systems on two separate occasions 3 months apart. The interobserver and intraobserver variation was assessed using kappa statistics. RESULTS: The level of agreement for classification into AO groups was almost perfect or substantial, and higher than other classification systems. When the fractures were further classified using the AO classification with subgroups, reliability became worse. CONCLUSIONS: The current study suggests that the AO classification system with groups can be used more reliably to measure intertrochanteric fractures of the proximal femur than Evans, Kyle, and Boyd classification systems. However, the reliability of the AO classification with subgroups is not satisfactory.     

Classification of proximal tibial fractures in children

Purpose  To develop a classification system for all proximal tibial fractures in children that accounts for force of injury and fracture patterns. Methods  At our institution, 135 pediatric proximal tibia fractures were treated from 1997 to 2005. Fractures were classified into four groups according to the direction of force of injury: valgus, varus, extension, and flexion–avulsion. Each group was subdivided into metaphyseal and physeal type by fracture location and Salter–Harris classification. Also included were tibial tuberosity and tibial spine fractures. Results  Of the 135 fractures, 30 (22.2%) were classified as flexion group, 60 (44.4%) extension group, 28 (20.8%) valgus group, and 17 (12.6%) varus group. The most common type was extension-epiphyseal-intra-articular-tibial spine in 52 fractures (38.5%). This study shows that proximal tibial fractures are age-dependent in relation to: mechanism, location, and Salter–Harris type. In prepubescent children (ages 4–9 years), varus and valgus forces were the predominate mechanism of fracture creation. During the years nearing adolescence (around ages 10–12 years), a fracture mechanism involving extension forces predominated. With pubescence (after age 13 years), the flexion–avulsion pattern is most commonly seen. Furthermore, metaphyseal fractures predominated in the youngest population (ages 3–6 years), with tibial spine fractures occurring at age 10, Salter–Harris type I and II fractures at age 12, and Salter–Harris type III and IV physeal injuries occurring around age 14 years. Conclusion  We propose a new classification scheme that reflects both the direction of force and fracture pattern that appears to be age-dependent. A better understanding of injury patterns based on the age of the child, in conjunction with appropriate pre-operative imaging studies, such as computer-aided tomography, will facilitate the operative treatment of these often complex fractures.