Objectives: To develop machine learning algorithms to determine predictive factors for the risk of postoperative surgical site infection in patients with high-energy lower extremity fractures. Design: Retrospective study. Setting: Level I trauma center. Patients/Participants: 1,579 patients with lower extremity fractures. Intervention: We evaluated different clinical and demographic variables to train four machine learning models (neural networks, boosted generalized linear model, naïve bayes, and penalized discriminant analysis). Performance was measured by the area under the curve score, Youdon’s index and Brier score. A multivariate adaptive regression splines (MARS) was used to optimize predictor selection. Main Outcome Measurements: Risk of postoperative surgical site infection Results: The final model consisted of 5 predictors. (1) Operating room time, (2) ankle region, (3) open injury, (4) body mass index and (5) age. The best performing ML algorithm had an area under the ROC curve, Youdon’s index and Brier score of 77.8%, 62.5% and 5.1%-5.6%, respectively. Conclusion: Machine learning models have gained significant importance in medicine and in the field of orthopaedic surgery. The proposed prediction model may assist surgeons in determining high risk factors for surgical site infections. Future investigations with external validations are required to establish the clinical role of this prediction model.

INTRODUCTION:Damage control orthopedics is associated with improved outcome in polytrauma patients. Although, some patients may benefit from early definitive fracture fixation. Therefore, adequate patient selection is key. According to Safe Definitive Surgery (SDS)-principles, intramedullary nailing (IMN) should be considered in cardiopulmonary compensated polytrauma patients. We hypothesized that instant IMN does not impair physiology nor inflammatory status in this case.

METHODS:A standardized porcine polytrauma (ISS=27) model was utilized including hypovolemic shock, liver and lung injuries as well as a unilateral femur fracture. Thereafter, animals were stabilized and cleared for intervention. Animals (n=12) were randomized for treatment and two groups were composed: Gr. IMN (instant IM-nailing) and Gr. ExF (external fixation). Cardiopulmonary status, metabolic and inflammatory parameters were monitored over 72hours and compared between groups.

RESULTS:All subjects were cleared for intervention. Before fracture fixation, hemoglobin levels decreased from 9.9 to 6.4 g/dl (P<0.001) and physiological parameters were comparable between groups. Post-interventional alterations of cardiopulmonary and metabolic status did not differ between the study conditions. After intervention, the neutrophil-to-lymphocyte ratio (NLR) increased from 0.89 to 2.99 (p<0.001). No differences between groups were seen, neither in systemic leukocyte numbers, neutrophil activation (Mac-1/L-selectin expression) or CRP-levels.

CONCLUSION:This experimental polytrauma study is the first to demonstrated that IM-nailing does not evoke a more intensified dysregulation of vital parameters or immune homeostasis than external fixation does. This suggests that instant IM-nailing is a feasible treatment option in patients with rapid cardiopulmonary compensation in polytrauma. These experimental findings further underline the relevance of Safe Definitive Surgery-principles.

INTRODUCTION: Extra-articular fractures of distal tibia present unique problems, since the distal tibia is mostly subcutaneous and has thin soft tissue cover. The choice of internal fixation modalities for such fractures (AO 43A3), remains controversial. There is limited literature comparing the stability of these modalities. Hence we conducted a biomechanical study for such a fracture stabilized by four different constructs: interlocking nail, anteromedial plate, anterolateral plate and posterior plate. METHODOLOGY: A biomechanical study on human cadaveric tibiae was undertaken. A total of 4 groups were tested; 8 bones in each group. These four groups underwent 3-point bending tests in antero-posterior (AP) and medio-lateral (ML) planes. Parameters evaluated were Bending stiffness, peak fracture gap angle and neutral zone. RESULTS: Intramedullary nails had the maximum biomechanical stability, in terms of higher bending stiffness, smaller peak fracture gap angle and smaller neutral zone. Statistically, a significant difference was noted in the AP bending stiffness of anterolateral plate versus intramedullary nail (lower with plate) and ML neutral zone of anterolateral plate versus intramedullary nail (higher with plate). CONCLUSION: Based on our results, we concluded that anterolateral plate had the lowest stability as the plate position on tibia is neither strictly anterior nor lateral, a significant toggle can be expected in both the AP and ML planes. The nail being an intramedullary implant provides high biomechanical stability to the construct. If at all plating is required, we can recommend both anteromedial and posterior plating as biomechanically sound options

Objective:The aim of the present study was to assess the reliability and repeatability of the commonly used Luo’s Three Column Classification with New Schatzker Classification.Materials and methods:Three observers of various levels of experience classified 200 Proximal tibia fractures. The same observers repeated the classification of the same fractures after an interval of 8 weeks. Inter- and intra observer variability was assessed using the mean Kappa Coefficient and mean percentage of agreement.Results:For Inter observer reliability, the mean Kappa coefficient values for Luo’s were 0.54,0.59 and 0.61 respectively and for New Schatzker Classification being 0.91,0.79 and 0.86 respectively. The mean percentage of agreement being 0.86,0.88 and 0.88 for Luo’s classification and 0.97,0.91 and 0.90 respectively. For intra observer variability , Kappa values were 0.92,0.81 and 0.74 for New Schatzker classification and 0.58,0.36 and 0.47 for Luo’s classification The mean percentage of agreement were 0.83,0.74 and 0.82 for Luo’s classification and 0.97,0.93 and 0.91 for New Schatzker classification.Conclusion:Our study concludes that both Luo’s three column classification and New Schatzker classification are accurate and surgeons need to understand them and implement to reduce variability over time.The inter observer reliability and intra observer reproducibility was found to be higher with New Schatzker classification as compared to Luo’s Three column classification. New Schatzker classification was found to be more accurate in knowing the fracture pattern and knowing the spatial location. Our study also concludes that observer with more years of experience had better agreement (intra and inter observer and had higher Kappa coefficient values.

Background: Distal femoral fractures are serious injuries. Treatment of such fractures has been controversial. The aim of this study was to compare the results of retrograde Nailing versus Plating technique in distal femoral fractures regarding alignment both radiologically and clinically. Patients and methods: we enrolled 36 patients with distal femoral fractures divided into two groups; Group A treated by RGN and group B treated by Plating technique. Clinical and radiological measurements of limb alignment, MAD, mLFDA, MPTA, pain, evidence of infection, deformities, and decrease of knee motion were performed to evaluate the outcomes after surgery in both techniques. Results: The MAD in normal limb was 4.66±1.32 in retrograde nail group while it was 4.88±1.58 in plating group, the MAD in fractured limb was 5.38±1.89 in retrograde nail group while it was 6.48±2.31 in plating groupwith no significant difference between groups and no significant difference between fractured and normal limb in both groups. Complications including infection were in 2 patients in group (A) and 4 patients in group (B);knee pain in six patients of group (A) and three patients in group (B);reduction range of knee motion was found in three patients in group (A) and seven patients in group (B); delayed union was 1 patient in group (B). The only significant difference was found is reduction range of motion which is in group (B), while there no significant difference regarding the other complications between the two groups.Conclusions: better outcomes in distal femoral nails group than plates .Keywords: Nailing; femur fracture; plating

Introduction: The purpose of this study was to evaluate the relationship between femoral anteversion and gait cycle analysis following the treatment of distal extraarticular femoral fractures.Methods: Extra-articular distal femoral fracture patients who were admitted to the hospital between May 2019 and May 2021 were evaluated retrospectively. A total of 52 patients were included in the study. 32 patients treated with femoral intramedullary nailing were included in group 1, and 20 patients treated with the Less Invasive Stabilization System were included in group 2. Age, gender, operation side, follow-up time, presence of anterior knee pain, WOMAC knee score, femoral anteversion, callus formation time, and static and dynamic gait cycle analysis were evaluated in the study.Results: It was determined that the static forefoot pressure value increased by 7% regardless of the surgical method after extra-articular distal femur fracture (P=0.045). In addition, when the femoral anteversion angle of patients who were operated on for all extra-articular distal femur fractures was analyzed, malrotation of > 10 degrees was found in 26.9% of the patients, and malrotation of >15 degrees was found in 19.2% of the patients.Conclusion: A 7% increase in static forefoot pressure was found in the gait cycle analysis of patients operated on for extra-articular distal femur fractures. The authors think that malrotation and foot load distribution that develops after the treatment of distal femur fractures affects the development of chronic forefoot pain and arthrosis in the long-term follow-up.Keywords: Distal femur fracture, Gait cycle analysis, femoral anteversion, functional score, LISS plate, intermedullary nailing

Introduction–Open fractures are complex injuries requiring multidisciplinary input associated with significant morbidity and mortality. Minimal data is available on the clinical outcome of open ankle fracture management in patients above 70. The primary aim of this study was to evaluate the clinical outcome following an open ankle fracture in patients above 70 years of age. Our secondary aim was to look at predictors of poor outcomes in this age group. Material and Methods – Following local audit department registration, 22 years of prospective collated data from an online electronic database in a District General Hospital was assessed. Results – There were 37 patients greater than 70 years of age who underwent surgical intervention after an open ankle fracture. Sixteen patients developed wound infections (16/37; 43%). Superficial wound infections (n=8) were managed without surgical intervention. Deep wound infections (n=8) required a median of 3 (range 2- 9) surgical interventions, with n=4 requiring multiple washouts; and one patient having metalwork removed. VTE incidence was 5.4% (2/37) during the patient’s hospital stay. The 30-day mortality rate in our study was 8.1% (3/37), with mortality at one year 19% (7/37). The 10-year mortality rate was 57% (21/37). The presence of a cardiac history is predictive of wound complications. (p = 0.045). Age, number of operations, and diabetic history increase the length of stay. Conclusion –Open ankle fractures in patients over 70 years of age lead to a 1 in 5 chance of requiring further surgical intervention (~21% risk of deep wound infections).

Introduction: Full thickness traumatic soft tissue defects are difficult to treat. Mesh graft transplantation alone causes frequently instable scar ulcerations with need for revision surgery. For that reason, in our study we used a collagen-elastin scaffold combined with mesh graft to improve wound healing and to reduce scar ulcerations and revision surgery. Patients and methods: In the period 3.2013 – 3.2020 45 trauma wounds from different types of injuries were treated with a collagen-elastin scaffold (Matriderm®, MD) augmented mesh graft. The wounds were separated in three subgroups (soft tissue injury (ST), closed fracture with soft tissue injury (F), open fracture (OF). Outcome variables were recurrence of wound defects with revision surgery and reduction of bacterial strains. For statistical analysis Student’s t-test, ANOVA, Mann-Whitney U test, and Pearson’s chi-squared test was used. Results: For the rate of recurrence there was no significant difference between the three groups (F: 0%; OF: 11.1%; ST: 9.5%). The duration of VAC / NPWT therapy for preconditioning the wounds, significantly differed between the groups (F: 10.8 days; OF 22.7 days; ST: 12.6 days (p<0.05)). With NPWT a clinically significant reduction of bacterial burden was achieved (bacterial shift (mean (SD), F: -2.25 (1.89); OF: -1.9 (1.37); ST:-2.6 (2.2)). Conclusion: Augmentation of mesh split-thickness graft with a collagen-elastin scaffold (MD) improves the wound healing of trauma soft tissue defects. The uptake rates are about 90%. NPWT leads to a relevant reduction of bioburden and plays therefore an important role in preconditioning of full thickness wounds.

Introduction:The purpose of this study is to evaluate the impact of prolonged extrication time and the time to fasciotomy applications on amputation requirement by giving quantitative and cut-off values.Methods: In this single-center study, the clinical records of patients with musculoskeletal injuries due to the 6 February Kahramanmaraş earthquake in Turkey were retrospectively reviewed. All patients who underwent fasciotomy or amputation regardless of age and gender were included in the study. In this study, 163 extremities of 140 patients who met the inclusion criteria were evaluated.Results: The mean age was 29 of earthquake victims included in the current study and and the gender distribution of the patients is almost equal. The mean extrication time in the current study was 36.49 hours. 8 (4.27%) fasciotomies of 7 (6.36%) patients underwent early fasciotomy (<12 hours) and 50 (26.7%) fasciotomies of 38 (34.5%) patients performed after 36 hours in this study. We performed 87 amputations of 65 patients and transtibial amputation (41.3%) was the most common type. Delayed fasciotomies performed after 45.5 hours increase 28.48-fold the amputation requirement. The patients with extrication time longer than 23 hours was associated with a 8.8-fold higher risk of amputation. There was no statistically significant difference in the timing of fasciotomy between patients who received dialysis and those who did not.Conclusions: We believe that knowledge of the relationship between earthquake survivors' prognosis and time of extrication, as well as the impact of fasciotomy timing on extremity loss, is essential for a more successful treatment management in future disasters.

Introduction: femoral nonunion following intramedullary nailing is uncommon. The standard treatment is exchange nailing. The alternatives include dynamization of the nail, internal fixation with plates and screws, bone grafting. We describe the application of Ilizarov fixator over an intramedullary nail to successfully heal femoral nonunion following intramedullary nailing. Placement of an Ilizarov external fixator over an intramedullary nail has been previously described in detail in bone lengthening. Patients and methods: 15 patients with femoral nonunion with an intramedullary nail in situ were treated by this technique. There were three female and twelve male patients ranging in age from 18 to 54 years. The nonunion were classified into hypertrophic in six cases, oligotrophic in six and atrophic three. The Ilizarov fixator was applied over the nail as a closed procedure in all patients. No bone graft was used. Results: union was achieved in 13 patients. Nonunion in two patients. The main time of union was 5.9 months. Deep infection reported in one case although superficial pin-track infections occurred in all patients. Discussion: Using Ilizarov external fixation over an intramedullary nail provides excellent mechanical stability and allows manipulation of the nonunion. The use of Ilizarov external fixation over a preexisting nail is a good alternative treatment option of femoral nonunion following intramedullary nailing.
Key words: femoral, intramedullary nail, nonunion, Ilizarov

Introduction: Tibia lengthening is a challenging orthopaedic procedure that can significantly improve the quality of life for patients with limb-length discrepancy. The Ilizarov technique has been used successfully in tibia lengthening procedures, with an intramedullary nail used to stabilize the bone during the lengthening process. This study aims to evaluate the efficacy and safety of tibia lengthening over an intramedullary nail with Ilizarov technique. Methods: A retrospective review of patients who underwent tibia lengthening over an intramedullary nail with Ilizarov technique was conducted. The study included patients with limb-length discrepancy due to various etiologies. Results: A total of 7 patients (5 males and 2 females) with a mean age of 26 years (range: 15-45 years) were included in the study. The mean lengthening achieved was 5.6 cm (range: 3-8 cm) with a mean duration of lengthening of 132 days (range: 85-190 days). The mean healing index was 40.5 days/cm (range: 20-70 days/cm). There were no cases of non-union or deep infection, and only two cases of pin site infection were reported, which were managed with oral antibiotics. Conclusion: Tibia lengthening over an intramedullary nail with Ilizarov technique is an effective and safe method for treating limb-length discrepancy. The technique allows for precise control of the lengthening process, leading to a high success rate with minimal complications. This study highlights the importance of proper patient selection, meticulous surgical technique, and careful postoperative management to achieve optimal outcomes.

Introduction: Even open reduction and plate fixation (ORPF) is the popular surgical method for humeral diaphyseal fractures (HDFs), delayed union remains a concern and the associated risks had seldom been reported. Thus, we aimed to evaluate the delayed union risks in patients following ORPF for HDFs. Method: 88 consecutive patients with HDFs (AO/OTA A and B fractures) underwent ORPF between 2017 and 2020 were retrospectively reviewed. Union was defined as presence of cortical bridging of at least three out of four cortices based on standard radiographs and pain-free activity. After excluding incomplete records, union achieved within 6 months postoperatively is timely (n=45), delayed (n=20) for 6 to 12 months, and nonunion (n=10) for ≥12 months. All demographic and radiological outcomes were recorded. Results: Compared with the timely group, the delayed group showed the significant difference in AO classification, larger postoperative fracture gap (1.6±1.1 vs 1.0±1.1 mm), less use of interfragmentary screw, higher complication rate (45.0% vs 17.8%), union time (8.5±2.1 vs 4.0±1.3 months] and higher secondary union pattern (90.0% vs 26.7%; p<0.05, all). Following the Logistic regression analysis, only the use of interfragmentary screw and the presence of postoperative complications were significantly associated with delayed union (adjusted odds ratio: 0.14 and 5.82, respectively). Conclusion: In ORPF for HDFs, there was 90% secondary union pattern in the delayed group even the compression technique was applied in osteosynthesis. The feasible application of interfragmentary screw reduce the risk of delayed union. In contrast, the postoperative complication induces delayed union.

Introduction: This prospective randomized study compared the effectiveness of Masquelet technique (MT) versus Ilizarov bone transport (IBT) for infected gap non-union of bones. Methods: Infected nonunion of tibia who had treated either by IBT (Group I, 15 patients) or by MT (Group II, 15) were included, while periarticular nonunion, pathological fractures and associated bone disorders, debilitating systemic disease were excluded. They were evaluated clinically with union, deformity, infection and leg-length discrepancy while functional outcomes were measured in limping, joint contracture, soft tissue dystrophy, pain and inactivity. Results: Non- union sites at proximal, middle and distal leg were (7, 2, 6) and (3, 8, 4) in Gp I and Gp II respectively, predominantly males (90%). Overall mean bone gap was 4.385 cm (3-6 cm) and 3.667 cm (2-6 cm) in Group I and Group II, respectively, (p,0.06). Mean gain in length with distraction osteogenesis was 4.308 cm (3-6 cm) in Group I and length maintained of mean 3.458 cm in Group II (p, 0.057) without corticotomy. Average fixator period was 10.88 months (6.5-15) and 16.42 months (13-18), in Group I and Group II respectively (p, <0.001). The bone outcomes were in groups I and II [excellent (53.84% vs. 33.3%), good (38.46% vs. 41.66%), and poor (7.69% vs. 25.0%)] (P, 0.74). Similarly, Functional results were [excellent (69.2% vs. 16.7%), good (23.1% vs. 58.3%) and poor (7.7% vs. 16.7%) in group I and Group II, respectively (p, 0.26). The functional and radiological results were comparable but more reliable in IBT than MT group.