OBJECTIVES: This study aims to analyze the biomechanics of three kinds of rigid internal fixation methods for condylar head fractures. METHODS: A three dimensional finite element model of the normal mandible was constructed. It was then used to prepare condylar head fracture finite element model and three kinds of rigid internal fixation finite element model (unilateral tension screw, bilateral tension screw, tension screw+titanium plate). The mechanical characteristics and changes of the mandible condyle under the same mechanical conditions were compared among the three different rigid internal fixation methods. RESULTS: The maximum equivalent stress and displacement of the non-free end of condyle under the rigid internal fixation method of unilateral tension screw were 71.03 MPa and 4.72 mm, respectively. The maximum equivalent stress and displacement of the free end of condyle were 78.45 MPa and 4.50 mm, respectively. The maximum stress of fracture suture was 3.27 MPa. The maximum equivalent stress and displacement of the non-free end of condyle under the rigid internal fixation method of bilateral tension screw were 70.52 MPa and 4.00 mm, respectively. The maximum equivalent stress and displacement of the free end of condyle were 72.49 MPa and 3.85 mm, respectively. The maximum stress of fracture suture was 2.33 MPa. The maximum equivalent stress and maximum displacement of the non-free end of condyle under the rigid internal fixation method of tension screw+titanium plate were 67.26 MPa and 2.66 mm, respectively. The maximum equivalent stress and maximum displacement of the free end of condyle were 69.66 MPa and 2.50 mm, respectively. The maximum stress of fracture suture was 2.18 MPa. CONCLUSIONS The tension screw+titanium plate rigid internal fixation method is the most conducive to biomechanical distribution for condylar head fractures.
Fracture Fixation, Internal/instrumentation* ; Mandibular Condyle/surgery* ; Biomechanical Phenomena ; Bone Screws ; Finite Element Analysis ; Humans ; Mandibular Fractures/surgery* ; Bone Plates ; Titanium ; Stress, Mechanical

OBJECTIVE: To investigate the difference of effectiveness between medial-lateral approach and posteromedian approach in the release of elbow stiffness after distal humeral fracture surgery. METHODS: A retrospective analysis was conducted on the clinical data of 41 patients with elbow stiffness following medial and lateral plate fixation for distal humeral fractures, admitted between January 2021 and June 2023 and meeting selection criteria. Patients were divided into the medial-lateral approach release group (study group, 20 cases) and the posteromedian approach release group (control group, 21 cases) based on surgical approach. Baseline data including age, gender, affected side, body mass index, disease duration, and preoperative extension angle, flexion angle, range of motion, visual analogue scale (VAS) pain score, Mayo elbow performance score, ulnar nerve symptoms, and heterotopic ossification showed no significant difference between groups ( P>0.05). The operation time, intraoperative blood loss, and complication incidence were recorded and compared between groups. Clinical effectiveness was evaluated using pre- and postoperative Mayo score, VAS score, elbow extension/flexion angles, and range of motion on the affected side. Statistical analysis focused on changes in these indicators relative to preoperative values. RESULTS: There was no significant difference in operation time and intraoperative blood loss between the two groups ( P>0.05). Patients in both groups were followed up 15-36 months, with a mean of 23.8 months; there was no significant difference in the follow-up time between the two groups ( t=-1.542, P=0.131). In the control group, 1 patient had obvious subcutaneous hematoma and 5 patients had poor wound healing within 2 months after operation, all of which were cured by symptomatic treatment, while no related complications occurred in the study group, there was a significant difference in poor wound healing incidence between the two groups ( P<0.05). At last follow-up, 2 patients in the study group and 3 patients in the control group had mild symptoms of ulnar nerve numbness, and there was no significant difference in the incidence of ulnar nerve symptoms ( P>0.05). All patients had no recurrence or new onset of heterotopic ossification, no skin necrosis or reoperation due to complications. At last follow-up, elbow extension angle, flexion angle, flexion-extension range of motion, VAS score, and Mayo score significantly improved in both groups when compared with the preoperative ones ( P<0.05). There was no significant difference between the change values in elbow extension angle and VAS score between the two groups ( P>0.05); the change values in flexion angle, range of motion, and Mayo score in the study group were significantly better than those in the control group ( P<0.05). CONCLUSION The medial-lateral approach can release the elbow stiffness and concurrently remove the medial, lateral, or posterior lateral plates. The incision minimizes disruption to rehabilitation exercises and reduces complications like inadequate wound healing, ultimately leading to improved treatment outcomes.
Humans ; Humeral Fractures/surgery* ; Male ; Female ; Retrospective Studies ; Elbow Joint/physiopathology* ; Middle Aged ; Fracture Fixation, Internal/adverse effects* ; Range of Motion, Articular ; Adult ; Bone Plates ; Postoperative Complications/surgery* ; Treatment Outcome ; Aged ; Humeral Fractures, Distal

OBJECTIVE: To compare the effectiveness of using a composite loop plate to reconstruct the coracoclavicular ligament around the coracoid process and using a clavicular hook plate for fixation in treatment of Rockwood type Ⅲ acute acromioclavicular joint dislocation. METHODS: A retrospective analysis was conducted on the clinical data of 60 patients with Rockwood type Ⅲ acute acromioclavicular joint dislocation who were admitted between June 2022 and September 2023 and met the selection criteria. Among them, 30 patients were treated with the composite loop plate to reconstruct the coracoclavicular ligament around the coracoid process (loop plate group) and 30 with clavicular hook plate fixation (hook plate group). There was no significant difference in baseline data between the two groups ( P>0.05), including gender, age, injured side, cause of injury, disease duration, preoperative visual analogue scale (VAS) score for pain, and Constant-Murley score. The incision length, operation time, length of hospital stay, and the occurrence of complications during follow-up were recorded. The Constant-Murley score and VAS score were used to evaluate shoulder joint function and pain, and the differences (change values) of the indicators between before operation and at 6 months after operation were calculated for inter-group comparison. In the loop plate group, the coracoclavicular distance (CCD) on the anteroposterior X-ray films of the acromioclavicular joint was measured at 1 day and 6 months after operation to assess the loss of acromioclavicular joint reduction. RESULTS: The incision length of the loop plate group was significantly shorter than that of the hook plate group ( P<0.05). There was no significant difference in the operation time and the length of hospital stay between the two groups ( P>0.05). All incisions healed by first intention after operation. All patients were followed up 12-18 months (mean, 16.3 months). There was no significant difference in the follow-up time between groups ( P>0.05). The Constant-Murley scores and VAS scores of both groups significantly improved at 6 months after operation when compared with those before operation ( P<0.05); the differences in the change values of the two indicators between groups were significant ( P<0.05). The CCD of the loop plate group were (10.40±0.83) mm at 1 day and (10.70±0.68) mm at 6 months and no repositioning loss was observed. Three cases in the hook plate group had residual shoulder joint pain after operation. The difference in the accidence of complications between groups was not significant ( P>0.05). CONCLUSION For Rockwood type Ⅲ acute acromioclavicular joint dislocation, compared with the clavicular hook plate fixation, the composite loop plate for reconstructing the coracoclavicular ligament around the coracoid process has the advantages of simple operation, safety, minimally invasive, good functional recovery, and fewer complications. Moreover, it avoids the need for a second surgery to remove the internal fixation device, and the patient acceptance and satisfaction are higher.
Humans ; Acromioclavicular Joint/surgery* ; Bone Plates ; Male ; Retrospective Studies ; Female ; Adult ; Ligaments, Articular/injuries* ; Joint Dislocations/surgery* ; Coracoid Process/injuries* ; Treatment Outcome ; Middle Aged ; Plastic Surgery Procedures/instrumentation* ; Fracture Fixation, Internal/instrumentation* ; Young Adult ; Clavicle/surgery*

OBJECTIVE: To investigate the effectiveness of three-dimentional (3D) printed personalized guide plate-assisted wrist arthroscopic repair for Palmer type ⅠB triangular fibrocartilage complex (TFCC) injury. METHODS: A retrospective analysis was conducted on the clinical data of 20 patients with Palmer type ⅠB TFCC injuries admitted between January 2023 and March 2024 who met the selection criteria. Among them, 13 were male and 7 were female; ages ranged from 23 to 35 years, with a mean age of 30.3 years. All patients had a history of trauma, 12 cases involved falls and 8 cases involved sprains. All patients demonstrated a positive "piano key sign". MRI revealed deep ulnar-side tears of the TFCC. Conservative treatment for 6 weeks yielded poor or no clinical improvement. The interval from injury to surgery ranged from 2 to 9 months, with a mean of 5.0 months. Patients underwent wrist arthroscopic repair assisted by 3D printed personalized guide plate. Functional recovery was assessed preoperatively and postoperatively using the visual analogue scale (VAS) score for pain, modified Mayo wrist score, and range of motion (ROM) measurements for wrist flexion-extension, ulnar-radial deviation, and pronation-supination. At last follow-up, MRI was performed to evaluate the healing of TFCC. RESULTS: All 20 patients underwent successful surgery without complications such as vascular or nerve injury, fracture, incisional infection, or joint stiffness. All patients were followed up 9-18 months (mean, 12.4 months). At last follow-up, patients demonstrated significant improvements in VAS scores, modified Mayo wrist scores, wrist flexion-extension ROM, ulnar-radial deviation ROM, and pronation-supination ROM compared to preoperative levels ( P<0.05). MRI at last follow-up showed preserved TFCC continuity, excellent healing, and secure fixation. CONCLUSION 3D-printed personalized guide plate significantly improve outcomes in wrist arthroscopic TFCC repair for Palmer type ⅠB injuries. They enable high-quality suturing, facilitate anatomical reconstruction, and markedly enhance wrist function.
Humans ; Arthroscopy/methods* ; Male ; Adult ; Triangular Fibrocartilage/diagnostic imaging* ; Female ; Retrospective Studies ; Printing, Three-Dimensional ; Wrist Injuries/diagnostic imaging* ; Young Adult ; Bone Plates ; Treatment Outcome ; Wrist Joint/surgery* ; Magnetic Resonance Imaging ; Range of Motion, Articular

OBJECTIVE: To investigate the effectiveness of TiRobot-assisted minimally invasive treatment for fragility fractures of the pelvis (FFP) in elderly patients. METHODS: A retrospective analysis was conducted on the clinical data of 176 patients with FFP who were admitted between July 2018 and July 2024 and met the selection criteria. Among them, 95 patients underwent TiRobot-assisted closed reduction and minimally invasive cannulated screw fixation (robot group), while 81 patients underwent traditional open reduction and plate screw fixation (control group). There was no significant difference in baseline data such as gender, age, fracture classification, disease duration, and preoperative visual analogue scale (VAS) pain scores between the two groups ( P>0.05). The following parameters were recorded and compared between the two groups, including operation time, intraoperative blood loss, intraoperative transfusion rate, volume of intraoperative blood transfusion, maximum incision length, hospital stay, maximum residual displacement, reduction quality, fracture healing time, incidence of complications, VAS scores, Majeed pelvic function scores, and functional grading. RESULTS: All surgeries in both groups successfully completed. The robot group exhibited significantly shorter operation time, reduced intraoperative blood loss, lower intraoperative transfusion rate, smaller volume of intraoperative blood transfusion, shorter maximum incision length, and shorter hospital stay compared to the control group ( P<0.05). In the robot group, a total of 14 INFIX internal fixation frames and 280 cannulated screws were implanted, among which 250 screws were rated as excellent, 17 as good, and 13 as poor, resulting in a screw placement excellent and good rate of 95.36%. Radiological review revealed that the excellent and good rate of reduction quality was in 91.58% (87/95) in the robot group and 81.48% (66/81) in the control group, with no significant difference in postoperative maximum residual fracture displacement or reduction quality between the two groups (P>0.05). All patients in both groups were followed up 12-66 months, with an average of 28.9 months, and there was no significant difference in follow-up time between the two groups ( P>0.05). The fracture healing time in the robot group was significantly shorter than that in the control group ( P<0.05). At last follow-up, both groups showed significant improvement in VAS scores compared to preoperative values ( P<0.05); the change values of VAS scores, Majeed scores, and the excellent and good rate of Majeed pelvic function were significantly higher in the robot group than in the control group ( P<0.05). Regarding postoperative complications, there was no significant difference between the two groups in terms of gait changes, secondary surgeries, heterotopic ossification, incision infections, walking difficulties, internal fixation failure, or mortality rates ( P>0.05); however, the incidence of delayed wound healing was significantly lower in the robot group than in the control group ( P<0.05). CONCLUSION TiRobot-assisted minimally invasive treatment of elderly FFP is superior to traditional open reduction and internal fixation in terms of surgical trauma control, postoperative rehabilitation speed, and functional recovery.
Humans ; Male ; Retrospective Studies ; Female ; Minimally Invasive Surgical Procedures/instrumentation* ; Fracture Fixation, Internal/instrumentation* ; Pelvic Bones/surgery* ; Aged ; Bone Screws ; Bone Plates ; Robotic Surgical Procedures/methods* ; Aged, 80 and over ; Treatment Outcome ; Osteoporotic Fractures/surgery* ; Operative Time ; Blood Loss, Surgical ; Fracture Healing ; Fractures, Bone/surgery*

OBJECTIVE: To review the main fixation methods for proximal tibial extra-articular fractures based on clinical and biomechanical results, and to provide evidence for clinical application. METHODS: Extensive related literature at home and abroad was conducted in recent years, and external fixation systems such as external fixation braces and external locking plates, as well as internal fixation systems such as plates and intramedullary nails, were systematically reviewed regarding their application indications, clinical efficacy, and biomechanical results in proximal tibial extra-articular fractures. RESULTS: External fixation systems have advantages in fractures with open or severe soft tissue injury, facilitating wound management and maintaining stability of the fracture site to some extent. However, in proximal tibial extra-articular fractures with good soft tissue conditions, internal fixation systems such as plates and intramedullary nails are still the first choice. Some studies have found that intramedullary nails allow patients to bear weight early, with shorter fracture healing time and higher rate of malunion, while other studies have found that both intramedullary nails and plates have similar clinical efficacy and can achieve satisfactory treatment results. CONCLUSION The choice of fixation method for proximal tibial extra-articular fractures depends not only on the type of fracture, but also on the surgeon's habits and operational skills. Larger-scale studies are still needed to clarify the advantages and disadvantages of intramedullary nails and locking plates in the treatment of proximal tibial extra-articular fractures.
Humans ; Tibial Fractures/surgery* ; Bone Plates ; Fracture Fixation, Intramedullary/instrumentation* ; Fracture Fixation, Internal/instrumentation* ; Fracture Healing ; External Fixators ; Bone Nails ; Fracture Fixation/instrumentation* ; Treatment Outcome ; Biomechanical Phenomena

OBJECTIVE: To investigate effectiveness of the bridge combined fixation system (BCFS) for Bado typeⅠchronic Monteggia fractures (CMF) in children. METHODS: A clinical data of 8 children with Bado type ⅠCMF, who were treated with the BCFS between November 2023 and February 2025, was retrospectively analyzed. There were 6 boys and 2 girls, with a mean age of 7.0 years (range, 4-12 years). The time from injury to operation ranged from 29 to 370 days (median, 68.5 days). Preoperative elbow range of motion was (111.3±17.9)° in flexion, (13.1±13.9)° in extension, (71.9±14.6)° in pronation, and (75.6±13.5)° in supination. Fracture healing time and postoperative complications were observed, and clinical outcomes were evaluated using the Mayo elbow performance score. RESULTS: All incisions healed by primary intention without infection, non-healing of the incision, or iatrogenic nerve injury. All children were followed up 4-18 months (mean, 10.3 months). At last follow-up, the elbow range of motion significantly improved to (142.5±2.7)° in flexion, (2.5±2.7)° in extension, (87.5±2.7)° in pronation, and (88.8±2.3)° in supination ( P<0.05). According to the postoperative Mayo elbow performance score, all cases were rated as excellent. Radiographic review showed no radial head dislocation, nonunion at the ulnar osteotomy site, or elbow stiffness, and no breakage of the BCFS or screw loosening. The fracture healing time ranged from 3 to 6 months, with a median of 4 months. CONCLUSION The BCFS was confirmed to be effective in the treatment of pediatric Bado type Ⅰ CMF, with good restoration of elbow function and the advantage of avoiding secondary implant removal surgery.
Humans ; Child ; Monteggia's Fracture/surgery* ; Male ; Female ; Child, Preschool ; Range of Motion, Articular ; Retrospective Studies ; Fracture Fixation, Internal/instrumentation* ; Elbow Joint/physiopathology* ; Bone Plates ; Treatment Outcome ; Fracture Healing ; Bone Screws ; Elbow Injuries

OBJECTIVE: To review the application progress of customized steel plates in osteotomy and orthopedic treatment for knee osteoarthritis (KOA), and provide reference for orthopedic surgeons and researchers. METHODS: Extensive review of the literature on customized steel plates for osteotomies and knee-preserving surgeries for KOA, 2015-2025, with an overview of the principles of customized steel plate design, clinical applications, and future directions, describing their advantages and shortcomings. RESULTS: Customized steel plates have demonstrated many advantages in osteotomy and orthopedic treatment of KOA, which not only enhance surgical outcomes and optimize mechanical properties, but also reduce the incidence of postoperative complications. However, high cost, long manufacturing period, and selection of patient indications are still important factors restricting their use. CONCLUSION Customized steel plates show promising potential in treating KOA. Not only do they reduce surgical duration and enhance postoperative healing outcomes, but they also effectively lower the incidence of postoperative complications, thereby improving patients' quality of life.
Humans ; Osteoarthritis, Knee/surgery* ; Osteotomy/methods* ; Bone Plates ; Postoperative Complications/epidemiology* ; Steel ; Quality of Life ; Treatment Outcome ; Knee Joint/surgery*

OBJECTIVE: To evaluate the short-term clinical efficacy of external fixation and internal fixation with steel plate in the treatment of unstable distal radius fractures (AO-23C type), based on the principles of Chinese osteosynthesis (CO). METHODS: Forty-eight patients with unstable distal radius fractures between January 2022 and February 2023 were retrospectively analyzed and divided into the CO external fixation group and internal fixation group. CO external fixation group consisted of 25 patients, including 7 males and 18 females, aged from 37 to 56 years old with an average of ( 52.6±11.3) years old. Among them, there were 7 patients of traffic accidents and 18 patients of falls, resulting in a total of 25 patients of closed fractures and no open fractures, the treatment was conducted using closed reduction and CO external fixation. The internal fixation group consisted of 23 patients, comprising 8 males and 15 females, age ranged from 41 to 59 years old, with an average age of(53.3±13.7) years old. Among them, 8 patients resulted from car accidents while the remaining 15 patients were caused by falls. All 23 patients were closed fractures without any open fractures observed. The technique of open reduction and internal fixation with steel plate was employed. The perioperative data, including injury-operation time, operation duration, blood loss, and length of hospital stay, were assessed in both groups. Additionally, the QuickDASH score and visual analogue scale (VAS) were evaluated. Range of motion and grip strength assessment, imaging findings such as palmar inclination angle, ulnar declination angle, radius length, articular surface step, intra-articular space measurements were also examined along with any complications. RESULTS: The follow-up duration ranged from 0 to 24 months, with an average duration of (16.0±3.8) months. The CO external fixation exhibited significantly shorter time from injury to operation (2.4±3.3) d vs (7.4±3.7) d, shorter operation duration (56.27±15.23) min vs (74.10±5.26) min, lower blood loss (14.52±6.54) ml vs (32.32±10.03) ml, and reduced hospitalization days (14.04±3.24 )d vs (16.45±3.05) d compared to the internal fixation group (P<0.05). The QuickDASH score at 12 months post-operation was (8.21±1.64) in the CO external fixation group, while no significant difference was observed in the internal fixation group (7.04±3.64), P>0.05. There were no statistically significant differences in VAS between two groups at 6 weeks, as well as 1 and 3 months post-surgery (P>0.05). Additionally, there were no significant disparities observed in terms of range of motion and grip strength between two groups at the 2-year follow-up after the operation (P>0.05). After 12 months of surgery, the CO external fixation group exhibited a significantly smaller palmar inclination angle (17.90±2.18) ° vs (19.87±3.21) °, reduced articular surface step (0.11±0.03) mm vs (0.17±0.02) mm, and shorter radius length (8.16±1.11) mm compared to the internal fixation group (9.59±1.02) mm, P<0.05. The ulnar deviation angle and intra-articular space did not show any significant difference between two groups (P>0.05). The reduced fell within the allowable range between the CO external fixation group (23 out of 25 cases) and the internal fixation group (21 out of 23 cases) was not statistically significant (P=0.29). There was no significant difference in complications between the two groups(P>0.05). CONCLUSION Both the CO external fixation and open reduction with plate internal fixation demonstrate clinical efficacy in managing unstable distal radius fractures. The CO external fixation offers advantages in shorter injury-to-operation times, reduced intraoperative blood loss, and decreased surgical durations, while radial shortening is more effectively controlled by internal fixation.
Humans ; Male ; Female ; Middle Aged ; Radius Fractures/physiopathology* ; Adult ; Bone Plates ; Fracture Fixation, Internal/methods* ; External Fixators ; Retrospective Studies ; Fracture Fixation/methods* ; Wrist Fractures

OBJECTIVE: To compare the short-term clinical efficacy and safety of closed reduction with Kirschner wire fixation versus open reduction with plate fixation for treating osteoporotic Colles' fractures in middle-aged and elderly patients. METHODS: Between January 2018 and January 2023, 119 patients with Colles fractures were retrospectively analyzed, including 39 males and 80 females, aged from 48 to 74 years old with an average of(60.58±6.71) years old. The time from injury to operation ranged 1 to 13 days with an average of (5.29±2.52) days. According to the surgical method, they were divided into Kirschner wire fixation group (Kirschner wire group) and plate internal fixation group (plate group). In Kirschner wire group, there were a total of 68 patients, comprising 21 males and 47 females. The average age was (61.15±6.24) years old, ranged from 49 to 74 years old. Among them, 41 cases involved the left side while 27 cases involved the right side. In the plate group, there were a total of 51 patients, including 18 males and 33 females. The average age was (59.78±5.71) years old ranged from 48 to 72 years old. Among them, there were 31 cases on the left side and 20 cases on the right side. The following parameters were recorded before and after the operation:operation time, intraoperative blood loss, hospitalization days, hospitalization expenses, postoperative complications, and radiographic parameters of distal radius (distal radius height, ulnar deviation angle, palmar tilt angle). The clinical efficacy was evaluated at 3 and 12 months after the operation using Gartland-Werley and disabilites of the arm shoulder and hand (DASH) scores. RESULTS: The patients in both groups were followed up for a duration from 12 to 19 months with an average of(13.32±2.02) months. The Kirschner wire group exhibited significantly shorter operation time compared to the plate group 27.91(13.00, 42.00) min vs 67.52(29.72, 105.32) min, Z=-8.74, P=0.00. Intraoperative blood loss was also significantly lower in the Kirschner wire group than in the plate group 3.24(1.08, 5.40) ml vs 21.91(17.38, 26.44) ml, Z=-9.31, P=0.00. Furthermore, patients in the Kirschner wire group had a shorter length of hospital stay compared to those in the plate group (8.38±2.63) days vs (11.40±2.78) days, t=-3.12, P=0.00. Additionally, hospitalization cost was significantly lower in the Kirschner wire group than in the plate group 10 111.29(6 738.98, 13 483.60) yuan vs 15 871.11(11 690.40, 20 051.82) yuan, Z=-5.62, P=0.00. The incidence of complications was 2 cases in the Kirschner wire group and 1 case in the plate group, with no statistically significant difference(P>0.05). At 3 months postoprative, the radial height of the Kirschner wire group was found to be significantly smaller than that of the plate group, with measurements of (11.45±1.69) mm and (12.11±1.78) mm respectively (t=-2.06, P=0.04). However, there were no statistically significant differences observed in ulnar deviation angle and palmar tilt angle between the two groups (P>0.05). The DASH score and Gartland-Werley score in the Kirschner group were significantly higher than those in the plate group at 3 months post-operation (19.10±9.89) vs (13.47±3.51), t=4.34, P=0.00;(11.15±3.61) vs (6.41±2.75), t=8.13, P=0.00). However, there was no significant difference between the two groups at 12 months post-operation (P>0.05). CONCLUSION Compared to plate internal fixation, closed reduction with Kirschner wire support fixation yields a slightly inferior recovery of radial height;however, there is no significant disparity in the functional score of the affected limb at 12 months post-operation. Nonetheless, this technique offers advantages such as shorter operation time, reduced intraoperative blood loss, decreased hospitalization duration, and lower cost.
Humans ; Female ; Male ; Middle Aged ; Aged ; Fracture Fixation, Internal/instrumentation* ; Bone Wires ; Bone Plates ; Retrospective Studies ; Colles' Fracture/surgery* ; Minimally Invasive Surgical Procedures/methods* ; Open Fracture Reduction/methods* ; Osteoporotic Fractures/surgery*