Is there evidence-based guidance for timing of soft tissue coverage of grade III B tibia fractures?

The treatment of soft tissue damage associated with severe complicated tibia fractures is a clinical challenge. A recent study of grade III B/C open tibia fractures treated by delayed soft tissue coverage resulted in 20% of patients having osteomyelitis, with a mean follow-up of only 10 months. This study prompted us to review the literature on the association of timing of soft tissue closure in complicated grade III B tibia fractures and the incidence of infections and bone union. A Medline literature search was performed focusing on evidence-based medicine with regard to the timing of soft tissue closure and patients developing bony union and complications such as osteomyelitis. It was difficult to analyze publications with rigor. It appears that the time of surgery has little influence on free-flap failure but that early aggressive debridement followed by soft tissue cover within 3 to 5 days reduces osteomyelitis and delayed bone union. A need for better designed studies is also indicate

Minimizing the translation error in the application of an oblique single-cut rotation osteotomy: Where to cut?

An oblique single cut rotation osteotomy enables correcting angular bone alignment in the coronal, sagittal and transverse planes, with just a single oblique osteotomy, and by rotating one bone segment in the osteotomy plane. However, translational malalignment is likely to exist if the bone is curved or deformed and the location of the oblique osteotomy is not obvious. In this paper we investigate how translational malalignment depends on the osteotomy location. We further propose and evaluate by simulation in 3-D, a method that minimizes translational malalignment by varying the osteotomy location and by sliding the distal bone segment with respect to the proximal bone segment within the oblique osteotomy plane. The method is finally compared to what three surgeons achieve by manually selecting the osteotomy location in 3-D virtual space without planning in-plane translations. The minimization method optimized for length better than the surgeons did, by 3.2 mm on average, range [0.1, 9.4] mm, in 82% of the cases. A better translation in the axial plane was achieved by 4.1 mm on average, range [0.3, 14.4] mm, in 77% of the cases. The proposed method generally performs better than subjectively choosing an osteotomy position along the bone axis. The proposed method is considered a valuable tool for future alignment planning of an oblique single-cut rotation osteotomy since it helps minimizing translational malalignmen

Observer Variability in Evaluating Pisotriquetral Osteoarthritis using Pisotriquetral View

A pisotriquetral (semilateral) view of the wrist may improve the assessment of pisotriquetral osteoarthritis (OA), but its reliability and reproducibility are unclear. The purpose of this cross-sectional observer study was to investigate (1) the inter- and intraobserver agreement of evaluating pisotriquetral OA using pisotriquetral views with a special focus on sclerosis, joint space width (JSW) narrowing and osteophyte formation, and (2) the incidence of these latter radiographic features in patients suspected for pisotriquetral OA. Five independent observers rated independently at two different occasions 27 pisotriquetral views from patients treated for ulnar-sided wrist pain suspected for pisotriquetral OA requiring a pisiform resection. The agreement was calculated using kappa statistic. Agreement between observers ranged from 0.38 (fair) to 0.56 (moderate). Average intraobserver agreement ranged from 0.43 (moderate) to 0.52 (moderate). In 36% of the ratings, JSW narrowing was observed, followed by osteophyte formation (30%) and sclerosis (28%). Observers found it especially difficult to detect JSW narrowing. Despite the availability of a pisotriquetral view to enhance visualization of the pisotriquetral joint, assessment of the specific features indicating pisotriquetral OA leads to only fair-to-moderate agreement. This limits the applicability of a radiographic assessment. A rationale for a more reliable radiologic approach in assessing the level of pisotriquetral OA is needed, which may require the use of more advanced imaging technique