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Background: The morphology and classification of posterior malleolus (PM) fractures remain controversial. An increasing number of studies have found that merely focusing on the fragment size does not lead to a satisfactory prognosis. This study aimed to demonstrate the fracture line and comminution zones of PM fractures using computed tomography (CT), in order to provide insights into the injury mechanism of PM fractures. Methods: We retrospectively reviewed the data of 95 patients with PM fractures between 2013 and 2018 at a level 1 trauma center. The CT data of the PM of the patients were reconstructed using software. Images of all patients were superimposed together, and drawn as a heat map of the fragments and line distributions of PM fractures. Results: Our study included 66 type I, 19 type II, and 10 type III PM fractures according to the classification of Haraguchi. In the single-fragment fracture group, the fracture lines were mainly concentrated in the posterolateral tibial tubercle area (Volkmann’s tubercle) and a larger tubercle area involving the tibialis posterior groove. In the multifragment fracture group, there were 10 (43.5%) patients with a 2-fragment pattern and 13 (56.5%) patients with a compressive-fragment pattern. Conclusion: According to the fracture map and previous studies on the syndesmosis, our study provides a different understanding of the pathomechanisms of ankle injuries compared with previous classifications of PM fractures. Level of Evidence: Level III, retrospective study.

This article describes the independent factors that affect kyphotic angle reduction in the treatment of osteoporotic vertebral compression fractures with kyphoplasty. Between January 2008 and September 2011, one hundred twenty-six patients with a single-level osteoporotic compression fracture who underwent kyphoplasty were evaluated for a minimum of 1 year postoperatively. Nine independent variables related to patient characteristics (age, sex, bone mineral density [BMD], and body mass index), fracture characteristics (fracture level, fracture age, and preoperative kyphotic angle), and surgical variables (total injected cement volume and cement leakage) were assessed. Kyphotic angle reduction was the dependent variable. Univariate and multivariate linear regression analyses were used to determine the factors associated with kyphotic angle reduction.Significant improvements occurred in mean anterior vertebral height variation, middle vertebral height variation, kyphotic angle, and visual analog scale and Oswestry Disability Index scores immediate postoperatively and at final follow-up compared with the preoperative values. Univariate analyses indicated correlations between kyphotic angle reduction with BMD, fracture age, preoperative kyphotic angle, and cement volume. The final multiple linear regression model resulted in a formula that accounted for 23.3% of the variability in kyphotic angle reduction: preoperative kyphotic angle (b=0.260; P=.002), BMD (b=-0.249; P=.004), and fracture age (b=-0.226; P=.009). Kyphoplasty is a safe and effective treatment for osteoporotic compression fractures.

Abstract. The glycoprotein, von Willebrand factor (VWF) is a carrier protein for factor VIII. When bound to platelets and the extracellular matrix, it promotes aggregation or adhesion of platelets to areas of vascular damage. A disintegrin and metalloproteinase with thrombospondin motif, member 13 (ADAMTS13) cleaves between the tyr1605 and met1606 residues in the central A2 domain of VWF decreasing its activity. The levels of ADAMTS13 and VWF are positively correlated with the risk of developing thrombosis and inversely correlated with the risk of bleeding. A total of 93 patients were observed, who underwent total hip arthroplasty or total knee arthroplasty. Blood samples were collected preoperatively and on postoperative days (PODs) 1, 2, 3, 5 and 7. Plasma levels of the ADAMTS13 antigen were determined using western blotting. The proteolytic activity was validated with the FRETS-VWF73 assay. VWF:Ag and VWF:RCo activity were measured using an enzyme-linked immunosorbent assay. Prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), antithrombin III and plasma fibrinogen levels were measured on a Sysmex ® CA500 system with corresponding reagents. D-dimer levels were measured on a STA-R fully automated coagulation analyzer. The results demonstrated that, the levels of VWF antigen and activity in the patient increased from postoperative day (POD) 1. By contrast, the level of the ADAMTS13 antigen and its activity in the patients decreased significantly. Starting on POD1, fibrinogen and D-dimer levels increased. No significant changes were observed in PT, APTT and TT. It was concluded that the ADAMTS13 and VWF levels exhibited a marked association with thrombosis risk. The levels of ADAMTS13 and VWF may be potentially useful as markers for predicting thrombotic complications following arthroplasty and inhibiting the activity of VWF may be a novel prophylaxis to reduce postoperative deep venous thrombosis and pulmonary embolism. IntroductionHemostasis is a physiological host defense mechanism focused on the arrest of bleeding following vascular injury. It preserves vascular integrity and prevents excessive blood loss. Arrest of bleeding requires rapid formation of hemostatic plugs at sites of vascular injury to prevent exsanguination. This depends on a complex series of regulatory pathways that activate the platelets and the coagulation system. By contrast, excessive activation of the coagulation system may lead to thrombosis (1).Total hip arthroplasty (THA) and total knee arthroplasty (TKA) have been performed with increasing frequency in previous years. In patients undergoing THA or TKA, different patterns of altered venous hemodynamics and hypercoagulability have been identified, thus the rate of distal deep venous thrombosis (DVT) has increased (2). In addition, the risk of venous thrombosis embolism (VTE) in THA and TKA is among the highest for all surgical procedures (3). VTE can be treated, however when left untreated it may be fatal (4).Thrombosis and hemostasis are dependent ...

Hyaluronic acid injection is becoming a popular way for penile augmentation. However, only few studies and follow-ups have investigated the various complications of hyaluronic acid injection and their corresponding management. In this study, a total of 230 patients who had penile augmentation with hyaluronic acid injection from January 2018 to December 2019 were examined on follow-up for penile girth, complications, and their corresponding management. At 1-month, 3-month, and 6-month postoperative follow-ups, the penile circumference had increased by 2.66 ± 1.24 cm, 2.28 ± 1.02 cm, and 1.80 ± 0.83 cm, respectively. During the entire 6-month follow-up, 4.3% had complications such as subcutaneous bleeding, subcutaneous nodules, and infection. There were no systemic or local allergic reactions among all the patients. All complications were treated accordingly, and no further deterioration or severe sequelae were observed. Although complications of hyaluronic acid injections are mild and rare, these may affect the patient's satisfaction postoperatively. Preoperative redundant prepuce may increase the incidence of penile edema or postoperative gel migration. Standardization of the surgery protocol and elucidation of the effects of other injection parameters are still lacking. Nevertheless, it still highlights the importance of preoperative preparation and surgical technique.

There is no well-established procedure for the management of small penis syndrome (SPS), especially when psychological interventions fail. This study aimed at systematically evaluating the physical and psychological benefits of penile augmentation (PA) using injectable hyaluronic acid (HA) gel. Thirty-eight patients receiving PA with HA gel from January 2017 to March 2020 were included and followed up for 1 year. Penile size, erectile function, and psychological burden measured by the Index of Male Genital Image (IMGI), Index of International Erectile Function (IIEF), and Beliefs about Penis Size (BPAS), respectively, were assessed at the beginning and at 1, 3, 6, and 12 months postinjection. The volume of HA gel injected was 21.5 ± 3.7 ml. Compared to baseline data, flaccid penile girth and length significantly increased by 3.41 ± 0.95 cm ( P < 0.01) and 2.55 ± 0.55 cm ( P < 0.01) at the 1 st month postinjection, respectively. At the endpoint, despite attenuations, statistically significant improvements in flaccid penis size were still obtained, namely 2.44 ± 1.14 cm in girth ( P < 0.01) and 1.65 ± 0.59 cm in length ( P < 0.01). Similarly, erectile penile girth statistically increased by 1.32 ± 1.02 cm ( P < 0.01) at the 1 st month but were only 0.80 ± 0.54 cm bigger than baseline ( P < 0.01) at the endpoint. At the 1 st month, the average score of IMGI and the mean score of IIEF statistically increased by 46.2 ± 10.5 ( P < 0.01) and 7.6 ± 6.2 ( P < 0.01), respectively; the score of BAPS significantly decreased by 18.3 ± 4.5 ( P < 0.01). These alterations remained steady during follow-up. Considering the significant penile size improvement, lasting psychological benefit, and low complication rate, PA with HA might serve as an appropriate alternative for patients with SPS.

Background Intraarticular impacted fragment (IAIF) of posterior malleolar fractures has been reported by a few studies. However its location, morphology, and the correlation of posterior malleolar fractures have not been described in detail. The aim of this study was to describe the morphology of IAIF in posterior malleolar fractures, to analyze the related factors between IAIF and posterior malleolar fragments, and explore the treatment of IAIF. Materials and methods Between January 2013 and December 2018, 108 consecutive patients with unilateral posterior malleolar fractures were managed in our hospital. Basic demographic and computed tomography (CT) data were collected and classified by Lauge–Hansen, OTA/AO, Haraguchi, and Mason classification. Additional radiographic data, including the length and area of posterior malleolar fragment, IAIF, and stable tibial plafond were measured. The location of IAIF was described, and involvement of the fibular notch and medial malleolus was also observed. Statistics were analyzed based on univariate analysis (Chi-square test, t-test, Mann–Whitney U test, Fisher’s test) and Spearman’s correlation test. Results Among the 108 cases of posterior malleolar fractures, 75 (69.4%) were with IAIF and 33 (30.6%) cases were without. There were 74 (68.5%) females and 34 (31.5%) males, and the average age of the patients was 49 years (18–89 years). The average LIFN/(LIFN + LSFN) [length of involving fibular notch/(length of involving fibular + length of stable notch fibular notch)] was 32.9% (11.6–64.9%). The APMF/(APMF + ASTP + AIAIF) [area of posterior malleolar fragment/(area of posterior malleolar fragment + area of IAIF + area of stable tibial plafond)] and AIAIF/APMF (area of IAIF/area of posterior malleolar fragment) were 13.1% (0.8–39.7%) and 52.6% (1.2–235.4%), respectively. Involvement of medial malleolus (fracture line extended to medial malleolus, P = 0.022), involvement of fibular notch (P = 0.021), LIFN/(LIFN + LSFN) (P = 0.037), LMPMF (P = 0.004), and APMF were significantly related to the occurrence of IAIF. Conclusion Our research indicates a high incidence of IAIF in posterior malleolar fractures. All IAIFs were found in posterior malleolar, and the most common location was within the lateral area A. Posterior malleolar fracture lines that extend to medial malleolus or fibular notch herald the incidence of IAIF. LIFN/(LIFN + LSFN), LMPMF and APMF are also associated with the incidence of IAIF. CT scans are useful for posterior malleolar fractures to determine the occurrence of IAIF and make operational plans. Operation approach selection should be based on the morphology of posterior malleolar fragments and the location of IAIF. Level of evidence Level III, retrospective case analysis.

The C2 dumbbell-shaped PNSTs were closely related to the suboccipital venous structures. Understanding and proper management of these venous structures is critical for reduced bleeding and successful surgery.