Comparable results using 2.0-mm vs. 3.5-mm screw augmentation in midshaft clavicle fractures: a 10-year experience

Purpose Absence of cortical alignment in wedge-shaped and multifragmentary fractures (Fx) results in decreased fixation stability. The aim of this study was to compare the outcome using 2.0- vs. 3.5-mm screws for open reduction and internal fixation (ORIF) in dislocated, wedge-shaped or fragmentary midshaft clavicle fractures. Materials and methods Patients suffering from AO/OTA 15 2.A-C midshaft clavicle fractures were operatively treated between 2008 and 2018. 2.0- or 3.5-mm cortical screws were used to restore anatomic alignment in dislocated, wedge-shaped and fragmentary clavicle fractures. Data of radiologic outcome were collected until fracture consolidation was identified. Results 80 consecutive patients with a mean age of 44.5 ± 16.3 years, who were operatively treated for dislocated midshaft clavicle fractures were enrolled. 40 patients were treated using 2.0-mm and 40 patients using routine 3.5-mm cortical screws, respectively. Time to fracture consolidation was 12.8 ± 7.8 months. No mal- or non-unions occurred during routine follow-up until 18 months postoperatively. Conclusion Restoring anatomic alignment in wedge or fragmentary clavicle fractures can ultimately be addressed using cortical screw augmentation. Both groups showed comparable results with respect to fracture reduction, fixation and stability as well as time to consolidation of the fracture, while the 2.0-mm screw diameter was associated with easier handling of small Fx fragments.

Treatment of Distal Forearm Fractures in Children

Background and Aims: Distal forearm is the most common fracture location in the growing skeleton. The aim of this article is to describe the current practice of these fractures. Materials and Methods: Case series accompanied by experts’ opinion. Results and Conclusion: Most of these injuries are benign incomplete distal metaphyseal torus fractures best treated with a dorsal below elbow splint for 2–3 weeks with no follow-up. Completely displaced metaphyseal fractures in prepubertal children can be either immobilized in bayonet position after axial alignment or fixed with K-wires after reduction. Complete fractures of distal metaphysis in adolescents should heal in near anatomic alignment because remodeling is uncertain. We advocate reduction of most greenstick and complete fractures at the distal metaphyseal diaphyseal junction and radiographic follow-up to monitor fracture alignment. Physeal fractures in adolescents and intra-articular fractures in children of all ages should be anatomically reduced. We perform most of our osteosyntheses with K-wires.

Correction of Talar Sagittal Alignment in Total Ankle Replacement using Cadence Biased Polyethylene Insert

Category: Ankle; Ankle Arthritis Introduction/Purpose: The success of total ankle arthroplasty (TAA) depends on many factors, including patient selection, prosthetic design, soft tissue balancing, severity of joint deformity, and component position. Malposition of the components increases contact pressures and diminishes prosthesis survival / patient outcomes; therefore, anatomic alignment of the prosthesis is desirable. Sagittal malalignment of the talar component is common and has been associated with lower outcome scores. Cadance Total ankle system is unique in that it has modular polyethene components with both an anterior and posterior biased option that may help improve reduction of the talus in the sagittal plane. The purpose of this study is to evaluate the effectiveness of anterior and posterior biased polyethylethene liners in improving sagittal component alignment in patients with preoperative sagittal translational deformities Methods: This is a prospective radiographic and clinical study of patients that underwent TAA with the CadenceTM system using biased polyethylene liners with at least 12-months follow-up. All surgeries were performed by a single surgeon with extensive experience in TAA between July 2016 and December 2018. Patients underwent TAA in a standard fashion using an anterior approach, and then underwent clinical evaluation at standardized time points with administration of the Ankle Osteoarthritis Scale (AOS) and the Short Form Health Survey (SF-26). Radiographic outcomes included assessment of sagittal plane component alignment using the tibiotalar (TT) ratio and tibial-axis-to-lateral-process distance at preoperative and at postoperative visits. Results: The cohort included a total of 7O TAA which demonstrated pre-operative sagittal talar malalignment and/or intra- operative sagittal instability where a biased polyethylene liner was inserted. Preoperative talar sagittal translation was 54 anterior, 6 posterior and 10 were neutral. 30 anterior biased polyethylene and 40 posterior biased polyethylene were used. Sagittal translation decreased from an average 4.2 mm to 0.8 mm. The T-T ratio averaged 40.8 +- 10.8 % on preoperative x-ray and 38.1 +- 3.6 % on postoperative. The pre and post-operative pain and disability scores displayed statistically significant improvements wherein AOS pain scores decreased 25.28 +- 14.34 points from an average of 45.86 points while AOS disability scores decreased -30.11 +- 22.70 from an average of 56.15 points. Conclusion: Sagittal translational deformities associated with end-stage ankle arthritis are common and should be corrected during TAA to improve loading kinematics and implant longevity. The Cadence TAA has anterior and posterior biased polyethylene liners that help to correct sagittal talar translational deformities. This study demonstrates that biased liners are effective in improved postoperative clinical outcomes with significant correction of pathological sagittal translation to near anatomic alignment.

Staged Surgical Management of Open Navicular Fracture Secondary to a Gunshot Injury

The management guidelines of gunshot wound (GSW) injuries to the lower extremities have primarily been described more recently in the literature. A navicular fracture with adjacent joint involvement is presented from a GSW with initial external fixation management to prevent loss of anatomic alignment as well as successful staged definitive treatment with internal fixation. Based on previous experiences with rearfoot joint involvement from GSW injuries, we were able to direct definitive treatment with arthrodesis of violated joints. After a one-year follow-up, the patient has returned to normal activities without any limitations. This case report demonstrates a stepwise approach to management of an open navicular fracture secondary to a GSW.

INFLUENCE OF LOWER EXTREMITY STATIC ALIGNMENT ON DYNAMIC KNEE VALGUS IN ADOLESCENTS FOLLOWING ACL RECONSTRUCTION

Background: Dynamic limb valgus, particularly high knee abduction moments, are a known risk factor for anterior cruciate ligament (ACL) injury. High knee abduction moments may result from poor static anatomic limb alignment, faulty biomechanics, or a combination of both. The distinction is important because anatomic limb alignment is difficult to change, while dynamic factors can be addressed through neuromuscular or biomechanical training. Hypothesis/Purpose: This study assessed the influence of static (lower extremity anatomic alignment) and dynamic (kinematic and kinetic) factors on external knee abduction moments during side-step cutting in uninjured adolescent athletes. Methods: This retrospective study included 43 adolescents with recent unilateral ACL reconstruction (mean age 15.3 years, SD 2.0, range 10-21; 17/43 female; 3-12 months post-surgery, mean 6.5, SD 2.1). Frontal plane hip to ankle imaging (EOS) was used to measure mechanical axis deviation (perpendicular distance from the center of the femoral condyles to the mechanical axis line connecting the center of the femoral head to the center of the talar dome) and tibial-femoral angle. Femoral anteversion was measured during physical examination. 3D motion capture provided lower extremity kinematics and kinetics during quiet standing and during the loading phase (initial contact to peak knee flexion) of an anticipated 45° side-step cut, with 2-3 trials per limb averaged for analysis. Relationships among imaging, static motion capture, and dynamic motion capture measures were investigated using correlation, and backward stepwise linear regression was used to evaluate potential predictors of average dynamic knee abduction moment. Results: Dynamic knee abduction moment was best predicted by a combination of dynamic measures: knee and hip abduction, external knee rotation, lateral trunk lean towards the planting foot, and ankle inversion during cutting (Table 1.1). Although EOS frontal plane tibial-femoral angle was correlated with dynamic knee abduction moment (r=0.24, p=0.02), no static/anatomic variables entered the model once the dynamic measures were included. Conclusion: Knee abduction moments during side-step cutting were related to dynamic factors reflecting frontal plane trunk, hip, knee, and ankle motion, as well as external knee rotation. Static (anatomic) lower limb alignment did not influence knee abduction moments once these dynamic factors were considered. Knee abduction moments and ACL injury risk are therefore not dictated by anatomic alignment and can be altered through neuromuscular/biomechanical training. [Table: see text]

Current Fixation Options for Elbow, Forearm, Wrist, and Hand Fractures

The universal goals of upper limb fracture management are to restore anatomic alignment, establish stable fracture fixation (while preserving blood supply), and allow for early mobilization of the elbow, wrist, and digits. However, the indications for operative management and fixation constructs are specific to each fracture type. This article systematically reviews current classifications and treatment options for adult fractures of the distal humerus, radius, ulna, scaphoid, metacarpals, and phalanges. For each anatomic location, we discuss the salient imaging features to guide management decisions (conservative versus internal and/or external fixation). Specifically, we emphasize the amount of displacement, angulation, comminution, and/or intra-articular involvement typically guiding operative management for each fracture type. Through this understanding of the surgical indications, rationale behind different fixation options, and common complications, the radiologist can better support the orthopaedic surgeon via more informed fracture reporting.

Hallux Valgus

Category: Bunion Introduction/Purpose: Abnormal motion of the first tarsometatarsal (TMT) joint disrupts the anatomic alignment of the metatarsal head, sesamoid complex and proximal first phalanx. This anatomic disruption combined with the deforming forces of the extensor hallucis longus, adductor tendons, and extensor hallucis brevis result in a hallux valgus deformity. First TMT arthrodesis or the Lapidus procedure has been described as treatment for moderate to severe hallux valgus deformities by correcting hypermobility and restoring anatomic alignment of the first ray. The aim of this study was to evaluate the safety of a percutaneous approach to the Lapidus procedure and its relation to anatomic structures. Methods: A percutaneous, modified Lapidus procedure was performed on 19 embalmed cadaveric feet under fluoroscopic guidance. The specimens were then dissected to identify the extensor hallucis longus (EHL), extensor hallucis brevis (EHB), tibialis anterior (TA), median branch of the superficial peroneal nerve (MBSPN), intermediate branch of the superficial peroneal nerve (IBSPN), deep peroneal neurovascular bundle (DPNVB) and saphenous vein (SV). The structures were localized with reference to percutaneous burr and screw placement during the procedure. Results: The tibialis anterior and intermediate branch of the superficial peroneal nerve were a mean of 3.75 millimeters (mm) and 5.08 mm from the closest burr or screw placement. The extensor hallucis longus and extensor hallucis brevis were at greatest risk under the new approach with mean distances of .92 to 4.08 mm to nearby instrumentation. The extensor hallucis longus or extensor hallucis brevis were either directly pierced or <2 mm from instrumentation on 26 occasions. A terminal branch of the saphenous vein was also either pierced or within 2 mm of instrumentation on 4 occasions. The deep peroneal neurovascular bundle and median branch of superficial peroneal nerve were relatively safe, coming within 2 mm of percutaneous burr or screw placement on only 2 occasions each. Conclusion: The minimally invasive percutaneous Lapidus arthrodesis provides a safe alternative to the traditional, open approach for patients with moderate to severe hallux valgus deformities. This may be a beneficial alternative to conventional open Lapidus procedures by minimizing soft tissue dissection. Further clinical studies must be performed to compare deformity correction, fusion rate, and complications with the modified percutaneous Lapidus procedure.

Arthroscopic Evaluation of Syndesmotic Instability and Malreduction

Ankle fractures are a common injury treated by orthopaedic surgeons. The distal tibiofibular syndesmosis can be injured during these fractures as well as in isolation. They pose a significant challenge with regard to the diagnosis of instability as well as evaluating reduction after fixation. Multiple studies have demonstrated that traditional radiographic analysis fails to accurately identify syndesmotic diastasis, instability, or malreduction. Ankle arthroscopy has been proposed as an alternative way to evaluate the syndesmosis. Ten transtibial amputation cadavers were utilized for this study. Two distinct analyses were undertaken. The first, analysis of instability, utilized 2 dissection groups, a superficial dissection only and a partial disruption instability model. The second analysis was of syndesmotic malreduction. For this, all 10 specimens underwent complete disruption of the syndesmosis and subsequent fixation in either anatomic alignment or malreduction. Both analyses were performed by surgeons blinded to the condition of the syndesmosis. Two groups of surgeons were able to identify syndesmotic instability a combined 75% of the time. Malreduction diagnosis was mixed with a 100% accurate diagnosis of sagittal plane displacement but only 50% accuracy for rotation and 17% for an anatomic reduction. Syndesmotic injury during ankle fracture presents a significant problem to the treating surgeon. Ankle arthroscopy has been shown in the literature to be highly sensitive for diagnosing instability but has not been evaluated in diagnosing malreduction. The current study shows moderate success in diagnosing both malreduction and instability. Levels of Evidence: Therapeutic, Level V: Basic Science