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Skin antisepsis with iodine povacrylex resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in patients with closed limb fractures but not in those with open fractures.

Purpose To compare the bone healing, clinical, and return to daily activity outcomes after either surgical or conservative management of acute zone 1, 2, and 3 fifth metatarsal fractures. Methods A literature search was performed to identify studies published from the earliest record to January 2019 using EMBASE (Ovid), MEDLINE via PubMed, CINAHL, and Web of Science. All articles assessing clinical outcomes of acute proximal fifth metatarsal fractures were included. Bone healing and clinical outcomes were thereafter calculated using a simplified pooling method. Results Thirty-two articles comprising of a total of 1,239 fractures were included, of which one was a randomized controlled trial, seven were prospective studies, and 24 were retrospective studies. 627 zone 1 fractures demonstrated union rates of 93.2% following conservative treatment and 95.1% following surgical treatment. Conservatively managed zone 1 fractures were displaced 49.5% of the time, compared to a rate of 92.8% for the surgically treated cases. For Jones’ (zone 2) fractures, bone healing outcomes of conservative versus surgical treatment showed union rates of 77.4% versus 96.3%, refracture rates of 2.4% versus 2.1%, and mean time to union of 11.0 weeks versus 9.4 weeks, respectively. Only ten proximal diaphyseal (zone 3) fractures were reported, with a mean return to work of 8.2 weeks. Conclusion Acute zone 1 fractures are preferably treated conservatively as similar union rates were found after both conservative and surgical management. In contradistinction, acute zone 2 fractures demonstrate higher union rates and faster time to union when treated surgically. The outcomes of acute zone 3 fractures are rarely reported in the literature, so treatment recommendations remain unclear. Further research of proximal fifth metatarsal fractures is warranted to provide more definitive conclusions, but current findings can aid surgeons during the shared clinical decision making process. Level of evidence IV.

Background Severe angulation or shortening can be a surgical indication for fifth metacarpal neck fracture. In a previous meta-analysis, antegrade intramedullary pinning was shown to produce better hand function outcomes than percutaneous transverse pinning or miniplate fixation for treatment of fifth metacarpal neck fractures. However, the outcomes of retrograde intramedullary pinning, to our knowledge, have not been compared with those of antegrade intramedullary pinning. Questions/purposes We asked whether the clinical and radiographic outcomes of antegrade intramedullary pinning are different from those of percutaneous retrograde intramedullary pinning for treating patients with displaced fifth metacarpal neck fractures. Methods Forty-six patients with displaced fifth metacarpal neck fractures with an apex dorsal angulation greater than 30° were enrolled in our prospective study. Subjects were treated randomly by antegrade intramedullary pinning (antegrade group) or by percutaneous retrograde intramedullary pinning (retrograde group). Clinical evaluations, which included active ROM of the fifth metacarpophalangeal joint, VAS for pain, grip strength, and DASH score, were performed at 3 months and 6 months postoperatively. Radiographic evaluations of apex dorsal angulation and axial shortening were performed preoperatively and 6 months postoperatively. Results Patients in the antegrade group achieved better outcomes than patients in the retrograde group for all clinical parameters at 3 months postoperatively (ROM: antegrade median 80° [range, 57°–90°] versus retrograde 69° [range, 45°–90°], difference of medians 11°, p < 0.001; VAS: antegrade median of 2 [range, 0–5] versus retrograde 4 [range, 0–7], difference of medians 2, p < 0.001; grip strength: antegrade median 81% [range, 60%–100%] versus retrograde 71% [range, 49%–98%], differences of medians 10%, p < 0.001; DASH: antegrade median 4.3 [range, 0–15.8] versus retrograde 10.3 [range, 0–28.4], difference of medians 6, p < 0.001), but these differences, with the numbers available, were not observed at 6 months postoperatively for any clinical parameters (ROM: antegrade median 88° [range, 81°–90°] versus retrograde 87° [range, 80°–90°], difference of medians 1°, p = 0.35; VAS: antegrade median 1 [range, 0–2] versus retrograde 1[range, 0–3], difference of medians 0, p = 0.67; grip strength: antegrade median 93% [range, 78%–104%] versus retrograde 91% [range, 76%–101%], difference of medians 2%, p = 0.41; DASH: antegrade median 3 [range, 0–12.5] versus retrograde of 4.3 [range, 0–15.8], difference of medians 1.3, p = 0.48). At 6 months postoperatively, there also were no differences, with the numbers available, in radiographic parameters between the antegrade and retrograde fixation groups. Residual angulation was not different (antegrade median: 7° [range, 2°–11°], retrograde: 9° [range, 3°–13°], difference of medians 2°, p = 0.56). Shortening between the two groups also was not different (antegrade median: 1 mm [range, 0 mm–2 mm], retrograde median: 1 mm [range, 0 mm–2 mm], difference of medians 0, p = 0.78). Conclusion Our study findings suggest antegrade intramedullary pinning has some clinical advantages during the early recovery period over percutaneous retrograde intramedullary pinning for treatment of displaced fifth metacarpal neck fractures, but the advantages are not evident at 6 months postoperatively. In addition, our study showed no differences in radiographic outcomes between antegrade and retrograde techniques. For patients who require an early return of hand function, such as athletes, antegrade intramedullary pinning can be recommended. Otherwise, treatment could be decided according to the surgeon’s preference and patient status, and based on consideration of the need for an accessory procedure for pin removal after antegrade intramedullary pinning. Level of Evidence Level I, therapeutic study.

Background Studies comparing plate with intramedullary nail fixation of displaced midshaft clavicle fractures show faster recovery in the plate group and implant-related complications in both groups after short-term followup (6 or 12 months). Knowledge of disability, complications, and removal rates beyond the first postoperative year will help surgeons in making a decision regarding optimal implant choice. However, comparative studies with followup beyond the first year or two are scarce. Questions/purposes We asked: (1) Does plate fixation or intramedullary nail fixation for displaced midshaft clavicle fractures result in less disability? (2) Which type of fixation, plate or intramedullary, is more frequently associated with implant-related irritation and implant removal? (3) Is plate or intramedullary fixation associated with postoperative complications beyond the first postoperative year? Methods Between January 2011 and August 2012, patients with displaced midshaft clavicle fractures were enrolled and randomized to plate or intramedullary nail fixation. A total of 58 patients with plate and 62 patients with intramedullary nails initially were enrolled. Minimum followup was 30 months (mean, 39 months; range, 30–51 months). Two patients (3%) with plate fixation and two patients (3%) with intramedullary nails were lost to followup. The QuickDASH was obtained at final followup and compared between patients who had plate fixation and those who had intramedullary nail fixation. Postoperative complications measured include infection, implant-related irritation, implant failure, nonunion, and refracture after implant removal. Indications for implant removal included implant-related irritation, implant failure, nonunion, patient’s wish, or surgeon’s preference. Results Between patients with plate versus intramedullary nail fixation, there were no differences in QuickDASH scores (plate, 1.8 ± 3.6; intramedullary nail, 1.8 ± 7.2; mean difference, −0.7; 95% CI, −2.2 to 2.04; p = 0.95). The proportion of patients having implant-related irritation was not different (39 of 56 [70%] versus 41 of 62 [66%]; relative risk, 1.05; 95% CI, 0.82–1.35; p = 0.683). Intramedullary fixation was associated with a higher likelihood of implant removal (51 of 62 [82%] versus 28 of 56 [50%]; relative risk, 1.65; 95% CI, 1.24–2.19; p < 0.001). Among the removed implants more plates than intramedullary nails were removed after the 1-year followup (12 of 28 [43%] versus six of 51 [12%]; p = 0.002). There were no infections, implant breakage, nonunions, or refractures between the 1-year and final followup in either group. Conclusions After a mean followup of 39 months, disability scores were excellent. Major complications did not occur after the 1-year followup. A frequent and bothersome problem after both surgical treatments is implant-related irritation, resulting in high rates of implant removal, after 1 year. Future research could focus on analyzing risk factors for implant irritation or removal. Level of Evidence Level II, therapeutic study.

Aims Which is the best extensile lateral (ELA) or sinus tarsi (STA) approach for osteosynthesis displaced intraarticular calcaneal fracture (DIACF) is still debatable. The current RCT’s primary objective was to compare the complications incidence after open reduction and internal fixation of DIACFs through STA vs. ELA. The secondary objectives were the differences in intraoperative radiation exposure, time to fracture union, functional and radiological outcomes. Methods Between August 2020 and February 2023, 157 patients with Sanders type II and III fractures were randomly assigned to either ELA (81 patients with 95 fractures) or STA (76 patients with 91 fractures). The primary outcome was the incidence of complications. The secondary outcomes were Böhler’s and Gissane angles angle, fracture union, and American Orthopaedic Foot and Ankle Society (AOFAS) score. Results No statistical differences between both groups regarding basic demographic data, injury characteristics, and fracture classification; however, patients in the STA group were operated upon significantly earlier (4.43 ± 7.37 vs. 7 ± 6.42 days, p  = 0.001). STA’s operative time was significantly shorter (55.83 ± 7.35 vs. 89.66 ± 7.12 min, p  < 0.05), and no statistical difference regarding intraoperative radiation exposure. The time to fracture union was significantly shorter in STA (6.33 ± 0.8 vs. 7.13 ± 0.7 weeks, p  = 0.000). Skin complications (superficial or deep infection) and Subtalar osteoarthritis were significantly higher in ELA (18.9% vs. 3.3%, p  = 0.001) and (32.6% vs. 9.9%, p  = 0.001), respectively. The radiological parameters were significantly better in STA postoperatively and at the last follow up. The AOFAS scores were significantly better in STA (83.49 ± 7.71 vs. 68.62 ± 7.05, respectively, p  = 0.000). Conclusion During osteosynthesis of Sanders type II and III DIACFs, STA is superior to ELA in terms of operating earlier, shorter operative time, fewer complications, and better radiological and functional outcomes.

Objective To investigate the efficacy of Endobutton plate combined with high-strength suture Nice knot fixation in the treatment of distal clavicular fractures with coracoclavicular ligament injuries. Methods A retrospective analysis was performed on 43 patients who sustained distal clavicular fractures along with injuries to the coracoclavicular ligament. These patients were treated between January 2017 and December 2023. The fractures were classified according to the fixation method: high-strength Nice knot suture fixation (experimental group, n  = 23) and acromioclavicular Kirschner wire fixation (control group, n  = 20). The basic information of the two groups of patients, including age, gender, cause of injury, fracture classification, hospitalization duration, fracture healing time and complications, was collected and analyzed. The increase rate of coracoclavicular space on the affected side was collected and analyzed. The pain level of the affected shoulder was assessed using the visual analog scale (VAS). The shoulder joint function was assessed using the American Shoulder and Elbow Surgeons (ASES) scores and Constant-Murley scores before and after surgery. Results No significant differences were observed in the general demographic data, including age, gender, injury etiology, Craig classification, and hospitalization duration between the two groups ( p  > 0.05). Both groups were followed for a period ranging from 12 to 33 months, with an average follow-up of 20.53 ± 5.16 months. The bone healing time in the experimental group was significantly shorter than in the control group (12.82 ± 1.12 weeks vs. 17.25 ± 1.71 weeks, p  < 0.05). At the final follow-up, The increase rate of coracoclavicular space was (9.25 ± 2.53) % in the experimental group and (8.10 ± 2.53) % in the control group, which was not significantly different ( p  > 0.05). Both groups demonstrated significant improvements in VAS scores, Constant-Murley scores, and ASES scores post-operatively compared to pre-operative values ( p  < 0.05 ). One month after surgery, the Constant-Murley and ASES scores were significantly superior in the experimental group compared to the control group ( p  < 0.05). However, no statistical difference was observed three months post-surgery or during the final follow-up ( p  > 0.05). The control group reported one case of infection related to the Kirschner wire and one case of Kirschner wire displacement postoperatively. Conversely, no significant complications were reported in the experimental group. Conclusion In the management of distal clavicle fractures accompanied by coracoclavicular ligament injuries, particularly oblique fractures or those with butterfly-shaped fragments, the application of a high-strength Nice knot suture in conjunction with Endobutton plate fixation can effectively stabilize the fracture site. This approach not only mitigates complications associated with Kirschner wire fixation but also enhances fracture healing, leading to favorable postoperative outcomes.

Purpose The aim of this study is to investigate the preoperative and postoperative psychological health status of patients with calcaneal fractures, and to explore the impact of preoperative psychological health status on the prognosis of surgical treatment for calcaneal fracture patients. Methods This study included 67 patients with calcaneal fractures who underwent surgical treatment in the Foot and Ankle Surgery Department of Honghui Hospital in Xi’an from November 2019 to September 2022. Patients were divided into two groups based on the presence of preoperative anxiety/depression symptoms, with patients exhibiting preoperative anxiety/depression symptoms assigned to Group A and those without such symptoms assigned to Group B. Preoperative and final follow-up assessments were conducted using the Hospital Anxiety and Depression Scale (HADS), Visual Analogue Scale (VAS), and the American Orthopaedic Foot and Ankle Society (AOFAS) Score to evaluate patients. Results Among the 67 patients with complete follow-up for calcaneal fractures, 33 patients exhibited preoperative anxiety/depression symptoms (49.25%). Both Group A and Group B patients showed significant improvements in various evaluation indicators after calcaneal fracture surgery compared to preoperative assessments, but the overall prognosis of Group A was worse than that of Group B. Conclusions The preoperative psychological health status of patients is related to postoperative clinical outcomes, and patients with poorer psychological health have a worse prognosis.

Background Complicated acetabular fractures comprise the most challenging field for orthopedists. The purpose of this study was to develop three-dimensional printed patient-specific (3DPPS) Ti-6Al-4 V plates to treat complicated acetabular fractures involving quadrilateral plate (QLP) disruption and to evaluate their efficacy. Methods Fifty patients with acetabular fractures involving QLP disruption were selected between January 2016 and June 2017. Patients were divided into a control group (Group A, 35 patients) and an experimental group (Group B, 15 patients), and were treated by the conventional method of shaping reconstruction plates or with 3DPPS Ti-6AL-4 V plates, respectively. The efficacy of Ti-6AL-4 V plates was evaluated by blood loss, operative time, reduction quality, postoperative residual displacement, and complications. Results The operative time and blood loss in Group B were reduced compared to Group A, and the difference was statistically significant ( P  < 0.05). There was no significant difference in reduction quality between the two groups ( P  > 0.05). Reduction quality in Group B was anatomic in 10 (66.7%), satisfactory in four (26.7%), and poor in one (6.7%). In Group A, they were anatomic in 18 (51.4%), satisfactory in 13 (37.1%), and poor in four (11.4%). Residual displacement in Group B was less than that in Group A, and the difference was statistically significant ( P  < 0.05). In Group B, one case exhibited loosening of the pubic screw postoperatively. In Group A, there was one case of wound infection, one of deep vein thrombosis (DVT) in the ipsilateral lower limb, one case of traumatic arthritis and two obturator nerve injuries. Conclusions The 3DPPS Ti-6AL-4 V plate is a feasible, accurate and effective implant for acetabular fracture treatment.

Infection associated with osteosynthesis material (IOM) is one of the most feared and challenging complications of trauma surgery and can cause significant functional loss, requiring multiple interventions and excessive consumption of antimicrobials. Evidence is needed about the best surgical procedure and the duration of antibiotic treatment according to the age of the implant or onset of infection symptoms, as it considers the biofilm formation and the state of fracture healing. There were not clinical trials evaluating the optimal duration of antibiotic therapy in IOM when implant is retained. Because there are antibiotics that have proven to be effective for the treatment of infection associated to implant, mainly in PJI, these antibiotics could be used in these infections. Investigating whether shorter duration of treatment is a priority in infectious diseases, as a way to reduce the exposure to antibiotics and help in controlling antimicrobial resistance and avoiding unnecessary adverse events and cost. We aim to describe the hypothesis, objectives, design, variables and procedures for a pragmatic randomized controlled trial comparing different durations of antibiotic treatment in IOM after long bone fractures treated with debridement and implant retention. This is a multicenter, open-label, non-inferiority, randomized, controlled, pragmatic phase 3 trial, comparing different durations of antibiotic treatment in IOM after long bone fractures treated with debridement and implant retention. Patients with microbiologically confirmed IOM will be included. Eligible patients are those older than 14 years, with early IOM (up to 2 weeks after the implant surgery) and delayed IOM (between 3 and 10 weeks after the implant surgery) with stabilized fracture and absence of bone exposure who sign the informed consent. Randomization will be 1:1 to receive a short-term antibiotic treatment (8 weeks in early IOM and 12 weeks in delayed IOM) or a long-term antibiotic treatment (12 weeks in early IOM or until fracture healing or implant removal in delayed IOM). The antibiotic treatment will be that used in routine practice by the specialist in infectious diseases. The primary outcome is the composited variable \"cure\" that includes clinical cure, radiological healing, and definitive soft tissue coverage, which will be evaluated in the test of cure at 12 months after the end of antibiotic therapy. Adverse events, resistance development during therapy and functional status will be collected. A total of 364 patients are needed to show a 10% non-inferiority margin, with 80% power and 5% one-sided significance level. If the hypothesis of non-inferiority of short vs. long antibiotic treatments is demonstrated, and the efficacy of antibiotics with less ecological impact in long treatments, the impact on reduction of bacterial resistance, toxicity and health costs will be observed. This trial is registered at ClinicalTrials.gov (NCT05294796) on Jan 26th 2022 and at the European Union Drug Regulating Authorities Clinical Trials (EUDRACT) (2021-003914-38) on Jul 16th 2021. The Sponsor Study Code is DURATIOM.

Background In 2012, Medicare began to tie reimbursements to inpatient complications, unplanned readmissions, and patient satisfaction, including satisfaction with pain management. Questions/purposes We aimed to identify factors that correlate with (1) pain intensity during a 24-hour period after surgery; (2) less than complete satisfaction with pain control; (3) less than complete satisfaction with staff attention to pain relief while in the hospital; and we also wished (4) to compare inpatient and discharge satisfaction scores. Methods Ninety-seven inpatients completed measures of pain intensity (numeric rating scale), satisfaction with pain relief, self-efficacy when in pain, and symptoms of depression days after operative fracture repair. The amount of opioid used in oral morphine equivalents taken during the prior 24 hours was calculated. Through initial bivariate and then multivariate analysis, we identified factors that were associated with pain intensity, less than complete satisfaction with pain control, and less than complete satisfaction with staff attention to pain relief. Results Patients who took more opioids reported greater pain intensity (r = 0.38). No factors representative of greater nociception (fracture type, number of fractures, days from injury to surgery, days from surgery to enrollment, or type of surgery) correlated with greater pain intensity. The best multivariable model for greater pain intensity included: depression or anxiety disorder (p = 0.019), smoking (0.047), and greater opioid intake (p = 0.001). Multivariable analysis for less than ideal satisfaction with pain control included the Pain Self-Efficacy Questionnaire (PSEQ) (odds ratio [OR], 0.95; 95% CI, 0.92–0.99) alone; for less than ideal satisfaction with staff attention to pain control, the PSEQ (OR, 0.96; 95% CI, 0.92–0.99) and opioid medication use before admission (OR, 3.6; 95% CI, 1.1–12) were included. Conclusions After operative fracture treatment, patients who take more opioids report greater pain intensity and less satisfaction with pain relief. Greater self-efficacy was the best determinant of satisfaction with pain relief. Evidence-based interventions to increase self-efficacy merit additional study for the management of postoperative pain during recovery from a fracture. Level of Evidence Level II, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.