Trauma
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Department of Orthopaedics and Traumatology, Freiburg University Hospital, Freiburg, Germany.
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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.
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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.
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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.
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The main characteristics of a nonunion are pain while weight bearing, and persistent fracture lines on X-ray.
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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.
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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
Department of Orthopaedics, Fengxian District Central Hospital, Shanghai, China
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Department of Orthopaedics, Fengxian District Central Hospital, Shanghai, China
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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.
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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.
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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.
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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
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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.
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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.
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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.
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Only in stable lesions and in those without displacement is conservative treatment indicated, along with immobilisation and initial avoidance of weight-bearing.
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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.
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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.
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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
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Pelvic ring fractures are rare injuries in the elderly though the incidence is increasing due to the increasing age of the population.
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Main goal of treatment is the quickest possible re-mobilization to prevent side-effects of immobilization such as osteopenia, pulmonary infections or thromboembolic events.
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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.
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Conservative treatment includes adequate analgesia, guided mobilization with partial weight bearing if possible and osteoanabolic medication.
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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
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Department of Orthopaedic Surgery, University Hospital Antwerp, Antwerp, Belgium
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Department of Orthopaedic Surgery, University Hospital Antwerp, Antwerp, Belgium
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Department of Orthopaedic Surgery, University Hospital Antwerp, Antwerp, Belgium
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In malunion cases, restoration of anatomy is a key factor in obtaining a good functional outcome, but this can be technically very challenging.
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Three-dimensional printed bone models can further improve understanding of the malunion pattern.
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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.
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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.
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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
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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.
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There are no sufficient clinical data to support reconstruction of the central band of the interosseous membrane in acute LRUD injuries.
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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.
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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
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Fractures of the proximal ulna range from simple olecranon fractures to complex Monteggia fractures or Monteggia-like lesions involving damage to stabilizing key structures of the elbow (i.e. coronoid process, radial head, collateral ligament complex).
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In complex fracture patterns a computerized tomography scan is essential to properly assess the injury severity.
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Exact preoperative planning for the surgical approach is vital to adequately address all fracture parts (base coronoid fragments first).
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The management of olecranon fractures primarily comprises tension-band wiring in simple fractures as a valid treatment option, but modern plate techniques, especially in comminuted or osteoporotic fracture types, can reduce implant failure and potential implant-related soft tissue irritation.
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For Monteggia injuries, the accurate anatomical restoration of ulnar alignment and dimensions is crucial to adjust the radiocapitellar joint.
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Caution is advised if the anteromedial facet (anatomical insertion of the medial collateral ligament) of the coronoid process is affected, to avoid posteromedial instability.
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Radial head reconstruction or replacement is essential in Monteggia-like lesions to restore normal elbow function.
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The postoperative rehabilitation programme should involve active elbow motion exercises without limitations as early as possible following surgery to avoid joint stiffness.
Cite this article: EFORT Open Rev 2019;4:1-9. DOI: 10.1302/2058-5241.4.180022.
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Treatment of distal humerus fractures is demanding. Surgery is the optimal treatment and preoperative planning is based on fracture type and degree of comminution.
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Fixation with two precontoured anatomical locking plates at 90o:90o orthogonal or 180o parallel is the optimal treatment.
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The main goal of surgical treatment is to obtain stable fixation to allow immediate postoperative elbow mobilization and prevent joint stiffness.
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Despite evolution of plates and surgical techniques, complications such as mechanical failure, ulnar neuropathy, stiffness, heterotopic ossification, nonunion, malunion, infection, and complications from olecranon osteotomy are quite common.
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Distal humerus fractures still present a significant technical challenge and need meticulous technique and experience to achieve optimal results.
Cite this article: EFORT Open Rev 2018;3:558-567. DOI: 10.1302/2058-5241.3.180009
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The reconstruction of anatomical joint surfaces, limb alignment and rotational orientation are crucial in the treatment of fractures in terms of preservation of function and range of motion. To assess reduction and implant position intra-operatively, mobile C-arms are mandatory to immediately and continuously control these parameters.
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Usually, these devices are operated by OR staff or radiology technicians and assessed by the surgeon who is performing the procedure. Moreover, due to special objectives in the intra-operative setting, the situation cannot be compared with standard radiological image acquisition. Thus, surgeons need to be trained and educated to ensure correct technical conduct and interpretation of radiographs.
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It is essential to know the standard views of the joints and long bones and how to position the patient and C-arm in order to acquire these views. Additionally, the operating field must remain sterile, and the radiation exposure of the patient and staff must be kept as low as possible.
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In some situations, especially when reconstructing complex joint fractures or spinal injuries, complete evaluation of critical aspects of the surgical results is limited in two-dimensional views and fluoroscopy. Intra-operative three-dimensional imaging using special C-arms offers a valuable opportunity to improve intra-operative assessment and thus patient outcome.
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In this article, common fracture situations in trauma surgery as well as special circumstances that the surgeon may encounter are addressed.
Cite this article: EFORT Open Rev 2018;3:541-549. DOI: 10.1302/2058-5241.3.170074
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Interfragmental ischaemia is a prerequisite for the initiation of the inflammatory and immunological response to fracturing of bone.
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Intrafragmental ischaemia is inevitable: the extent of the initial ischaemic insult does not, however, directly relate to the outcome for healing of the fracture zones and avascular necrosis of the humeral head. The survival of distal regions of fragments with critical perfusion may be the result of a type of inosculation (blood vessel contact), which establishes reperfusion before either revascularization or neo-angiogenesis has occurred.
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Periosteum has a poorly defined role in fracture healing in the proximal humerus. The metaphyseal periosteal perfusion may have a profound effect, as yet undefined, on the healing of most metaphyseal fractures of the proximal humerus, and may be disturbed further by inadvertent surgical manipulation.
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The metaphysis can be considered as a ‘torus’ or ring of bone, its surface covered by periosteum antero- and posterolaterally, through which the tuberosity segments gain perfusion and capsular reflections antero- and posteromedially, through which the humeral head (articular) fragment gains perfusion.
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The torus is broken in relatively simple primary patterns: a fracture line at the upper surface of the torus is an anatomical ‘neck’ fracture; a fracture line at the lower surface of the torus is the surgical ‘neck’ fracture. Secondary fragmentation (through compression and/or distraction) of the torus itself creates complexity for analysis (classification), alters the capacity and outcome for healing (by variable interruption of the fragmental blood supply) and influences interfragmental stability.
Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.180005