Search Results (99)

Introduction: Displaced intra-articular calcaneal fractures (DIACFs) are associated with a high incidence of wound complications. Minimally invasive approaches (MIAs) have enabled earlier intervention compared with the extensile lateral approach (ELA). However, the relationship between surgical timing, approach and outcome remains poorly defined. This systematic review evaluated the relationship between surgical timing, approach, and postoperative outcomes in DIACFs. Materials and Methods: A systematic review was conducted in accordance with the PRISMA 2020 guidelines. Studies published between January 1990 and April 2026 were searched through PubMed, Embase and Web of Science. Studies reporting the timing to surgery, approach, and postoperative outcomes in operated DIACFs were included. Patients were stratified into three groups according to timing (0–7 days, 8–21 days, and >21 days). Complication rates, radiographic and functional outcomes were analyzed. Results: A total of 25 studies, encompassing 1915 patients, were included. Patients mostly underwent surgery within seven days (60.1%), followed by 8–21 days (37.8%) and >21 days (2.1%). The complication rate was 21.7%, with wound dehiscence (8.9%) and infection (5.2%) being the most prevalent. Dehiscence and necrosis were predominantly associated with the ELA, particularly between days 8–21. Infection rates increased when the delayed sinus tarsi approach was used. No differences were found in radiographic or functional outcomes. Conclusions: Surgical timing does not appear to be an independent outcomes predictor. Complications depend on the interplay of timing, approach, and soft-tissue condition. An individualized treatment, with no rigid temporal thresholds, is probably the best approach. Full article

Background and Objectives: The surgical management of displaced scapular fractures remains controversial, particularly regarding the importance of restoring scapular alignment. This study evaluated radiologic restoration and clinical outcomes following posterior fixation of displaced scapular fractures, with a particular focus on correction of lateral border offset (LBO) and angular deformity. Materials and Methods: This retrospective case series included 20 patients who underwent posterior open reduction and internal fixation for displaced scapular fractures between 2017 and 2024 with a minimum follow-up of 12 months. Surgical indications included lateral border offset (LBO) > 20 mm, angular deformity > 30°, or displaced intra-articular fractures with step-off > 3 mm. Radiologic parameters including LBO, angular deformity, and intra-articular step-off were measured using computed tomography before and after surgery. Clinical outcomes were evaluated using shoulder range of motion (ROM), Disabilities of the Arm, Shoulder and Hand (DASH) score, and modified American Shoulder and Elbow Surgeons (ASES) score. Results: Significant postoperative improvement was observed in all radiologic parameters. Mean LBO improved from 18.9 ± 10.7 mm (range, 0–45.5 mm) to 3.1 ± 7.1 mm (range, 0–29.9 mm), angular deformity improved from 28.7° ± 11.3° (range, 10.2–48.1°) to 0.9° ± 3.9° (range, 0–17.8°), and intra-articular step-off improved from 6.4 ± 2.0 mm (range, 3.7–9.7 mm) to 1.8 ± 0.5 mm (range, 1–2.5 mm). At final follow-up, mean forward flexion was 126° ± 34.4° (range, 10–170°) and external rotation was 62.3° ± 20.8° (range, 0–90°). Mean DASH and modified ASES scores were 27.3 ± 17.3 (range, 8.3–74.2) and 71.6 ± 15.0 (range, 25.8–89), respectively. Glenoid involvement was not associated with inferior clinical outcomes, whereas associated ipsilateral upper extremity injuries tended to be related to poorer functional results. Conclusions: Posterior fixation effectively restored scapular alignment and articular congruity in displaced scapular fractures. Restoration of LBO and correction of angular deformity may represent important surgical objectives for correction of glenoid medialization and restoration of normal scapular alignment. Full article

(1) Background: Mandibular condylar fractures continue to be a subject of debate, traditionally framed as a choice between open and conservative management. However, this binary approach fails to adequately account for fracture-level anatomy, Temporomandibular joint (TMJ) involvement, and functional outcomes. (2) Purpose: To present an imaging-guided, fracture-level-based algorithm that integrates radiologic evaluation, surgical approach selection, fixation biomechanics, and functional rehabilitation. (3) Review Strategy: This invited review combines current evidence with a 13-year institutional experience involving 495 joints. High-resolution Computed Tomography (CT) Imaging was used to assess fracture morphology, displacement, and ramal height, while Magnetic Resonance Imaging (MRI) was selectively employed in intracapsular fractures to evaluate disc–condyle relationships when intra-articular involvement was suspected. Management decisions, including surgical approach and fixation strategy, were guided by an institutional algorithm tailored to fracture characteristics. (4) Results: Implementation of this approach yielded consistent and predictable outcomes. Mouth opening improved from approximately 18.77 mm preoperatively to 40 mm at 6 months. Lateral excursions became symmetrical (~9.6 mm), occlusion was restored in all patients, and bite force returned to near-physiological levels. Pain scores showed near complete resolution within 1 month. Postoperative morbidity remained low, with predominantly transient facial nerve weakness. (5) Conclusions: This imaging-guided, algorithmic framework provides reproducible functional outcomes and signifies a shift toward structured, anatomically driven management of condylar fractures. Full article

Background/Objectives: The optimal surgical approach for displaced intra-articular calcaneal fractures (DIACFs) remains controversial. While the extensile lateral approach (ELA) has traditionally been preferred for complex fractures, the sinus tarsi approach (STA) has gained popularity due to its potentially lower soft tissue morbidity. However, comparative data focusing on patient-centered outcomes remain limited. This study aimed to compare clinical, radiological, functional, cosmetic, and complication outcomes between STA and ELA in Sanders type II–IV DIACFs. Methods: A retrospective comparative cohort study was conducted including patients treated with open reduction and internal fixation using either STA or ELA between February 2019 and October 2024. Functional outcomes were assessed using the AOFAS Ankle–Hindfoot Score and VAS. Radiological evaluation included Böhler and Gissane angles measured preoperatively, early postoperatively, and at final follow-up. Patient-centered outcomes included time to full weight bearing, return to work, heel width difference, and changes in shoe size. Complications were recorded throughout follow-up. Results: Baseline demographic and fracture characteristics were comparable between groups. Patients treated with STA demonstrated significantly shorter hospital stay, earlier progression to full weight bearing, and earlier return to work (p < 0.001). Functional outcomes favored STA, with significantly lower VAS scores and higher AOFAS scores at final follow-up (p < 0.05). No significant differences were observed between groups regarding Böhler or Gissane angles at any time point (p > 0.05). Wound-related complications were significantly more frequent in the ELA group (p = 0.018), although overall complication rates were comparable. Conclusions: The sinus tarsi approach was associated with comparable radiological restoration to the extensile lateral approach while demonstrating earlier functional recovery and lower wound-related morbidity. Given the retrospective and non-randomized design, these findings should be interpreted as associations rather than causal effects. STA may represent a safe and effective surgical option in appropriately selected Sanders type II–IV intra-articular calcaneal fractures. Full article

Background: The impact that various methods of calcaneal fracture treatment have on functional outcomes is not thoroughly understood. The purpose of this study was to analyze the impact of calcaneal fractures on the level of physical activity and foot and ankle mobility following various fixation methods. Methods: In our two-center retrospective analysis, we compared treatment outcomes of intra-articular calcaneal fractures in 50 patients treated with the Ilizarov method and 49 patients who underwent internal plate fixation. The following parameters were analyzed: range of motion of the foot and ankle joint; the UCLA Activity Scale, the Saltin–Grimby scale, and the Visual Analog Scale (VAS) of Activity. No multivariable adjustment was performed. Accordingly, between-group comparisons are unadjusted, except where stratified analyses are indicated. Results: Postoperatively, a significant improvement was noted in terms of UCLA Activity parameters and the Saltin–Grimby score in the Ilizarov group. A comparison of post-treatment physical activity levels in the two groups revealed significantly better scores in the Grimby scale and VAS activity in the Ilizarov group than in the internal fixation group. The ranges of motion in the Ilizarov group showed significantly worse mobility in the operated limb than in the intact limb. The ranges of dorsiflexion, foot inversion, and foot eversion in the ORIF group were comparable for the treated and intact limb. A comparison of ranges of motion in the study groups showed significantly lower ranges of motion in the Ilizarov group than in the ORIF group. Conclusions: Calcaneal fracture treatment with the Ilizarov method may be associated with better physical activity levels than internal plate fixation. Foot and ankle mobility following calcaneal fracture treatment is better in patients treated with internal plate fixation. The results should be taken with caution due to the lack of randomization, two-center design and the retrospective nature of the study. Full article

Background: Pilon fractures refer to distal tibial fractures that may involve extra-articular, partial articular, or complete intra-articular components, most commonly caused by high-energy trauma. The choice between early (<72 hours) and delayed (>7 days) surgical fixation significantly impacts clinical outcomes. This study aimed to compare the effects of early vs. delayed plate fixation on fracture healing time, functional outcomes, and complication rates. Materials and Methods: This retrospective study analyzed 80 patients who underwent surgical treatment for pilon fractures between 2018 and 2023. Patients were divided into two groups: Early surgery (<72 hours, n=40); Delayed surgery (>7 days, n=40). Additionally, patients were categorized based on the fixation method: Single plate fixation (n=40); Double plate fixation (n=40). Outcome Measures: Fracture healing time (weeks) - Defined as cortical continuity on radiographs; Functional outcomes (AOFAS score); Complication rates (infection, malunion, implant failure). Results: Shorter healing time was observed in the early surgery group (14.2 vs. 16.8 weeks, p<0.05). Better functional outcomes were recorded in the early surgery group (AOFAS score: 82.3±6.5 vs. 78.1±7.2, p<0.05). Lower infection rates were noted in the delayed surgery group (7.5% vs. 12.5%, p<0.05). Double plate fixation provided better mechanical stability but resulted in higher soft tissue complication rates. Single plate fixation preserved soft tissue integrity but had higher malunion and implant failure rates. Conclusion: Early surgery is associated with shorter healing time and better functional outcomes, but increased soft tissue complications require careful management. Delayed surgery offers a safer approach for soft tissue healing but may prolong functional recovery. While double plate fixation ensures greater stability, it may increase soft tissue morbidity, whereas single plate fixation reduces soft tissue complications but may compromise stability. A personalized surgical approach is recommended for optimal outcomes in pilon fracture management. Full article

Background and Objectives: Simultaneous bilateral scapular fractures are exceptionally rare injuries and are most commonly associated with high-energy trauma, convulsions, or electrical injury. Their occurrence following low-energy trauma is extremely uncommon. This study aimed to conduct a scoping review of the literature on simultaneous bilateral scapular fractures, with emphasis on demographic characteristics, mechanisms of injury, fracture patterns, treatment strategies, and clinical outcomes. To provide clinical context, the findings are illustrated by a case of a 43-year-old previously healthy recreational athlete who sustained simultaneous bilateral scapular fractures after a low-energy fall directly onto the back. Materials and Methods: A scoping review of the literature was conducted in accordance with PRISMA-ScR guidelines using the PubMed/MEDLINE and Scopus databases. Studies reporting simultaneous bilateral scapular fractures were identified and analyzed with respect to demographic characteristics, mechanisms of injury, fracture patterns, treatment modalities, and outcomes. Results: Thirty-seven studies published between 1946 and 2025 were included, comprising a total of 43 patients. Most cases resulted from high-energy trauma (41.9%), convulsions (25.6%), or electrical injury (16.3%). Low-energy trauma and spontaneous fractures were rare. The scapular body was the most commonly involved anatomical region. Conservative treatment predominated and was generally associated with favorable functional outcomes, while surgical intervention was reserved for displaced or intra-articular fractures. The illustrative case involved bilateral comminuted extra-articular fractures of the scapular bodies and spines without associated injuries and was managed conservatively, resulting in complete fracture healing and full, painless shoulder range of motion. Conclusions: The findings of this scoping review, illustrated by the representative clinical case, indicate that simultaneous bilateral scapular fractures may occur even after low-energy trauma in otherwise healthy individuals. Bilaterality alone should not be interpreted as an independent indication for surgical treatment when fractures are stable and minimally displaced. A high index of clinical suspicion and appropriate radiological evaluation are therefore warranted, particularly in emergency and trauma settings, in order to avoid missed or delayed diagnosis, even in cases with seemingly benign mechanisms of injury. Full article

Background/Objectives: Multimodal large language models (MLLMs) are increasingly evaluated for diagnostic tasks in medical imaging, including radiographic interpretation. However, most studies focus primarily on binary fracture detection and rarely assess clinically relevant fracture characteristics such as displacement or intra-articular extension, which influence treatment decisions. In addition, most evaluations rely on single-run inference designs that do not assess response reproducibility. This study evaluated the diagnostic performance and inter-run reliability of five MLLMs for radiographic assessment of distal radius fractures. Methods: Fifty fracture-positive distal radius radiographs were evaluated by five MLLMs (ChatGPT 5.3, Gemini 3.1 Pro, Claude Opus 4.6, Grok 4.1, and ERNIE 5.0) across five independent zero-shot inference runs (n = 1250 observations). Diagnostic tasks included fracture detection, intra-articular extension, and displacement. Sex and age were exploratory endpoints. Performance was summarized using sensitivity (fracture detection) and accuracy (other tasks), with inter-run reliability assessed via Fleiss’ κ. Results: Performance varied across tasks and models. Fracture detection sensitivity ranged from 39.6% to 99.6%, with two models exceeding 90%. Intra-articular extension accuracy ranged from 51.6% to 55.6%, consistent with chance-level performance. Displacement classification ranged from 34.8% to 70.4%. One model achieved substantial inter-run agreement across binary tasks (κ > 0.60), whereas two models showed slight agreement (κ < 0.20). Conclusions: Only two models exceeded 90% sensitivity for fracture detection, while intra-articular extension remained at chance level (≤55.6%). Substantial inter-run reliability (κ > 0.60) was observed in only one model. These findings indicate that current MLLMs do not reliably support multidimensional fracture assessment and that single-run evaluations overestimate robustness. Full article

Background: Displaced intra-articular calcaneal fractures are difficult to treat due to their complex anatomy and the high risk of soft-tissue complications. Although open reduction and internal fixation (ORIF) enables accurate anatomical reconstruction, it can be associated with substantial wound morbidity. Minimally invasive techniques have been developed to mitigate these risks. This study aims to describe a modified external fixation technique and report its clinical and radiographic outcomes in consecutive cases of patients with displaced intra-articular calcaneal fractures, with a minimum follow-up period of one year. Methods: The surgical technique is described in detail. The technique was evaluated by analyzing the treatment results in a case series of 17 patients. The time from injury to surgery, radiographic parameters (Böhler’s angle and time to union) and clinical outcomes were recorded and analyzed, as were complication rates. The minimum follow-up period was 12 months. Results: Surgical reconstruction was performed at a mean of three days (range 1–6 days; SD 1.5) after injury. Preoperative radiographic parameters showed significant deformity, with calcaneal morphology restored at follow-up. At 12 months, the mean Böhler angle had increased to 27.8°, and all fractures had achieved radiographic union. Functional outcomes improved progressively over time, with increases in both the AOFAS and SF-12 P scores. One complication was observed: K-wire displacement requiring conversion to ORIF in a psychiatric patient. Conclusions: The proposed technique facilitates early surgical treatment and the satisfactory restoration of calcaneal morphology with no soft-tissue complications. It appears to be safe and effective in selected patients. A longer follow-up will provide further insight into long-term outcomes, such as subtalar osteoarthritis. Full article

Background: Calcaneal fractures are complex injuries frequently associated with significant soft tissue damage and a high risk of post-operative complications, particularly infection. Despite advances in surgical techniques, infectious complications remain a major cause of morbidity and can severely compromise functional outcomes. The aim of this systematic review was to analyze the incidence, management strategies, and clinical impact of infectious complications following surgical treatment of calcaneal fractures. Methods: A systematic literature search was conducted in MEDLINE, Scopus, and Web of Science in accordance with PRISMA guidelines, including studies published up to May 2025. Randomized controlled trials and prospective and retrospective cohort studies involving adult patients surgically treated for calcaneal fractures and reporting post-operative infectious outcomes were included. Data extraction focused on patient demographics, fracture characteristics, surgical techniques, infection rates, microbiological findings, management strategies, complications, and functional outcomes. Methodological quality and risk of bias were assessed using the MINORS score. Due to substantial heterogeneity, results were synthesized descriptively. Results: Forty studies met the inclusion criteria, encompassing 5343 patients and 4638 surgically treated calcaneal fractures. Displaced intra-articular fractures predominated, with Sanders type II and III accounting for 79.8% of classified fractures, while Sanders type IV fractures represented 20.2% and were associated with higher complication rates. The overall post-operative infection rate was 9.4%, including 6.3% superficial surgical site infections and 3.0% deep infections. Open fractures accounted for 7.5% of reported cases and demonstrated markedly higher infection rates than closed injuries. Deep infections frequently required implant removal (62%), prolonged intravenous antibiotic therapy (100%), and additional surgical procedures (71%). Staphylococcus aureus, including methicillin-resistant strains, was the most commonly isolated pathogen. Functional outcomes were consistently worse in patients who developed infections. Conclusions: Infectious complications remain a clinically significant problem following surgical treatment of calcaneal fractures, particularly in severe fracture patterns, open injuries, and patients with relevant comorbidities. Deep infections are associated with substantial morbidity and inferior functional outcomes. Optimization of patient-related risk factors, careful surgical planning, and the selective use of minimally invasive approaches may help reduce infection risk. Further high-quality prospective studies with standardized outcome measures are needed to define optimal management strategies. Full article

Purpose: Floating knee (FK) injuries are complex high-energy traumas associated with poor functional outcomes. This study aimed to identify independent predictors of functional prognosis and to develop a novel, multidimensional scoring system to predict long-term functional outcomes. Methods: A retrospective analysis was performed on 182 adult patients with ipsilateral femur and tibia fractures treated between January 2010 and December 2023. Functional outcomes were assessed using the Karlström–Olerud criteria and dichotomized as excellent–good versus fair–poor. Variables significant in univariate analysis were entered into a multivariate logistic regression model. Independent predictors were used to construct the FKS-score. Predictive performance was evaluated using ROC analysis. Results: Of the 182 patients, 103 (56.6%) achieved excellent–good outcomes, while 79 (43.4%) had fair–poor results. Multivariate analysis identified Fraser IIA–B (OR 2.12), Fraser IIC (OR 3.85), Gustilo I–II (OR 1.42), Gustilo IIIA–B (OR 2.61), Gustilo IIIC (OR 3.22), segmental fractures (OR 2.18), extensor mechanism injury (OR 2.04), vascular injury (OR 4.89), intra-articular extension (OR 1.92), and patella fracture (OR 1.76) as independent predictors of poor functional outcome. The FKS-score, ranging from 0 to 15, demonstrated high predictive accuracy (AUC = 0.89). An optimal cut-off value of ≥9 points yielded a sensitivity of 78% and specificity of 85%. Conclusions: The FKS-score is the first comprehensive prognostic scoring system specifically developed for floating knee injuries. It provides a reliable, practical tool for early risk stratification and the prediction of long-term functional outcomes, thereby supporting clinical decision-making and patient counseling. Full article

Background/Objectives: Hip fractures among elderly patients are associated with significant morbidity and mortality. Delayed surgery is common and often results in inadequate pain control and increased opioid consumption, which may have adverse effects. This study evaluates the effectiveness of preoperative intra-articular injection of multimodal analgesics (IA MDI) for reducing pain caused by a displaced femoral neck fracture (FNF). Methods: A prospective randomized controlled trial was conducted using 18 geriatric patients with displaced FNFs scheduled for hip arthroplasty. The patients were randomized into two groups: IA MDI and control groups (n = 9 each). The IA MDI group was administered a preoperative intra-articular injection of ropivacaine, morphine, and adrenaline, in addition to standard oral and intravenous (IV) analgesics, while the control group was administered standard oral and IV analgesics alone. The primary outcome was the perioperative pain score assessed via the 10-point numerical rating scale (NRS). The secondary outcomes were morphine consumption, perioperative complications, length of hospital stay, and functional outcome. Results: During the first 24 h preoperative period after admission, the IA MDI group exhibited a significant reduction in the average NRS at all timepoints (p < 0.05 all) and in the median dosage of morphine consumption (0 mg vs. 6 mg, p = 0.033) compared to the control group. There was no significant difference between groups in terms of postoperative pain and complications, length of hospital stays, or functional outcomes (p > 0.05 all). Conclusions: Preoperative IA MDI significantly reduced pain intensity and opioid consumption during the preoperative 24 h window among elderly patients with FNFs without provoking a corresponding increase in observed complications in this pilot randomized controlled study. IA MDI is a feasible option and could be a useful adjunct for preoperative pain management for FNFs. Full article

Background: The sustentaculum screw plays a crucial role in achieving stable osteosynthesis for intra-articular calcaneal fractures, particularly when using minimally invasive or percutaneous techniques. Accurate placement of the screw within the sustentaculum tali is technically demanding due to the complex anatomy and the limited intraoperative visualization provided by standard fluoroscopic views. Methods: Patients were positioned in a standardized lateral decubitus position. Beginning with a standard lateral fluoroscopic view, the C-arm was tilted approximately 25° to align the central beam with the plane of the lower ankle joint. This adjustment enables clear visualization of the borders of the sustentaculum tali and allows precise definition of the target point for guide-wire insertion. To evaluate whether this technique improves screw positioning, two groups were compared: one using the described fluoroscopic view and a control group using conventional imaging alone. Results: Screw placement accuracy was significantly higher in the group using the dedicated fluoroscopic view compared with the control group. Conclusions: With meticulous preoperative planning, standardized positioning, and the use of a dedicated fluoroscopic setting—referred to as the “sustentaculum view”—accurate and safe screw placement can be achieved with significantly higher accuracy than with conventional imaging alone. Full article

Background/Objectives: Intensive postoperative pain is a common challenge after knee surgeries such as total knee arthroplasty, arthroscopy, cruciate ligament or meniscus repair, and fixation of tibial plateau or distal femoral fractures. This scoping review mapped and summarized non-regional postoperative analgesia strategies to provide an overview of available approaches when regional blocks or neuraxial anesthesia are not feasible. Methods: We followed established methodological guidance for scoping reviews and report the data in accordance with the PRISMA-ScR checklist. We searched PubMed/MEDLINE, EMBASE, Scopus, and ClinicalTrials.gov in January 2025. Eligible designs included randomized controlled trials, non-randomized trials, observational studies, case series, and pilot studies. Results: We screened 3390 records and assessed 332 in full text. A total of 43 studies met the inclusion criteria, and the literature was grouped into: (1) arthroplasty, (2) arthroscopy, (3) cruciate ligament or meniscus repair, and (4) tibial plateau or distal femoral fractures. We identified substantial heterogeneity in interventions, comparators, and outcome measures across the first three sets of literature but found no focused articles for tibial plateau or distal femoral fractures. Most studies evaluated multimodal approaches combining systemic analgesics with local periarticular or intraarticular techniques. Evidence on functional recovery and mobilization was limited. Conclusions: Current evidence on non-regional postoperative analgesia in knee surgery is fragmented and varies considerably in design, intervention, and reported outcomes. Multimodal regimens and pre-emptive NSAID use were frequently associated with reduced early postoperative pain and lower opioid requirements, although comparability across studies remains limited. As existing evidence largely focuses on outcomes during hospitalization, future research should prioritize standardized pain and functional outcome reporting and directly compare systemic and local multimodal strategies, while extending follow-up beyond discharge to better characterize sustained clinical relevance. Full article

Bennett fractures are common intra-articular fractures of the base of the first metacarpal. Not optimal restoration of the articular surface often leads to osteoarthritis, with pain and limited movement. In patients with established and symptomatic TMC osteoarthritis, arthroplasty with MAIA^® prosthesis could be a valid option. In July 2024, a right-handed man of 68 years old fell on his hand. Radiographs showed a Bennett fracture in a setting of Eaton–Littler stage 3 osteoarthritis, already painful and disabling according to the patient. For correct pre-operative planning, a 3D model of the affected hand was produced. The patient underwent TMC arthroplasty with a MAIA^® prosthesis. Two months after surgery, the results reported no pain (VAS scale) and considerable functionality and mobility of the first ray (AROM, Kapandji score, and PRWHE were investigated). The mean pinch strength of the right hand was 7 kg and of the left hand 7.5 kg using a pinch meter. At one-year follow-up, no complications were reported: the implant did not show signs of loosening or subsidence. TMC arthroplasty in Bennett fractures could represent a safe procedure in patients with established TMC osteoarthritis; however, further studies are requested in order to clarify effectiveness and indications. Full article