Background: Tibial malrotation is a complication that is seen in approximately 30% of patients following locked intramedullary nailing. In this cohort study, we evaluated the hypothesis that tibial malrotation would lead to impaired functional outcomes. Methods: Patients with a unilateral tibial shaft fracture who were managed with intramedullary nailing between 2003 and 2007 were identified with use of ICD-10 (International Classification of Diseases, 10th Revision) codes. After institutional review board approval and written informed consent had been obtained, specific assessment of eligible patients was achieved with use of computed tomography, functional measures (Lower Extremity Functional Scale, Olerud-Molander Score, six-minute walk test), and physical examination. Measures were compared between patients with and without tibial malrotation (defined as tibial rotation of ≥10°) on imaging studies. Results: Of the 288 patients who were identified, 100 were eligible for the study and seventy consented to participate. The mean duration of follow-up (and standard deviation) for these seventy patients was 58 ± 11 months. Twenty-nine patients (41%) had tibial malrotation. Lower Extremity Functional Scale scores were similar between the groups with and without malrotation (mean, 70.8 ± 8.6 points compared with 72.6 ± 8.7 points; p = 0.41). The results for the other functional tests were also similar. Conclusions: Despite high rates of tibial malrotation following locked intramedullary nailing of isolated tibial diaphyseal fractures, this finding does not have a significant intermediate-term functional impact. Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Background: Thromboembolic events occur following musculoskeletal injury, and some have serious sequelae, including death. The purpose of this study was to determine the incidence of thromboembolic events and its relationship with risk factors in ambulatory patients with ankle fracture requiring open reduction and internal fixation. Methods: We conducted a retrospective chart review of 2478 patients who underwent open reduction and internal fixation of an ankle fracture at any one of three university hospitals between January 1, 1997, and April 30, 2005. One thousand five hundred and forty patients meeting the inclusion criteria and with complete records (minimum follow-up, six months) were identified. The median age of the patients at the time of surgery was forty-six years, and there was an equal proportion of male and female patients. Fracture types included 45% unimalleolar fractures, 31% bimalleolar, and 24% trimalleolar. Charts were reviewed to identify thromboembolic events, risk factors (neoplasia, hormone use, pregnancy, blood dyscrasia, history of a previous thromboembolic event, a current history of smoking, obesity, dyslipidemia, atherosclerotic vascular disease, or paralysis), and use of thromboprophylactic agents. A thromboembolic event was defined as symptomatic when deep venous thrombosis was confirmed with use of Doppler ultrasonography or when pulmonary embolism was confirmed with use of ventilation and perfusion scintigraphy or helical computed tomography. Results: The incidence of thromboembolic events was 2.99% (forty-six patients), with 2.66% (forty-one patients) involving a deep venous thrombosis and 0.32% (five patients) involving a nonfatal pulmonary embolism. There were no fatal pulmonary emboli recorded. The incidence did not differ among hospitals. Of the 1540 patients, 16.43% received thromboprophylaxis during their hospital stay and for six weeks (for the 10.78% taking low-molecular-weight heparin) or three months (for the 5.65% taking warfarin) after discharge without significantly modifying the incidence of thromboembolic events (2.56% vs. 2.37%, relative risk = 0.91). However patients with one or more risk factors had a greater risk of a thromboembolic event than did patients with no risk factors (3.59% vs. 2.38%, respectively; relative risk = 0.66). The use of thromboprophylaxis had no apparent impact on the occurrence of thromboembolic events in patients who did or did not have risk factors (3.68% vs. 3.55%, respectively; relative risk = 0.96). No significant correlation could be identified between the occurrence of thromboembolic events and fracture types, age, or sex. Conclusions: Clinically detectable thromboembolic events after surgical treatment of ankle fractures are uncommon and do not appear to be influenced by the use of thromboprophylaxis. Patients with risk factors appear to be at higher risk for these events, but there is a need for prospective studies to determine the efficacy of thromboprophylaxis after surgical treatment of ankle fractures. Level of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Patients that sustain anterior shoulder dislocation frequently experience recurrence. Immobilisation in external rotation has been proposed as a treatment that could lower this risk. There is a difference in recurrence rates between immobilization in internal or external rotation following a first-time anterior shoulder dislocation. Single-center randomized controlled trial. Fifty patients with a first episode of traumatic anterior dislocation were randomly assigned to immobilization in internal rotation (IR; 25 patients) or external rotation (ER; 25 patients) for three weeks. Clinical follow-up: 24 months. Additionally, some patients underwent a magnetic resonance imaging with intra-articular contrast (MR arthrography) within seven days after trauma, and then at three months. recurrence of dislocation. Secondary outcome: healing rate of labral lesions on MR arthrography. Follow-up rate in the IR and ER group was 92% and 96% respectively. Recurrence rate did not show a statistically significant difference overall (IR 47.8% vs. ER 29.2%; p=0.188), but showed a significant difference favouring ER in the 20-40 years subgroup (IR 50% vs. ER 6.4%; p=0.044). Labral lesions' healing rate was 46.2% vs. 60% (IR vs ER; p=0.680). The recurrence rate among those with healed vs. non-healed labrum (regardless of immobilization) was 11.1% vs. 77.7% (p=0.001). This study suggests that immobilization in ER compared to IR reduces the risk of recurrence after a first-time anterior shoulder dislocation in patients aged between 20 and 40 years. II, low-powered prospective randomized trial.