Esmat Elabjer

Minimally-invasive plate osteosynthesis in distal tibial fractures: Results and complications

INTRODUCTION Distal tibial or pilon fractures are usually the result of combined compressive and shear forces, and may result in instability of the metaphysis, with or without articular depression, and injury to the soft tissue. The complexity of injury, lack of muscle cover and poor vascularity make these fractures difficult to treat. Surgical treatment of distal tibial fractures includes several options: external fixation, IM nailing, ORIF and minimally-invasive plate osteosynthesis (MIPO). Management of distal tibial fractures with MIPO enables preservation of soft tissue and remaining blood supply. This is a report of a series of prospectively studied closed distal tibial and pilon fractures treated with MIPO. MATERIALS AND METHODS A total of 21 patients with closed distal tibial or pilon fractures were enrolled in the study between March 2008 and November 2013 and completed follow-up. Demographic characteristics, mechanism of injury, time required for union, ankle range of motion and complications were recorded. Fractures were classified according to the AO/OTA classification. Nineteen patients were initially managed with an ankle-spanning external fixator. When the status of the soft tissue had improved and swelling had subsided enough, a definitive internal fixation with MIPO was performed. Patients were invited for follow-up examinations at 3 and 6 weeks and then at intervals of 6 to 8 weeks until 12 months. RESULTS Mean age of the patients was 40.1 years (range 19-67 years). Eighteen cases were the result of high-energy trauma and three were the result of low-energy trauma. According to the AO/OTA classification there were extraarticular and intraarticular fractures, but only simple articular patterns without depression or comminution. The average time for fracture union was 19.7 weeks (range 12-38 weeks). Mean range of motion was 10° of dorsiflexion (range 5-15°) and 28.3° of plantar flexion (range 20-35°). Three cases were metalwork-related complications. Two patients underwent plate removal at 24 weeks because of plate impingement. There was one case of wound breakdown at 11 weeks. One patient had fracture union with tibial recurvatum of approximately 10°, without functional impairment. Two patients had delayed union. CONCLUSION MIPO is a reliable method of treatment for distal tibial fractures; it provides a high union rate and good functional outcome with minimal soft tissue complications. Skin impingement remains a common complication with MIPO, but this can be solved by timely plate removal.

Combined surgical therapy and orthotic management of stress and tuberosity avulsion fracture of the fifth metatarsal bone : a case report

The incidence of fifth metatarsal fracture is somewhat common in sports and can be complicated in nature. Fractures of the fifth metatarsal can occur at a number of locations. Although some of these fractures respond well to conservative treatment, others have been notoriously hard to heal, with high rates of nonunions and other complications. Foot orthotic devices are commonly used as aids in the treatment of foot problems. In our case, we considered the combined effect of the surgical treatment and application of the custom-made foot orthoses. Special attention was taken with adjustments to the orthotic devices along and beneath the affected regions of the foot for adequate pain management and quick recovery to return to normal sports activities. Requirements for computer aided design/computer aided manufacturing orthotic design and manufacturing in this case were specific and considerably different from the usual procedure.

Our experience with dermofat graft in reconstruction of anophthalmic socket.

Purpose: To present our experience with dermofat graft in reconstruction of anophthalmic socket. Material and methods: In period from September 2005 until June 2009, eight patients have undergone orbital surgery of transplantation of dermofat graft. In six patients the dermofat graft was used as the secondary orbital implant after extrusion of hydroxyapatite orbital implant with major defect of bulbar conjunctiva. The other indication for the dermofat graft was correction of deep superior sulcus of the upper lid in anophthalmic socket in two patients. The graft was harvested from the left side of the belly. The size of the graft purposely exceeded the size of the defect to account for the expected tissue resorption. Results: We experienced no major complication. Approximately 20–40% of dermofat graft reduction was noticed in 3-months period postoperatively. It took 6–8 weeks for the graft to fully epithelize from the conjunctival edge. Silicone conformer was introduced for that period of time. Subsequently, in two out of six patients with dermofat graft as the secondary implant, fornix had to be reconstructed later on with oral mucosa graft. Conclusion: Dermofat graft is a valuable material in orbital reconstruction especially in anophthalmic socket.

Tibial plateau fracture management: arthroscopically-assisted versus ORIF procedure – clinical and radiological comparison

INTRODUCTION Tibial plateau fractures are articular injuries that may influence final functional outcome of the knee. Although these fractures comprise only 1% of all fractures, the fracture pattern is usually complex and requires anatomical reduction and absolutely stable fixation to achieve satisfactory results. The development of knee osteoarthritis is a common late complication and it can be strongly influenced by additional, underestimated cartilage defects, and meniscal and ligament tears. MATERIALS AND METHODS Between January 2012 and February 2015, a total of 78 patients with tibial plateau fractures (Schatzker type I-III) were enrolled in the study. Patients were divided into two groups: one group was treated with arthroscopically-assisted reduction and internal fixation (ARIF) and the other with open reduction and internal fixation (ORIF). The final number of patients was 75; 40 in the ARIF group and 35 in the ORIF group. Radiography and computed tomography were used to assess fracture pattern. An immediate postoperative radiograph was performed, and then repeated at 6 weeks, and 3,6 and 12 months after surgery. Demographic data (age and sex), additional intraarticular injuries, hospital stay and complications were noted, and clinical and radiological Rasmunssen score at 3, 6 and 12 months after surgery were evaluated. RESULTS Additional intraarticular lesions were found in 27 patients; 20 in the ARIF group and 7 in the ORIF group (p = 0.06). There was a statistically significant difference in average duration of hospital stay: 3.10 ± 0.63 days for the ARIF group and 5.51 ± 1.66 days for the ORIF group (p = 0.0001). All fractures healed within 3 months following surgery. The overall complication rate was 12%. There was no statistically significant difference in complication rate between the two groups (p = 0.63). Clinical and radiological scores were excellent in most patients in both groups. There was no statistically significant difference in average clinical and radiological Rasmunssen scores between the two groups. CONCLUSIONS Both ARIF and ORIF can provide equally good results; however, ARIF seems to offer a more precise evaluation and treatment of associated intraarticular lesions and to reduce the duration of hospital stay.

Posterior fragment in ankle fractures: anteroposterior vs posteroanterior fixation

INTRODUCTION The aim of this study was to compare reduction quality and functional outcome of posterior malleolus fractures treated with indirect reduction and anteroposterior (AP) fixation or with direct reduction via a posterolateral approach and posteroanterior (PA) fixation. METHODS Forty-eight patients with trimalleolar fracture were enrolled in the study. Patients were randomised in two groups: indirect reduction and AP fixation (AP group) and direct reduction and PA fixation (PA group). Inclusion criteria were: posterior fragment involving more than 25% of the articular surface, displacement over 2mm and ankle instability. The quality of reduction was evaluated using postoperative plain radiographs. Residual displacement of the posterior fragment, articular step-off and/or articular surface gap were analysed. The reduction was considered excellent (<1mm), good (1-2mm) or poor (>2mm). Range of motion (ROM) was measured bilaterally, and the difference in dorsiflexion between the injured and uninjured side was considered as dorsiflexion restriction. Demographic data (age, sex), type of fracture (AO/ASIF classification) and complications were noted. RESULTS Forty-six patients completed all follow-up examinations. There was no statistically significant difference in age (p = 0.41), sex (p = 0.29) or specific type of fracture (p = 0.83) distribution between the AP and PA groups. All fractures completely healed within 3 months. The overall complication rate was 8.7%. There was no statistically significant difference in complication rate between the two groups (p = 0.71). Radiological evaluation of the ankle showed there was significantly better quality of reduction with direct reduction via a posterolateral approach in the PA group. Excellent reduction was achieved in 79.2% and 45.5% of the PA and AP groups, respectively. The quality of reduction was significantly higher in the PA group compared with the AP group (p = 0.04). The mean restriction of dorsiflexion was lower in the PA group (5.96 ± 0.65°) compared with the AP group (6.45 ± 1.06°), but this difference did not reach statistical significance (p = 0.07). CONCLUSIONS The direct reduction technique via a posterolateral approach and PA fixation enables higher quality of reduction and better functional outcome in the management of the posterior fragment compared with indirect reduction and percutaneous AP fixation.