EVALUATION OF FUNCTIONAL OUTCOME OF DISTAL TIBIAL FRACTURES STABILIZED WITH DISTAL TIBIAL LOCKING PLATE

Background: The present study is an attempt to evaluate the results of locking compression plate for distal tibia in lower tibial fractures using open reduction internal fixation and minimally invasive plate osteosynthesis technique. Methods: The patients attending the OPD/Emergency OPD in post graduate institute of medical education and research, chandigarh during September 2018 to August 2019 with distal tibial fractures. The patients treated with locking compression plates using MIPO or ORIF are reviewed for inclusion and exclusion criteria’s. Patients fitting into inclusion criteria has formed the study group. Results: Out of 52 patients, 48.4% patients undergo open reduction internal fixation had excellent results and 28.6% patients undergo MIPPO technique had excellent results. p value is 0.352 which is not significant. Overall 40.4% patients had excellent results. Conclusion: We observed excellent/ good functional outcome in 65.3% of patients. Keywords: Functional outcome, MIPPO, Tibia

An Ode to Gillies and Millard: “The Ten Commandments Applied to Self-Inflicted Head and Neck Gunshot Wounds”

Within the field of craniofacial trauma surgery, reconstruction following high-energy ballistic injuries to the face remains a daunting task requiring a multidisciplinary approach for best outcomes. These injuries are complex with large defects requiring reconstruction of different lamellae and skeletal buttresses of the face and no 2 are exactly alike. The reconstruction efforts are multidimensional and focus on restoring facial height, width, projection, jaw occlusion, and function. We present a challenging course of a 56 year old patient with a self- inflicted gunshot wound to the face that resulted in devastating injuries to the mandible and midface. We describe our multistage and multiple technique surgical approach that spanned nearly 2 years and 11 operations that included open reduction, internal fixation of extensive facial fractures, primary bone grafting, free fibula for maxillary reconstruction and palatal fistula obliteration, pre-expanded paramedian forehead flap, and mandibular distraction. In reviewing the patient’s course, his complications, and wins, we were inspired by the fundamentals principles of head and neck reconstruction as we interpreted from the famous “Ten Commandments of Drs. Gillies and Millard.” We discuss these Commandments with the reader in our reflection of this challenging reconstruction and hope others, particularly, those in training are encouraged to find application of the “Ten Commandments” we review as they develop their own surgical practices and styles.

Arthroscopically Assisted Treatment of Volar Rim Fractures

Background Arthroscopically-assisted reduction and internal fixation (AARIF) for distal radius fractures (DRF) has been extensively described. Little information is available about AARIF in AO “B3” and “C” DRF with displaced lunate facet volar rim fragment (VRF) and volar carpal subluxation. However, lunate volar rim fragment (LVRF) may be very difficult to reduce and fix under arthroscopic control using the flexor carpi radialis (FCR) or FCR extended approaches while traction is applied. Purposes The aims were to describe our surgical technique of AARIF of partial or complete DRF with VRF and provide information about how often this technique may be necessary, based on a large DRF database. Methods The dual-window volar approach for complete articular AO C DRF with volar medial fragment was described in 2012 for performing open reduction internal fixation (ORIF). Since 2015, we have used the dual-window approach for AARIF of “B3” or “C” DRF with volar carpal subluxation. We analyzed our PAF database, searching for patients treated with AARIF in “B3” and “C” fractures. Results The dual-window volar approach is very useful when using AARIF for AO “B3” and “C” DRF with displaced VRF and volar carpal subluxation. The anteromedial part of the exposure allows a direct access to reduction and fixation of the LVRF under traction and arthroscopic control. Overall, 1% of all articular DRF in this series showed a displaced LVRF amenable to the dual-window volar approach. Conclusion It is almost impossible to access and properly fix a VRF using traction and arthroscopic control through the FCR or FCR extended FCR approach because of the stretched flexor tendon mass. The use of the dual-window approach during AARIF of AO “B3” or “C” DRF has not previously been reported. Displaced VRF are rare whether they were part of “B3” or “C” fractures. If AARIF is chosen, we strongly recommend the use of the dual-window volar approach for AO “B3” and “C” fractures with VRF. A single anteromedial approach can also be used for isolated “B3” anteromedial DRF.

Arthroscopic reduction and internal fixation of capitellar and trochlear fractures: A case series

Background In a simple isolated capitellar/trochlear fracture without extensive posterior comminution, arthroscopic reduction and internal fixation (ARIF) can provide an alternative option to open reduction internal fixation. The purpose of this retrospective case series was to report on the technique and outcomes of arthroscopic reduction and internal fixation of capitellar/trochlear fractures. Methods All patients that underwent ARIF at a single upper extremity referral centre in the last twenty years were reviewed. Patient demographics, preoperative, intraoperative, and postoperative records were obtained through chart review and telephone followup. Results Ten cases of ARIF were identified over a twenty year period performed by two surgeons. The average age of patients was 37 years (17–63 years), with nine females and one male. With an average followup of eight years, nine of ten patients had a mean range of motion from 0 to 142 degrees. Their average MEPI and PREE score were 93 ± 7 and 8 ± 14, respectively. Four patients had focal cartilage collapse with three that required a reoperation. There were no infections, nonunions, or arthroscopy related complications. Conclusion ARIF offers an alternative to ORIF for capitellar/trochlear fractures producing good results while providing better visualization of the fracture reduction and minimizing soft tissue dissection.

Rates of Operative Management of Midshaft Clavicle Fracture in Adolescents Have Increased in Florida between 2005 and 2014

Background: It is not known if the adult literature on midshaft clavicle fracture treatment with open reduction internal fixation (ORIF) has influenced injury management in adolescents. Purpose: We sought to longitudinally evaluate the rates of operative management of adolescent midshaft clavicle fractures in the state of Florida. Methods: We conducted a retrospective review of data from the following Healthcare Cost and Utilization Project databases: the State Inpatient Database, the State Ambulatory Surgery and Services Database, and the State Emergency Department Database. Patients in Florida ages 10 to 18 years with midshaft clavicle fractures between 2005 and 2014 were identified along with data on age, sex, race/ethnicity, insurance type, treatment, and income percentile. We reviewed the data to identify trends in the rates of operative management of midshaft clavicle fractures. We then compared the rates of operative management between the first 3 years and the most recent 3 years (2005–2007 vs 2012–2014). Various demographic and socioeconomic factors were compared between patients treated with and without surgery. Descriptive statistics as well as univariate and multivariate analyses were performed. Results: There were 4297 midshaft clavicle fractures in adolescents identified between 2005 and 2014, and 338 (7.8%) of these fractures underwent operative management. There was a significant increase in the rate of operative management; it increased from 4.3% (n = 59) of the 1373 clavicle fractures that occurred between 2005 and 2007 to 11.2% (n = 130) of the 1164 clavicle fractures that occurred between 2012 and 2014. Patients with commercial insurance and patients who were older were more likely to undergo ORIF. Patients with Medicaid were more likely to undergo ORIF between 2012 and 2014 compared with patients with Medicaid between 2005 and 2007. Conclusions: Operative management rates of adolescent midshaft clavicle fractures have significantly increased in Florida over a decade; additional research is needed to understand these findings.

Arthroscopy-Assisted Reduction Percutaneous Internal Fixation Versus Open Reduction Internal Fixation for Tibial Plateau Fracture: A Systematic Review and Meta-analysis

Background: Arthroscopy-assisted reduction percutaneous internal fixation (ARIF) has emerged recently as an alternative treatment method in treating lower-energy tibial plateau fractures. To date, the comparison of clinical efficacy between ARIF and open reduction internal fixation (ORIF) is limited, with divergent conclusions. Purpose: To review studies on the clinical efficacy of ARIF and ORIF in the treatment of tibial plateau fracture. Study Design: Systematic review; Level of evidence, 3. Methods: A search was conducted using the PubMed, Web of Science, Cochrane Library, and EMBASE databases between inception and August 20, 2020, for retrospective and prospective studies evaluating ARIF versus ORIF in the treatment of tibial plateau fracture. We identified 6 clinical studies that met the inclusion criteria, with 231 patients treated with ARIF and 386 patients treated with ORIF. The risk of bias and the quality of evidence of the included studies were assessed. The 2 treatment types were compared in terms of clinical results and complications by using odds ratios (ORs), mean differences (MDs), or standardized mean differences (SMDs), with 95% confidence intervals (CIs). Heterogeneity among studies was quantified using the I 2 statistic. Results: The quality of the studies was high. Compared with ORIF, treatment with ARIF led to better clinical function (SMD = 0.31; 95% CI, 0.14 to 0.48; I 2 = 15%; P = .0005), shorter hospital stay (MD = –2.37; 95% CI, –2.92 to –1.81; I 2 = 0%; P < .001), and more intra-articular lesions found intraoperatively (OR = 3.76; 95% CI, 1.49 to 9.49; I 2 = 66%; P = .005). There were no complications or significant differences between the techniques in the radiological evaluation of reduction. Conclusion: Compared with ORIF, the ARIF technique for tibial plateau fractures led to faster postoperative recovery and better clinical function and the ability to find and treat more intra-articular lesions during the operation. However, the radiological evaluation of reduction and complications were not significantly different between the 2 groups.