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Background and Objectives: Management of acetabular fractures is aimed at anatomically reducing and fixing all displaced or unstable fractures, as the accuracy of fracture reduction has been demonstrated to strongly correlate with clinical outcomes. However, there is a noticeable gap in the literature concerning the perioperative and postoperative care of patients with acetabular fractures, which ultimately can be potential risk factors for adverse outcomes and permanent disabilities. This study aimed to systematically review the available literature regarding rehabilitation practices, including weight-bearing protocols, across time points in surgically treated acetabular fracture patients and correlate these practices with functional outcomes. Methods: We systematically reviewed the Medline and PubMed databases and the Cochrane Central Register of Controlled Trials in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The inclusion criteria were studies with adult patients (19+ years), publications from the last 10 years, articles focusing on rehabilitation or mentioning any aspect related to rehabilitation (such as weight-bearing or muscle training), and describing the surgical management of acute, isolated acetabulum fractures. Specific information was collected, including the fracture classification, time to surgery, surgical approach, surgical time, blood loss, fixation strategy, quality of reduction, postoperative rehabilitation protocol, complication rate, type(s) of complication, and outcome measurement(s). The choice(s) of surgical approach, surgical time, blood loss, and fixation strategy were stratified based on the fracture classification. The complication rate and type(s) of complication were calculated for all studies. Fractures were classified based on the Letournel classification. Results: A total of 494 articles were identified from the initial search, of which 22 (1025 patients) were included in the final review. The most common rehabilitation protocol favored isometric quadriceps and abductor strengthening exercises starting on the first postoperative day, with passive hip movement at 1-3 days postoperatively and active hip movement ranging from the first postoperative day to 4 weeks postoperatively. Partial weight-bearing with a walker or a pair of crutches was permitted from 1 to 12 weeks after surgery, and full weight-bearing was allowed depending on the patient's general condition and fracture healing state (generally at the end of 3 months). In only three studies did the patients start bearing weight in the early postoperative period (≤1 week). Meta-regression analysis was not performed due to the discrepancy between studies that reported a weight-bearing protocol ≤1 week and >1 week postoperatively. Conclusions: Our study suggests that an accelerated postoperative rehabilitation protocol, including early permissive weight-bearing, does not appear to increase the risk of loss of reduction or the rate of complications after surgical treatment of acetabular fractures. However, a proper meta-analysis was not possible, and the heterogeneity of the included studies did not allow us to conclude anything about the potential biomechanical and clinical benefits nor the negative effects related to this rehabilitation regimen in terms of functional results. There is an inconsistent use of PROMs for objectively calculating the effect size of the accelerated protocol compared with restricted weight-bearing regimes. We pose the need for higher-level evidence to proof our hypothesis.

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PURPOSE: To systematically review the currently available existing evidence related to the presentation and management of simultaneous floating hip and knee injuries to identify injury characteristics, treatment strategies, and complications. METHODS: Data sources: Relevant articles were identified by searching Medline, PubMed, and Google Scholar databases with no language restrictions. Manual searches of other relevant databases (SciELO and grey literature databases) and reference lists of primary articles found from initial searches were also conducted. STUDY SELECTION: All types of study designs published from January 1st, 2000 to October 1st, 2022 involving skeletally mature patients with simultaneous floating hip and knee injuries were included. DATA EXTRACTION: Basic information and specific injury-related information were collected. RESULTS: Eight case reports were included. No study adequately reported the case with sufficient detail to allow other investigators to make inferences, nor was the result properly calculated, nor was the follow-up considered adequate for adequate functional assessment to occur in 80% of the studies. CONCLUSION: The exact treatment strategy and the follow-up time are not uniform across the included studies; therefore, they are not sufficient to adequately recommend surgical approach, timing of fixation, and fixation method. Our findings warrant the need for better documentation and reporting information about the mode of treatment of simultaneous floating hip and knee injuries.

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PURPOSE: The primary aim was to analyse the lateral malleolus morphology with a focus on the shape of the distal fibula for IM fixation of the fibula in infra- and transsyndesmotic fracture patterns. The secondary aim was to propose a treatment algorithm according to the lateral malleolar anatomy. METHODS: 77 healthy, skeletally mature volunteers underwent CT scanning of the ankle. The fibula medullary canal and its cortical thickness were quantitatively analysed at 4 different levels measured from the fibular tip (1.5 cm, 3.0 cm, 4.5 cm, and 6.0 cm). A geometric classification was proposed, and a decision algorithm was developed. Statistical significance was set at a p-value < 0.05. RESULTS: The smallest diameter of the medullary canal of the fibula was at 6.0 cm from the tip of the fibula, in 98.2% of the ankles. The distal fibula can be classified into triangular and rectangular type, according to the cortical thickness index (p < 0.0001). In 16.7% ankles, the internal diameter of the fibula at 6.0 cm was equal or narrower than 3.5 mm (p < 0.05). CONCLUSION: The shape of the distal fibula as evaluated by CT-guided analysis allows for IM osteosynthesis of the lateral malleolus in 83% of individuals. In our study, the smallest diameter of the medullary canal of the fibula was located 6.0 cm from the tip of the lateral malleolus. Coronal CT evaluation is advantageous in indicating which type of IM implant should be used safely for infra- and transsyndesmotic fracture patterns, potentially reducing intraoperative risks.

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Over the last year, with the social isolation imposed by the coronavirus disease pandemic, there has been a significant increase in complaints associated with physical violence against women. In the present study, an exploratory literature review was carried out on the role of the on-call orthopedic surgeon when faced with a suspicion of domestic violence, in accordance with Brazilian legislation. The main objective of the study was to show the role of this specialist in identifying victims of domestic violence by recognizing their profiles and associated risk factors. The secondary objectives were to demonstrate the most common skeletal and non-skeletal injuries in this type of violence and to present a quick and practical guide on how to identify, approach, and manage cases of domestic violence against women. The findings revealed that the main aggressors were close partners, such as spouses and ex-spouses. Young adult women, black or multiracial, and low socioeconomic status are major risk factors for intimate partner violence. Head and neck injuries are the most frequently observed lesions in this population, with more than one-third of victims reporting falls. Musculoskeletal injuries are present in up to 42% of victims of domestic violence, occurring predominantly in the upper limbs and chest, and are the leading cause of death in women aged 1 to 34 years. A practical guide for orthopedic surgeons who work in emergency departments is proposed, with basic information about their role and responsibility in identifying potential victims of intimate partner violence.

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High-energy fractures of the proximal tibia with extensive fragmentation of the posterolateral (PL) quadrant of the tibial plateau are challenging to manage. Herein, we present a review of the literature on the patterns and options of approach and fixation of the PL fragment of the tibial plateau to optimize the treatment of this specific injury pattern. We searched PubMed (1980-May 2020) to identify and summarize the most relevant articles evaluating both the morphology and treatment recommendations, including the choice of approach and fixation strategy, for the PL tibial plateau fracture. We found PL fragment can present in several patterns as a pure split, split depression, contained pure depression, and noncontained depression (rim crush), which are mostly determined by the position of the knee and the force magnitude applied during the course of the accident. Based on previous concepts described by Schatzker and Kfuri, we suggest a simplified treatment algorithm highlighting the two concepts (buttressing and containment) used for plating the PL tibial plateau fragments. Based on the available current evidence, we propose an algorithm for these two morphological types of PL tibial plateau fracture. Shear-type fractures need buttressing (the "rule of thumb"), whereas noncontained peripheral rim-type fractures need peripheral repair and containment. Contained pure depression fractures are not frequent and need percutaneous-assisted elevation and subchondral rafting, either controlled by fluoroscopy or arthroscopically. It is believed that such an approach would simplify their assessment and preoperative planning and would assist the clinicians to appreciate and manage more consistently these complex injuries.

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OBJECTIVE: The aim of this study was to evaluate the neuromuscular structures at risk during modified anterior minimally invasive plating osteosynthesis technique (Belangero-Livani) for humeral shaft fractures. METHODS: Eight fresh-frozen human specimens ranging from 38 to 82 years old were used. Specimens were positioned supine with the shoulder in 70° abduction and the forearm in full supination. Anterior minimally invasive plating osteosynthesis technique according to Belangero-Livani technique was performed in each specimen. Under radioscopic control, the plate was introduced in retrograde fashion through the subbrachialis path. Anatomical structures were inspected and different anatomical parameters were measured after dissection at the end of the surgical procedures. Measurements were performed using a high digital caliper. Statistical analysis was performed using the Pearson's correlation coefficient test. A p value of < 0.05 was used to define statistical significance. RESULTS: There were no macroscopic lesions of myotendinous or neurovascular structures in any specimen. The mean distance between the radial nerve to the distal lateral end of the plate was 8.63 mm (range 4.14-13.83 mm). The mean total length of the humerus was 328.59 mm. We found a significant direct correlation between the total length of the humerus and both specimen height and weight. CONCLUSION: The modified Belangero-Livani anterior MIPO technique for humeral shaft fractures performed in retrograde fashion is safe and useful, without major risk to the soft tissue of the anterior compartment of the arm, including the radial nerve in the lateral intermuscular septum. Intraoperative dissection, avoiding deep lateral retraction on the distal approach, minimizes the risk of radial nerve damage. Strict surgical planning and appreciation for the anatomic landmarks can reduce the risk of damage to neuromuscular structures. LEVEL OF EVIDENCE: Level IV; Case series with no comparison group; Treatment study.

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PURPOSE: Despite the fact that open reduction and internal fixation with a plate, either non-locked or locked, is the standard of care for managing lateral malleolus fractures, intramedullary (IM) fixation of the fibula has been recently introduced as an alternative, mainly for some potential complicated situations. We hypothesized that almost all patterns of distal fibula fracture can be safely fixed with an IM device, with the potential benefit of providing biomechanical efficiency, but using a soft-tissue friendly implant. Here, we present a multicenter case series based on a proposed algorithm. PATIENTS AND METHODS: Sixty-nine consecutive patients were managed with fibular IM fixation for closed malleolar fractures. Twenty patients were managed by IM screw fixation and 49 by fibular nailing. Outcome was measured both according to the American Orthopaedic Foot and Ankle Society (AOFAS) score for ankle and hindfoot, and the time to bone union. RESULTS: The mean AOFAS for Group I was 99.35 ± 1.95 points and that for Group II was 89.30 ± 16.98 points. There were no significant differences between the fracture pattern, according to the Lauge-Hansen classification, and post-operative levels of pain and functional activity among patients in both groups (p > 0.05). All fractures healed uneventfully in both groups. The mean time to union for Group I was 8.15 weeks and for Group II was 8.25 weeks (p > 0.05). CONCLUSION: In this multicenter case series, intramedullary fixation for the lateral malleolus fracture presented itself as a viable and safe option for the treatment of almost all patterns of fibula fracture in adults. Overall, we were able to demonstrate the potential indications of the proposed algorithm for the choice of IM implant for the lateral malleolus fracture in terms of the Lauge-Hansen staged classification.

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The management of both-column fractures of the acetabulum is challenging for the orthopaedic surgeon. Operative treatment is usually recommended in this particular fracture pattern, as residual joint surface displacement has been shown to increase local contact stress, drastically leading to rapid cartilage destruction. In this review, we present an overview of operative steps and surgical technique for both-column acetabular fracture reconstruction. Therefore, we demonstrate how correct understanding of fracture morphology and displacement, preoperative preparation, including choice of approach and patient positioning, reduction strategies, and programmed sequential fixation, starting from superior fracture lines on the anterior acetabular column and ending on the posterior components of this fracture type, may provide satisfactory outcomes in this difficult acetabular fracture pattern.

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Our objective is to describe the technique of intramedullary (IM) nailing of lateral malleolus in the surgical management of ankle fractures. Fracture reduction is performed either percutaneously with a small pointed reduction clamp in simple oblique fractures or using longitudinal traction and rotation for comminuted fractures, thus reducing complications related to open reduction and internal fixation with a plate. The technique has been shown to be simple and reproducible. In addition, the technique allows early weight bearing, which accelerates rehabilitation and potentially fasten fracture healing. IM nailing is a viable option for the fixation of the of lateral malleolus in ankle fractures and should be considered in the surgeon's armamentarium.

Nosso objetivo é descrever a técnica de fixação intramedular (IM) da fíbula no tratamento cirúrgico das fraturas maleolares do tornozelo. A redução é realizada sempre de forma percutânea: quando o traço de fratura é oblíquo simples, utilizamos uma pinça de redução de pontas e quando a fratura apresenta padrão multifragmentar, usa-se tração longitudinal e rotação. Isso reduz as complicações relacionadas à redução aberta e fixação interna com placa. A técnica demonstrou ser simples e reprodutível. Além disso, essa forma de fixação permite apoio precoce do peso corporal, o que acelera o processo de reabilitação e potencialmente acelera a cicatrização da fratura. A fixação IM da fíbula mostrou-se uma opção viável para a fixação do maléolo lateral nas fraturas do tornozelo, devendo ser considerada no arsenal do cirurgião.

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RESUMO Nosso objetivo é descrever a técnica de fixação intramedular (IM) da fíbula no tratamento cirúrgico das fraturas maleolares do tornozelo. A redução é realizada sempre de forma percutânea: quando o traço de fratura é oblíquo simples, utilizamos uma pinça de redução de pontas e quando a fratura apresenta padrão multifragmentar, usa-se tração longitudinal e rotação. Isso reduz as complicações relacionadas à redução aberta e fixação interna com placa. A técnica demonstrou ser simples e reprodutível. Além disso, essa forma de fixação permite apoio precoce do peso corporal, o que acelera o processo de reabilitação e potencialmente acelera a cicatrização da fratura. A fixação IM da fíbula mostrou-se uma opção viável para a fixação do maléolo lateral nas fraturas do tornozelo, devendo ser considerada no arsenal do cirurgião.

ABSTRACT Our objective is to describe the technique of intramedullary (IM) nailing of lateral malleolus in the surgical management of ankle fractures. Fracture reduction is performed either percutaneously with a small pointed reduction clamp in simple oblique fractures or using longitudinal traction and rotation for comminuted fractures, thus reducing complications related to open reduction and internal fixation with a plate. The technique has been shown to be simple and reproducible. In addition, the technique allows early weight bearing, which accelerates rehabilitation and potentially fasten fracture healing. IM nailing is a viable option for the fixation of the of lateral malleolus in ankle fractures and should be considered in the surgeon's armamentarium.

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There is a significant burden of disease associated with infected fractures, and their management is challenging. Prevention of infection after musculoskeletal trauma is essential because treatment of an established infection continues to be a major obstacle. Despite the need for evidence-based decision making, there is a lack of consensus around strategies for prevention and surgical management of the infected fracture. The current evidence for the prevention of the infected fracture is reviewed here with a focus on evidence for antibiotic therapy and debridement, the induced membrane technique, management of soft-tissue defects, patient optimization, and adjuncts to prevent infection.

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OBJECTIVE: To examine associations of major complications after surgical treatment of slipped upper femoral epiphysis (SUFE) with condition- and treatment-related risk factors. STUDY DESIGN: This systematic review and meta-analysis of observational studies used an electronic literature search of Embase and Medline supplemented by a manual search of bibliographies. The studies enrolled children and adolescents with SUFE, defined stable and unstable disease, and reported at least 3 primary endpoints: avascular necrosis (AVN), chondrolysis, and reoperation. Random-effects meta-regression analysis was performed when possible. RESULTS: The weighted risk for AVN, derived from intercept-only meta-regression, was estimated as 5.3% (95% confidence interval [CI], 3.4%-7.2%). Patients with unstable slips had a 9.4-fold greater risk of developing AVN. Instability proved to be an independent predictor for AVN. The weighted risk of chondrolysis was 0.8% (95% CI, 0.2%-1.4%), associated with unstable slips and osteotomies. The risk of reoperation was estimated at 5.5% (95% CI, 1.7%-9.3%). Loss of fixation was the primary reason for reoperation. CONCLUSIONS: Current evidence indicates that unstable slips are at a significantly higher risk for AVN than stable slips, regardless of the attempted surgical approach. Little clinical information is available regarding chondrolysis and reoperation in relation to the stability of the physis.

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