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Emmanuele Santolini, Nikolaos K. Kanakaris, and Peter V. Giannoudis

  • Sacral fractures are a heterogeneous group of fractures occurring in young people following road traffic accidents and falls from height, or in the elderly with osteoporosis following trivial trauma.

  • This heterogeneity, combined with the low incidence of sacral fractures, determines a lack of experience amongst physicians, often leading to misdiagnosis, underestimation and inadequate treatment. The diagnosis should be made by assessing specific features during the clinical presentation, while computed tomography (CT) scan continues to be the choice of investigation.

  • Sacral fractures can be treated non-operatively or surgically. Non-operative treatment is based on rest, pain relief therapy and early mobilization as tolerated. Surgical techniques can be split into two main groups: posterior pelvic fixation techniques and lumbopelvic fixation techniques. Anterior pelvic fixation techniques should be considered when sacral fractures are associated with anterior pelvic ring injuries, in order to increase stability and reduce the risk of posterior implant failure. To improve fracture reduction, different solutions could be adopted, including special positioning of the patient, manipulation techniques and use of specific reduction tools. Patients suffering from spinopelvic dissociation with associated neurologic lesions hardly ever recover completely, with residual lower-limb neurologic sequelae, urinary problems and sexual disfunction.

  • Herein, we present issues, challenges and solutions related to the management of sacral fractures.

Cite this article: EFORT Open Rev 2020;5:299-311. DOI: 10.1302/2058-5241.5.190064

Carlos A. Encinas-Ullán, José M. Martínez-Diez, and E. Carlos Rodríguez-Merchán

  • The use of an external fixator (EF) in the emergency department (ED) or the emergency theatre in the ED is reserved for critically ill patients in a life-saving attempt. Hence, usually only fixation/stabilization of the pelvis, tibia, femur and humerus are performed. All other external fixation methods are not indicated in an ED and thus should be performed in the operating room with a sterile environment.

  • Anterior EF is used in unstable pelvic lesions due to anterior-posterior compression, and in stable pelvic fractures in haemodynamically unstable patients.

  • Patients with multiple trauma should be stabilized quickly with EF.

  • The C-clamp has been designed to be used in the ED to stabilize fractures of the sacrum or alterations of the sacroiliac joint in patients with circulatory instability.

  • Choose a modular EF that allows for the free placement of the pins, is radiolucent and is compatible with magnetic resonance imaging (MRI).

  • Planning the type of framework to be used is crucial.

  • Avoid mistakes in the placement of EF.

Cite this article: EFORT Open Rev 2020;5:204-214. DOI: 10.1302/2058-5241.5.190029

Maria Tennyson, Matija Krkovic, Mary Fortune, and Ali Abdulkarim

  • Various technical tips have been described on the placement of poller screws during intramedullary (IM) nailing; however studies reporting outcomes are limited. Overall there is no consistent conclusion about whether intramedullary nailing alone, or intramedullary nails augmented with poller screws is more advantageous.

  • We conducted a systematic review of PubMed, EMBASE, and Cochrane databases. Seventy-five records were identified, of which 13 met our inclusion criteria. In a systematic review we asked: (1) What is the proportion of nonunions with poller screw usage? (2) What is the proportion of malalignment, infection and secondary surgical procedures with poller screw usage? The overall outcome proportion across the studies was computed using the inverse variance method for pooling.

  • Thirteen studies with a total of 371 participants and 376 fractures were included. Mean follow-up time was 21.1 months. Mean age of included patients was 40.0 years. Seven studies had heterogenous populations of nonunions and acute fractures. Four studies included only acute fractures and two studies examined nonunions only.

  • The results of the present systematic review show a low complication rate of IM nailing augmented with poller screws in terms of nonunion (4%, CI: 0.03–0.07), coronal plane malunion (5%, CI: 0.03–0.08), deep (5%, CI: 0.03–0.11) and superficial (6%, CI: 0.03–0.11) infections, and secondary procedures (8%, CI: 0.04–0.18).

  • When compared with the existing literature our review suggests intramedullary nailing with poller screws has lower rates of nonunion and coronal malalignment when compared with nailing alone. Prospective randomized control trial is necessary to fully determine outcome benefits.

Cite this article: EFORT Open Rev 2020;5:189-203. DOI: 10.1302/2058-5241.5.190040

Faustine Vallon and Axel Gamulin

  • Trochanteric femur fractures are frequently fixed with a four-hole side plate sliding hip screw device, but in recent decades two-hole side plates have been used in an attempt to minimize operative time, surgical dissection, blood loss and post-operative pain.

  • The aim of this review was to determine whether two-hole sliding hip screw constructs are an acceptable option for fixation of AO-OTA 31-A1 and A2 trochanteric femur fractures.

  • An electronic MEDLINE® database search was performed using PubMed®, and articles were included in this review if they were reporting historical, biomechanical, clinical or outcome data on trochanteric fracture fixation using a two-hole sliding hip screw device.

  • A two-hole dynamic hip screw with a minimally invasive muscle-splitting approach is recommended for fixation of AO-OTA 31-A1 simple trochanteric fractures; this implant is biomechanically safe, and allows the use of a minimally invasive muscle-splitting approach which potentially provides better clinical outcome, such as decreased surgical trauma, shorter operative time, less blood loss, decreased analgesics use, and shorter incision length. As the majority of reviewed publications relate to the dynamic hip screw, it is not clear whether the above recommendations can be extended to any other sliding hip screw device.

  • An intramedullary device is recommended for all other extra-capsular proximal femoral fractures.

Cite this article: EFORT Open Rev 2020;5:118-125. DOI: 10.1302/2058-5241.5.190020

Hagen Schmal, Michael Brix, Mats Bue, Anna Ekman, Nando Ferreira, Hans Gottlieb, Søren Kold, Andrew Taylor, Peter Toft Tengberg, Ilija Ban, and Danish Orthopaedic Trauma Society

  • Nonunions are a relevant economic burden affecting about 1.9% of all fractures. Rather than specifying a certain time frame, a nonunion is better defined as a fracture that will not heal without further intervention.

  • Successful fracture healing depends on local biology, biomechanics and a variety of systemic factors. All components can principally be decisive and determine the classification of atrophic, oligotrophic or hypertrophic nonunions. Treatment prioritizes mechanics before biology.

  • The degree of motion between fracture parts is the key for healing and is described by strain theory. If the change of length at a given load is > 10%, fibrous tissue and not bone is formed. Therefore, simple fractures require absolute and complex fractures relative stability.

  • The main characteristics of a nonunion are pain while weight bearing, and persistent fracture lines on X-ray.

  • Treatment concepts such as ‘mechanobiology’ or the ‘diamond concept’ determine the applied osteosynthesis considering soft tissue, local biology and stability. Fine wire circular external fixation is considered the only form of true biologic fixation due to its ability to eliminate parasitic motions while maintaining load-dependent axial stiffness. Nailing provides intramedullary stability and biology via reaming. Plates are successful when complex fractures turn into simple nonunions demanding absolute stability. Despite available alternatives, autograft is the gold standard for providing osteoinductive and osteoconductive stimuli.

  • The infected nonunion remains a challenge. Bacteria, especially staphylococcus species, have developed mechanisms to survive such as biofilm formation, inactive forms and internalization. Therefore, radical debridement and specific antibiotics are necessary prior to reconstruction.

Cite this article: EFORT Open Rev 2020;5:46-57. DOI: 10.1302/2058-5241.5.190037

Hua Luo, Yongwei Su, Liang Ding, Haijun Xiao, Ming Wu, and Feng Xue

  • With advances in the treatment of femoral shaft nonunion after intramedullary nailing, the optimal option remains controversial. This study aimed to quantitatively investigate outcomes in a comparison of exchange nailing and augmentative plating for femoral shaft nonunion after intramedullary nailing.

  • The EMBASE, PubMed, Cochrane library and Clinical databases were systematically searched dating from their inception to March 2018. All retrospective controlled and prospective trials evaluating exchange nailing and augmentative plating for the treatment of femoral shaft nonunion after intramedullary nailing were identified. Two investigators extracted all related data independently and we used the review manager software to perform the meta-analysis.

  • Three studies with a total of 232 patients were eligible for data extraction in our study. The meta-analysis indicated that the augmentative plating group had a lower nonunion rate, shorter time to union, less intra-operative blood loss, and shorter operative time than the exchange nailing group. While for the infection rate, there was no significant difference between augmentative plating and exchange nailing group.

  • The available evidence has shown that augmentative plating is superior to exchange nailing for femoral shaft nonunion after intramedullary nailing.

Cite this article: EFORT Open Rev 2019;4:513-518. DOI: 10.1302/2058-5241.4.180054

Inmaculada Moracia-Ochagavía and E. Carlos Rodríguez-Merchán

  • It is essential to know and understand the anatomy of the tarsometatarsal (TMT) joint (Lisfranc joint) to achieve a correct diagnosis and proper treatment of the injuries that occur at that level.

  • Up to 20% of Lisfranc fracture-dislocations go unnoticed or are diagnosed late, especially low-energy injuries or purely ligamentous injuries. Severe sequelae such as post-traumatic osteoarthritis and foot deformities can create serious disability.

  • We must be attentive to the clinical and radiological signs of an injury to the Lisfranc joint and expand the study with weight-bearing radiographs or computed tomography (CT) scans.

  • Only in stable lesions and in those without displacement is conservative treatment indicated, along with immobilisation and initial avoidance of weight-bearing.

  • Through surgical treatment we seek to achieve two objectives: optimal anatomical reduction, a factor that directly influences the results; and the stability of the first, second and third cuneiform-metatarsal joints.

  • There are three main controversies regarding the surgical treatment of Lisfranc injuries: osteosynthesis versus primary arthrodesis; transarticular screws versus dorsal plates; and the most appropriate surgical approach.

  • The surgical treatment we prefer is open reduction and internal fixation (ORIF) with transarticular screws or with dorsal plates in cases of comminution of metatarsals or cuneiform bones.

Cite this article: EFORT Open Rev 2019;4:430-444. DOI: 10.1302/2058-5241.4.180076

Markus A. Küper, Alexander Trulson, Fabian M. Stuby, and Ulrich Stöckle

  • Pelvic ring fractures are rare injuries in the elderly though the incidence is increasing due to the increasing age of the population.

  • Main goal of treatment is the quickest possible re-mobilization to prevent side-effects of immobilization such as osteopenia, pulmonary infections or thromboembolic events.

  • Isolated anterior pelvic ring fractures are stable injuries and therefore they usually can be treated conservatively, while pelvic ring injuries with involvement of the posterior ring are considered unstable and should undergo surgical stabilization if the patient’s condition allows for it.

  • Conservative treatment includes adequate analgesia, guided mobilization with partial weight bearing if possible and osteoanabolic medication.

  • The appropriate surgical procedure should be discussed in an interdisciplinary round considering patient’s pre-injury condition, anaesthetic and surgical risks.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180062

Maartje Michielsen, Annemieke Van Haver, Matthias Vanhees, Roger van Riet, and Frederik Verstreken

  • In malunion cases, restoration of anatomy is a key factor in obtaining a good functional outcome, but this can be technically very challenging.

  • Three-dimensional printed bone models can further improve understanding of the malunion pattern.

  • The use of three-dimensional (3D) computer planning, and the assembly of patient-specific instruments and implants, especially in complex deformities of the upper limb, allow accurate correction while reducing operation time, blood loss volume and radiation exposure during surgery.

  • One of the major disadvantages of the 3D technique is the additional cost because it requires specific computer software, a dedicated clinical engineer, and a 3D printer.

  • Further technical developments and clinical investigations are necessary to better define the added value and cost/benefit relationship of 3D in the treatment of complex fractures, non-unions, and malunions.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180074

Panagiotis T. Masouros, Emmanuel P. Apergis, George C. Babis, Stylianos S. Pernientakis, Vasilios G. Igoumenou, Andreas F. Mavrogenis, and Vasileios S. Nikolaou

  • Reconstruction of the central band of the interosseous membrane is an emerging procedure implemented in the treatment of longitudinal radioulnar dissociation (LRUD), usually in its chronic setting, after Essex-Lopresti injuries of the forearm.

  • There are no sufficient clinical data to support reconstruction of the central band of the interosseous membrane in acute LRUD injuries.

  • Clinical and cadaveric studies comparing autografts (palmaris longus, flexor carpi radialis and bone-patellar-bone), allografts (Achilles tendon) and synthetic ligaments have not shown superiority of one technique versus another; however, they have shown special concerns with respect to the use of synthetic grafts.

  • Latrogenic fracture, decrease of rotational range of movement, iatrogenic nerve injury (superficial radial and median nerve), donor site morbidity with autografts and recurrent instability are the complications reported in literature after interosseous membrane reconstruction.

Cite this article: EFORT Open Rev 2019;4:143-150. DOI: 10.1302/2058-5241.4.180072