Search Results (114)

Background: The optimal management of comminuted proximal humerus fractures in the elderly remains controversial. Although hemiarthroplasty is widely used for complex fracture patterns, its functional superiority over reconstruction is not consistently demonstrated. The aim of this study was to compare early functional outcomes following open reduction and internal fixation (ORIF) versus hemiarthroplasty in elderly patients with three- and four-part proximal humerus fractures. Methods: This retrospective single-center study included elderly patients with comminuted proximal humerus fractures treated between 2020 and 2024 by either ORIF or hemiarthroplasty. Functional outcomes were assessed at 6 months using the Constant–Murley and DASH scores. Secondary outcomes included complication rates, range of motion, and early reintervention. Results: At 6 months, the ORIF group showed a mean Constant–Murley score of 62.1 ± 9.4 compared with 58.0 ± 10.2 in the hemiarthroplasty group. DASH scores were 34.2 ± 10.8 for ORIF and 38.5 ± 11.3 for hemiarthroplasty. Pain levels were similarly low in both groups (VAS 2.6 ± 1.1 vs. 2.9 ± 1.2). Complication rates were comparable, with fixation-related issues occurring in 17% of ORIF cases and tuberosity-related complications in 11% of hemiarthroplasty cases. Conclusions: Hemiarthroplasty should not be regarded as the default treatment strategy for comminuted proximal humerus fractures in elderly patients. When stable anatomic reduction is achievable, ORIF can yield comparable early functional results, emphasizing that patient selection and tuberosity management remain more important than the choice of implant. Full article

Background: Paediatric pelvic and acetabular fractures are rare and usually the consequence of high-energy trauma, often associated with life-threatening injuries. The majority are managed non-operatively; however, open reduction and internal fixation (ORIF) is indicated in selected, complex, or displaced, acetabular fractures. The modified Stoppa approach is well established in adults, but has been rarely reported in skeletally immature patients, and evidence guiding surgical approach and fixation in children remains limited. Methods: We report the case of an 11-year-old girl who sustained a transverse acetabular fracture following a high-energy trauma. The fracture was treated with ORIF through a modified Stoppa approach. We also performed a systematic review of the literature, focusing on ORIF of acetabular fractures in children. Results: In our patient, ORIF of the acetabular fracture was performed, achieving an anatomical reduction, 10 days after initial damage-control fixation of a concomitant open tibial plateau fracture. Postoperative management consisted of four weeks of non-weight bearing, followed by progressive weight bearing. At six months, she had returned to full daily activities and sports. The review of the literature identified 16 studies (retrospective series and case reports) describing paediatric acetabular fractures treated with ORIF using plates, screws, or flexible nails. In the literature, good to excellent clinical and radiographic outcomes were reported when anatomical reduction and stable fixation were achieved, although growth disturbance and avascular necrosis were described, particularly in cases with delayed reduction or severe triradiate cartilage injury. Conclusions: Our case illustrates the technical feasibility of the modified Stoppa approach in a skeletally immature patient with a complex acetabular fracture, with excellent mid-term outcome. Although it is not contraindicated in paediatric patients, it should be reserved for treating this type of complex fracture. The available literature supports that satisfactory results are reported after ORIF in children, but the heterogeneity and low level of evidence preclude firm recommendations on the optimal approach. Full article

Background/Objectives: Subcondylar mandibular fractures represent a challenging subset of maxillofacial trauma due to their proximity to the temporomandibular joint and the facial nerve. The retromandibular approach can be performed through either an anteroparotid or a transparotid route, but comparative clinical data remain limited. This study aimed to evaluate clinical outcomes, complication profiles, and operative parameters associated with the retromandibular anteroparotid versus transparotid approach for open reduction and internal fixation (ORIF) of subcondylar fractures. Methods: A retrospective analysis was conducted on 80 consecutive patients treated for subcondylar mandibular fractures at the Department of Maxillofacial Surgery, Umberto I General Hospital, Sapienza University of Rome, between 2018 and 2025. All patients underwent ORIF via a retromandibular approach (anteroparotid or transparotid) with a minimum follow-up of 6 months. Demographic data, trauma etiology, fracture morphology (classified as simple or complex), associated fractures, surgical approach, fixation details, operative time, hospital stay, and postoperative complications were collected. Facial nerve function was clinically assessed and graded using the House–Brackmann scale. Associations between fracture type, surgical approach, number of plates, and complications were evaluated using Chi-square or Fisher’s exact tests, while operative time was compared using one-way ANOVA and Kruskal–Wallis tests (p < 0.05). Results: The cohort had a mean age of 41.9 years and was predominantly male (67.5%). The anteroparotid route was used in 54 patients (67.5%) and the transparotid route in 26 (32.5%). Overall, 10 patients (12.5%) developed postoperative complications, including transient facial nerve weakness, malocclusion, visible scarring, and sialocele. All cases of sialocele occurred in the transparotid subgroup, whereas no salivary complications were observed after the anteroparotid approach. No permanent facial nerve deficits, temporomandibular joint ankylosis, or long-term facial asymmetry were recorded at 6 months. No significant association was found between surgical approach and overall complication rate, but complex fracture patterns were significantly associated with increased operative time. Conclusions: The retromandibular approach is a safe and effective option for ORIF of subcondylar mandibular fractures. Both anteroparotid and transparotid routes provided reliable exposure and stable fixation with low complication rates. The anteroparotid route appears to minimize parotid-related complications, such as sialocele, while maintaining comparable functional outcomes. These findings support the retromandibular anteroparotid approach as a valuable alternative in the surgical management of subcondylar fractures. Full article

Objectives: Against common belief, mandibular condyle fractures are not that rare, with morbidity rates ranging from 19 to 52%, depending on actual literature sources. Practitioners try to improve the surgical techniques applied to obtain the most satisfactory anatomical and functional effect. The purpose of this study is to identify the relationships that affect bone loss around screws and plates in mandibular condylar process fractures treated surgically using the Open Reduction and Internal Fixation (ORIF) technique. Materials and Methods: Our research covered 276 fractures of the base, low and high neck of the condylar process. No formal sample size calculation was performed; the study enrolled patients treated at the Department during the last 4 years, based on informed consent granted both prospectively and retrospectively compares to the actual treatment time. The study group was selected based on injury type and the ability to implement surgical treatment. The imaging modality selected for the study was computed tomography (CT), which was assessed in each case by the same operator. Therefore, there was no need to account for inter-rater variability in the results. Based on CT scans, we studied various parameters, including bone healing in the fracture area, bone loss in the screws and plates area, change in the length of the mandibular ramus following osteosynthesis and on the opposite side after 12 months, as well as deformities of the mandibular head. Results: Using screws and plates is the gold standard for treating mandibular condylar process fractures. The number of screws used affects the bone loss ratio around head of the screw. Another factor that impacts the results achieved is the distance from the plate edge to the lateral pole of the mandibular head. Statistical evaluation indicated that proximity to the lateral pole is a risk factor for bone resorption at the plate edge. Conclusions: Based on the collected data, it is possible to predict bone loss, determine the location and selection of plates and screws, as well as to plan the procedure, achieving the lowest possible loss rates. Full article

Background: Maxillofacial trauma can impair crucial functions of the stomatognathic system. Mandibular condyle fractures, in particular, often lead to temporomandibular joint (TMJ) dysfunction. Methods: This study evaluated the effectiveness of open rigid internal fixation (ORIF) in restoring TMJ function, using the Helkimo Index to compare pre- and post-operative outcomes. Results: A total of 395 patients who underwent ORIF for condylar fractures were analyzed (302 males, 93 females). TMJ function improved significantly from baseline to 6-month follow-up (p < 0.001), with a mean reduction of 2.18 grades on the Helkimo Index. Higher post-operative Helkimo grades (2–3) occurred more frequently during warm months than during cold months (p < 0.05). Low body mass index (BMI) was associated with a greater risk of post-surgical TMJ dysfunction (p < 0.001). TMJ function correlated with facial nerve recovery: patients with poorer pre-operative TMJ function showed additionally slower facial nerve recovery during the first five months after surgery. Age, gender, place of residence, injury characteristics, comorbidities, delay of surgery, duration of surgery, surgical approach, fixing material and laboratory blood tests showed no significant association with post-operative TMJ function. Residual TMJ dysfunction was observed in 3% of treated patients (Di = 3). Conclusions: ORIF, combined with appropriate post-operative physiotherapy, effectively restores TMJ function after condylar fractures—including severe injuries. Simple clinical indices such as the Helkimo Index reliably capture functional improvement. Full article

Aim: Periprosthetic fracture-related infections (PFRIs) are a serious complication of total arthroplasty, with incidence rates increasing in line with the growing number of joint replacements. PFRI can lead to prolonged hospitalization, multiple surgical procedures and suboptimal functional outcomes. The diagnosis of PFRI remains challenging due to the overlap of clinical symptoms with other post-traumatic conditions, and identification of the pathogen often fails through conventional methods. This study also highlights the importance of a personalized medicine approach in managing PFRI, where diagnostic and therapeutic decisions are tailored to the individual patient’s comorbidities, immune status and bone healing capacity. By integrating clinical, microbiological and imaging data, our findings support precision-based strategies to optimize outcomes and minimize complication. Methods: This retrospective case series was conducted at the Unit of Osteoarticular Infection of the University of Turin, Italy, from January 2018 to December 2023. Patients who developed septic complications after open reduction and internal fixation (ORIF) of periprosthetic fractures involving hip or knee implants were included. The infection was diagnosed in accordance with established guidelines, and treatment decisions were based on clinical, microbiological and radiological findings. Results: In the present study, periprosthetic fractures complicated by infections were identified in nine patients (5.4%), constituting a small but significant subset of cases. The cases were then categorized into four clinical scenarios based on the following variables: joint involvement, fracture healing and infection progression. Scenario A, involving fractures without prosthetic involvement and unhealed fractures, included three patients (33%) and was treated with debridement and change of the fixation device. Scenario B, involving fractures without prosthetic involvement but with healed fractures, involved one patient (11%), where the ongoing infection was confirmed despite the healed fracture and where the device could be removed. The third scenario (C), which pertains to cases involving prosthetic involvement, included three patients (33%) who required replacement or removal of the prosthesis and, in some cases, a second stage. The fourth scenario, involving patients with limited operability, included two patients (22%) for whom no surgery was performed. Despite the significant clinical challenges encountered, the paucity of literature on the management of periprosthetic fractures with septic complications is limited, highlighting the need for further research in this understudied area. Conclusions: PFRI remains a challenging complication that necessitates a multidisciplinary approach to diagnosis and treatment. Despite advances in imaging and microbiological testing, the early detection and identification of pathogens remain challenging, emphasizing the necessity for enhanced diagnostic methods. This study offers valuable insights into the management of PFRI and provides a foundation for future research to develop optimal diagnostic and therapeutic strategies. Full article

Ankle fractures are extremely common and often require surgical management, historically with open reduction and internal fixation (ORIF), although fibular intramedullary nailing (IMN) has demonstrated promising results in recent years. The purpose of this study is to report on risk factors, quality of reduction, and complications in a series of patients undergoing fibular IMN for management of ankle fractures using a novel device via a retrospective case series. Patients undergoing locked fibular IMN with the Flex-Thread nail (Conventus Flower Orthopedics, Horsham, PA, USA) by a single surgeon from January 2023 to March 2025 were included, with at least 6 months of follow-up. Demographics, comorbidities, injury characteristics, reduction quality, and post-operative complications were recorded. Descriptive analyses were reported for categorical variables. A total of 15 patients were included, with a mean age of 58.9 ± 22.0 (range 18–91) and mean BMI of 31.5 ± 5.7 kg/m². All patients experienced a fall as their mechanism of injury, with 12 Weber B and 3 Weber C fractures. The mean time to surgery from the date of injury was 9.5 ± 5.5 days. Of 15 patients, 66.7% had good reduction quality, 26.7% had fair, and 1 patient experienced poor reduction quality requiring subsequent hardware removal. There was one patient who experienced delayed wound healing. Patients undergoing fibular fixation using the novel Flex-Thread nail experience a fair to good quality of reduction, with limited complications. Both young and elderly patients have relatively positive early post-operative outcomes. Additional research with longer-term follow-up will be required to confirm its efficacy. Full article

Background/Objectives: The Kocher–Langenbeck approach is widely used for surgical fixation of posterior acetabular wall fractures. While previous studies have focused on mechanical outcomes and the risk of post-traumatic osteoarthritis, the effects on peripheral circulation and neuromuscular recovery remain underexplored. This study aimed to evaluate dynamic changes in neuromuscular function and microcirculation following open reduction and internal fixation (ORIF) using this approach. Methods: A retrospective analysis was conducted on 34 patients (aged 23–75) treated for posterior acetabular wall fractures between 2014 and 2022. All patients underwent ORIF via the Kocher–Langenbeck approach. Assessments at 8 and 12 months postoperatively included electromyography (EMG), chronaximetry, and rheovasography (RVG). Asymmetry coefficients were calculated to quantify blood flow and functional differences. Results: At 12 months postoperatively, significant microcirculatory asymmetry persisted in the operated limb, with arterial and venous coefficients exceeding 25% (27.5% and 26.8%, respectively). EMG revealed sustained reductions in gluteus maximus and rectus femoris activity (asymmetry ~39%). Chronaximetry showed delayed nerve conduction recovery, particularly in the common peroneal nerve (AC = 44%). The femoral segment demonstrated the most severe impairment in both arterial inflow and venous outflow. Conclusions: ORIF via the Kocher–Langenbeck approach is associated with long-term disturbances in neuromuscular function and regional circulation. Further research should explore alternative surgical approaches (e.g., ilioinguinal, Stoppa) in prospective studies, assess vascular integrity using advanced imaging (e.g., contrast-enhanced ultrasound), and incorporate long-term functional outcomes. Studies on neurovascular-sparing techniques and optimised rehabilitation protocols may help reduce postoperative morbidity and improve recovery. Full article

Background: The high perimandibular approach (HPA) is a feasible surgical technique for open reduction and internal fixation (OR-IF) of mandibular condylar fractures, offering reduced complication rates. In this study, we retrospectively evaluated the treatment outcomes and complications associated with HPA use. Patients and Methods: Patients who underwent OR-IF for mandibular condylar fractures using the HPA at three hospitals in Shimane between June 2019 and March 2024 were included. Data collected included the mechanism of injury, AO classification of the fracture site, fracture type and mode, surgical duration, mouth-opening range at 6 months post-operatively, and peri- and post-operative complications. Results: A total of 42 patients (46 condylar fractures; 18 males and 24 females; mean age, 63.0 years) were included. The fracture pattern included dislocations in 18 cases (42.8%). The mean surgical duration was 75.0 min. Post-operative trismus occurred in 16 patients (38.1%) at 6 months. Longer surgical duration and dislocated fractures were significantly associated with post-operative trismus (p < 0.05). Conclusions: The HPA is safe and effective for managing mandibular condylar fractures. However, post-operative trismus may be influenced by longer surgical duration and fracture types, warranting further investigation and potential post-surgical management. Full article

Background: Fractures of the distal humerus (DHFs) represent challenging intra-articular injuries that are often followed by postoperative complications, most notably ulnar neuropathy. There is still debate regarding the best method of handling the ulnar nerve during open reduction and internal fixation (ORIF). Objective: The primary objective was to evaluate the incidence of postoperative ulnar neuropathy (UN) in patients who underwent open reduction and internal fixation (ORIF) for DHFs, comparing anterior transposition (AT) with in situ decompression (ISD) of the ulnar nerve. Additionally, we investigated the influence of AT on individuals presenting with preoperative UN. Methods: A retrospective review was conducted on 68 patients (26 females and 42 males; mean age: 46.3 years) who underwent ORIF for intra-articular DHF between 2018 and 2022. Patients were divided into two groups: anterior transposition (n = 14) and in situ decompression (n = 54). Ulnar neuropathy was evaluated using the modified McGowan classification, and radiographic outcomes were assessed with AO/OTA fracture classification. Results: Sixty-eight patients (26F/42M) were included. The mean age was 46.3 years (20–77 years) and the mean follow-up time was 53 months (36–76 months). The postoperative UN incidence was 30.8% (21/68). Neuropathy was significantly higher in the transposition group compared to in situ decompression (57.1% vs. 24%; p = 0.012). Olecranon osteotomy (36.3% vs. 20%; p = 0.042) and parallel plate configuration (33.3% vs. 12.5%; p = 0.037) were also associated with increased neuropathy risk. Among patients with preoperative ulnar neuropathy (n = 12), functional recovery was more favorable with transposition, where 71% experienced full resolution compared to 60% in the in situ group. Conclusions: Routine anterior transposition of the ulnar nerve during ORIF for DHF is associated with an increased risk of postoperative neuropathy and should be avoided in patients without preoperative symptoms. However, transposition appears beneficial in patients with pre-existing ulnar neuropathy. Surgeons should individualize ulnar nerve management to balance surgical risks and neurological outcomes. Full article

Open reduction and internal fixation (ORIF) for mandibular condyle fractures remains a controversial and challenging issue, with the exception of basal and low-neck fractures. Currently, there is a consensus that fractures causing irreparable malocclusion or dislocation, when the fracture line runs through the base or lower neck of the condyle, require ORIF. Due to the different characteristics of fractures, various surgical approaches and their modifications are available. The use of a minimally invasive intraoral approach during endoscope-assisted procedures is considered safer for the facial nerve and provides good esthetic results without facial scarring. This study aimed to compare two surgical approaches—retromandibular and intraoral—to examine post-operative outcomes and to guide surgical decision-making in the treatment of simple fractures of the base and low-neck condylar process of the mandible. Forty-nine patients (thirteen female, thirty-six male) were analyzed: eighteen were treated with the intraoral approach, and thirty-one with the retromandibular approach. There were no statistical differences in the duration of surgery, but intraoperative blood loss was significantly lower in patients treated endoscopically compared with those treated with an extraoral approach. Post-operative facial nerve and TMJ function were comparable in both groups. The endoscope-treated patients were at a higher risk of fracture non-union, but these findings should be considered with connection with the small sample size. The intraoral approach is a valuable option for basal or low-neck fractures but demands significant surgical experience due to its technical complexity. Full article

Background: There is no consensus on the “best” sequencing for open reduction and internal fixation (ORIF) in multiple mandibular fractures involving the condyle. Objective: The objective of this study is to compare the outcomes between a “top-to-bottom” and a “bottom-to-top” ORIF sequence for multifocal mandibular fractures at the author’s institution. Patients and Methods: A retrospective cohort study of adult dentate patients with multifocal mandibular fractures treated with ORIF. Inclusion criteria were the presence of at least one condylar neck or basis fracture and one “non-condylar” mandibular fracture. The authors evaluated the reduction quality using radiological and clinical parameters, including the ramus/condylar neck angle, the presence of a gap at the lingual aspect in the dentate area, dental occlusion, the need for a redo operation, and the need for postoperative occlusal fine-tuning. Results: A total of 31 patients had a bottom-to-top sequence, 4 patients had a substandard outcome, 4 had an acceptable outcome, and 23 achieved an ideal outcome. Ten patients underwent a top-to-bottom sequence; one patient had an acceptable outcome, and nine patients achieved ideal outcomes. There was no significant difference between sequencing and outcome. (p = 0.231). However, the odds ratio for a suboptimal outcome regarding the bottom-to-top surgery as opposed to the top-to-bottom surgery was 4.80 (CI: 0.53–236.07). In other words, the odds of having a suboptimal outcome and a bottom-to-top sequence were 4.80 times higher than having a suboptimal outcome and a top-to-bottom sequence. Conclusions: Based on our results, the top-to-bottom ORIF sequence appeared to be a favorable factor. Full article

The management of severely comminuted acetabular posterior wall fractures in young, active patients presents a significant surgical challenge. When anatomical open reduction and internal fixation (ORIF) is not feasible, primary total hip arthroplasty (THA) is often considered but is a suboptimal solution due to concerns over long-term implant survivorship and the inevitability of revision surgery. This single-patient technical note presents a novel joint-preserving technique for managing unreconstructible acetabular posterior wall fractures using with cement-augmented screw fixation via the Kocher–Langenbeck approach. A 28-year-old male sustained a left posterior hip dislocation with a comminuted acetabular posterior wall fracture involving >30% of the articular surface, alongside a tibial shaft fracture, following a high-energy motorcycle collision. Intraoperative assessment confirmed the posterior wall was unreconstructible, with six non-viable osteochondral fragments. A joint-preserving salvage procedure was performed. After debridement, a stable metallic framework was created using three screws anchored in the posterior column. Polymethylmethacrylate (PMMA) bone cement was then applied over this framework in its doughy phase, meticulously contoured to reconstruct the articular surface. The hip was reduced, and the tibia was fixed with an intramedullary nail. The patient was mobilized with weight-bearing as tolerated on postoperative day 3. At the 21-month follow-up, the patient reported no pain during daily activities and only mild discomfort during deep squatting. Radiographic and CT evaluations demonstrated a stable hip joint, concentric reduction, well-maintained joint space, and no evidence of implant loosening or osteolysis. Level of Evidence: V (Technical Note/single-patient Case report). For unreconstructible, comminuted fractures of the non-weight-bearing portion of the acetabular posterior wall in young patients, cement-augmented screw fixation offers a viable joint-preserving alternative to primary THA. This technique provides immediate stability, facilitates early mobilization, and preserves bone stock. While long-term outcomes require further study, this case demonstrates excellent functional and radiographic results at 21 months, presenting a promising new option for managing these complex injuries. Full article

Objectives: The optimal rehabilitation protocol following open reduction and internal fixation (ORIF) for Neer type-4 valgus impacted proximal humeral fractures (VIPHF) remains controversial. This study aimed to compare the long-term efficacy and safety of early active mobilization versus conventional rehabilitation in these patients. Methods: We conducted a retrospective cohort study at a single tertiary hospital involving 128 patients who underwent ORIF for Neer type-4 VIPHF between January 2018 and December 2022. Participants were divided into two groups based on the rehabilitation protocol received: the Early Active Activation (EAA) group (n = 64), which initiated controlled active exercises on postoperative day 1, and the Conventional Rehabilitation (CR) group (n = 64), which followed a delayed protocol. The primary outcome was the Constant–Murley score at 24 months. Secondary outcomes included scores at 3, 6, and 12 months, pain VAS scores, active range of motion, fracture healing time, and complications. Results: The EAA group demonstrated significantly superior outcomes, including a higher 24-month Constant–Murley score (88.7 ± 6.5 vs. 75.3 ± 9.2, p < 0.001), lower VAS scores at all time points (p < 0.001), greater range of motion (p < 0.001), and shorter fracture healing time (10.2 ± 1.8 vs. 12.5 ± 2.3 weeks, p < 0.001). Complication rates did not differ significantly (4.7% vs. 6.3%, p = 0.718). Conclusions: For patients with surgically stabilized Neer type-4 VIPHF, early active rehabilitation initiated on postoperative day 1 was associated with significantly improved functional outcomes, accelerated recovery, and a favorable safety profile. However, these findings should be interpreted with caution due to the retrospective design, single-center setting, and potential residual confounding. Further validation through prospective, multicenter studies is recommended. Full article

Background/Objectives: Radial head arthroplasty (RHA) and open reduction and internal fixation (ORIF) have emerged as predominant methods of surgical management for radial head fractures. The objective of this study was to evaluate national trends in management of radial head fractures among ABOS oral examination candidates and to compare complication rates between RHA and ORIF. Methods: A search of the American Board of Orthopaedic Surgery (ABOS) oral examination database identified radial head fractures treated with RHA or ORIF between 2003 and 2021 in patients 18 years or older. Results: RHA cases increased significantly from 2003–2021 (p < 0.001). Patients undergoing RHA were older (52.4 years vs. 42.9 years, p < 0.001) and predominantly female (60.8% vs. 45.7%, p < 0.001). Medical and surgical complications within 60 days were higher after RHA (2.9% vs. 1.6%, p = 0.012; 24.9% vs. 20.4%, p = 0.001), most commonly stiffness (10.8% vs. 7.1%, p < 0.001), nerve injury (3.3% vs. 2.7%, p = 0.26), and implant failure (3.4% vs. 2.4%, p = 0.064). Non-union or delayed union (0.5% vs. 2.5%, p < 0.001) was significantly higher after ORIF, and fracture (1.1% vs. 0.3%, p = 0.008) was significantly higher after RHA. The highest proportion of RHA to ORIF was performed by surgeons with shoulder and elbow fellowship training (p < 0.001). Conclusions: Among ABOS Candidates, RHA volume surpassed ORIF for radial head fractures in 2010. Surgical complication rates for radial head fractures are high at 60 days follow-up for both procedures. RHA is associated with higher complication rates, especially stiffness; however, similar reoperation and readmission rates suggest that RHA may have been selected for more complex injuries. Full article