Duration of incapacity of work after tibial plateau fracture is affected by work intensity

Abstract Background Tibial plateau fractures requiring surgery are severe injuries of the lower extremity. Tibial plateau fractures have an impact not only on physically demanding jobs but notably on general professional life too. The aim of this study was to assess how the professional activity of patients will be affected after a tibial plateau fracture. Methods 39 consecutive patients (ages 20–61 years) were retrospectively included in the study and were clinically examined at a minimum of 14 month postoperatively. Inclusion criteria were surgical treatment of tibial plateau fractures between November 2009 and December 2012. The clinical evaluation included the Lysholm score and the Oxford Knee Score. Fractures were classified and analyzed using the AO classification. Intensity of work was classified as established by the REFA Association. The patients themselves provided postoperative duration of the incapacity of work and subjective ratings. Results 17 (43.6%) women and 22 (56.4%) men were examined with a mean follow-up of 29.7 ± 10.4 months (range 14–47). According to the AO classification there were 20 (51.3%) B-type-fractures and 19 (48.7%) C-type-fractures. The median incapacity of work was 120 days (range 10–700 days) with no significant differences between B- and C-type-fractures. Four (10.3%) patients reduced their working hours by 10.5 h per week on average. Patients with low workload (REFA 0–1, median incapacity of work 90 days, range 10–390 days) had a significant shorter incapacity of work than patients with heavy workload (REFA 2–4, median incapacity of work 180 days, range 90–700 days) (p < 0.05). The median Lysholm score decreased significantly from 100 points (range 69–100) before the injury to 73 points (range 23–100) at the time of the follow-up. All patients received postoperative physiotherapy (median 25 appointments, range 6–330), with a significant higher number of appointments for C-type-fractures than for B-type-fractures (p = 0.004). Conclusion A relationship was found between workload and the duration of incapacity of work after tibial plateau fractures. The post-injury shift to less demanding jobs and the reduction of working hours highlight the impact of a tibial plateau fracture on a patient’s subsequent physical ability to work

Internal Fixation of Garden Type III Femoral Neck Fractures with Sliding Hip Screw and Anti-Rotation Screw: Does Increased Valgus Improve Healing?

Background and Objectives: The aim of this study was to compare the effect of valgus versus anatomic reduction on internal fixation of Garden type III femoral neck fractures using the sliding hip screw (SHS) and anti-rotation screw (ARS) regarding the radiographic and therapeutic outcome. Patients and Methods: A retrospective case-controlled study was performed in a level I trauma center. All patients between 2006 and 2020 aged younger than 70 years with a Garden type III femoral neck fracture and a Kellgren&ndash;Lawrence score under grade III stabilized using SHS and ARS were identified. One-hundred and nine patients were included, with a group distribution of sixty-eight patients in group A (anatomic reduction) and forty-one patients in group B (valgus reduction). Results: Mean age was 55 years, and the mean Kellgren&ndash;Lawrence score was 1 in both groups. Mean femoral neck angle was 130.5 &plusmn; 3.8&deg; in group A and 142.8 &plusmn; 4.3&deg; in group B (p = 0.001), with an over-correction of 12&deg; in group B. Tip-apex distance was 10.0 &plusmn; 2.8 mm in group A versus 9.3 &plusmn; 2.8 mm in group B (p = 0.89). Healing time was 9 weeks in group A compared to 12 weeks in group B (p = 0.001). Failure rate was 4.4% in group A and 17.1% in group B (p = 0.027). Conclusions: Anatomic reduction of Garden type III femoral neck fractures in patients younger than 70 years treated using SHS and ARS resulted in significantly lower failure rates and shorter healing times than after valgus reduction. Therefore, it can be recommended to achieve anatomic reduction

Mid-Term Results following Traumatic Knee Joint Dislocation

Purpose: Although treatment strategies of knee joint dislocations have evolved, there is still no consensus on the best method and timing. New therapeutic concepts suggest that early one-stage treatment, including suturing and bracing of the cruciate ligaments in acute knee joint dislocation, are leading to improved functional results. This study aimed to evaluate the midterm functional outcome following traumatic knee joint dislocation and to determine whether the outcome is influenced by the surgical management, patient habitus or concomitant injuries. Methods: In this retrospective single center study, 38 patients with acute Schenck type II to IV knee dislocations were treated over an eight-year period in a level I trauma center. At follow-up, various clinical scores, such as the International Knee Documentation Committee (IKDC) Score, Lysholm Score, and Tegner Activity Scale (TAS), and individual questions about rehabilitation and activity levels of 38 patients were evaluated. Results: Mean follow-up was 5.5 ± 2.7 years. The mean IKDC Score was 65.6 ± 15.7 points, the average Lysholm Score was 70.5 ± 16.4 points and the median TAS was 4 (0–7), resulting in a loss of activity of 2 (range 0–6) points. There was no significant difference between a one-stage treatment compared to a two-stage approach. Ligament reconstruction of the ACL in a two-stage approach was required in only 33.3%. Further operations (early and late) were performed in 37% of cases. Being overweight was associated with more complications and worse outcomes, and external fixation with arthrofibrosis. Conclusions: Knee dislocation is a severe trauma that often leads to a prolonged loss of function and increased knee pain over years, affecting the patient’s activity. Clinical outcome is influenced significantly by concomitant injuries. Severe cases with initial external fixation are associated with a higher risk of knee stiffness and should be considered during rehabilitation. Obese patients present a challenge due to higher complication rates and lower postoperative knee function. Level of evidence: Retrospective single center study, level III

What is the frequency of nerve injuries associated with acetabular fractures?

BACKGROUND Acetabular fractures and surgical interventions used to treat them can result in nerve injuries. To date, only small case studies have tried to explore the frequency of nerve injuries and their association with patient and treatment characteristics. High-quality data on the risk of traumatic and iatrogenic nerve lesions and their epidemiology in relation to different fracture types and surgical approaches are lacking. QUESTIONS/PURPOSES The purpose of this study was to determine (1) the proportion of patients who develop nerve injuries after acetabular fracture; (2) which fracture type(s) are associated with increased nerve injury risk; and (3) which surgical approach was associated with the highest proportion of patients developing nerve injuries using data from the German Pelvic Trauma Registry. Two secondary aims were (4) to assess hospital volume-nerve-injury relationship; and (5) internal data validity. METHODS Between March 2001 and June 2012, 2236 patients with acetabular fractures were entered into a prospectively maintained registry from 29 hospitals; of those, 2073 (92.7%) had complete records on the endpoints of interest in this retrospective study and were analyzed. The neurological status in these patients was captured at their admission and at the discharge. A total of 1395 of 2073 (67%) patients underwent surgery, and the proportions of intervention-related and other hospital-acquired nerve injuries were obtained. Overall proportions of patients developing nerve injuries, risk based on fracture type, and risk of surgical approach type were analyzed. RESULTS The proportion of patients being diagnosed with nerve injuries at hospital admission was 4% (76 of 2073) and at discharge 7% (134 or 2073). Patients with fractures of the "posterior wall" (relative risk [RR], 2.0; 95% confidence interval [CI], 1.4-2.8; p=0.001), "posterior column and posterior wall" (RR, 2.9; CI, 1.6-5.0; p=0.002), and "transverse+posterior wall" fracture (RR, 2.1; CI, 1.3-3.5; p=0.010) were more likely to have nerve injuries at hospital discharge. The proportion of patients with intervention-related nerve injuries and that of patients with other hospital-acquired nerve injuries was 2% (24 of 1395 and 46 of 2073, respectively). They both were associated with the Kocher-Langenbeck approach (RR, 3.0; CI, 1.4-6.2; p=0.006; and RR, 2.4; CI, 1.4-4.3; p=0.004, respectively). CONCLUSIONS Acetabular fractures with the involvement of posterior wall were most commonly accompanied with nerve injuries. The data suggest also that Kocher-Langenbeck approach to the pelvic ring is associated with a higher risk of perioperative nerve injuries. Trauma surgeons should be aware of common nerve injuries, particularly in posterior wall fractures. The results of the study should help provide patients with more exact information on the risk of perioperative nerve injuries in acetabular fractures. LEVEL OF EVIDENCE Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence

Early Functional Postoperative Therapy of Distal Radius Fracture with a Dynamic Orthosis: Results of a Prospective Randomized Cross-Over Comparative Study

<div><p>Introduction</p><p>This study was conducted according to GCP criteria as a prospective randomized cross-over study. The primary goal of the study was to determine clinical findings and patient satisfaction with postoperative treatment. 29 patients with a distal radius fracture that was surgically stabilized from volar and who met the inclusion criteria were enrolled over a 12-month period. Each patient randomly received either a dorsal plaster splint or a vacuum-fit flexible but blocked orthosis applied postoperatively in the operating theatre to achieve postoperative immobilization. After one week all patients were crossed over to the complementary device maintaining the immobilization until end of week 2. After week 2 both groups were allowed to exercise wrist mobility with a physiotherapist, in the orthosis group the device was deblocked, thus allowing limited wrist mobility. After week 4 the devices were removed in both groups. Follow-up exams were performed after postoperative weeks 1, 2, 4 and 12.</p><p>Results and Discussion</p><p>Results were determined after week 1 and 2 using SF 36 and a personally compiled questionnaire; after weeks 4 and 12 with a clinical check-up, calculation of ROM and the DASH Score. Comparison of the two groups showed a significant difference in ROM for volar flexion after 4 weeks, but no significant differences in DASH Score, duration of disability or x-ray findings. With regard to satisfaction with comfort and hygiene, patients were significantly more satisfied with the dynamic orthosis, and 23 of the 29 patients would prefer the flexible vacuum orthosis in future.</p><p>Trial Registration</p><p>German Clinical Trials Register (DRKS) <a href="https://drks-neu.uniklinik-freiburg.de/drks_web/" target="_blank">DRKS00006097</a></p></div

Immune Cell Induced Migration of Osteoprogenitor Cells Is Mediated by TGF-β Dependent Upregulation of NOX4 and Activation of Focal Adhesion Kinase

The cytokines secreted by immune cells have a large impact on the tissue, surrounding a fracture, e.g., by attraction of osteoprogenitor cells. However, the underlying mechanisms are not yet fully understood. Thus, this study aims at investigating molecular mechanisms of the immune cell-mediated migration of immature primary human osteoblasts (phOBs), with transforming growth factor beta (TGF-&beta;), nicotinamide adenine dinucleotide phosphate (NADPH) oxidase 4 (NOX4) and focal adhesion kinase (FAK) as possible regulators. Monocyte- and macrophage (THP-1 cells &plusmn; phorbol 12-myristate 13-acetate (PMA) treatment)-conditioned media, other than the granulocyte-conditioned medium (HL-60 cells + dimethyl sulfoxide (DMSO) treatment), induce migration of phOBs. Monocyte- and macrophage (THP-1 cells)-conditioned media activate Smad3-dependent TGF-&beta; signaling in the phOBs. Stimulation with TGF-&beta; promotes migration of phOBs. Furthermore, TGF-&beta; treatment strongly induces NOX4 expression on both mRNA and protein levels. The associated reactive oxygen species (ROS) accumulation results in phosphorylation (Y397) of FAK. Blocking TGF-&beta; signaling, NOX4 activity and FAK signaling effectively inhibits the migration of phOBs towards TGF-&beta;. In summary, our data suggest that monocytic- and macrophage-like cells induce migration of phOBs in a TGF-&beta;-dependent manner, with TGF-&beta;-dependent induction of NOX4, associated production of ROS and resulting activation of FAK as key mediators

Mean and standarddeviation of the 8 SC-36 Scales.

<p>SF-36 Measurement Model: Physical Health: Physical Functioning (PF), Role-Physical (RP), Bodily Pain (BP), and General Health (GH); Mental Health: Vitality (VT), Social Functioning (SF), Role-Emotional (RE), and Mental Health (MH). Scales of our sample were standardized on German normative postoperativ evaluation [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0117720#pone.0117720.ref021" target="_blank">21</a>]. The normative German postoperative evaluation has mean 50 and standarddeviation 10.</p

CONSORT 2010 Flow Diagram.

<p>CONSORT 2010 Flow Diagram.</p

Mean and standard deviation of dorsal extension at time-point 3 and time-point 4 postoperative.

<p>Mean and standard deviation of dorsal extension at time-point 3 and time-point 4 postoperative.</p

DASH Score at time-point 3 and time-point 4.

<p>DASH Score at time-point 3 and time-point 4.</p