Open reduction internal fixation versus external fixation with limited internal fixation for displaced comminuted closed pilon fractures: A randomised prospective study

Background: Pilon fractures involve the dome of the distal tibial articular surface. The optimal treatment for high-energy pilon fractures remains controversial. Some authors advocate the use of open reduction and internal fixation (ORIF) to avoid articular incongruence. Others advocate the use of bridging external fixation with limited internal fixation (EFLIF) to reduce soft tissue complications. Literature reports of prospective studies comparing the radioclinical outcomes of ORIF and EFLIF in high-energy fractures are scarce. Retrospective studies have their limitations because of insufficient randomisation. The objective of this randomised prospective study is to compare the clinical, radiologic and functional outcomes of displaced and comminuted closed pilon fractures, Rüedi and Allgöwer type II and III, treated by either ORIF or EFLIF. Materials and methods: Forty-two patients were selected for the study. Twenty-two patients were subjected to ORIF and 20 patients were subjected to EFLIF. We used the American Orthopaedic Foot and Ankle Society score as a standard method of reporting clinical status of the ankle. Patients were followed-up clinically and radiologically for over 2 years after the surgical treatment. Results: The results of ORIF and EFLIF in treatment of high-energy pilon fractures are equally effective in terms of functional outcomes and complication rates on the short term. Conclusion: Soft tissue integrity and fracture comminution seem to have a significant influence on outcomes of intervention. A prospective multicentre study with a larger sample size that controls for other associated variables and comorbidities is warranted. Level of evidence: Level II. 中文摘要: 背景: Pilon骨折涉及脛骨遠端關節面的圓頂。高能量Pilon骨折的最佳治療方法仍然存在爭議。 一些作者主張使用開放復位和內固定(ORIF)來避免關節不一致。 其他作者主張用橋接外固定和有限內固定(EFLIF)來減少軟組織並發症。 比較ORIF和EFLIF在高能量骨折中的放射臨床結局的前瞻性研究的文獻報導很少。 回顧性研究由於隨機化不足而有其局限性。 這項隨機前瞻性研究的目的是比較以ORIF或EFLIF治療移位的粉碎性閉合Pilon骨折Rüedi和Allgöwer II型和III型的臨床、放射學和功能結果。 材料與方法: 選擇42例患者進行研究。 二十二名患者接受了ORIF, 二十名患者接受了EFLIF。 我們使用美國骨科腳踝學會(AOFAS)評分作為報告踝關節臨床狀態的標準方法。 患者的臨床和放射學隨訪超過手術治療後兩年。 結果: ORIF和EFLIF治療高能量Pilon骨折的療效在短期內功能結局和並發症發生率方面同樣有效。 結論: 軟組織完整性和骨折粉碎似乎對手術結果有顯著影響。 具有較大樣本量的前瞻性多中心研究以控制其他相關變量和合併症是有必要的。 Keywords: external fixation, internal fixation, intraarticular ankle fractures, prospective, tibial plafon

Ultrasound-guided serratus anterior plane block versus thoracic paravertebral block for perioperative analgesia in thoracotomy

Background: Thoracotomy needs adequate powerful postoperative analgesia. This study aims to compare the safety and efficacy of ultrasound (US)-guided serratus anterior plane block (SAPB) and thoracic paravertebral block (TPVB) for perioperative analgesia in cancer patients having lung lobectomy. Patients and Methods: This clinical trial involved 90 patients with lung cancer scheduled for lung lobectomy randomly divided into three groups according to the type of preemptive regional block. Group TPVB received US-guided TPVB. In Group SAPB, US-guided SAPB was performed. The patients of the control Group received general anesthesia alone. The outcome measures were postoperative visual analog scale (VAS) score, intraoperative fentanyl consumption, time of first rescue analgesic, total dose postoperative analgesic, and drug-related adverse effects. Results: Analgesia was adequate in TPVB and SAPB groups up to 24 h. VAS score was comparable in TPVB and SAPB groups and significantly lower compared to control group up to 9 h postoperatively. At 12 and 24 h, TPVB group had significantly lower VAS score relative to SAPB and control groups. Total intraoperative fentanyl consumption was significantly lower in TPVB and SAPB Groups compared to control group. The majority of TPVB Group cases did not need rescue morphine, while the majority of control group needed two doses (P < 0.001). The hemodynamic variables were stable in all patients. Few cases reported trivial adverse effects. Conclusion: Preemptive TPVB and SAPB provide comparable levels of adequate analgesia for the first 24 h after thoracotomy. TPVB provided better analgesia after 12 h. The two procedures reduce intraoperative fentanyl and postoperative morphine consumption