Knotts, Christopher; Workman, Meredith; Sawan, Kamal; El Amm, Christian
Edentulous mandible fractures present a unique and challenging surgical problem, particularly because of lack of occlusive dental surfaces to capitalize upon maxillomandibular fixation (MMF). We present a novel technique to achieve MMF using rigid plates spanning the oral cavity to fixate the maxilla to the mandible. The process is rapid and allows stability using the established principles of rigidity, external fixation, and osteosynthesis. This technique allows for a faster MMF than with a Gunning splint and allows for easier oral hygiene. An illustrative case and pre- and postoperative imaging are provided. PMID:23449752
Knotts, Christopher; Workman, Meredith; Sawan, Kamal; El Amm, Christian
Edentulous mandible fractures present a unique and challenging surgical problem, particularly because of lack of occlusive dental surfaces to capitalize upon maxillomandibular fixation (MMF). We present a novel technique to achieve MMF using rigid plates spanning the oral cavity to fixate the maxilla to the mandible. The process is rapid and allows stability using the established principles of rigidity, external fixation, and osteosynthesis. This technique allows for a faster MMF than with a Gunning splint and allows for easier oral hygiene. An illustrative case and pre- and postoperative imaging are provided.
Müller, Steffen; Bürgers, Ralf; Ehrenfeld, Michael; Gosau, Martin
The present study aimed at evaluating the treatment outcome of fractures of the edentulous atrophic mandible by means of an extraoral approach using open reduction and internal fixation with macroplates. Eighteen patients with 21 fractures of the atrophic mandible, who had been treated between 1997 and 2006, were retrospectively analysed. Mandible height was categorised according to the Luhr classification and the patients' general health (The American Society of Anesthesiologists (ASA) classification). Three types of titanium macroplates were used. Demographic data, treatment outcomes and the pre- and postoperative ability to wear mandible dentures were evaluated. The study population consisted of five men and 13 women with a median age of 78 years. The mean follow-up duration was 28 months. The most common cause of fractures was accidental falls (50%); the mandible was affected in 77.8%. Three fractures occurred in class I (bone height 15-20 mm), seven in class II (10-15 mm), and 11 in class III atrophy (<10 mm). According to the ASA classification, the collective showed a mean value of 3. An overall complication rate of 16.7% was noted, consisting of two minor and one major complication that required a second intervention. Five patients needed removal of the osteosynthesis material for prosthetic reasons. Only 50% of the patients were able to wear their dentures before surgery, and all but one were able to wear their prosthesis postoperatively. Treatment of atrophic mandible fractures with macroplates by means of an extraoral approach showed good results and a low complication rate. This procedure allows elderly patients to instantly load the mandible in the means of prosthetic and masticatory rehabilitation, preventing the necessity for second interventions.
Gaball, Curtis; Lovald, Scott; Baack, Bret; Olson, Garth
To optimize design variables of a bioabsorbable bone plate using a finite element model of the mandible and to discover a minimally invasive bioabsorbable bone plate design that can provide the same mechanical stability as a titanium plate. A finite element model of a mandible with a fracture in the body was subjected to bite loads. An analysis was run to determine the principal strain in the fracture callus and von Mises stress in a titanium plate. These values were then set as the limits within which the bioabsorbable bone plate must comply. The model then considered a bone plate made of the polymer poly(L-lactide-co-D,L-lactide) (P[L/DL]LA) 70/30. An optimization routine determined the smallest volume of bioabsorbable bone plate that can perform as well as a titanium bone plate when fixating mandibular fractures. A P(L/DL)LA plate volume of 315 mm(2) with a thickness of 1.5 mm provided as much mechanical stability as a commonly used titanium strut structure of 172 mm(2). The peak plate stress was well below the yield strength of the material. The P(L/DL)LA bioabsorbable bone plate design is as strong as a titanium plate when fixating fractures of the mandible body despite the polymer material having only 6% of the stiffness of the titanium. The P(L/DL)LA plate can be less than half the volume of its strut-style counterpart.
Farber, Scott J; Nguyen, Dennis C; Harvey, Alan A; Patel, Kamlesh B
Mandibular fractures represent a substantial portion of facial fractures in the pediatric population. Pediatric mandibles differ from their adult counterparts in the presence of mixed dentition. Avoidance of injury to developing tooth follicles is critical. Simple mandibular fractures can be treated with intermaxillary fixation (IMF) using arch bars or bone screws. This report describes an alternative to these methods using silk sutures and an algorithm to assist in treating simple mandibular fractures in the pediatric population. A retrospective chart review was performed and the records of 1 surgeon were examined. Pediatric patients who underwent treatment for a mandibular fracture in the operating room from 2011 to 2015 were identified using Common Procedural Terminology codes. Data collected included age, gender, type of fracture, type of treatment used, duration of fixation, and presence of complications. Five patients with a mean age of 6.8 years at presentation were identified. Fracture types were unilateral fractures of the condylar neck (n = 3), bilateral fractures of the condylar head (n = 1), and a unilateral fracture of the condylar head with an associated parasymphyseal fracture (n = 1). IMF was performed in 4 patients using silk sutures, and bone screw fixation was performed in the other patient. No post-treatment complications or malocclusion were reported. Average duration of IMF was 18.5 days. An algorithm is presented to assist in the treatment of pediatric mandibular fractures. Silk suture fixation is a viable and safe alternative to arch bars or bone screws for routine mandibular fractures. Copyright © 2016 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Oruç, Melike; Işik, Veysel Murat; Kankaya, Yüksel; Gürsoy, Koray; Sungur, Nezih; Aslan, Gürcan; Koçer, Uğur
Abstract Mandible fractures have a special place within the injuries of the other bones of the maxillofacial system. In their management, cosmetic issues and functional aspects such as chewing, speaking, and swallowing become very important. In this study, a retrospective analysis of 419 mandible fractures in 283 patients was performed in relation to epidemiologic factors, treatment strategies, and complications. The average age was 32.14 years (4–69 years). The male/female ratio was 4/1. The most frequent etiologic factor was interpersonal violence (104 patients, 36.7%). The parasymphysis region was the mostly affected site (28.4%). A total of 157 patients (55.5%) were presented with single fracture and the rest with 2, 3, or 4 fracture lines on the mandible. The most common fracture combination was angulus–parasymphysis fracture combination (24.6%). Open reduction and fixation with mini plates and screws was the most preferred treatment strategy (48.2%). Transient short arch bars were not used intraoperatively for any of the patients. There was not any difference in terms of complications between the patients treated with plating systems and plating systems plus intermaxillary fixation. In conclusion, proper treatment of mandible fractures is critical. Except certain fracture types, the usage of intermaxillary fixation as an adjunct to fixation with plating systems is not necessary. PMID:27536913
Ram, Hari; Shadab, Mohammad; Vardaan, Ajay; Aga, Pallavi
Osteogenesis imperfecta is a genetic disorder characterised by fragility and multiple fractures of bones. Clinical signs and symptoms vary depending on the type of disease. Fractures of facial bones are rare compared with load-bearing long bones. We report a case of fracture of the mandible during yawning which was managed by open reduction and internal fixation.
Tay, Andrew Ban Guan; Lai, Juen Bin; Lye, Kok Weng; Wong, Wai Yee; Nadkarni, Nivedita V; Li, Wenyun; Bautista, Dianne
This prospective observational cohort study sought to determine the prevalence of inferior alveolar nerve (IAN) injury after mandibular fractures before and after treatment and to elucidate factors associated with the incidence of post-treatment IAN injury and time to normalization of sensation. Consenting patients with mandibular fractures (excluding dentoalveolar, pathologic, previous fractures, or mandibular surgery) were prospectively evaluated for subjective neurosensory disturbance (NSD) and underwent neurosensory testing before treatment and then 1 week, 1.5, 3, 6, and 12 months after treatment. Eighty patients (men, 83.8%; mean age, 30.0 yr; standard deviation, 12.6 yr) with 123 mandibular sides (43 bilateral) were studied. Injury etiology included assault (33.8%), falls (31.3%), motor vehicle accidents (25.0%), and sports injuries (6.3%). Half the fractures (49.6%) involved the IAN-bearing posterior mandible; all condylar fractures (13.0%) had no NSD. Treatment included open reduction and internal fixation (ORIF; 74.8%), closed reduction and fixation (22.0%), or no treatment (3.3%). Overall prevalence of IAN injury was 33.7% (95% confidence interval [CI], 24.8-42.6) before treatment and 53.8% (95% CI, 46.0-61.6) after treatment. In the IAN-bearing mandible, the prevalence was 56.2% (95% CI, 43.2-69.2) before treatment and 72.9% (95% CI, 63.0-82.7) after treatment. In contrast, this prevalence in the non-IAN-bearing mandible was 12.6% (95% CI, 4.1-21.1) before treatment and 31.6% (95% CI, 20.0-43.3) after treatment. Factors associated with the development of post-treatment IAN injury included fracture site and gap distance (a 1-mm increase was associated with a 27% increase in odds of post-treatment sensory alteration). Time to normalization after treatment was associated with type of treatment (ORIF inhibited normalization) and fracture site (IAN-bearing sites took longer to normalize). IAN injury was 4 times more likely in IAN-bearing posterior mandibular
Slade, J F; Jaskwhich, D
The scaphoid proximal pole and waist fractures presented here were treated by a novel dorsal percutaneous technique with arthroscopic assistance. All fractures healed, with good final functional results and no complications. The advantages of the dorsal percutaneous approach to scaphoid fixation are: (1) the proximal-to-distal placement of the guide pin and screw allow for more precise placement along the central axis of the scaphoid, which decreases healing time and reduces risk of screw thread exposure. (2) The dorsal approach avoids injuring the vulnerable volar ligament anatomy. And (3) the insertion of the screw from the proximal to distal direction allows the more rigid fixation of proximal scaphoid fractures. Arthroscopy allows confirmation of fracture reduction and screw implantation as well as evaluation of concurrent ligament injuries not detected with standard imaging. Percutaneous K-wires act as joysticks to reduce and compress fracture fragments prior to fixation. The presented technique allows for early, rigid internal fixation with minimal associated morbidity. Patients successfully treated with this technique include those with stable and unstable acute fractures of the scaphoid at all locations, including the proximal pole. Nondisplaced fractures that present with delayed or fibrous union without evidence of avascular necrosis, cyst formation, or bony sclerosis may also be treated with this technique. This technique allows for faster rehabilitation and an earlier return to work or avocation without restriction once CT scan confirms a solid union. Some articles document extraordinary rapid healing by standard radiographs; however, we caution that scaphoid bone healing cannot accurately be determined without CT scan. Percutaneous, arthroscopically assisted internal fixation by a dorsal approach may be considered in all acute scaphoid fractures selected for surgical fixation. The dorsal guidewire permits dorsal and volar implantation of a cannulated
Cornelius, Carl-Peter; Audigé, Laurent; Kunz, Christoph; Rudderman, Randal; Buitrago-Téllez, Carlos H.; Frodel, John; Prein, Joachim
This tutorial outlines the details of the AOCMF image-based classification system for fractures of the mandible at the precision level 2 allowing description of their topographical distribution. A short introduction about the anatomy is made. Mandibular fractures are classified by the anatomic regions involved. For this purpose, the mandible is delineated into an array of nine regions identified by letters: the symphysis/parasymphysis region anteriorly, two body regions on each lateral side, combined angle and ascending ramus regions, and finally the condylar and coronoid processes. A precise definition of the demarcation lines between these regions is given for the unambiguous allocation of fractures. Four transition zones allow an accurate topographic assignment if fractures end up in or run across the borders of anatomic regions. These zones are defined between angle/ramus and body, and between body and symphysis/parasymphysis. A fracture is classified as “confined” as long as it is located within a region, in contrast to a fracture being “nonconfined” when it extents to an adjoining region. Illustrations and case examples of mandible fractures are presented to become familiar with the classification procedure in daily routine. PMID:25489388
Owusu, James A; Bellile, Emily; Moyer, Jeffrey S; Sidman, James D
The mandible is arguably the most frequently fractured facial bone in children. However, facial fractures are rare in children compared with adults, resulting in few large studies on patterns of pediatric facial fractures. To report the patterns, demographics, and cause of pediatric mandible fractures across the United States. A retrospective analysis was conducted of the Healthcare Cost and Utilization Project's National Emergency Department Sample from January 1 to December 31, 2012, using the International Classification of Disease, Ninth Revision, codes for mandible fractures (802.20-802.39) among patients 18 years and younger who presented to emergency departments. Demographics, fracture site, and fracture mechanism were analyzed to identify factors associated with fractures. Analysis was conducted from July 9 to July 28, 2015. There were 1984 records, representing a weighted estimate of 8848 cases of pediatric mandible fracture. The mean patient age was 14.0 years (95% CI, 13.6-14.3). The male to female ratio was 4:1 and females were comparatively younger, with a mean age of 12.5 years (95% CI, 11.8-13.1; P < .001). The most frequently fractured sites were the condyle, in 1288 patients (14.6% [95% CI, 12.6%-16.5%]), and the angle, in 1252 patients (14.1% [12.4%-15.9%]). Associated intracranial injuries occurred in 756 patients (8.5% [7.1%-10.0%]), and cervical spine fractures occurred in 393 (4.4% [3.5%-5.4%]). The fracture site and mechanism of injury varied with age and sex. For patients 12 years and younger, the most frequent fracture site was the condyle, accounting for 636 fractures (27.9% [24.2%-31.6%]), and the most frequent cause was falls, accounting for 692 fractures (30.3% [25.9%-34.8%]). In teenaged patients (13-18 years), the angle was the most frequent fracture site, accounting for 1157 fractures (17.6% [15.6%-19.6%]), and the most frequent cause was assault, accounting for 2619 fractures (39.9% [36.4%-43.3%]). For male patients, the angle was
Lovald, Scott T; Khraishi, Tariq; Wagner, Jon; Baack, Bret
Bioabsorbable bone plates can eliminate the necessity for a permanent implant when used to fixate fractures of the human mandible. They are currently not in widespread use because of the low strength of the materials and the requisite large volume of the resulting bone plate. The aim of the current study was to discover a minimally invasive bioabsorbable bone plate design that can provide the same mechanical stability as a standard titanium bone plate. A finite element model of a mandible with a fracture in the body region is subjected to bite loads that are common to patients postsurgery. The model is used first to determine benchmark stress and strain values for a titanium plate. These values are then set as the limits within which the bioabsorbable bone plate must comply. The model is then modified to consider a bone plate made of the polymer poly-L/DL-lactide 70/30. An optimization routine is run to determine the smallest volume of bioabsorbable bone plate that can perform and a titanium bone plate when fixating fractures of this considered type. Two design parameters are varied for the bone plate design during the optimization analysis. The analysis determined that a strut style poly-L-lactide-co-DL-lactide plate of 690 mm2 can provide as much mechanical stability as a similar titanium design structure of 172 mm2. The model has determined a bioabsorbable bone plate design that is as strong as a titanium plate when fixating fractures of the load-bearing mandible. This is an intriguing outcome, considering that the polymer material has only 6% of the stiffness of titanium.
Baldi, Jesús R. Manzani; Wolff de Freitas, Daniel A.
Dog bite injury frequently occurs in children, and many of these bites involve the facial region. On the other hand, facial fractures due to dog attacks are a rare complication, with the orbital, nasal, and maxillary bones most often affected. We present a case report of a child who suffered a double facial fracture, mandible and left zygoma, due to a dog bite. The clinical diagnosis was supported by X-rays and computed tomography, which also provided information about the characteristics of the fracture. Internal fixation was done with titanium miniplates. Finally, the pathophysiological mechanism and the biomechanics of the fracture, as well as the use of resorbable versus nonresorbable material on infants, are discussed. PMID:24436750
Dougherty, Paul J; Silverton, Craig; Yeni, Yener; Tashman, Scott; Weir, Robb
Temporary external fixation is the most common method of initial stabilization of diaphyseal fractures in forward surgical hospitals. Once the patient arrives at a stable environment, usually the United States, the fracture is managed with intramedullary nailing, small-pin external fixation, or a modified external fixator. Future research should be directed toward improving methods of care. It is not precisely known when is the best time to convert to definitive fixation without increasing the risk of infection. The risk factors leading to infection and nonunion are not well-established, making that determination even more difficult. Clinical studies of a suitable size should provide insight into these problems. Although temporary external fixation is commonly used, an optimal construct has not been determined. Data from studies of in vivo fracture-site motion after application of the temporary external fixator should be compared with biomechanical testing of similar constructs. These data could be used to recommend optimal temporary external fixation constructs of tibia, femur, and humerus fractures using currently available devices as well as to provide groundwork for the next generation of fixators.
emphasized. Keywords�Mandible,fracture, miniplate , FE modeling I. INTRODUCTION In oral and maxilofacial surgery different techniques have been used for...the fixation of mandibular fractures, one of which is the, miniplate osteosnythesis. Even though several mini-plates and screws with different...the fracture. Since the maximum tensile and compressive stresses occur at the upper most fibers of the bone, miniplates are intended to be
Ye, Ye; Hao, Jiandong; Mauffrey, Cyril; Hammerberg, E Mark; Stahel, Philip F; Hak, David J
Optimizing stability of femoral neck fracture fixation is important in obtaining a successful outcome. The mechanical problems and strategies for achieving optimal stability differ depending on patients' age and degree of osteoporosis. Femoral neck fractures in younger adults usually result from high-energy trauma and have a vertical fracture pattern. Strategies for optimizing fixation stability in this group include placing additional screws at right angles to the fracture plane and medial buttress plate augmentation. In elderly patients, screw position relative to the intact cortical femoral neck bone is of critical importance. Additional strategies for optimizing fixation stability in this group include the concept of length stable fixation, use of adjunctive calcium phosphate cement, and use of novel fixed angle fixation implants. Copyright 2015, SLACK Incorporated.
Vogel, Susan R; Anderson, David E
External skeletal fixation (ESF) is a versatile method for rigid immobilization of long bone fractures in cattle. Traditional ESF devices may be used in young calves for clinical management of open fractures. Transfixation pinning and casting is an adaptation of ESF principles to improve versatility and clinical management of selected fractures. Copyright © 2014 Elsevier Inc. All rights reserved.
Hoelsbrekken, Sigurd Erik; Opsahl, Jan-Henrik; Stiris, Morten; Paulsrud, Øyvind; Strømsøe, Knut
There are two types of surgical treatment for fractures of the femoral neck; internal fixation and arthroplasty. Internal fixation is associated with a higher risk of complications such as secondary displacement, non-union and avascular necrosis. To improve treatment results of internal fixation, we have tried to identify procedure related risk-factors associated with fixation failure. A retrospective study was conducted based on the medical records and X-ray images of 337 patients sustaining intracapsular fractures of the hip during the period 1999-2000. The patients were treated with closed reduction and internal fixation at Oslo University Hospital, Aker. The reduction of the fracture and the placement of the fixation implants were evaluated and scored (six points representing best achievable result). Fixation failed in 23 (18,3 %) out of 126 patients with displaced fractures awarded six points for the reduction. In contrast, fixation failed in five (50 %) out of ten patients given a score of three points or less (p = 0.017). The risk of non-union increased when patients were treated more than 48 hours after the initial injury. In this group, 5 (25 %) out of 20 patients developed non-union compared to 16 (8 %) out of 200 patients treated within 48 hours (p = 0.014). Our findings emphasize the importance of achieving anatomical reduction of displaced femoral neck fractures, and to perform surgery within 48 hours unless an acute medical condition needs to be stabilized.
Crofts, C E; Trowbridge, A; Maung Aung, T; Brook, I M
The use of porcine rib pairs as an in vitro analog for the edentulous mandible is described. Using this model, the relative degree of fixation achieved with a screw plate (Champy) and a paraskeletal clamp plate (Mennen) has been evaluated. The fractured plated ribs failed at significantly lower bending forces than the non-sectioned controls. However, no statistically significant difference in force at failure between the two different methods of plate fixation could be demonstrated.
Castro-Núñez, Jaime; Cunningham, Larry L; Van Sickels, Joseph E
The management of atrophic mandibular fractures poses a challenge because of anatomic variations and medical comorbidities associated with elderly patients. The purpose of this article is to review and update the literature regarding the management of atrophic mandible fractures using load-bearing reconstruction plates placed without bone grafts. We performed a review of the English-language literature looking for atrophic mandibular fractures with or without continuity defects and reconstruction without bone grafts. Included are 2 new patients from our institution who presented with fractures of their atrophic mandibles and had continuity defects and infections. Both patients underwent reconstruction with a combination of a reconstruction plate, recombinant human bone morphogenetic protein 2, and tricalcium phosphate. This study was approved as an "exempt study" by the Institutional Review Board at the University of Kentucky. This investigation observed the Declaration of Helsinki on medical protocol and ethics. Currently, the standard of care to manage atrophic mandibular fractures with or without a continuity defect is a combination of a reconstruction plate plus autogenous bone graft. However, there is a need for an alternative option for patients with substantial comorbidities. Bone morphogenetic proteins, with or without additional substances, appear to be a choice. In our experience, successful healing occurred in patients with a combination of a reconstruction plate, recombinant human bone morphogenetic protein 2, and tricalcium phosphate. Whereas primary reconstruction of atrophic mandibular fractures with reconstruction plates supplemented with autogenous bone graft is the standard of care, in selected cases in which multiple comorbidities may influence local and/or systemic outcomes, bone morphogenetic proteins and tricalcium phosphate can be used as a predictable alternative to autogenous grafts. Copyright © 2017 American Association of Oral and
Mighell, Mark A; Stephens, Brent; Stone, Geoffrey P; Cottrell, Benjamin J
Distal humerus fractures are challenging injuries for the upper extremity surgeon. However, recent techniques in open reduction internal fixation have been powerful tools in getting positive outcomes. To get such results, the surgeon must be aware of how to properly use these techniques in their respective practices. The method of fixation depends on the fracture, taking the degree of comminution and the restoration of the columns and articular surface into account. This article helps surgeons understand the concepts behind open reduction internal fixation of the distal humerus and makes them aware of pitfalls that may lead to negative results. Copyright © 2015 Elsevier Inc. All rights reserved.
Kim, Myung-Good; Yoo, Roh-Eul; Chang, Hak; Kwon, Sung-Tack; Baek, Rong-Min; Minn, Kyung-Won
We have devised a new technique to improve stabilization of fractured facial bone fractures (frontal sinus fractures, zygomatic fractures, mandibular condyle fractures) by intermaxillary fixation screw traction wires (stainless steel wires through intermaxillary fixation screws). A retrospective study evaluating intermaxillary fixation screw traction wires was performed. We have used this technique for 3 cases of frontal sinus fractures, 9 cases of zygomatic fractures, and 7 cases of mandibular condyle fractures. After dissection of a fractured site, a hole is drilled on the fractured bone where it does not interfere with positioning the plate across the fracture line. After an intermaxillary fixation screw is inserted, a stainless steel wire is tied through a hole in the screw head. By the aid of wire for traction, the displaced fractured bone is easily aligned to the proper position. Plates and screws are applied readily on the predetermined area. A retrospective study on 19 patients using intermaxillary fixation screw traction wires was performed. The diagnoses and associated complications of the cases were recorded. No associated complication as a result of using this technique was identified. The use of intermaxillary fixation screw traction wire enhances stabilization and visualization without possible risk for surrounding soft tissue injury using, a sharp traction device like a bone hook. An intermaxillary fixation screw traction wire is an useful aid for visualization and stabilization during facial bone fracture reduction, particularly where exposure is difficult such as in the condylar region of the mandible. And unlike a classic traction wire, the intermaxillary fixation screw traction wire has almost no risk of having it loosened from the screw.
Shenoy K, Vandana; Kengagsubbiah, Srivatsa; V, Sathyabhama; Priya, Vishnu
Condylar fracture is the second most common site in the mandibular fractures. Motor vehicle accident and fall are the major causes of such fractures. Because of the anatomical weakness of the condyle and the shape of the condylar head the antero-medial dislocation of the condyle is common. Open reduction and closed reduction is always debatable. The open reduction will bring back the normal function much earlier than closed reduction. Medially dislocated condylar fracture fragments are always managed with open method. In superior or high condylar fractures,exact reduction with conventional open reduction can be difficult due to the limited surgical and visual fields. In such cases extracorporeal fixation of condyle using vertical ramus osteotomy may be better choice to achieve perfect alignment and absolute maintaince of vertical height of the ramus and facial symmetry. We here present a case of extracorporeal fixation of unilateral left high condylar fracture. PMID:25386546
Ngeow, W C; Lian, C B
Fractures of the mandible and their management are discussed in detail in textbooks and articles dealing with facial trauma. This paper presents the management and treatment of a case of a unilateral comminuted and complicated fracture of the mandible due to dog attack on a geriatric patient. The attack also severed the patient's right arm. Due to the severity of the trauma, an emergency surgery was performed on the mandible and arm.
Li, Ying; Bao, Rong-Hua; Jiang, Zhi-Qiang; Wu, Huo-Yan
Objective: The purpose of this study focused on a number of factors that have been implicated in calcaneal complications and find the incidence of wound complications. Methods: This was a retrospective study. A total of 162 patients (176 feet) who underwent calcaneal fractures between 2007 and 2012 were included. The patient’s personal details, age, time from injury to surgery, cause of injury, type of fracture, operative details, operating and tourniquet times were collected from hospital computers and paper records. Evidence of complications including wound infection, wound necrosis, pain, malunion, nonunion, impingement, loss of fixation, ect were studied. Results: Forty-seven of one hundred and seventy-six fractures (26.704%) had complications, wound infection was noted in seven fractures (3.977%), twelve fractures developed necrosis (6.818%), 14 fractures (7.955%) developed pain. Malunion was found in five fractures (2.841%), nonunion in two fractures (1.136%) and loss of fixation in four fractures (2.272%). Three neurologic injury was also seen in our study (1.705%). Operating time, time from injury to surgery and type of fracture had some association with complications in operative fixation of calcaneal fractures, which showed a statistically significant improvement (P=0.000, 0.031, 0.020, respectively), but there were no evidence that age and tourniquet time affect the incidence of complication after calcaneal fracture surgery (P=0.119, 0.682, respectively). Conclusions: Despite developments in the surgical treatment of calcaneal fracture, wound complications still remain inevitable. Advanced imaging techniques, less invasive surgical procedures, wealth of anatomical knowledge, surgical experience and better postoperative care should be ensured. PMID:27648028
Petrie, J; Sassoon, A; Haidukewych, G J
Most hip fractures treated with modern internal fixation techniques will heal. However, failures occasionally occur and require revision procedures. Salvage strategies employed during revision are based on whether the fixation failure occurs in the femoral neck, or in the intertrochanteric region. Patient age and remaining bone stock also influence decision making. For fractures in young patients, efforts are generally focused on preserving the native femoral head via osteotomies and repeat internal fixation. For failures in older patients, some kind of hip replacement is usually selected. Disuse osteopenia, deformity, bone loss, and stress-risers from previous internal fixation devices all pose technical challenges to successful reconstruction. Attention to detail is important in order to minimise complications. In the majority of cases, good outcomes have been reported for the various salvage strategies.
Cousin, G C S
Stainless steel wire is often used in the management of jaw fractures to provide intraoperative or postoperative intermaxillary fixation (IMF). Wiring of the jaws is time-consuming, a second procedure is needed to remove it, and needlestick injuries occur during placement. We report on 151 consecutive patients who had wire-free fixation of jaw fractures, and outline the value of a system of plastic anchorage points applied to individual teeth in both jaws that allows for wire-free IMF when they are linked by elastics (Rapid IMF, Synthes, PA, USA). A total of 150 successive patients had wire-free fixation of 146 mandibular and 5 maxillary fractures. Ninety-eight were hand-held in occlusion, and 52 were treated using Rapid IMF. There were few complications.
Mandibular fractures are commonly encountered by the maxillofacial surgeon. Maxillomandibular fixation (MMF) and open reduction and internal fixation (ORIF), or a combination of both, are the accepted standard treatments. This study aims to assess the role of a conservative minimal intervention protocol in the management of undisplaced/minimally displaced fractures of the dentate portion of the adult mandible and the complications associated with such minimalistic intervention. Thirty-four patients with undisplaced/minimally displaced fractures of the dentate portion of the adult mandible were advised to restrict mouth opening and limit themselves to a soft diet for a minimum of 4 weeks. All patients were advised follow-up at regular intervals for at least 3 months. Five patients were lost to follow-up. Symphysis and parasymphysis fractures were the most common fracture locations. Fourteen patients needed tension band stabilization with a mandibular arch bar/bridle wiring and three patients required extraction of luxated teeth. All patients showed satisfactory healing except three in whom additional intervention (ORIF) was performed. The improvement in mouth opening was statistically significant. Complications were seen more frequently among smokers and alcoholics. For patients with minimally displaced mandibular fractures, it is necessary to consider if the perceived benefits of intervention justify the associated added costs and possible complications. Patients have to be fully informed about the possible complications while using this minimal intervention protocol. This study concludes that a conservative minimal intervention management protocol for such fractures of the dentate portion of the mandible can produce satisfactory results. PMID:26889344
Senekjian, Lara; Nirula, Raminder
Rib fractures are a frequently identified injury in the trauma population. Not only are multiple rib fractures painful, but they are associated with an increased risk of adverse outcomes. Pneumonia in particular can be devastating, especially to an elderly patient, but other complications such as prolonged ventilation and increased intensive care and hospital durations of stay have a negative impact on the patient. Computed tomography scan is the best modality to diagnosis rib fractures but the treatment of fractures is still evolving. Currently patient care involves a multidisciplinary approach that includes pain control, aggressive pulmonary therapy, and possibly surgical fixation. Copyright Â© 2016 Elsevier Inc. All rights reserved.
Culp, Randall W; Johnson, Jeff W
Arthroscopic-assisted reduction and fixation of Bennett-type fractures of the thumb metacarpal allow for the confirmation of reduction as well as the assessment of the degree of chondral damage. With use of a 1.9-mm arthroscope and a traction tower, direct visualization and reduction is possible. Traditional methods of fixation are used to secure the fracture fragment. Postoperative rehabilitation follows the usual protocol used in both open and percutaneous techniques. However, the potential to obtain and confirm a more accurate articular reduction may reduce the incidence of late arthritis of the thumb carpometacarpal articulation.
... 21 Food and Drugs 8 2010-04-01 2010-04-01 false External facial fracture fixation appliance. 878.3250 Section 878.3250 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN... External facial fracture fixation appliance. (a) Identification. An external facial fracture fixation...
... 21 Food and Drugs 8 2011-04-01 2011-04-01 false External facial fracture fixation appliance. 878.3250 Section 878.3250 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN... External facial fracture fixation appliance. (a) Identification. An external facial fracture fixation...
McAlister, Ian; Sems, Stephen Andrew
Arthrofibrosis after periarticular fractures can create clinically significant impairments in both the upper and lower extremities. The shoulder, elbow, and knee are particularly susceptible to the condition. Many risk factors for the development of arthrofibrosis cannot be controlled by the patient or surgeon. Early postoperative motion should be promoted whenever possible. Manipulations under anesthesia are effective for a period of time in certain fracture patterns, and open or arthroscopic surgical debridements should be reserved for the patient for whom nonoperative modalities fail and who has a clinically significant deficit. Copyright © 2016 Elsevier Inc. All rights reserved.
Beltran, Michael J; Collinge, Cory A; Gardner, Michael J
Stress modulation is the concept of manipulating bridge plate variables to provide a flexible fixation construct that allows callus formation through uneventful secondary bone healing. Obtaining absolute stability through the anatomic reduction of all fracture fragments comes at the expense of fracture biology, whereas intramedullary nailing, which is more advantageous for diaphyseal fractures of the lower extremity, is technically demanding and often may not be possible when stabilizing many metaphyseal fractures. Overly stiff plating constructs are associated with asymmetric callus formation, early implant failure, and fracture nonunion. Numerous surgeon-controlled variables can be manipulated to increase flexibility without sacrificing strength, including using longer plates with well-spaced screws, choosing titanium or stainless steel implants, and using locking or nonlocking screws. Axially dynamic emerging concepts, such as far cortical locking and near cortical overdrilling, provide further treatment options when bridge plating techniques are used.
Franciosi, Edgardo; Mazzaro, Eduardo; Larranaga, Juan; Rios, Alfredo; Picco, Pedro; Figari, Marcelo
The aim of the study is to analyze the effectiveness of rigid internal fixation (RIF) for treating edentulous mandibular fractures. Because of the low incidence of fractures in edentulous mandible, there is no consensus of the optimal treatment for it. This study included all edentulous patients with mandibular fracture diagnosis, who were treated with internal fixation at the Hospital Italiano de Buenos Aires from November 1991 to July 2011. Data such as age, gender, etiology and location of fracture, surgical approach, type of osteosynthesis used, and postoperative complications were analyzed. A total of 18 patients, 76.2 years mean age, 12 females (66.6%), presented a total of 35 mandibular fractures. The mandibular body was the most common localization of the fractures. Twenty-five fractures received surgical treatment with RIF, mainly approached extraorally. Reconstruction plates were the most common type of fixation used. Fracture reduction was considered satisfactory in 96.5%, with 22.2% of complications and 11.1% of reoperations needed. Open reduction and RIF demonstrated to be a reliable method for treating edentulous mandibular fractures. Nevertheless, there is lack of high-level recommendation publication to support this. PMID:24624255
Karakasli, Ahmet; Hapa, Onur; Erduran, Mehmet; Dincer, Cemal; Cecen, Berivan; Havitcioglu, Hasan
For talar neck fractures, open reduction and internal fixation have been thought to facilitate revascularization and prevent osteonecrosis. Newer screw systems allow for placement of cannulated headless screws, which provide compression by virtue of a variable pitch thread. The present study compared the biomechanical fixation strength of cannulated headless variable-pitch screw fixation and locking plate fixation. A reproducible talar neck fracture was created in 14 fresh cadaver talar necks. Talar head fixation was then performed using 2 cannulated headless variable-pitch 4-mm/5-mm diameter (4/5) screws (Acutrak; Acumed, Hillsboro, OR) and locking plate fixation. Headless variable-pitch screw fixation had lower failure displacement than did locking plate fixation. No statistically significant differences were found in failure stiffness, yield stiffness (p = .655), yield load (p = .142), or ultimate load between the 2 fixation techniques. Cannulated headless variable-pitch screw fixation resulted in better failure displacement than locking plate fixation in a cadaveric talus model and could be considered a viable option for talus fracture fixation. Headless, fully threaded, variable-pitch screw fixation has inherent advantages compared with locking plate fixation, because it might cause less damage to the articular surface and can compress the fracture for improved reduction. Additionally, plate fixation can increase the risk of avascular necrosis owing to the wider incision and dissection of soft tissues.
Murakami, Kazuhiro; Yamamoto, Kazuhiko; Sugiura, Tsutomu; Horita, Satoshi; Matsusue, Yumiko; Kirita, Tadaaki
This study was performed to evaluate stresses in various types of plates placed for a virtually reduced unilateral condylar fracture of the mandible using computed tomography-based 3-dimensional finite element (FE) models of a patient to select the optimal plate system. A computed tomography-based FE model of the mandible of a patient with a unilateral condylar fracture was constructed. The fracture was virtually reduced and fixed with 1 straight titanium plate; 2 straight titanium plates; 2 straight poly-L-lactic acid plates; and 4-hole (box), 5-hole (strut), and 7-hole (lambda) condylar plates. Stresses developing in these plates were analyzed by applying 478.1 N of bite force at the first molar of the contralateral side of the mandible. The magnitudes of tensile stress were within the tensile strength in all types of plates. However, the magnitudes of compressive stress in 1 straight titanium plate and 2 straight poly-L-lactic acid plates were beyond the compressive strength. The tensile and compressive stresses of the 5-hole (strut) plate were the smallest among the 3 types of condylar plates. Fixation by 2 straight titanium plates or any type of condylar plate was biomechanically indicated for the condylar fracture of this patient. Among these plates, the 5-hole (strut) plate was considered optimal. FE analysis is useful in selecting the optimal fixation method in the individual patient. Copyright © 2017 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Burke, Charity S; Roberts, Craig S; Nyland, John A; Radmacher, Paula G; Acland, Robert D; Voor, Michael J
The purpose of this study was to measure and map scapula osseous thickness to identify the optimal areas for internal fixation. Eighteen (9 pairs) scapulae from 2 female and 7 male cadavers were used. After harvest and removal of all soft tissues, standardized measurement lines were made based on anatomic landmarks. For consistency among scapulae, measurements were taken at standard percentage intervals along each line approximating the distance between two consecutive reconstruction plate screw holes. Two-mm-diameter drill holes were made at each point, and a standard depth gauge was used to measure thickness. The glenoid fossa (25 mm) displayed the greatest mean osseous thickness, followed by the lateral scapular border (9.7 mm), the scapula spine (8.3 mm), and the central portion of the body of the scapula (3.0 mm). To optimize screw purchase and internal fixation strength, the lateral border, the lateral aspect of the base of the scapula spine, and the scapula spine itself should be used for anatomic sites of internal fixation of scapula fractures.
Doshi, H. K.; Selvaraj, Dahshaini; Chan, William; Naidu, G.; Ramason, R.
Introduction: Although there is evidence of improved functional outcomes with our “integrated care pathway” for geriatric hip fractures, we do not know if there is a significant difference in functional recovery of activities of daily living and attainment of independence in self-care between patients who underwent fixation and those treated with arthroplasty. Objective: To determine whether such a difference exists in surgically fixed hip fractures. Materials and Methods: Patients with hip fracture treated surgically were divided into group A (internal fixation, n = 213) and group B (arthroplasty, n = 199). Demographic data, Charlson comorbidity index (CCI) score, time to surgery, and length of stay were recorded. Inpatient complications and mortality rates were also documented. Modified Barthel Index (MBI) scores were recorded for the following intervals: prefall, discharge, 6-month, and at 1-year follow-up. Results: The mean age (A: 80 years and B: 81years), CCI (A: 5.41 and B: 5.43), and length of stay (A: 13.6 days and B: 15.2 days) were not significantly different. However, there was a significant difference (P < .05) in time to surgery (A: 102.2 hours and B: 86.6 hours). Complication rates were about 6% in both groups (A = 6.57%: urinary infections = 13, wound infections = 1 and B = 6.03%: urinary infections = 10, wound infections = 1, pressure ulcer = 1). The preinjury MBI scores were significantly different (P < .05; A: 91.65 and B: 88.19), however, there was no significant difference in scores measured at discharge (A: 60.79 and B: 59.39), 6 months (A: 77.65 and B: 77.47) and 1 year (A: 80.71 and B: 83.03). Patients who underwent surgery for hip fracture had overall recovered 90.9% of their preinjury function (overall MBI at 1 year: 81.83). Conclusion: The MBI scores reflect the extent of attainment of independence in self-care, and actual functional recovery is gauged from the percentage of recovery of preinjury function at 1 year postsurgery. We
Lovald, Scott; Baack, Bret; Gaball, Curtis; Olson, Garth; Hoard, Anna
To design and optimize a bone plate for fractures of the mandibular symphysis that will provide maximum fracture stability with minimal implanted volume and patient intrusion. The design will be driven by the unique biomechanics specific to this fracture location. A finite element model of a fractured human mandible was created using computed tomography scans. The boundary conditions included simulating molar, canine, and incisal loading. The bone plate design process included a shape optimization routine and design parameter analysis using the model. The optimized bone plate design was finally compared with standard bone plate configurations according to stress and strain measures. Compared with the miniplate combination, the InterFlex III plate, with the same thickness and just 14% more implanted volume, had only 55% of the plate stress and 25% less fracture strain under the strongest loads considered by the model. Compared with the band/fracture plate combination, the InterFlex plate had 88% of the fracture strain and 74% of the plate stress, despite having only 60% of the plate volume. The results have demonstrated that the new optimized plate is a hybrid of fixation hardware with the small profile of the smallest miniplate configuration and the superior fixation strength and safety that exceeds that of the larger fracture plate configuration. Copyright 2010 American Association of Oral and Maxillofacial Surgeons. All rights reserved.
Douglas-de-Oliveira, Dhelfeson-Willya; Stella, Paulo-Eduardo-Melo; Rocha-dos Santos, Cássio-Roberto
Background Intermaxillary fixation is used to achieve proper occlusion during and after oral and maxillofacial fracture surgery. The aim of this systematic review was to compare Erich arch bar fixation with other intermaxillary fixation methods in terms of the operating time, safety during installation, oral health maintenance and occlusal stability. Material and Methods An electronic online search was conducted of the Scirus, PubMed, Ovid, Cochrane Library and VHL databases. A clinical trial dating from the inception of the data bases until August 2013 was selected. Studies that compared Erich arch bars with other intermaxillary fixation methods in patients older than 18 years-old were included. The studies were assessed by two independent reviewers. The methodological quality of each article was analyzed. Results Nine hundred and twenty-five manuscripts were found. Seven relevant articles were analyzed in this review. The risk of bias was considered moderate for four studies and high for three clinical trials. Conclusions There is not enough evidence to conclude that the Erich arch bar is the best intermaxillary fixation method in cases of oral and maxillofacial fractures. Key words: Facial injuries, jaw fixation techniques, mandible, maxilla. PMID:26034929
Kang, Joon Soon; Moon, Kyoung Ho; Shin, Joong Sup; Shin, Eun Ho; Ahn, Chi Hoon; Choi, Geon Hong
Subcapital femoral neck is known to cause many complications, such as avascular necrosis (AVN) of the femoral head or nonunion, compared with other femoral neck fractures. The purpose of this study was to analyze the incidence of AVN and fixation failures in patients treated with internal fixation using cannulated screws for the subcapital femoral neck fractures. This study targeted a total of 84 cases of subcapital femoral neck fractures that underwent internal fixation using cannulated screws. The average follow-up time after surgery was 36.8 months (range, 24 to 148 months). Nine hips (10.7%) showing AVN of the femoral head and 6 hips (7.1%) showing fixation failures were observed. The factors affecting the incidence of AVN of the femoral head after sustaining fractures correlated well with fracture types in the Garden classification (p = 0.030). The factors affecting fixation failure were the degree of reduction (p = 0.001) measured by the Garden alignment index and firm fixation (p = 0.009) assessed using the technique of 3-point fixation through the inferomedial cortical bone of the femoral neck. The complication rates for subcapital femoral neck fractures were lower than those previously reported; hence, internal fixation could be a primary treatment option for these fractures.
Scolaro, John A; Broghammer, Francis H; Donegan, Derek J
The optimal treatment strategy for distal tibia fractures, especially those with intraarticular extension, remains controversial. Although open reduction and internal fixation with a plate and screw device is commonly performed for these injuries, the risk of soft tissue complications using this approach is significant. Staged treatment protocols and alternative means of fixation have been proposed to address these undesired events. Although potentially more technically demanding than fixation of diaphyseal or extraarticular tibial fractures, intramedullary nail (IMN) fixation of simple intraarticular distal tibia fractures is a viable treatment alternative with unique advantages. This article presents a review of the literature and rationale for intramedullary tibial nail fixation of simple intraarticular distal tibia fractures and a surgical approach commonly utilized for successful implementation.
Lowenberg, David W; Githens, Michael; Boone, Christopher
There is a growing mass of literature to suggest that circular external fixation for high-energy tibial fractures has advantages over traditional internal fixation, with potential improved rates of union, decreased incidence of posttraumatic osteomyelitis, and decreased soft tissue problems. To further advance our understanding of the role of circular external fixation in the management of these tibial fractures, randomized controlled trials should be implemented. In addition to complication rates and radiographic outcomes, validated functional outcome tools and cost analysis of this method should be compared with open reduction with internal fixation. Copyright © 2014 Elsevier Inc. All rights reserved.
Gali, Rajasekhar; Devireddy, Sathya Kumar; Venkata, Kishore Kumar Rayadurgam; Kanubaddy, Sridhar Reddy; Nemaly, Chaithanyaa; Dasari, Mallikarjuna
Introduction: Free grafting or extracorporeal fixation of traumatically displaced mandibular condyles is sometimes required in patients with severe anteromedial displacement of condylar head. Majority of the published studies report the use of a submandibular, retromandibular or preauricular incisions for the access which have demerits of limited visibility, access and potential to cause damage to facial nerve and other parotid gland related complications. Purpose: This retrospective clinical case record study was done to evaluate the preauricular transmasseteric anteroparotid (P-TMAP) approach for open reduction and extracorporeal fixation of displaced and dislocated high condylar fractures of the mandible. Patients and Methods: This retrospective study involved search of clinical case records of seven patients with displaced and dislocated high condylar fractures treated by open reduction and extracorporeal fixation over a 3-year period. The parameters assessed were as follows: a) the ease of access for retrieval, reimplantation and fixation of the proximal segment; b) the postoperative approach related complications; c) the adequacy of anatomical reduction and stability of fixation; d) the occlusal changes; and the e) TMJ function and radiological changes. Results: Accessibility and visibility were good. Accurate anatomical reduction and fixation were achieved in all the patients. The recorded complications were minimal and transient. Facial nerve (buccal branch) palsy was noted in one patient with spontaneous resolution within 3 months. No cases of sialocele or Frey's syndrome were seen. Conclusion: The P-TMAP approach provides good access for open reduction and extracorporeal fixation of severely displaced condylar fractures. It facilitates retrieval, transplantation, repositioning, fixing the condyle and also reduces the chances of requirement of a vertical ramus osteotomy. It gives straight-line access to condylar head and ramus thereby permitting
Galos, David; Taylor, Benjamin; McLaurin, Toni
Rib fractures are extremely common injuries and vary in there severity from single nondisplaced fractures to multiple segmental fractures resulting in flail chest and respiratory compromise. Historically, rib fractures have been treated conservatively with pain control and respiratory therapy. However this method may not be the best treatment modality in all situations. Operative fixation of select rib fractures has been increasing in popularity especially in patients with flail chest and respiratory compromise. Newer techniques use muscle sparing approaches and precontoured locking plate technology to obtain stable fixation and allow improved respiration. Current reports shows that rib fracture fixation offers the benefits of improved respiratory mechanics and improved pain control in the severe chest wall injury with resultant improvement in patient outcomes by decreasing time on the ventilator, time in the intensive care unit, and overall hospital length of stay.
Lepilin, A V; Raĭgorodckiĭ, Iu M; Nozdrachev, V G; Erokina, N L
145 patients (60 with phlegmons of submandibular and submental regions, 85--with fractures of mandible) were observed and treated with the use of moving pulse magnetic field (MPMF) produced by special apparatus (AMO-ATOS-E,
Leyes, Manuel; Torres, Raúl; Guillén, Pedro
This article discusses the complications after open reduction and internal fixation of ankle fractures. Complications are classified as perioperative (malreduction, inadequate fixation, and intra-articular penetration of hardware), early postoperative (wound edge dehiscence, necrosis, infection and compartment syndrome), and late (stiffness, distal tibiofibular synostosis, degenerative osteoarthritis, and hardware related complications). Emphasis is placed on preventive measures to avoid such complications.
Freeland, Alan E; Luber, Kurre T
The fracture management principles of anatomic or near anatomic reduction, fracture stabilization, minimal operative trauma, and early joint motion are paramount in man-aging unstable distal radial fractures. The operative approach and plate selection should correlate with the fracture configuration. Plates have the advantages of providing secure fixation throughout the entire healing process without protruding wires or pins and allowing early and intensive forearm, wrist, and digital exercises. Disadvantages include additional operative trauma, including fragment devascularization; some additional risk of wrist stiffness; occasional tendon rupture; and at times, the need for plate removal. New developments in plate and screw design and operative strategies, fragment specific fixation, and plate strength have improved results with plate fixation. Fixed angle blades and locking screws and pegs enhance overall plate stability, support the articular surface of the distal radius, and are effective in fractures occurring in osteopenic bone.
Rancy, Schneider K.; Zelken, Jonathan A.; Lipman, Joseph D.; Wolfe, Scott W.
Background Headless screw fixation of scaphoid fractures and nonunions yields predictably excellent outcomes with a relatively low complication profile. However, intramedullary implants affect the load to failure and stress distribution within bone and may be implicated in subsequent fracture. Case Description We describe a posttraumatic fracture pattern of the scaphoid proximal pole originating at the previous headless screw insertion site in three young male patients with healed scaphoid nonunions. Each fracture was remarkably similar in shape and size, comprised the volar proximal pole, and was contiguous with the screw entry point. Treatment was challenging but successful in all cases. Literature Review Previous reports have posited that stress-raisers secondary to screw orientation may be implicated in subsequent peri-implant fracture of the femoral neck. Repeat scaphoid fracture after screw fixation has also been reported. However, the shape and locality of secondary fracture have not been described, nor has the potential role of screw fixation in the production of distinct fracture patterns. Clinical Relevance Hand surgeons must be aware of this difficult complication that may follow antegrade headless screw fixation of scaphoid fracture nonunion, and of available treatment strategies. PMID:26855840
Natoli, R M; Baer, M R; Bednar, M S
Distal radius fractures are common injuries treated in a multitude of ways. One treatment paradigm not extensively studied is initial treatment by external fixation (EF) followed by conversion to open reduction internal fixation (ORIF). Such a paradigm may be beneficial in damage control situations, when there is extensive soft tissue injury, or when appropriate personnel/hospital resources are not available for immediate internal fixation. There is no increased risk of infection when converting EF to ORIF in the treatment of complex distal radius fractures when conversion occurs early or if EF pin sites are overlapped by the definitive fixation. Using an IRB approved protocol, medical records over nine years were queried to identify patients with distal radius fractures that had undergone initial EF and were later converted to ORIF. Charts were reviewed for demographic data, injury characteristics, operative details, time to conversion from EF to ORIF, assessment of whether the EF pin sites overlapped the definitive fixation, presence of infection after ORIF, complications, and occupational therapy measurements of range of motion and strength. In total, 16 patients were identified, only one of which developed an infection following conversion to ORIF. Fisher's exact testing showed that infection did not depend on open fracture, time to conversion of one week or less, presence of EF pin sites overlapping definitive fixation, fracture classification, high energy mechanism of injury, or concomitant injury to the DRUJ. Planned staged conversion from EF to ORIF for complex distal radius fractures does not appear to result in an increased rate of infection if conversion occurs early or if the EF pin sites are overlapped by definitive fixation. This treatment paradigm may be reasonable for treating complex distal radius fractures in damage control situations, when there is extensive soft tissue injury, or when appropriate personnel/hospital resources are not available
Hanselman, Andrew E; Murphy, Timothy R; Bal, George K; McDonough, E Barry
Although clavicle fractures often heal well with nonoperative management, current literature has shown improved outcomes with operative intervention for specific fracture patterns in specific patient types. The 2 most common methods of midshaft clavicle fracture fixation are intramedullary and plate devices. Through retrospective analysis, this study performed a direct cost comparison of these 2 types of fixation at a single institution over a 5-year period. Outcome measures included operative costs for initial surgery and any hardware removal surgeries. This study reviewed 154 patients (157 fractures), and of these, 99 had intramedullary fixation and 58 had plate fixation. A total of 80% (79 of 99) of intramedullary devices and 3% (2 of 58) of plates were removed. Average cost for initial intramedullary placement was $2955 (US dollars) less than that for initial plate placement (P<.001); average cost for removal was $1874 less than that for plate removal surgery (P=.2). Average total cost for all intramedullary surgeries was $1392 less than the average cost for all plating surgeries (P<.001). Average cost for all intramedullary surgeries requiring plate placement and removal was $653 less than the average cost for all plating surgeries that involved only placement (P=.04). Intramedullary fixation of clavicle fractures resulted in a statistically significant cost reduction compared with plate fixation, despite the incidence of more frequent removal surgeries. [Orthopedics.2016; 39(5):e877-e882.].
Nieto, H; Baroan, C
Alternatives to internal fixation of long-bone fracture comprise, depending on location, external fixation or joint replacement. Limitations comprise risk of infection and functional outcome quality, which vary according to technique. The present study examines these limitations, based on comparative or large-scale studies from which certain significant results emerge. Four main questions are dealt with: (1) the present role of locking plates; (2) conditions for intramedullary nailing in Gustilo grade IIIb open fracture; (3) the limitations of conversion from external fixation to intramedullary nailing in open lower leg fracture; (4) and the limitations of definitive anterograde femoral nailing in multiple trauma. Locking plate fixation has yet to prove clinical superiority in any of the anatomic sites for which good-quality comparative analyses are available. Infection risk in Gustilo grade IIIb open lower leg fracture is equivalent when treated by intramedullary nailing or external fixation, if wound care and debridement are effective, antibiotherapy is initiated rapidly and skin cover is restored within 7days. Conversion from primary external fixation to intramedullary nailing is possible if the external fixator was fitted less than 28days previously and skin cover was restored within 7days. The pulmonary and systemic impact of peripheral lesions or definitive anterograde intramedullary nailing of femoral fracture in multiple trauma calls for caution and what is known as "damage-control orthopedics" (DCO), a term covering the general consequences of both the initial trauma and its treatment. Femoral intramedullary nailing is thus contraindicated in case of hemorrhagic shock (blood pressure<90mmHg), hypothermia (<33°C), coagulation disorder (platelet count<90,000) or peripheral lesions such as multiple long-bone fractures, crushed limb or primary pulmonary contusion. In such cases, external fixation or retrograde nailing with a small-diameter nail and without
Lewis, Sarah; Argintar, Evan; Jahn, Ryan; Zusmanovich, Mike; Itamura, John; Rick Hatch, George F.
Background Although operative treatment may offer an appropriate management option for displaced glenoid fractures, there is sparse research assessing post-operative functional outcomes. This study assessed functional outcomes of patients after undergoing open reduction and internal fixation of displaced glenoid fractures. Methods Fifteen patients were treated with open reduction and internal fixation for displaced intra-articular fractures between 2005 and 2010. The indication for operative fixation was intra-articular displacement >4 mm. Post-operative functional outcomes were assessed via retrospective chart review. Evaluation included review of pre-operative imaging for fracture type, review of post-operative plain radiographs for fracture healing, Disabilities of the Arm Shoulder and Hand (DASH) and American Shoulder and Elbow Surgeon Assessment (ASES) scores at last follow-up. Results At a mean follow-up of 49 months (24–87 months) all patients had radiographic healing. The mean DASH score was 10 (range 0.83–29.17). Mean ASES score was 90 (range 41.7–100). No patients had evidence of hardware failure or infection. Conclusions Open reduction and internal fixation of displaced intra-articular glenoid fractures results in stable fixation and is associated with good functional outcome. Level of evidence Level IV. Case series. PMID:24396240
Fuller, David A
The purpose of this video is to demonstrate the surgical repair of an intraarticular distal humerus fracture. A polytrauma patient with an intraarticular distal humerus fracture is shown. The patient is positioned laterally, with a posterior skin incision and olecranon osteotomy for exposure. An anatomic reduction is achieved, and internal fixation with perpendicular plating of the distal humerus is performed. The video is 18 minutes, 34 seconds duration in time and 2,048,752,000 bytes in size. Open reduction with internal fixation of a distal humerus fracture is demonstrated in this video.
Cornelius, Carl-Peter; Audigé, Laurent; Kunz, Christoph; Rudderman, Randal; Buitrago-Téllez, Carlos H.; Frodel, John; Prein, Joachim
This tutorial outlines the details of the AOCMF image-based classification system for fractures of the mandibular arch (i.e. the non-condylar mandible) at the precision level 3. It is the logical expansion of the fracture allocation to topographic mandibular sites outlined in level 2, and is based on three-dimensional (3D) imaging techniques/computed tomography (CT)/cone beam CT). Level 3 allows an anatomical description of the individual conditions of the mandibular arch such as the preinjury dental state and the degree of alveolar atrophy. Trauma sequelae are then addressed: (1) tooth injuries and periodontal trauma, (2) fracture involvement of the alveolar process, (3) the degree of fracture fragmentation in three categories (none, minor, and major), and (4) the presence of bone loss. The grading of fragmentation needs a 3D evaluation of the fracture area, allowing visualization of the outer and inner mandibular cortices. To document these fracture features beyond topography the alphanumeric codes are supplied with distinctive appendices. This level 3 tutorial is accompanied by a brief survey of the peculiarities of the edentulous atrophic mandible. Illustrations and a few case examples serve as instruction and reference to improve the understanding and application of the presented features. PMID:25489389
Kraan, Gerald A; Krijnen, Matthijs R; Eerenberg, Jan Peter
A 24-year-old woman with pain in the right elbow after a fall demonstrated a coronal shear fracture on radiographic studies. Perioperative a coronal shear fracture was seen and treated successfully with a polylactide Rigid fix resorbable pin. The operative correction resulted in normal function at 6 months follow-up. We state that a capitellum shear fracture can be fixated with a single resorbable pin, leading to successful fusion. PMID:23378544
Kumar, Krishna; Acosta, Natasha
Isolated bilateral fractures of the coronoid processes of the mandible occurred in this patient without any significant trauma. The definite etiology of this case is unknown, but possible causes or contributing factors may include acute reflex contraction of the patient’s temporalis muscles leading to bilateral stress fractures, coronoid process hyperplasia, or the patient’s long-term use of omeprazole. The planned treatment for this patient included pain control with Mobic and tramadol and splint fabrication followed by arch bar placement with training elastics for six weeks. PMID:27882276
Bravman, Jonathan T; Taylor, Michal L; Baldini, Todd; Vidal, Armando F
Higher rates of poor outcomes in displaced midshaft clavicle fractures treated nonoperatively have recently been reported. Along with expanding indications for operative fixation and increasing application of locked plate constructs, it is unknown whether complications related to bicortical penetration of the clavicle can be avoided using unicortical fixation. The purpose of this study is to compare the biomechanical properties of unicortical and bicortical fixation in precontoured vs manually contoured locking clavicle plates. Forty-eight Sawbone composite human clavicle specimens (item #3408; Pacific Research Laboratories, Vashon, Washington) with a midshaft clavicle osteotomy were reduced and plated in 8 specimens each using a bicortical and unicortical fixation for each of 3 locked plate constructs (3.5-mm LCP Reconstruction Plate; 3.5-mm LCP Superior Clavicle Plate; 3.5-mm LCP Superior Anterior Clavicle Plate; Synthes, Inc, West Chester, Pennsylvania). Specimens were tested for stiffness in axial torsion and cantilever bending and then loaded to failure in 3-point bending. Data were analyzed using 2-way analysis of variance and Tukey's test (P<.05). No significant differences were found between unicortical and bicortical fixation in failure load, cantilever bending, and cross body stiffness. Bicortical fixation was significantly stiffer than unicortical fixation in torsion only for the same plates. Significant differences also existed between plates in torsion. Unicortical locked plate fixation may be a reasonable option in the treatment of displaced midshaft clavicle fracture fixation to avoid complications associated with posteroinferior hardware penetration following clavicle fracture fixation based on the biomechanical performance of these constructs. However, it remains unclear whether these differences will be clinically significant.
Manor, Esther; Joshua, Ben Zion; Levy, Jacov; Brennan, Peter A; Bodner, Lipa
Congenital insensitivity to pain with anhidrosis (CIPA) is a rare hereditary sensory and autonomic neuropathy (HSAN) characterized by pain, self-mutilating behaviour, anhidrosis and recurrent hyperthermia. CIPA has a multisystem involvement, including fractures of the extremities with slow healing, immunologic abnormalities, and a chronic inflammatory state. The mandible is reported to have a higher incidence of osteomyelitis, though mandibular fracture among CIPA patients, is very rare, with to our knowledge no reports in children. A case of pathological fracture of the mandible in a 6-year-old child with CIPA treated by ORIF is reported. In contrast to the slow healing reported in long bones, the mandible healed very quickly, possibly indicating that the osteoporotic mandible in this group of patients is different from that seen in the elderly. Furthermore, the standard ORIF technique can be safely used in this rare group.
Duwelius, P J; Rangitsch, M R; Colville, M R; Woll, T S
Seventy-five adults who sustained 76 tibial plateau fractures were treated according to a prospective protocol using instability in extension as the principal indication for operative fixation. Patients showing instability underwent closed manipulative reduction under fluoroscopic guidance. If significant joint depression persisted after reduction, elevation of the fracture was performed either from below using bone punches through a cortical window or via limited arthrotomy. Iliac crest bone graft was used to buttress depressed fractures. Fixation was then secured using 7-mm cannulated screws with washers or buttress plates and screws. Postoperatively, 58 of 76 knees were managed in a hinged knee brace, allowing the patient early range of motion and protected weightbearing for 8 weeks. Patients who were found to have a stable knee were treated with Bledsoe braces according to the postoperative protocol. In the 75 patients, 18 of the 76 knees were unsuitable for percutaneous screw fixation because of fracture complexity requiring plates, severe open injuries, or inadequate reductions with limited fixation had been done. A minimum followup of 12 months was obtained in 55 patients (range, 12-59 months). All fractures had healed at the time of followup. Eighty-seven percent of the patients at followup had a successful outcome using Rasmussen's criteria. Fourteen of these patients had arthroscopic assisted reduction or evaluation. All seven patients who had poor outcomes had AO Type C3 fracture patterns. Severely depressed or comminuted fractures or fractures with significant metaphyseal diaphyseal extension may not be suitable for this technique and require the addition of an external fixation device or buttress plate to maintain the reduction and allow for early range of motion.
Rossignol, Fabrice; Brandenberger, Olivier; Mespoulhes-Rivière, Céline
To describe the surgical treatment outcome of cervical fractures in 3 horses. Case report. Three client-owned horses with cervical vertebral fractures. Three horses were refered for neck stiffness, pain, and ataxia after a cervical trauma because of a fall. Radiographic examination showed an oblique displaced fracture of the caudal aspect of the body of the second cervical vertebra (C2) in horse 1, an oblique displaced fracture of the caudal aspect of C4 involving the disc between C4 and C5 in horse 2, and a displaced transverse fracture of the body of the axis (C2) extending to the lateral arches and involving the vertebral canal in horse 3. In horse 1, the fracture was reduced and stabilized using a 14-hole narrow DCP plate, applied ventrally, and fixed with cancellous screws. A cervical fusion was performed. In horses 2 and 3, fracture fixation was performed using a 5-hole narrow LCP and 5 mm locking screws. All horses showed improvement and returned to full activity. The fracture healed in all horses. Internal fixation of cervical fracture in these horses was associated with minimal complications, and was associated with healing and a highly functional outcome in all horses. The LCP was preferred and would be recommended for ventral stabilization of selected cases of vertebral fractures. © Copyright 2015 by The American College of Veterinary Surgeons.
Feng, Yongzeng; Yu, Yang; Shui, Xiaolong; Ying, Xiaozhou; Cai, Leyi; Hong, Jianjun
Open reduction and internal fixation has been widely used to treat displaced intra-articular calcaneus fractures in children. However, the complications of surgical trauma and the wound created through the extended lateral approach cannot be ignored. This study analyzed the outcomes of displaced intra-articular calcaneal fractures in children treated with closed reduction and percutaneous fixation. Medical records of pediatric patients who had displaced intra-articular calcaneus fractures and underwent closed reduction and percutaneous fixation at the study institution between January 2008 and January 2013 were reviewed. Preoperative radiographs and computed tomography scans were used to evaluate and classify the fractures. Clinical outcomes and radiographic findings were assessed at postoperative follow-up. The study included 14 displaced intra-articular calcaneal fractures in 11 patients (7 boys and 4 girls). Mean patient age was 11.18 years (range, 6-16 years), and average follow-up time was 42.8 months postoperatively (range, 12-72 months). There were 6 tongue-type fractures and 8 joint depression-type fractures, based on the Essex-Lopresti classification, and there were 11 type II and 3 type III fractures, based on the Sanders classification. Average Böhler angle was 8.00° (range, -5° to 18°) preoperatively and 30.79° (range, 26° to 40°) postoperatively (P<.001). Average subjective American Orthopaedic Foot and Ankle Society hindfoot score was 65.7 (range, 52-68). No patients had wound breakdown or infection. In the treatment of displaced intra-articular calcaneal fractures in pediatric patients, closed reduction and percutaneous fixation achieved good outcomes, with few complications. [Orthopedics. 2016; 39(4):e744-e748.]. Copyright 2016, SLACK Incorporated.
Hayes, J S; Richards, R G
The use of metal in fracture fixation has demonstrated unrivalled success for many years owing to its high stiffness, strength, biological toleration and overall reliable function. The most prominent materials used are electropolished stainless steel and commercially pure titanium, along with the more recent emergence of titanium alloys. Despite the many differences between electropolished stainless steel and titanium, both materials provide a relatively predictable clinical outcome, and offer similar success for fulfilling the main biomechanical and biological requirements of fracture fixation despite distinctive differences in implant properties and biological responses. This article explores these differences by highlighting the limitations and advantages of both materials, and addresses how this translates to clinical success.
Clinical studies do not allow a quantitative correlation between stability of fracture fixation and outcome of bone healing. This limits the biomechanical improvement of fracture fixation techniques. The most practical quantitative parameter to describe the stability of a fracture fixation is the stiffness. This can be determined for several types of fixation through biomechanical methods and in some clinical studies in vivo. By using numerical fracture healing models, it is now possible to use the tissue differentiation rules found in basic research to calculate optimal stiffness parameters for various fixation techniques. For a tibial fracture as an example the possibilities of a numerical fracture healing simulation have been demonstrated. The effects of the diameter of an intramedullary nail, type of fracture, fracture gap size and nail material on healing could be demonstrated. To circumvent complex and time consuming calculations for several fixations a map was calculated which shows the expected bone healing quality as a function of the axial stiffness and the shear stiffness of the fixation device. By comparing the stiffness of various fixation techniques with the stiffness map it becomes evident that the methods most often used (e.g. unreamed nail, plate and external fixator) have a low shear and/or rotational stiffness that is too low to achieve the optimal healing outcome. The high axial stiffness of plates next to the plate surface can lead to very low tissue strain directly adjacent to the plate and can delay the bone healing process at this location.
Schoen, R; Fakler, O; Metzger, M C; Weyer, N; Schmelzeisen, R
Temporomandibular joint (TMJ) function was evaluated following endoscope-assisted transoral open reduction and miniplate fixation of displaced bilateral condylar mandibular fractures. The transoral treatment of bilateral condylar fractures was performed in 13 patients from May 2000 to December 2004. Eleven of the 13 patients had additional mandibular fractures. Out of 26 fractures of the condylar process, 11 were located at the condylar neck and 15 were subcondylar. One, 6 and 12 months after surgery TMJ function was evaluated. Anatomic reduction was achieved using an endoscope-assisted transoral approach even when the condylar fragment was displaced medially and in fractures with comminution. Good TMJ function was noted 6 and 12 months after surgery. Mouth opening was measured to be more than 40 mm without deviation. Postoperative range of motion with a satisfying lateral excursion was found. Early rehabilitation and pre-injury TMJ function was achieved following minimally invasive anatomic fracture reduction.
Lui, T H
Achilles tendon ruptures occur commonly in the midsubstance of the tendon, usually 2-6 cm proximal to the insertion to the calcaneus. Ruptures near its insertion into the calcaneus are less common and mostly found in hyperpronators with a heel spur (Haglund's deformity). Avulsion of the bony insertion of the Achilles tendon at the calcaneus is infrequent and is diagnosed by radiography. Open reduction and internal fixation is indicated to achieve bone to bone healing and restoration of the function and continuity of the triceps surae mechanism. Screw fixation is not effective to resist the pull out tension of the triceps surae. Moreover, the prominent screw head may cause skin impingement. More secure fixation method is necessary in order to allow early functional rehabilitation. We describe a technique to fix the avulsed fragment of Achilles tendon insertion with 2 suture anchors. This can neutralize the pull of the triceps surae and early post-operative rehabilitation programme is allowed.
Schmidt, A H; Swiontkowski, M F
Infection complicating internal fixation of fractures is a serious complication that is difficult to treat. Whenever metallic devices are implanted in vivo, successful biointegration requires that host cells colonize the highly reactive implant surface. Bacteria such as staphylococci can also become adherent to metallic or polymeric implants and will compete with host cells for colonization of the implant surface. Once adherent, these bacteria form a biofilm and undergo phenotypic changes that make them resistant to the normal host immune response as well as to antibiotics. Furthermore, metallic implants themselves cause specific deficits in the function of the local immune system that may render the host response to infection inadequate. Any associated soft-tissue injury causes even greater impairment of local immune function. Despite the potentially detrimental impact of internal fixation, fracture stability is of paramount importance in achieving fracture union and in preventing infection. It has been demonstrated in animal models that contaminated fractures without internal fixation develop clinical infection more commonly than similar fractures treated with internal fixation at the time of colonization. Because of the potential for infection whenever internal fixation is utilized, appropriate prophylactic antibiotic coverage for staphylococci and Gram-negative organisms should be provided. Open wounds and severely damaged soft tissues require aggressive management so that a viable soft-tissue envelope is maintained around the implant. Host factors such as smoking and malnourishment should be corrected. Early diagnosis and aggressive treatment of implant-related infection with antibiotics, debridement, and maintenance of stable internal fixation are essential to successful treatment.
Degala, Saikrishna; Shetty, Sujeeth; Ramya, S
Context: In this prospective study, 13 randomly selected patients underwent treatment for zygomatic–complex fractures (2 site fractures) and mandibular fractures using 1.5 / 2 / 2.5-mm INION CPS biodegradable plates and screws. Aims: To assess the fixation of zygomatic-complex and mandibular fractures with biodegradable copolymer osteosynthesis system. Materials and Methods: In randomly selected 13 patients, zygomatic-complex and mandibular fractures were plated using resorbable plates and screws using Champy's principle. All the cases were evaluated clinically and radiologically for the type of fracture, need for the intermaxillary fixation (IMF) and its duration, duration of surgery, fixation at operation, state of reduction at operation, state of bone union after operation, anatomic reduction, paresthesia, occlusal discrepancies, soft tissue infection, immediate and late inflammatory reactions related to biodegradation process, and any need for the removal of the plates. Statistical Analysis Used: Descriptives, Frequencies, and Chi-square test were used. Results: In our study, the age group range was 5 to 55 years. Road traffic accidents accounted for the majority of patients six, (46.2%). Postoperative occlusal discrepancies were found in seven patients as mild to moderate, which resolved with IMF for 1-8 weeks. There were minimal complications seen and only as soft tissue infection. Conclusions: Use of biodegradable osteosynthesis system is a reliable alternative method for the fixation of zygomatic-complex and mandibular fractures. The biodegradable system still needs to be refined in material quality and handling to match the stability achieved with metal system. Biodegradable plates and screws is an ideal system for pediatric fractures with favorable outcome. PMID:23662255
Parsons, S W; Fitzgerald, J A; Shearer, J R
A prospective study of the management of 30 patients with 37 unstable or complex metacarpal or phalangeal fractures treated with the "Shearer" micro-external fixator was carried out over an 18-month period. The stability achieved, with minimal soft-tissue tethering, allowed early joint mobilisation with good or excellent function in 94% of metacarpal and 85% of phalangeal fractures by nine weeks. There were no cases of non-union and few complications.
Batista, Bruno Bellaguarda; Salim, Rodrigo; Paccola, Cleber Antonio Jansen; Kfuri, Mauricio
OBJECTIVE: Evaluate safety and reliability of internal fixator for the treatment of intra-articular and periarticular distal femur fractures. METHODS: Retrospective data evaluation of 28 patients with 29 fractures fixed with internal fixator was performed. There was a predominance of male patients (53.5%), with 52% of open wound fractures, 76% of AO33C type fractures, and a mean follow up of 21.3 months. Time of fracture healing, mechanical axis deviation, rate of infection and postoperative complications were registered. RESULTS: Healing rate was 93% in this sample, with an average time of 5.5 months. Twenty-seven percent of patients ended up with mechanical axis deviation, mostly resulting from poor primary intra-operative reduction. There were two cases of implant loosening; two implant breakage, and three patients presented stiff knee. No case of infection was observed. Healing rate in this study was comparable with current literature; there was a high degree of angular deviation, especially in the coronal plane. CONCLUSION: Internal fixators are a breakthrough in the treatment of knee fractures, but its use does not preclude application of principles of anatomical articular reduction and mechanical axis restoration. Level of Evidence II, Retrospective Study. PMID:25061424
Capo, John T; Kinchelow, Tosca; Brooks, Kenneth; Tan, Virak; Manigrasso, Michaele; Francisco, Kristin
Implants available for distal radius fracture fixation include dorsal nonlocked plating (DNLP), volar locked plating (VLP), radial-ulnar dual-column locked plating (DCPs), and locked intramedullary fixation (IMN). This study examines the biomechanical properties of these four different fixation constructs. In 28 fresh-frozen radii, a wedge osteotomy was performed, creating an unstable fracture model and the four fixation constructs employed (DNLP, VLP, DCPs, and IMN). Dorsal bending loads were applied and bending stiffness, load to yield 5 mm displacement, and ultimate failure were measured. Bending stiffness for VLP (16.7 N/mm) was significantly higher than for DNLP (6.8 N/mm), while IMN (12.6 N/mm) and DCPs (11.8 N/mm) were similar. Ultimate load to failure occurred at 278.2 N for the VLP, 245.7 N for the IMN, and 52.0 N for the DNLP. The VLP was significantly stronger than the DNLP and DCPs, and the IMN and DCPs were stronger than the DNLP. The VLP has higher average bending stiffness, ultimate bending strength, and resistance to 5 mm displacement than the other constructs and significantly higher ultimate bending strength than the DCPs and DNLP. There was no statistically significant difference between the VLP and IMN. VLP and IMN fixation of distal radius fractures can achieve comparable stability.
Background Fractures of the pelvic ring including disruption of the posterior elements in high-energy trauma have both high morbidity and mortality rates. For some injury pattern part of the initial resuscitation includes either external fixation or plate fixation to close the pelvic ring and decrease blood loss. In certain situations – especially when associated with abdominal trauma and the need to perform laparotomies – both techniques may put the patient at risk of either pintract or deep plate infections. We describe an operative approach to percutaneously close and stabilize the pelvic ring using spinal implants as an internal fixator and report the results in a small series of patients treated with this technique during the resuscitation phase. Findings Four patients were treated by subcutaneous placement of an internal fixator. Screw fixation was carried out by minimally invasive placement of two supra-acetabular iliac screws. Afterwards, a subcutaneous transfixation rod was inserted and attached to the screws after reduction of the pelvic ring. All patients were allowed to fully weight-bear. No losses of reduction or deep infections occurred. Fracture healing was uneventful in all cases. Conclusion Minimally invasive fixation is an alternative technique to stabilize the pelvic ring. The clinical results illustrate that this technique is able to achieve good results in terms of maintenance of reduction the pelvic ring. Also, abdominal surgeries no longer put the patient at risk of infected pins or plates. PMID:24606833
... 21 Food and Drugs 8 2012-04-01 2012-04-01 false External facial fracture fixation appliance. 878.3250 Section 878.3250 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Prosthetic Devices §...
... 21 Food and Drugs 8 2013-04-01 2013-04-01 false External facial fracture fixation appliance. 878.3250 Section 878.3250 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Prosthetic Devices §...
... 21 Food and Drugs 8 2014-04-01 2014-04-01 false External facial fracture fixation appliance. 878.3250 Section 878.3250 Food and Drugs FOOD AND DRUG ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) MEDICAL DEVICES GENERAL AND PLASTIC SURGERY DEVICES Prosthetic Devices § 878.3250...
The more common dorsal fracture subluxations at the base of the middle phalanx have an intact dorsal buttress of articular surface in continuity with the shaft. Capitalizing on this foundation, various fixation methods have met with relatively equivalent success including Kirschner wires, screws only, nonlocking plate and screws, and external fixation. Pilon fractures are complete articular fractures, where the comminuted articular fragments lack any structural connection to the more distal shaft of the middle phalanx, and have largely relied upon external fixation traction systems. The theoretical concept is that axial distraction prevents articular collapse and that the surrounding soft tissue envelope acts to gather the articular fragments; the term "ligamentotaxis" is often applied. Most constructs are founded on a transverse wire through the axis of rotation in the head of the proximal phalanx with the idea that patients will pursue active motion, termed "dynamic fixation." In practice, patients find it difficult to move well while the construct is in place and have rarely achieved much range by the time of removal. These cases are prone to loss of articular reduction leading to posttraumatic arthritis, substantial proximal interphalangeal joint stiffness, and pin-tract infection. Such problems are solved with locking plates that support the articular reduction throughout healing and permit immediate range of motion while avoiding other complications such as pin-tract infection. Outcomes are reported for 40 patients treated with locking plates applied from volar, dorsal, and lateral to treat pilon fractures.
Kanno, T; Sukegawa, S; Tatsumi, H; Nariai, Y; Ishibashi, H; Furuki, Y; Sekine, J
We evaluated the safety, efficacy, and morbidity associated with the treatment of displaced mandibular condylar neck fractures using a retromandibular transparotid approach to reduce and rigidly fix using two 2.0-mm locking miniplates. Our surgical inclusion criteria were: patient selection of open reduction and fixation, displaced unilateral condylar fractures with derangement of occlusion, and bilateral condylar fractures with an anterior open bite. The study group consisted of 19 patients who underwent surgery for 19 mandibular condylar neck fractures; patients were analyzed prospectively, with more than 6 months of follow-up, and were evaluated in terms of functional results, scar formation, postoperative complications, and stability of fixation. The results showed that functional occlusion identical to the preoperative condition and correct anatomical reduction of the condylar segments in centric occlusion, followed by immediate functional recovery, was achieved in all patients. No patient suffered from any major or permanent complication postoperatively, although there were two cases (11%) of temporary facial nerve palsy, which resolved completely within 3 months. Surgical scars were barely visible. The retromandibular transparotid approach with open reduction and rigid internal fixation for displaced condylar neck fractures of the mandible is a feasible and safe, minimally invasive surgical technique that provides reliable clinical results.
Laux, Christoph J; Grubhofer, Florian; Werner, Clément M L; Simmen, Hans-Peter; Osterhoff, Georg
Despite numerous available treatment strategies, the management of complex proximal humeral fractures remains demanding. Impaired bone quality and considerable comorbidities pose special challenges in the growing aging population. Complications after operative treatment are frequent, in particular loss of reduction with varus malalignment and subsequent screw cutout. Locking plate fixation has become a standard in stabilizing these fractures, but surgical revision rates of up to 25% stagnate at high levels. Therefore, it seems of utmost importance to select the right treatment for the right patient. This article provides an overview of available classification systems, indications for operative treatment, important pathoanatomic principles, and latest surgical strategies in locking plate fixation. The importance of correct reduction of the medial cortices, the use of calcar screws, augmentation with bone cement, double-plate fixation, and auxiliary intramedullary bone graft stabilization are discussed in detail.
Perrone, Gabriel S.; Leisk, Gary G.; Lo, Tim J.; Moreau, Jodie E.; Haas, Dylan S.; Papenburg, Bernke J.; Golden, Ethan B.; Partlow, Benjamin P.; Fox, Sharon E.; Ibrahim, Ahmed M. S.; Lin, Samuel J.; Kaplan, David L.
Metallic fixation systems are currently the gold standard for fracture fixation but have problems including stress shielding, palpability and temperature sensitivity. Recently, resorbable systems have gained interest because they avoid removal and may improve bone remodelling due to the lack of stress shielding. However, their use is limited to paediatric craniofacial procedures mainly due to the laborious implantation requirements. Here we prepare and characterize a new family of resorbable screws prepared from silk fibroin for craniofacial fracture repair. In vivo assessment in rat femurs shows the screws to be self-tapping, remain fixed in the bone for 4 and 8 weeks, exhibit biocompatibility and promote bone remodelling. The silk-based devices compare favourably with current poly-lactic-co-glycolic acid fixation systems, however, silk-based devices offer numerous advantages including ease of implantation, conformal fit to the repair site, sterilization by autoclaving and minimal inflammatory response.
Maung Aung, T; Brook, I M; Crofts, C E; Trowbridge, E A
A paraskeletal clamp plate (Mennen) offers a novel method of fixation for mandibular fractures. Its application is relatively atraumatic and this together with the minimal disruption to the local blood supply may make this clamp particularly suited to fixation of fractures of the atrophic edentulous jaw. Its use in six such cases is reported.
Talerico, Michael; Ahn, Jaimo
The objective of this article is to highlight the salient points of preoperative planning, intraoperative considerations for fracture reduction methods, and implant fixation when treating distal diaphyseal or diametaphyseal tibia fractures with an intramedullary nail. Through review of the necessary preoperative considerations, techniques available to hold and maintain a reduction, and lastly how to maximize the selected implant of intramedullary nail, we hope to assist the treating surgeon in simplifying these sometimes complex fractures into manageable injuries that can be treated successfully with an intramedullary implant.
Vangundy, T E; Hulse, D A; Nelson, J K; Boothe, H W
Twenty-three canine pelves were tested bilaterally to determine the stiffness and strength of intact ilium and stabilized oblique iliac osteotomies that simulated a common clinical fracture. Fixation systems tested were three 4.0 mm cancellous screws inserted ventral to dorsal across the osteotomy site and one laterally placed five hole 3.5 mm dynamic compression plate. Specimens were mechanically tested to failure under torsional, axial, or axial plus bending loads. Lag screw fixation was stiffer and stronger than plate fixation in all testing modes. The differences were statistically significant (p less than .05) in the torsional and axial plus bending loading modes. Fatigue testing was performed on implanted specimens with low-level cyclic loading under axial plus bending loading conditions. Physiologic loading conditions failed to produce mechanical failure of either fixation system after 100,000 cycles.
Parker, Martyn J; Das, Avishek
Extramedullary fixation of hip fractures involves the application of a plate and screws to the lateral side of the proximal femur. In external fixators, the stabilising component is held outside the thigh by pins or screws driven into the bone. This is an update of a Cochrane review first published in 1998, and last updated in 2005. To assess the relative effects of different types of extramedullary fixation implant, as well as external fixators, for treating extracapsular proximal femoral (hip) fractures in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 2), MEDLINE (1966 to June Week 4 2011), EMBASE (1988 to 2011 Week 25), various other databases, conference proceedings and reference lists. Randomised or quasi-randomised controlled trials comparing extramedullary implants or external fixators for fixing extracapsular hip fracture in adults were included. Two review authors independently selected trials, assessed risk of bias and extracted data. Data were pooled where appropriate. The 18 included trials tested seven comparisons in a total of 2615 mainly female and older participants with a total of 2619 fractures. All trials had methodological flaws that may affect the validity of their results.Three trials of 355 participants comparing a fixed nail plate (Jewett or McLaughlin) with the sliding hip screw (SHS) found an increased risk of fixation failure for fixed nail plates.The two trials of 433 participants comparing the Resistance Augmented Bateaux (RAB) plate with the SHS had contrasting results, notably in terms of operative complications, fixation failure and anatomical restoration.One trial of 100 participants comparing the Pugh nail and the SHS found no significant difference between implants.Three trials of 458 participants compared the Medoff plate with the SHS. There was a trend to higher blood losses and
Broderick, J. M.; Bruce-Brand, R.; Stanley, E.; Mulhall, K. J.
Osteoporotic hip fractures are a major cause of morbidity and mortality in the elderly. Furthermore, reduced implant anchorage in osteoporotic bone predisposes towards fixation failure and with an ageing population, even low failure rates represent a significant challenge to healthcare systems. Fixation failure in fragility fractures of the hip ranges from 5% in peritrochanteric fractures through to 15% and 41% in undisplaced and displaced fractures of the femoral neck, respectively. Our findings, in general, support the view that failed internal fixation of these fragility fractures carries a poor prognosis: it leads to a twofold increase in the length of hospital stay and a doubling of healthcare costs. Patients are more likely to suffer a downgrade in their residential status upon discharge with a consequent increase in social dependency. Furthermore, the marked disability and reduction in quality of life evident before salvage procedures may persist at long-term followup. The risk, of course, for the elderly patient with a prolonged period of decreased functioning is that the disability becomes permanent. Despite this, however, no clear link between revision surgery and an increase in mortality has been demonstrated in the literature. PMID:23476139
Luo, Cong-Feng; Sun, Hui; Zhang, Bo; Zeng, Bing-Fang
1) To introduce a computed tomography-based "three-column fixation" concept; and 2) to evaluate clinical outcomes (by using a column-specific fixation technique) for complex tibial plateau fractures (Schatzker classification Types V and VI). Prospective cohort study. Level 1 trauma center. Twenty-nine cases of complex tibial plateau fractures were included. Based on routine x-ray and computed tomography images, all the fractures were classified as a "three-column fracture," which means at least one separate fragment was found in lateral, medial, and posterior columns in the proximal tibia (Schatzker classification Types V and VI). The patients were operated on in a "floating position" with a combined approach, an inverted L-shaped posterior approach combined with an anterior-lateral approach. All three columns of fractures were fixed. Operative time, blood loss, quality of reduction and alignment, fracture healing, complications, and functional outcomes based on Hospital for Special Surgery score and lower-extremity measure were recorded. All the cases were followed for average 27.3 months (range, 24-36 months). All the cases had satisfactory reduction except one case, which had a 4-mm stepoff at the anterior ridge of the tibial plateau postoperatively. No case of secondary articular depression was found. One case had secondary varus deformity, one case had secondary valgus deformity, and two cases of screw loosening occurred postoperatively. No revision surgery was performed. Two cases had culture-negative wound drainage. No infection was noted. The average radiographic bony union time and full weightbearing time were 13.1 weeks (range, 11-16 weeks) and 16.7 weeks (range, 12-24 weeks), respectively. The mean Short Form 36, Hospital for Special Surgery score, and lower-extremity measure at 24 months postoperatively were 89 (range, 80-98), 90 (range, 84-98), and 87 (range, 80-95), respectively. The average range of motion of the affected knee was 2.7° to 123.4° at
Wu, Yao-Sen; Lin, Yan; Zhang, Xiao-Lei; Tian, Nai-Feng; Sun, Liao-Jun; Xu, Hua-Zi; Chi, Yong-Long; Pan, Zhi-Jun
This study describes a percutaneous technique for C2 transpedicular screw fixation and evaluates its safety and efficacy in the treatment of patients with hangman's fracture. Ten patients with hangman's fracture were treated by percutaneous C2 transpedicular screw fixation. There are six males and four females, who were, based on the classification of Levine and Edwards, sorted as follows: type I fracture, three cases; type II, five cases; type IIa, two cases. The causes of injury were road traffic accident in six patients and falling injury in four patients. Other associated lesions included rib fractures (7 patients), head injuries (4 patients), and fractures of extremities (6 patients). The new technique was performed successfully in all cases. The average operation time was 98 min (range 60-130 min) and the estimated blood loss was 25 ml (range 15-40 ml). No complications such as vascular or neural structures injuries were found intraoperatively. Postoperative CT scans demonstrated that 17 (85 %) of 20 screws were placed satisfactorily, and 3 (15 %) screws showed perforations of the pedicle wall (<2 mm). These patients were asymptomatic and no further intervention was required postoperatively. After 8-25 months follow-up (mean 15.3 months), solid fusion was demonstrated by computed tomography. All cases got well-sagittal alignment and no angulation or dislocation was found at the segment of C2-C3. There was no loss of fixation. Clinical examination showed a full range of motion in the neck in all patients. The fluoroscopically assisted percutaneous C2 transpedicular screw fixation method is a technically feasible and minimally invasive technique for hangman's fracture.
Gardner, R O E; Bates, J H; Ng'oma, E; Harrison, W J
HIV is thought to be associated with increased rates of fracture non-union. We report on a prospective cohort of 96 HIV positive patients with 107 fractures that required internal fixation. The CD4 count was measured and patients were reviewed until eventual clinical or radiological union or non-union was established. Four percent of fractures (4 out of 100) failed to unite. Three patients required one further procedure to induce union, and two developed avascular necrosis. The CD4 count was not related to fracture union. Contrary to previous assumptions, this study suggests that HIV infection does not increase rates of non-union in surgically managed fractures. Crown Copyright © 2012. Published by Elsevier Ltd. All rights reserved.
Kyung, Hyunwoo; Song, Seung Han; Kang, Nakheon; Oh, Sang-Ha
The Medpor implant is (Prous polyethylene, Porex Surgical Inc, Newnan, GA, USA) widely used to reconstruct orbital wall defects. However, this implant is commonly associated with numerous complications, including implant displacement. Therefore, the authors have hypothesized that fixation of the Medpor implant with fibrin glue (Tisseel, Baxter Healthcare, Norfolk, UK), compared to other fixation methods, may be more stable and could provide better results than other fixation methods.In this study, 485 patients who had been treated for blowout fractures from 2008 to 2012 were evaluated. Medpor implants fixed using Tisseel were used to reconstruct bone defects of the orbital wall. The patients' hospital records and radiologic images were reviewed according to sex, fracture site, and postoperative complications.According to retrospective chart review and radiologic evaluation, the complication rate was low and included diplopia (7%; 33 patients), enophthalmos (4%; 17 patients), and extraocular movement limitation (3%; 13 patients).This study suggests that Medpor implant fixation using Tisseel is a simpler, more secure, and more suitable for reconstruction of the fractured orbital wall compared with other methods.
Mehin, Ramin; Jones, Bryn; Zhu, Qingan; Broekhuyse, Henry
Background Conventional internal fixation entails the use of an interfragmentary lag screw along with a plate. Not all acetabular fractures are amenable to the placement of an interfragmentary lag screw, and the fracture may be displaced during tightening of the interfragmentary lag screw. Locking plates are a possible solution. We sought to determine whether a locking plate construct can provide stability equivalent to that provided with a conventional construct for transverse acetabular fractures. Methods We used 5 paired fresh-frozen cadaveric acetabula. We fixed one side with the conventional technique and the other side with a locking plate. We subjected each fixation to a cyclic compressive force up to 500 cycles, followed by compressive force until failure. We monitored 3-dimensional motion of the fracture. Results The average fracture gap at 50 N compressive force after 500 loading cycles was 0.41 (standard deviation [SD] 0.49) mm for the conventional plate and lag screw construct compared with 0.76 (SD 0.62) mm for the locked plate construct (p = 0.46). The force to failure, as defined by 2 mm of fracture gap, was 848 (SD 805) N for the conventional plate and lag screw construct compared with 506 (SD 277) N for the locked plate fixation (p = 0.34). Conclusion The locking plate construct is as strong as the conventional plate plus interfragmentary lag screw construct for fixing transverse acetabular fractures. Locking plates may improve management of acetabular fractures by eliminating the need for placement of an interfragmentary lag screw. Furthermore, they may be helpful in revision hip arthroplasty in patients with pelvic discontinuity. PMID:19503667
Regev, Eran; Shiff, Jacob S; Kiss, Alex; Fialkov, Jeffrey A
The degree of rigidity of internal fixation required for the treatment of mandibular angle fractures has long been at the center of debate in the literature. A statistical comparison between rigid fixation and monocortical fixation has been difficult because of multiple terms, definitions, and technical variations. The purpose of this study was to use the meta-analysis tool to combine information from multiple studies and to compare complication rates for different fixation methods. An English language literature search was conducted for articles on mandibular angle fractures. Information was collected on four variables of interest: compression/noncompression technique, monocortical/bicortical screws, number of plates, and location of plates. Five outcome rates were analyzed: infection, reoperation, hardware removal, malunion, and nonunion. Meta-analyses were run using Comprehensive Meta Analysis, version 2.2.03. Twenty-four studies with relevant data on the variables and outcomes of interest met the inclusion criteria. Significantly higher rates of infection, reoperation, and hardware removal were found for compression compared with noncompression, two plates compared with one plate, and for plates located on both the inferior and superior borders as compared with superior or inferior only. There were also significantly higher infection rates for bicortical screws compared with monocortical screws and higher malunion rates for compression compared with noncompression plating techniques. The results of this meta-analysis found lower complication rates with the use of noncompression, monocortical, and single-plate fixation, supporting the trend toward a single, superiorly placed, monocortical miniplate for fixation of mandibular angle fractures.
Reynolds, Jennifer A; MacDonald, Joel D
Acute complex C2 vertebral body fracture specifically does not involve the odontoid process or C2 pars interarticularis. External stabilization can be effective but may prolong healing and increase morbidity. Many traditional surgical techniques can achieve internal stabilization at the expense of normal cervical motion. We describe direct surgical C2 pedicle screw fixation as an option for managing acute complex C2 vertebral body fracture. Three patients were treated with direct pedicle screw fixation of acute traumatic complex C2 vertebral body fractures. All fractures were coronally oriented Benzel type 1. None of the patients sustained neurological injury. Stereotactic navigation with intraoperative computed tomography scanning was used for each procedure. Surgery provided immediate internal orthosis and stability, as judged by intraoperative dynamic fluoroscopy. Rigid cervical collar bracing was used for 1 month after surgery when the patients were out of bed. Initial radiographs showed acceptable screw placement and fracture alignment. Dynamic radiographs at 3 months showed structural stability at the fracture site and adjacent levels, and complete bony union was confirmed with late computed tomography scanning (>1 year) in each case. Each patient reported resolution of trauma-related and postsurgical pain at 30-day follow-up. Postoperative Neck Disability Index questionnaires for each patient suggested no significant disability at 1 year. Direct pedicle screw fixation of acute complex C2 vertebral body fracture appeared to be safe and effective in our 3 patients. It may provide a more-efficient and less-morbid treatment than halo brace or cervical collar immobilization in some patients. Copyright © 2016 Elsevier Inc. All rights reserved.
Sales, Jafar Ganjpour; Soleymaopour, Jafar; Ansari, Maroof; Afaghi, Farhad; Goldust, Mohamad
Tibial condyle fractures affect knee stability and motion. Treatment of bicondylar type of tibial plateau fracture is a challenging problem. This study aimed at evaluating the application of hybrid external fixators with minimum deformation in these patients and the resulted outcomes. In this descriptive analytical study, 28 patients with bicondylar tibial plateau fractures treated by HEF device were evaluated. The surgeon used a semicircular and one circular wire instead of the one or two loop of conventional HEF device for a better range of motion of the knee joint. Treatment outcomes including quality of walking, union condition, knee range of motion, complications and the final outcome according to the knee score (rusmussen) were checked. Twenty-eight male patients, with the mean age of 40.54 +/- 13.83 years were enrolled in the study. Complications occurred in 8 (28.6%) patients; 7 cases with superficial infection and 1 patient with deep vein thrombosis. All complications were managed medically with no significant consequences left. All the patients were able to walk with no aid except in one case. In 96.4% and 89.3% of the cases, the clinical and radiological outcomes were good to excellent, respectively according to the knee score. In 85.7% of the patients, the knee range of motion was in normal limits. Application of hybrid external fixator using one and half ring instead of one or two fixator rings in treating bicondylar tibial fractures was associated with desired clinical and radiological results.
Aoki, Stephen K; Curtis, Stuart H
This study evaluates the initial fixation strength of tibial eminence fracture repair using 1, 2, 3, and 4 sutures to determine the optimal number of sutures required to adequately secure the avulsed fragment to the tibia. Sixteen skeletally immature porcine knees were stripped of all soft tissues, isolating the femur-anterior cruciate ligament (ACL)-tibia complex. Type III tibial eminence fractures were simulated in the specimens, and each specimen was randomly assigned to a repair group using 1, 2, 3, or 4 #2 FiberWire sutures (Arthrex, Inc, Naples, Florida). Initial fixation strength of the repair was measured by single cycle pull to failure testing using a materials testing machine (Instron, Norwood, Massachusetts). The mean ultimate failure force during anterior tibial translation was 389±128, 627±66, 703±77, and 802±29 N for 1, 2, 3, and 4 sutures, respectively. The lower limit of the 95% confidence interval was >500 N (estimated force of native ACL during activities of daily living) for each group with ≥2 sutures. In this study, at least 2 high-strength sutures were needed for tibial eminence fracture repairs to withstand potential forces seen across the ACL in the postoperative period. Suture fixation of tibial eminence fractures is a reproducible method requiring a minimum of 2 high-strength polyester sutures to resist forces seen during early rehabilitation.
Kempegowda, Harish; Maniar, Hemil H; Richard, Raveesh; Tawari, Akhil; Jove, Graham; Suk, Michael; Beebe, Michael J; Han, Chris; Tornetta, Paul; Kubiak, Erik N; Horwitz, Daniel S
The purpose of this study was to evaluate posterior malleolar injuries associated with nailed tibial fractures and to determine the quality of reduction based on the sequence of fixation in associated fracture patterns. Retrospective cohort study. 1113 tibia fractures treated with an intramedullary nail at 3 level I trauma centers. Tibial shaft fractures with posterior malleolar injury were analyzed regarding type of fracture, mechanism of injury, energy of injury, fracture characteristic, surgical characteristics including sequence of fixation, obvious intraoperative displacement of the posterior malleolar fragment, and the quality of reduction. One group ("malleolus-first") consisted of patients in whom the posterior malleolus was fixed before tibial nailing and the other group ("tibia-first") included patients in whom tibial nailing was done before posterior malleolus fixation. Intraoperative displacement, quality of reduction. Ninety-six of 1113 (9%) nailed tibial shaft fracture patients had a concomitant posterior malleolus fracture (9%). Of the 96 posterior malleolar fracture patients, 70 patients were operatively treated (73%). In the malleolus-first group (54 patients), intraoperative displacement of the posterior malleolar fragment was observed in 1 patient, and 1 case of poor reduction of the posterior malleolar fragment was observed (2%). In the tibia-first group (16 patients), obvious intraoperative displacement of the posterior malleolar fragment was observed in 5 patients (31%), and poor reduction of the posterior malleolar fragment was observed in 7 patients (44%). These percentages of patients with poor quality of reduction were statistically significantly different (p ≤ 0.01). Many low-energy tibia fractures with a spiral configuration do have an associated posterior malleolus fracture. In order to avoid intraoperative displacement and poor reduction, we recommend fixation of the posterior malleolar fragment before nailing of the tibia in
Gras, Florian; Marintschev, Ivan; Klos, Kajetan; Fujak, Albert; Mückley, Thomas; Hofmann, Gunther O
Periprosthetic fractures are severe complications of total hip arthroplasty with increasing incidence. Most fractures are localized around the femoral component of prosthesis, whereas periacetabular fractures are rare and their management is difficult. In most cases, an operative procedure with revision and exchange of the acetabular cup is necessary. The approaches are demanding and an increased risk of complications is reported. We present the case of a female patient with a cementless total hip arthroplasty due to severe arthritis, suffering of an infratectal transverse periprosthetic fracture. After an initial conservative treatment attempt, we performed a minimally invasive screw fixation using navigated 2-dimensional fluoroscopic guidance. In this report, the literature for treatment recommendations is reviewed and the chosen navigation technique discussed. Copyright © 2010. Published by Elsevier Inc.
Son, Jang-Ho; Ha, Jinhee; Cho, Yeong-Cheol; Sung, Iel-Yong
To investigate whether biodegradable plates are applicable in endoscope-assisted open reduction and internal fixation (EAORIF) of mandibular subcondyle fractures. This retrospective case-series study included patients with mandibular subcondyle fractures treated with EAORIF using an unsintered hydroxyapatite particles/poly-l-lactide biodegradable plate system, with at least 6 months of clinical follow-up data available. The outcome variables were fracture healing with postoperative stability and postoperative complications. Other variables included age, gender, fracture site, cause of injury, accompanying mandibular fracture, total follow-up period, fracture classification, extent of displacement, preoperative status of occlusion, preoperative mandibular movements, fixation materials in accompanying mandibular fracture, location and number of fixation plates, periods of intermaxillary fixation/elastic bands, and postoperative mandibular movements. Fracture healing in these patients was assessed by comparing the immediate postoperative cone-beam computed tomography (CBCT) images with those obtained at least 3 months after surgery. A total of 11 patients, 9 male and 2 female, with a mean ± standard deviation age of 35.3 ± 15.9 years, were included. The mean follow-up period was 18.8 ± 7.8 months. Four patients had an accompanying mandibular fracture. Two 4-hole, 2.0-mm biodegradable plates were fixed with 6-mm screws along the posterior border of the mandibular ramus and near the sigmoid notch. Complete bone formation around the fracture lines or fading of the fracture lines, with no change in the position of the fractured segments, was observed on the postoperative CBCT images at 3 months. With the exception of 2 patients, no patient complained of plate palpability, deviation in occlusion, or discomfort during the postoperative follow-up period. EAORIF using biodegradable plates for mandible subcondylar fractures is a stable and reliable method, with
OʼToole, Robert V; Gary, Joshua L; Reider, Lisa; Bosse, Michael J; Gordon, Wade T; Hutson, James; Quinnan, Stephen M; Castillo, Renan C; Scharfstein, Daniel O; MacKenzie, Ellen J
The treatment of high-energy open tibia fractures is challenging in both the military and civilian environments. Treatment with modern ring external fixation may reduce complications common in these patients. However, no study has rigorously compared outcomes of modern ring external fixation with commonly used internal fixation approaches. The FIXIT study is a prospective, multicenter randomized trial comparing 1-year outcomes after treatment of severe open tibial shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18-64. The primary outcome is rehospitalization for major limb complications. Secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. One-year treatment costs and patient satisfaction will be compared between the 2 groups, and the percentage of Gustilo IIIB fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated.
Peng, Weihai; Zheng, Wei; Shi, Kai; Wang, Wangshu; Shao, Ying; Zhang, Duo
Internal fixation of bone fractures using biodegradable poly(L-lactic-acid) (PLLA)-based materials has attracted the attention of many researchers. In the present study, 36 male beagle dogs were randomly assigned to two groups: PLLA/PLLA-gHA (PLLA-grafted hydroxyapatite) group and PLLA group. PLLA/PLLA-gHA and PLLA plates were embedded in the muscular bags of the erector spinae and also implanted to fix mandibular bone fractures in respective groups. At 1, 2, 3, 6, 9, and 12 months postoperatively, the PLLA/PLLA-gHA and PLLA plates were evaluated by adsorption and degradation tests, and the mandibles were examined through radiographic analysis, biomechanical testing, and histological analysis. The PLLA/PLLA-gHA plates were non-transparent and showed a creamy white color, and the PLLA plates were transparent and faint yellow in color. At all time points following surgery, adsorption and degradation of the PLLA/PLLA-gHA plates were significantly less than those of the PLLA plates, and the lateral and longitudinal bending strengths of the surgically treated mandibles of the beagle dogs in the PLLA/PLLA-gHA group were significantly greater than those of the PLLA group and reached almost the value of intact mandibles at 12 months postoperatively. Additionally, relatively rapid bone healing was observed in the PLLA/PLLA-gHA group with the formation of new lamellar bone tissues at 12 months after the surgery. The PLLA/PLLA-gHA nano-composite can be employed as a biodegradable material for internal fixation of mandibular bone fractures.
Claessen, Femke M A P; Braun, Yvonne; Peters, Rinne M; Dyer, George; Doornberg, Job N; Ring, David
Surgery for fixation of olecranon fractures is associated with reoperation, mostly for implant removal. A study of a large cohort of patients treated by many different surgeons allows us to determine if specific techniques or implants are associated with a higher rate of reoperation. After open reduction and internal fixation of isolated olecranon fractures, what factors are associated with (1) reoperation and (2) implant removal? Three hundred ninety-two adult patients who had operative treatment of a displaced olecranon fracture not associated with other fractures, dislocation, or subluxation at two area hospitals between January 2002 and May 2014 were analyzed to determine factors associated with reoperation. One hundred thirty-eight (35%) patients had plate and screw fixation and 254 (65%) tension band wiring. Nearly 100% of patients with displaced olecranon fractures are currently treated operatively at our hospitals. All patients were followed for at least four months. Two hundred three of the 392 (52%) patients were followed for one year or more. Ninety-nine patients (25%) had a second operation, 92 (93%) at least in part for implant removal (12 for wire migration [3% of all fractures, 12% of reoperations]). We considered patient-related, fracture-related, and implant-related endpoints as possible factors associated with reoperation. With a total sample size of 99 reoperations, an α of 0.05, and an effect size of 0.3, we had 87% power. Reoperation was less common in men (36 [36%], women: 63 [64%]; adjusted odds ratio, 0.32; 95% confidence interval, 0.18-0.56; p < 0.001) and older patients (adjusted odds ratio, 0.75; 95% confidence interval, 0.65-0.87; p < 0.001). Similarly, request for implant removal was less in men (33 [36%], women: 59 [64%], adjusted odds ratio, 0.31; 95% confidence interval, 0.18-0.56; p < 0.001) and older patients (adjusted odds ratio, 0.75; 95% confidence interval, 0.65-0.87; p < 0.001). Patients who have operative fixation of a
Von Keudell, Arvind; Kachooei, Amir R; Moradi, Ali; Jupiter, Jesse B
The purpose of this study was to report the long-term outcome and complications of surgically fixated lateral unicondylar distal humerus fractures. Retrospective Review. Two level 1 Trauma Centers, Massachusetts General Hospital and Brigham and Women's Hospital. Between 2002 and 2014, 24 patients treated with open reduction and internal fixation for lateral unicondylar distal humerus fractures (OTA/AO type B1 fractures) were retrospectively reviewed. Open reduction and internal fixation. Union rates, early complications, functional outcome, and the range of elbow motion were evaluated. Disabilities of the arm, shoulder, and hand, Mayo elbow Performance Index, satisfaction, pain scale, and American Shoulder and Elbow Surgeons. The mean age of patients was 46 ± 23 years at the time of surgery. The average final flexion/extension arc of motion was 108°. Reoperations were performed in 9 of 24 elbows after an average 21 ± 31 months. Twenty of the 24 patients were available for the clinical follow-up at an average of 70 months (range: 16-144 months). Disabilities of the arm, shoulder, and hand averaged at 10.8 ± 11.7 points, satisfaction at 9.5 ± 1.2, American Shoulder and Elbow Surgeons score at 88.5 ± 13.3 points at final follow-up. Based on the functional classification proposed by Jupiter, 16 demonstrated good to excellent results, 2 fair and 2 poor result. Outcome of open reduction and internal fixation of isolated lateral column distal humerus fractures can result in high union rates with acceptable outcome scores and high patient satisfaction despite a high reoperation rate. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Fitzgibbons, Peter G; Louie, Dexter; Dyer, George Sinclair Mitchell; Blazar, Philip; Earp, Brandon
Historically, the published literature on "terrible triad" injuries has shown a high rate of unacceptable results. The use of systematic treatment protocols may improve functional outcome. The authors performed a retrospective study of all patients aged 18 years or older who underwent surgical treatment for "terrible triad" elbow fracture dislocation at their institution over a period 7 years. Surgical treatment involved fixation or replacement of the radial head, repair of the anterior capsule or coronoid fracture in most cases, and repair of the lateral collateral ligament. Outcomes included grip strength, range of motion, Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire score, and a visual analog score for pain as well as radiographic assessment of arthritis, maintenance of reduction, and development of heterotopic ossification. Eighteen patients were identified and 11 enrolled. Seven patients had suture fixation of the coronoid fragment and anterior capsule, 2 had screw fixation, and 2 had no repair of the coronoid. The radial head was replaced in 9 patients and repaired in 1, and a fracture fragment was excised in another. The average follow-up was 38 months. The average arc of motion of the injured elbow was 112° and that of the contralateral elbow was 142°. The average DASH score was 19.7 (scale, 0-100). The average visual analog score for pain was 2.2 (scale, 0-10). No patients had recurrent elbow instability. Three patients underwent further surgical procedures, all for loss of motion. The authors concluded that a systematic approach to the fixation of "terrible triad" elbow fracture dislocations can provide predictable elbow stability and functional range of motion in the medium term.
Shibuya, Yasuyuki; Yabase, Akiko; Ishida, Suguru; Kobayashi, Masaki; Komori, Takahide
In this study, we investigated cases of mal fracture occurring during the split-crest procedure. In all subjects (six patients), the free cortical bone segment caused by the mal fracture was carefully maintained in the lateral position without fixation using a titanium plate or screw. On pre- and postoperative multiplanar reconstruction CT, the average total alveolar increase was 5.0 mm in the lower portion 1 mm from the top of the alveolar ridge, and the average total alveolar increase in the lower portion 11 mm from the top of the alveolar ridge was 2.2 mm. A total of 11 dental implants were placed immediately at the same time as the split-crest procedure, while three dental implants were placed after a waiting period of 4-11 months from bone augmentation. During an average follow-up of 27.8 months, there were no complications or cases of failed implants. Consequently, among the patients who experienced mal fracture during the split-crest technique, a sufficient volume of alveolar bone was obtained without the need for rigid fixation of the free bone segment, and the dental implants placed within the area of the mal fracture showed a good prognosis.
Lozano-Calderón, Santiago A.; Doornberg, Job N.
A change in the practice of a single surgeon provided an opportunity for retrospective comparison of comparable cohorts treated with percutaneous fixation (17 patients) or a volar plate and screws (23 patients) an average of 30 months after surgery. The final evaluation was performed according to the Gartland and Werley and Mayo rating systems and the DASH questionnaire. There were no significant differences on the average scores for the percutaneous and volar plating groups, respectively: Gartland and Werley, 4 vs 5; Mayo, 82 vs 83; and DASH score 13 for both cohorts. Motion, grip, and radiographical parameters were likewise comparable. Volar internal plate and screw fixation can achieve results comparable to percutaneous fixation techniques in the treatment of fractures of the distal radius. PMID:18780085
Christie, J; Howie, C R; Armour, P C
One hundred and twenty-seven consecutive patients with displaced subcapital fractures of the femoral neck (Garden Grade III or IV) all under 80 years of age and independently mobile, were randomly allocated to fixation with either double divergent pins or a single sliding screw-plate device. The incidence of non-union and infection in the sliding screw-plate group was significantly higher, and we believe that when internal fixation is considered appropriate multiple pinning should be used. Mobility after treatment was disappointing in about half of the patients, and we feel that internal fixation can only be justified in patients who are physiologically well preserved and who maintain a high level of activity.
Aldrian, Silke; Schuster, Rupert; Haas, Nicole; Erhart, Jochen; Strickner, Markus; Blutsch, Beate; Wernhart, Simon; Leitgeb, Johannes; Platzer, Patrick
Literature does not provide any reliable comparison between angular stable plate fixation and rigid nail fixation for stabilization of supracondylar periprosthetic femoral fractures. Thus, the purpose of this study was to compare these two implants in clinical practice relating to fracture healing, functional results and treatment-related complications. In this retrospective study (level IV), clinical and radiographic records of 86 patients (62 female and 24 male, average age: 75.6) with supracondylar periprosthetic femoral fractures between 1996 and 2010 were analyzed. 48 patients underwent lateral plate fixation by an angular stable plate system (LISS), whereas 38 patients were stabilized by a rigid interlocking nail device. Sixty-four (76 %) patients returned to their pre-injury activity level and were satisfied with their clinical outcome. We had an overall Oxford outcome score of 2.21, with patients following angular stable plate fixation of 2.22, and patients after rigid nail fixation of 2.20. Successful fracture healing within 6 months was achieved in 74 (88 %) patients. Comparing between plate fixation and nail fixation, statistical analysis did not reveal any significant differences. Overall, we had a relatively high rate of fracture healing and a satisfactory functional outcome with both implants. Both methods of fixation showed similar results relating to the functional outcome and individual satisfaction of the patients. However, with regards to fracture healing and treatment-related complications, intramedullary nail fixation showed slight advantages.
Nimick, Craig J; Collman, David R; Lagaay, Pieter
Accurate reduction of the syndesmosis has been shown to be an important prognostic factor for functional outcome in ankle injuries that disrupt the syndesmosis. The purpose of the present case series was to assess the fixation orientation and the position of the fibula within the tibial incisura after open reduction and internal fixation of ankle fractures with syndesmosis injury. Computed tomography was used to assess the accuracy of the reduction. Twelve patients were included in the present case series. A ratio representing the relationship between the tibia and fibula and the orientation of the syndesmotic fixation was measured preoperatively and postoperatively and compared with the uninjured contralateral ankle, representing the patient's normal anatomy. The measurements were accomplished electronically to one tenth of 1 mm using Stentor Intelligent Informatics, I-site, version 3.3.1 (Phillips Electronics; Andover, MA). Posteriorly oriented syndesmotic fixation caused posterior translation of the fibula with respect to the tibia and anteriorly oriented syndesmotic fixation caused anterior translation. Copyright © 2013. Published by Elsevier Inc.
Hickey, Ben; Jones, Huw M; Jones, Stephen
Subtrochanteric fracture is a recognized complication following cannulated screw fixation of intracapsular hip fracture. We investigated the incidence of subtrochanteric fracture in a consecutive series of 304 patients and its association with screw entry point in the lateral femoral cortex. A retrospective consecutive case series of patients treated with internal fixation for intracapsular hip fracture by our unit between January 2003 and January 2010 were included. Two authors reviewed radiographs independently to determine distal screw entry point in the lateral femoral cortex. Hickey zone 1 was an entry point above the level of the upper border of the lesser trochanter. Hickey zone 2 was defined as an entry point between the upper and lower borders of the lesser trochanter. Hickey zone 3 was an entry point below the lower border of the lesser trochanter. Clinical notes were reviewed for subsequent subtrochanteric fracture. Association between subtrochanteric fracture and distal screw entry point in the lateral femoral cortex in relation to the upper border of the lesser trochanter was determined. Two hundred and fifty-six post-operative radiographs were available for analysis. Mean patient age was 73 years (30–98), 75% were women. There were 24 patients with screw entry point in Hickey zone 1, 225 in Hickey zone 2, and 7 in Hickey zone 3. Two patients sustained subtrochanteric fracture. No subtrochanteric fractures occurred in patients with Hickey zone two-screw entry. Subtrochanteric fracture is rare following cannulated screw fixation of intracapsular neck of femur fracture (0.78%). In this retrospective consecutive case series, no subtrochanteric fractures occurred when the entry point of the lowest screw in the lateral femoral cortex is between the levels of the upper and lower borders of the lesser trochanter.
Beriashvili, G K; Menabde, G T; Chikhladze, R T
The Purpose of the research was to study in the experiment morphological particularities of mandible fracture consolidation by osteosynthesis using Kollapan and Retabolil. The experiments were carried out on sexually matured rabbits. In the first series of the experiments (the control group), mandibula bones fracture was prototyped lower, whereas bone fragments were fixed by miniplate. In the second series of the experiments (the study group) bone fragments were bolted by the above mentioned way but diastase between bone fragments was filled by Kollapan granules, containing klaforan, and animals were intramuscularly anabolic material (the retabolil 0.4 mg/kg). On the 3-d and 15-th days, as well as, after 1 and 2 months after operation observing all corresponding rules, animals were killed and patologico-anatomic study of jaw bone was carried out. The analysis of the results showed that in experimental animals both in the control and the study groups reparative regeneration of bone tissues runs with the formation of periosteum and intermedium regenerator, at the same time consolidation of the bone defect in the main group occurs earlier than in the control group. The Results of the studies point out that Retabolil under osteosynthesis is an osteoinductive material and Kollapan, having osteoinductive, osteoconductive, and osteoprotective characteristics, promotes speeding of the process of jaw bones fracture consolidation.
Background Currently up to 58% of Canadian surgeons would forego screening radiographs after stable fracture fixation. It is therefore expected that reducing screening radiographs will be well accepted, provided that patient safety is not compromised, resulting in a cost reduction. The study objective was to measure the savings of a simplified radiographic protocol for well-fixed fractures and establish feasibility for a noninferiority trial that proves patient safety. Methods Patients were randomized after fixation. The control group received screening radiographs immediately after fixation and at 2 weeks. The experimental group received radiographs only when clinically indicated. At 6 weeks all patients received radiographs. The cost of imaging, time spent in clinic and patient satisfaction was measured. A blinded reviewer documented adverse events, either detected or missed. Results Of the 90 patients screened, 39 were randomized and 26 had complete follow-up. The mean cost of radiographs over the first 6 weeks was $44.51 (95% confidence interval [CI] 38.64–50.38) per patient in the experimental group, and $129.23 (95% CI 120.23–138.23) in the control group (p < 0.001). The mean time spent in clinic at 2 weeks was 46 min (95% CI 32–60) per patient for the experimental group and 68 min (95% CI 55–81) for the control group (p = 0.018). Two complications occurred in the experimental group. Both were detected clinically and did not qualify as missed events. Conclusion Implementing a simplified radiography protocol after stable fracture fixation saves time and money. Additionally, no adverse events were missed with the study protocol. Recommendations are made toward a noninferiority trial to establish protocol safety. PMID:28234590
Frisch, Nicholas B; Charters, Michael A; Sikora-Klak, Jakub; Banglmaier, Richard F; Oravec, Daniel J; Silverton, Craig D
Intraoperative periprosthetic femur fracture is a known complication of total hip arthroplasty (THA) and a variety of cerclage systems are available to manage these fractures. The purpose of this study was to examine the in situ biomechanical response of cerclage systems for fixation of periprosthetic femur fractures that occur during cementless THA. We compared cobalt chrome (CoCr) cables, synthetic cables, monofilament wires and hose clamps under axial compressive and torsional loading. Metallic constructs with a positive locking system performed the best, supporting the highest loads with minimal implant subsidence (both axial and angular) after loading. Overall, the CoCr cable and hose clamp had the highest construct stiffness and least reduction in stiffness with increased loading. They were not demonstrably different from each other. Copyright © 2015 Elsevier Inc. All rights reserved.
Hambright, Dustin S; Walley, Kempland C; Hall, Amber; Appleton, Paul T; Rodriguez, Edward K
Patella fractures with comminution, osteoporotic bone, and/or previously failed fixation are exceedingly difficult to reduce and fix. Moreover, the risk of symptomatic constructs and patients who are poorly compliant with postoperative activity restrictions can make these complex fracture patterns an even more challenging scenario. Although there is an array of techniques described for comminuted patella fractures, there lacks an accepted surgical technique for these difficult cases. In this clinical series, we describe an enhancement to the traditional tension band construct that uses additional wires and multiple tension bands to gather and fix comminuted fracture patterns in nontransverse planes, bolster osteoporotic bone, and secure fractures in patients undergoing a revision and/or have potential to be poorly compliant with postoperative activity restrictions. The clinical outcomes of 27 patients demonstrate high rates of bony union, functional range of motion, and low rates of both infection and failure. In conclusion, using the basic principles of tension band wiring remains highly versatile, useful, and economical in approaching difficult patella fractures.
Hatt, J-M; Christen, C; Sandmeier, P
The repair of seven tibiotarsal fractures, three humeral fractures, three tarsometatarsal fractures, two femoral fractures and 13 radial and ulnar fractures with a tubular external fixator system was evaluated prospectively in 10 common pigeons (Columba livia), 11 psittacine birds, six birds of prey and one Bali starling (Leucopsar rothschildii). The fixations included type 1, type 2 and intramedullary tie-in methods, and the fractures healed in all but three cases. A comparison of the weight of different connecting bars showed that the external fixation system and polymethylmethacrylate are the lightest available systems and that there was no clinically relevant difference between them.
Li, Kunpeng; Zhang, Wen; Liu, Dan; Xu, Hui; Geng, Wei; Luo, Dawei; Ma, Jinzhu
Abstract Background: Use of a pedicle screw at the level of fracture, also known as an intermediate screw, has been shown to improve clinical results in managing thoracolumbar(TL) fractures, but there is a paucity of powerful evidence to support the claim. The aim of this study was to compare outcomes between pedicle screw fixation combined with intermediate screw at the fracture level and conventional pedicle screw fixation (one level above and one level below the fracture level) for thoracolumbar (TL) fractures. Methods: A meta-analysis of cohort studies was conducted between pedicle screw fixation combined with intermediate screw at the fracture level (combined screw group) and conventional pedicle screw fixation (conventional group) for the treatment of TL fractures from their inception to December 2015. An extensive search of studies was performed in PubMed, Medline, Embase, and the Cochrane library. The following outcome measures were extracted: visual analogue scale (VAS), operation time and intraoperative blood loss, Cobb angle and anterior vertebral height (AVH), and complications. Data analysis was conducted with RevMan 5.3.5. Results: From 10 relevant studies identified, 283 patients undergoing pedicle screw fixation combined with intermediate screw at the fracture level were compared with 285 conventional pedicle screw procedures. The pooled analysis showed that there was statistically significant difference in terms of postoperative Cobb angle (95% confidence interval (CI), −3.00, −0.75; P = 0.001) and AVH (95% CI, 0.04, 12.23; P = 0.05), correction loss (Cobb angle: P < 0.0001; AVH: P < 0.0001) and implant failure rate (95% CI, 0.06, 0.62; P = 0.006), and blood loss (W 95% CI, 2.22, 23.60; P = 0.02) between 2 groups. But in terms of other complications, there were no differences between 2 groups (95% CI, 0.23, 2.04; P = 0.50). No difference was found in operation time (95% CI, −5.36, 14.67; P = 0.36) and VAS scores (95% CI, −0.44, 0
Yang, Z; Yuan, Z Z; Ma, J X; Ma, X L
Objective: To make a systematic assessment of the complications of open reduction and internal fixation versus external fixation for unstable distal radius fractures. Method: A computer-based online search of PubMed, ScienceDirect, EMBASE, BIOSIS, Springer and Cochrane Library were performed.The randomized and controlled trials of open reduction and internal fixation versus external fixation for unstable distal radius fractures were collected.The included trials were screened out strictly based on the criterion of inclusion and exclusion.The quality of included trials was evaluated.RevMan 5.0 was used for data analysis. Result: A total of 17 studies involving 1 402 patients were included.There were 687 patients with open reduction and internal fixation and 715 with external fixation.The results of Meta-analysis indicated that there were statistically significant differences with regard to the postoperatively total complications, infection, malunion, tendon rupture (I(2)=8%, RR=0.77(95%CI 0.65-0.91, Z=3.10, P<0.05). There were no statistically significant differences observed between two approaches with respect to nounion, re-operation, complex regional pain syndrome, carpal tunnel syndrome, neurapraxia, tendonitis, painful hardware, scar(P>0.05). Conclusion: Postoperative complications are present in both open reduction and internal fixation and external fixation.Compared with external fixation, open reduction and internal fixation is lower in total complications postoperatively, infection and malunion, but external fixation has lower tendon rupture incidence.
Ho, Michael; Garau, Giorgio; Walley, Gayle; Oliva, Francesco; Panni, Alfredo Schiavone; Longo, Umile Giuseppe
We compared a minimally invasive surgical technique to the conventional (open approach) surgical technique used in fixation of hip fractures with the dynamic hip screw (DHS) device. Using a case-control design (44 cases and 44 controls), we tested the null hypothesis that there is no difference between the two techniques in the following outcome measures: duration of surgery, time to mobilisation and weight bearing postoperatively, length of hospital stay, mean difference of pre- and postoperative haemoglobin levels, position of the lag screw of the DHS device in the femoral head, and the tip–apex distance. The minimally invasive DHS technique had significantly shorter duration of surgery and length of hospital stay. There was also less blood loss in the minimally invasive DHS technique. The minimally invasive DHS technique produces better outcome measures in the operating time, length of hospital stay, and blood loss compared to the conventional approach while maintaining equal fixation stability. PMID:18478227
Fan, Yanping; Lei, Jianyin; Zhu, Feng; Li, Zhiqiang; Chen, Weiyi; Liu, Ximing
This study aims to evaluate the biomechanical mechanism of fixation systems in the most frequent T-shaped acetabular fracture using finite element method. The treatment of acetabular fractures was based on extensive clinical experience. Three commonly accepted rigid fixation methods (double column reconstruction plates (P × 2), anterior column plate combined with posterior column screws (P + PS), and anterior column plate combined with quadrilateral area screws (P + QS)) were chosen for evaluation. On the basis of the finite element model, the biomechanics of these fixation systems were assessed through effective stiffness levels, stress distributions, force transfers, and displacements along the fracture lines. All three fixation systems can be used to obtain effective functional outcomes. The third fixation system (P + QS) was the optimal method for T-shaped acetabular fracture. This fixation system may reduce many of the risks and limitations associated with other fixation systems. PMID:26495030
Cai, Haoqi; Wang, Zhigang; Cai, Haiqing
To compare the use of crossed K-wire and prebent intramedullary nail techniques for the fixation of distal radius metaphyseal fracture in children. Intraoperative and follow-up data for children with distal radius metaphyseal fracture, treated using crossed K-wire or prebent intramedullary nail fixation, were retrospectively analysed. Patient groups were matched for age, sex and clinical parameters (fracture location, affected side, fracture type). Patients treated using prebent intramedullary nail fixation (n = 52) had significantly shorter surgery duration, fewer intraoperative X-radiographs, and lower prevalence of postoperative redisplacement and malalignment deformity than those treated using crossed K-wire fixation (n = 52). Both techniques resulted in similar postoperative complications and recovery of forearm rotation. Prebent intramedullary nail fixation has a better functional outcome than crossed K-wire fixation in the treatment of distal radial epiphyseal fracture in children. © The Author(s) 2015.
Xiao, Jian-Rui; Li, De-Hua; Chen, Yu-Xuan; Chen, Shu-Jun; Guan, Su-Min; Kong, Liang
This study aimed to investigate the effects of an expandable implant (EI) in ovariectomized sheep. The EI and taper implant (control group) were produced and placed in mandibles of ovariectomized sheep. Twelve weeks after implantation, resonance frequency analysis, biomechanical tests, histomorphometry, and micro-computed tomography were applied to detect the osseointegration in the 2 groups. The implant stability quotient values, maximal pullout forces, and bone-implant contact (BIC) were 60.3 ± 7.9, 511.0 ± 18.7 N, and 53.14% ± 4.56%, respectively, in the EI group and 58.3 ± 8.9, 394.5 ± 54.5 N, and 46.85% ± 5.04%, respectively, in the control group. There was no significant difference between the 2 groups in implant stability quotient values (P > .05); however, in the EI group the maximal pullout force and BIC were increased significantly (P < .05 and P < .01, respectively). Micro-computed tomography analysis showed that the bone volume/total volume ratio and trabecular number increased significantly (P < .01) and trabecular separation decreased significantly (P < .05) in the EI group. EI could improve osseointegration in osteoporosis after 12 weeks of implantation by increasing BIC around the implant and by supplying an extra osseointegration surface. Copyright © 2013 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
de OLIVERA, Leandro Benetti; SANT'ANA, Eduardo; MANZATO, Antonio José; GUERRA, Fábio Luis Bunemer; ARNETT, G. William
Among the osteotomies performed in orthognathic surgery, the sagittal osteotomy of the mandibular ramus (SOMR) is the most common, allowing a great range of movements and stable internal fixation (SIF), therefore eliminating the need of maxillomandibular block in the postoperative period. Objectives: The purpose of this study was to evaluate the biomechanical resistance of three national systems used for SIF in SOMR in sheep mandibles. Material and methods: The study was performed in 30 sheep hemi-mandibles randomly divided into 3 experimental groups, each containing 10 hemi-mandibles. The samples were measured to avoid discrepancies and then subjected to SOMR with 5-mm advancement. In group I, 2.0x12 mm screws were used for fixation, inserted in an inverted "L" pattern (inverted "L" group). In group II, fixation was performed with two 2.0x12 mm screws, positioned in a linear pattern and a 4-hole straight miniplate and four 2.0x6.0 mm monocortical screws (hybrid group). In group III, fixation was performed with two 4-hole straight miniplates and eight 2.0x6.0 mm monocortical screws (mini plate group). All materials used for SIF were supplied by Osteosin - SIN. The hemimandibles were subjected to vertical linear load test by Kratos K2000MP mechanical testing unit for loading registration and displacement. Results: All groups showed similar resistance during mechanical test for loading and displacement, with no statistically significant differences between groups according to analysis of variance. Conclusion: These results indicate that the three techniques of fixation are equally effective for clinical fixation of SOMR. PMID:23032203
DiMaio, F R; Haher, T R; Splain, S H; Mani, V J
Fractures occurring after fixation of intertrochanteric femur fractures have been described previously in the literature. Terms such as "stress-riser fracture" and "Young's modulus fracture" have been applied. The prevalence of these fracture types has increased, and so has use of the sliding screw plate device for fixation of intertrochanteric hip fractures. The object of this paper is to describe, by case examples, types of stress-related fractures of the proximal femur in association with the sliding screw plate and to define each biomechanical type in review.
Ganeshan, Raghavendra Marappa; Mamoowala, Neville; Ward, Mathew; Sochart, David
Acute compartment syndrome is a surgical emergency that most commonly occurs after trauma or reperfusion after prolonged arterial occlusion. It is caused by a build-up of blood and oedema fluid within a closed muscle compartment, and can be limb and life-threatening. It is therefore imperative that a prompt diagnosis is made. The risk of developing this condition is <1% in patients with distal radius fractures and 4-5% in those with tibial diaphyseal fractures. Pain management is an important aspect of treatment following any fracture. Regional anaesthesia can be used during surgical fixation of the fracture and has the potential to reduce the need for specialist postoperative care and analgesia, as well as to shorten the length of hospitalisation. With this case report, we hope to highlight the potential risk of masking symptoms of compartment syndrome while using regional blocks, as this can cause a delay in diagnosis and treatment, leading to associated complications. 2015 BMJ Publishing Group Ltd.
Ludwig, Meryl; Hymes, Robert A; Schulman, Jeff; Pitta, Michael; Ramsey, Lolita
Tibia fracture is the most common type of long bone fracture, and intramedullary nailing is the preferred treatment. In open fractures, a provisional plate is often used to maintain reduction. It is unknown whether this practice increases the risk of infection or other complications. This study retrospectively compared patients who were treated at a level 1 trauma center with intramedullary nailing of an open tibia fracture. Patients who were included: (1) were 18 years or older; (2) were treated between January 1, 2005, and June 30, 2013; (3) had an open fracture of the tibia; and (4) were treated operatively with intramedullary nailing, with or without provisional plate fixation. Patient sex, history of diabetes, history of smoking, mechanism of injury, and side of injury were analyzed. Postoperative complications included infection, delayed union or non-union, compartment syndrome, and death. After the authors controlled for age, Gustilo-Anderson type, and AO/Orthopaedic Trauma Association classification, they found that provisional plate use did not significantly increase the risk of infection (adjusted odds ratio, 1.64; 95% confidence interval, 0.51-5.32; P=.41) or any other complications (adjusted odds ratio, 1.24; 95% confidence interval, 0.46-3.35; P=.67). In the subgroup of patients who had a provisional plate (n=35), removal of the plate did not significantly decrease the risk of infection (adjusted odds ratio, 0.43; 95% confidence interval, 0.07-2.69; P=.36) or other complications (adjusted odds ratio, 0.55; 95% confidence interval, 0.12-2.46; P=.44). In open tibia fractures treated with intramedullary nailing, provisional plate stabilization, a valuable reduction aid, did not increase the risk of infection or other complications. Because of the small subgroup size, however, definitive conclusions cannot be drawn about removal of these provisional plates. [Orthopedics. 2016; 39(5):e931-e936.]. Copyright 2016, SLACK Incorporated.
Sangkomkamhang, Thananit; Singjam, Udomsin; Leeprakobboon, Duangjai
The aim of this study was to determine the risk factors for loss of fixation in pediatric supracondylar humeral fractures. The data were analyzed regarding assessed loss of fixation in 256 supracondylar fractures from January 2010 to December 2012, all of which were treated by closed or open reduction and Kirschner wire fixation. The confounding factors that were thought to cause loss of reduction were collected. Multivariate logistic regression analysis was performed to predict risk factors. Reduction was lost in 14.8% of the patients. Poor surgical technique was significantly higher in the cases with lost reduction (odds ratio: 15.21). Additionally, cases with only lateral pins placement (odds ratio: 2.57), Gartland type 3 fractures (odds ratio: 2.38), and, obesity with a BMI ≥ 25 (odds ratio: 14.35) had a significantly higher risk of losing reduction and fixation. Other factors including age, energy type of injury, time of surgery, and time to surgery were not associated with risk. The loss of reduction following fracture fixation is associated with poor surgical technique,fixation with lateral pinning only, Gartland type 3 fractures, and pediatric obesity (BMI > 25). The stability of fracture fixation in pediatric supracondylar fractures is largely dependent on the use of effective fixation techniques. Cross pinning provides a more stabile fixation than lateral pinning.
Cienfuegos, Ricardo; Sierra, Eduardo; Ortiz, Benjamin; Fernández, Gerardo
Treatment options for palatal fractures range from orthodontic braces, acrylic bars, and arch bars for maxillomandibular fixation to internal fixation, with plates and screws placed under the palate mucosa and periosteum, together with pyriform aperture or alveolar plating plus buttress reconstruction. Forty-five patients, ages 4 to 56, were treated using medium- or high-profile locking plates placed over the palatal mucosa as an external fixator for palatal fractures, together with treatment for other associated facial fractures. In open fractures, plates were placed after approximating the edges of the mucosal wounds. Plates and screws for palate fixation were removed at 12 weeks, when computed tomography scans provided evidence of fracture healing. All palatal fractures healed by 12 weeks, with no cases of mucosal necrosis, bone exposure, fistulae, or infections. This approach achieves adequate stability, reduces the risk of bone and mucosal necrosis, and promotes healing of mucosal wounds in case of open fractures. PMID:22132261
McKee, Michael D
Clavicle fractures are common, and they comprise close to 3% of all fractures seen in fracture clinics. Midshaft fractures account for approximately 80% of all clavicle fractures and are the focus of this article. In carefully selected cases primary plate fixation of displaced midshaft clavicle fractures improves outcome, results in earlier return to function, and reduces the nonunion and symptomatic malunion rate significantly compared with nonoperative treatment.
Adams, S B
External fixation is a very useful method of treating selected fractures in cattle. The economics of therapy and the availability of the techniques to all veterinarians will continue to make external fixation the most frequently used method of fracture repair in cattle.
Osti, Michael; Mittler, Christoph; Zinnecker, Richard; Westreicher, Christoph; Allhoff, Clemens; Benedetto, Karl Peter
This study compared functional and radiological outcomes after treatment of extension-type distal radius fractures with conventional titanium nonlocking T-plates or titanium 1.5-mm locking plates. A total of 60 patients were included and followed for 4 to 7 years after receiving nonlocking T-plates (group A; n=30) or locking plates (group B; n=30) with and without dorsal bone grafting. Bone grafting was significantly more often performed in the nonlocking group to increase dorsal fracture fixation and stability (P<.003). Pre- and postoperative and follow-up values for palmar tilt, radial inclination, radial shortening, and ulnar variance were recorded. Age, sex, and fracture type were similarly distributed between the 2 groups. Postoperative and follow-up evaluation revealed equal allocation of intra-articular step formation and osteoarthritic changes to both groups. The overall complication rate was 25%. Compared with the nonlocking system, patients undergoing locking plate fixation presented with statistically significantly better values for postoperative palmar tilt (5.53° vs 8.15°; P<.02) and radial inclination (22.13° vs 25.03°; P<.02). However, forearm pronation was significantly better in group A (P<.005). At follow-up, radial inclination tended to approach a statistically significant difference in favor of group B. All clinical assessment, including Mayo wrist score, Disabilities of the Arm, Shoulder, and Hand score, Green and O'Brien score, Gartland and Werley score, visual analog scale score, and grip strength, yielded no statistically significant difference between the 2 groups. Locking plates seem to provide benefits regarding surgical technique and comfort, improvement in implant anchorage (especially in osteoporotic bone), and reduce the necessity of additional bone grafting. Copyright 2012, SLACK Incorporated.
Frisch, Nicholas B; Pepper, Andrew M; Jildeh, Toufic R; Shaw, Jonathan; Guthrie, Trent; Silverton, Craig
Hip fractures are common orthopedic injuries and are associated with significant morbidity/mortality. Intraoperative normothermia is recommended by national guidelines to minimize additional morbidity/mortality, but limited evidence exists regarding hypothermia's effect on orthopedic patients. The purpose of this study was to determine the incidence of intraoperative hypothermia in patients with operatively treated hip fractures and evaluate its effect on complications and outcomes. Retrospective chart review was performed on clinical records from 1541 consecutive patients who sustained a hip fracture and underwent operative fixation at the authors' institution between January 2005 and October 2013. A total of 1525 patients were included for analysis, excluding those with injuries requiring additional surgical intervention. Patient demographic data, surgery-specific data, postoperative complications, length of stay, and 30-day readmission were recorded. Patients with a mean intraoperative temperature less than 36°C were identified as hypothermic. Statistical analysis with univariate and multivariate logistic regression modeling evaluated associations with hypothermia and effect on complications/outcomes. The incidence of intraoperative hypothermia in operatively treated hip fractures was 17.0%. Hypothermia was associated with an increase in the rate of deep surgical-site infection (odds ratio, 3.30; 95% confidence interval, 1.19-9.14; P=.022). Lower body mass index and increasing age demonstrated increased association with hypothermia (P=.004 and P=.005, respectively). To the authors' knowledge, this is the first and largest study analyzing the effect of intraoperative hypothermia in orthopedic patients. In patients with hip fractures, the study's findings confirm evidence found in other surgical specialties that hypothermia may be associated with an increased risk of deep surgical-site infection and that lower body mass index and increasing age are risk factors
Akoh, Craig C; Schick, Cameron; Otero, Jesse; Karam, Matthew
Fat embolism syndrome (FES) is a multi-organ disorder with potentially serious sequelae that is commonly seen in the orthopaedic patient population after femur fractures. The major clinical features of FES include hypoxia, pulmonary dysfunction, mental status changes, petechiae, tachycardia, fever, thrombocytopenia, and anemia. Due to technological advances in supportive care and intramedullary reaming techniques, the incidence of FES has been reported as low as 0.5 percent. Here, we present a rare case of FES with cerebral manifestations. A previously healthy 24-year old nonsmoking male was admitted to our hospital after an unrestrained head-on motor vehicle collision. The patient's injuries included a left olecranon fracture and closed bilateral comminuted midshaft femur fractures. The patient went on to develop cerebral fat embolism syndrome (CFES) twelve hours after immediate bilateral intramedullary nail fixation. His symptoms included unresponsiveness, disconjugate gaze, seizures, respiratory distress, fever, anemia, thrombocytopenia, and visual changes. Head computed tomography and brain magnetic resonance imaging showed pathognomonic white-matter punctate lesions and watershed involvement. With early recognition and supportive therapy and seizure therapy, the patient went on to have complete resolution of symptoms without cognitive sequelae. PMID:25328460
Tosounidis, Theodoros H; Giannoudis, Peter V
Distal femoral periprosthetic fractures are on the rise. Increased mortality of these injuries is also evident from recent data. Their incidence and risk factors have been extensively reported in the past but new data are being available that merit attention. The increased incidence and the even higher projected incidence should direct the focus of future strategies to the education of surgeons, relevant capacity of hospital and reconfiguration of health care resources. New and potentially modifiable risk factors should be taken into consideration to the informed consent process and new studies should be developed to clarify the causative relationship of the new risk factors such as the peptic ulcer disease and the COPD. The main internal fixation techniques remain the lateral locking plating and the retrograde intramedullary nailing. New techniques in plating are the supplementary medial plate in selected cases and the far cortical locking. Nailing is considered a valid option especially in fractures located well above the anterior flange of the femoral component of the arthroplasty. Results and outcomes from good quality studies are still sparse regarding the comparison between plating and nailing. Interprosthetic fractures constitute an entity that is lately gaining considerable attention. The best method of management of these injuries is still evolving with considerable amount of work being done in the clinical and biomechanical level.
Aksakal, Bunyamin; Gurger, Murat; Say, Yakup; Yilmaz, Erhan
Biomechanical comparison of straight DCP and helical plates for fixation of transversal and oblique tibial bone fractures were analyzed and compared to each other by axial compression, bending and torsion tests. An in vitro osteosynthesis of transverse (TF) and oblique bone fracture (OF) fixations have been analysed on fresh sheep tibias by using the DCP and helical compression plates (HP). Statistically significant differences were found for both DCP and helical plate fixations under axial compression, bending and torsional loads. The strength of fixation systems was in favor of DC plating with exception of the TF-HP fixation group under compression loads and torsional moments. The transvers fracture (TF) stability was found to be higher than that found in oblique fracture (OF) fixed by helical plates (HP). However, under torsional testing, compared to conventional plating, the helical plate fixations provided a higher torsional resistance and strength. The maximum stiffness at axial compression loading and maximum torsional strength was achieved in torsional testing for the TF-HP fixations. From in vitro biomechanical analysis, fracture type and plate fixation system groups showed different responses under different loadings. Consequently, current biomechanical analyses may encourage the usage of helical HP fixations in near future during clinical practice for transverse bone fractures.
Shui, Xiaolong; Ying, Xiaozhou; Mao, Chuanwan; Feng, Yongzeng; Chen, Linwei; Kong, Jianzhong; Guo, Xiaoshan; Wang, Gang
Crescent fracture-dislocation of the sacroiliac joint (CFDSIJ) is a type of lateral compression pelvic injury associated with instability. Open reduction and internal fixation is a traditional treatment of CFDSIJ. However, a minimally invasive method has never been reported. The purpose of this study was to assess the outcome of closed reduction and percutaneous fixation for different types of CFDSIJ and present their clinical outcome. The authors reviewed 117 patients diagnosed with CFDSIJ between July 2003 and July 2013. Closed reduction and percutaneous fixation was performed in 73 patients. Treatment selection was based on Day's fracture classification. For type I fractures, fixation perpendicular to the fracture line were performed. For type II fractures, crossed fixation was performed. For type III fractures, fixation was performed with iliosacral screws. Forty-four patients were treated by open reduction and plate fixation. Demographics, fracture pattern distribution, blood loss, incision lengths, revision surgeries, radiological results, and functional scores were compared. All 117 patients were followed for more than 6 months (mean, 14 months [range, 6-24 months]). Blood loss, extensive exposure, duration of posterior ring surgery, duration of hospital stay, and infection rates were lower in the closed group (P<.01). Patients in the closed group achieved better functional performance (P<.01). There were no significant differences in reduction quality (P=.32), revision surgery rates (P=.27), and iatrogenic neurologic injuries (P=.2) between the 2 groups. The authors' results indicate that closed reduction and percutaneous fixation is a safe and effective surgical method for CFDSIJ.
Peleg, Michael; Sawatari, Yoh
The gunshot wound to the mandible is a unique traumatic injury. The resultant injury from the gunshot wound is diverse because of the variability of the projectile, motion, velocity, and tissue characteristics. When a high-velocity projectile strikes the mandible, often times the wound will consist of a severely comminuted mandible surrounded by nonvital soft tissues and the implantation of multiple foreign bodies. This represents a challenge for the treating surgeon. The anatomy and function of the mandible make it such that the care of the gunshot wound requires a combination of trauma and reconstructive surgeries. There are varying techniques advocated for the management of gunshot wound to the face. However, for the comminuted mandible fracture sustained from a gunshot wound, an approach involving the fabrication of an occlusal splint, intermaxillary fixation, aggressive debridement of hard and soft tissues, and immediate reconstruction with a titanium plate is a comprehensive approach that can restore the appropriate function and contour of the patient. At the Division of Oral and Maxillofacial Surgery, University of Miami, this approach to the comminuted mandible fracture secondary to the gunshot wound has led to the effective management of this specific subset of injury. The complication rate is comparable with the current literature and provides an advantage as a 1-stage management to restore appropriate function and cosmesis to the patient.
Shulman, Brandon S; Egol, Kenneth A
Proximal humerus fractures account for approximately 5% of all fractures. It is estimated that due to our aging population, orthopaedic surgeons will see a three-fold increase in proximal humerus fractures over the next 30 years. Internal fixation with locked plating is the current mainstay of treatment for functionally active patients who desire minimal loss of function. A thorough understanding of the indications, techniques, and drawbacks of treatment with internal fixation is essential to achieve the highest quality of patient care.
Griffin, Damian R; Starr, Adam J; Reinert, Charles M; Jones, Alan L; Whitlock, Shelly
To measure the failure rate of percutaneous iliosacral screw fixation of vertically unstable pelvic fractures and particularly to test the hypothesis that fixations in which the posterior injury is a vertical fracture of the sacrum are more likely to fail than fixations with dislocations or fracture-dislocations of the sacroiliac joint. Retrospective review. Level 1 trauma center. All patients with pelvic fractures admitted between January 1, 1993, and December 31, 1998, were identified from the trauma registry. Hospital records were used to identify patients treated with iliosacral screws. Radiologic studies were examined to identify patients who had unequivocally vertically unstable pelvic fractures. Immediate postoperative and follow-up anteroposterior, inlet, and outlet radiographs from a minimum of 12 months postinjury were examined. Position, length, and numbers of iliosacral screws and any evidence of screw failure (eg, bending or breakage) were recorded. Residual postoperative displacement and late displacement of the posterior pelvis were measured. The main outcome measure was failure, defined as at least 1cm of combined vertical displacement of the posterior pelvis compared with immediate postoperative position. The main analysis was for association between fracture pattern and failure. Patient demographic data, iliosacral screw position, and anterior pelvic fixation method also were studied. The study group comprised 62 patients with unequivocally vertically unstable pelvic fractures in whom the posterior injury was treated with closed reduction and percutaneous iliosacral screw fixation. Of patients, 32 had dislocations or fracture-dislocations of the sacroiliac joint, and 30 had vertical fractures of the sacrum. Fixation failed in four patients, all with vertical sacral fractures and all within the first 3 weeks after surgery. These four patients required revision fixation. In two further cases with vertical sacral fractures, there was evidence that
Griffin, Damian R; Starr, Adam J; Reinert, Charles M; Jones, Alan L; Whitlock, Shelly
To measure the failure rate of percutaneous iliosacral screw fixation of vertically unstable pelvic fractures and particularly to test the hypothesis that fixations in which the posterior injury is a vertical fracture of the sacrum are more likely to fail than fixations with dislocations or fracture-dislocations of the sacroiliac joint. Retrospective review. Level 1 trauma center. All patients with pelvic fractures admitted between January 1, 1993, and December 31, 1998, were identified from the trauma registry. Hospital records were used to identify patients treated with iliosacral screws. Radiologic studies were examined to identify patients who had unequivocally vertically unstable pelvic fractures. Immediate postoperative and follow- up anteroposterior, inlet, and outlet radiographs from a minimum of 12 months postinjury were examined. Position, length, and numbers of iliosacral screws and any evidence of screw failure (eg, bending or breakage) were recorded. Residual postoperative displacement and late displacement of the posterior pelvis were measured. The main outcome measure was failure, defined as at least 1cm of combined vertical displacement of the posterior pelvis compared with immediate postoperative position. The main analysis was for association between fracture pattern and failure. Patient demographic data, iliosacral screw position, and anterior pelvic fixation method also were studied. The study group comprised 62 patients with unequivocally vertically unstable pelvic fractures in whom the posterior injury was treated with closed reduction and percutaneous iliosacral screw fixation. Of patients, 32 had dislocations or fracture-dislocations of the sacroiliac joint, and 30 had vertical fractures of the sacrum. Fixation failed in four patients, all with vertical sacral fractures and all within the first 3 weeks after surgery. These four patients required revision fixation. In two further cases with vertical sacral fractures, there was evidence that
Sawada, Hideyoshi; Shinohara, Takaaki; Natsume, Tadahiro; Hirata, Hitoshi
Ulnar styloid fractures are often associated with distal radius fractures. However, controversy exists regarding whether to treat ulnar styloid fractures. This study aimed to evaluate clinical effects of internal fixation for ulnar styloid fractures after distal radius fractures were treated with the volar locking plate system. We used prospectively collected data of distal radius fractures. 111 patients were enrolled in this study. A matched case-control study design was used. We selected patients who underwent fixation for ulnar styloid fractures (case group). Three control patients for each patient of the case group were matched on the basis of age, sex, and fracture type of distal radius fractures from among patients who did not undergo fixation for ulnar styloid fractures (control group). The case group included 16 patients (7 men, 9 women; mean age: 52.6 years; classification of ulnar styloid fractures: center, 3; base, 11; and proximal, 2). The control group included 48 patients (15 men, 33 women; mean age: 61.1 years; classification of ulnar styloid fractures: center, 10; base, 31; and proximal, 7). For radiographic examination, the volar tilt angle, radial inclination angle, and ulnar variance length were measured, and the union of ulnar styloid fractures was judged. For clinical examination, the range of motions, grip strength, Hand20 score, and Numeric Rating Scale score were evaluated. There was little correction loss for each radiological parameter of fracture reduction, and these parameters were not significantly different between the groups. The bone-healing rate of ulnar styloid fractures was significantly higher in the case group than in the control group, but the clinical results were not significantly different. We revealed that there was no need to fix ulnar styloid fractures when distal radius fractures were treated via open reduction and internal fixation with a volar locking plate system. Copyright © 2016 The Japanese Orthopaedic Association
Hay, Robyn Aik Siew; Tay, Shian Chao
To compare K-wire and screw fixation of distal phalanx (DP) fractures with respect to union and functional outcome. This retrospective study identified patients with DP fractures from a clinic registry taken from 2007 to 2013. Clinical data collected included patient demographics, range of motion (ROM), removal of implant (ROI), and complications. Radiographic data collected included fracture type, location, configuration, fracture displacement, and radiographic union. Statistical analysis was done using a chi-squared test for categorical variables and paired Student's t test for continuous variables. A total of 172 patients with DP fractures were seen in our clinic between 2007 and 2013. Of these, 141 patients were managed conservatively and 31 patients had surgery for 33 DP fractures, of which 12 had K-wire and 21 had screw fixation. Mean union incidence for screw was 100% compared with 83% for K-wire. Time to union was 2.4 months for screw fixation compared with 4.1 months for K-wire fixation. ROM for screw fixation was significantly better (60°) compared with K-wire fixation (45°). ROM for non-transarticular K-wire (46°) was similar to transarticular K-wire (44°). ROI was performed in 52% of patients with screw fixation. Other than fingertip tenderness, which resolved after ROI, no other complications were noted. Our study showed that the union incidence and time to union for screw fixation were comparable to those for K-wire fixation. Screw fixation of DP fractures resulted in greater distal interphalangeal joint motion compared with K-wire fixation but required removal in half of cases. Therapeutic III. Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Singh, V; Kshirsagar, R; Halli, R; Sane, V; Chhabaria, G; Ramanojam, S; Joshi, S; Patankar, A
The objective of this study was to evaluate the efficacy and stability of bioresorbable plates in condylar fractures in adults. Twelve adult patients who had sustained a condylar fracture, either alone or in combination with other mandibular fractures, were clinically and radiologically assessed for the efficacy and stability of bioresorbable plate and screw fixation. Intraoperatively, a total of seven screw breakages were noted. Six cases showed instability of the fractured fragments after fixation with bioresorbable plates and screws; the other six cases showed adequate stability. A single bioresorbable plate does not provide satisfactory stability for condylar fractures. Also, the screw breakages add additional surgical time and cost to the patient.
Park, Jin young; Kim, Che Keun; Huh, Soon Ho; Kim, Se Jin; Jung, Bo Hyun
Acetabular fractures can be treated with variable method. In this study, acetabular posterior wall fracture was treated with arthroscopic reduction and fixation using cannulated screw. The patient recovered immediately and had a satisfactory outcome. In some case of acetabular fracture could be good indication with additional advantages of joint debridement and loose body removal. So, we report our case with technical note. PMID:27536654
Quinnan, Stephen M.
Summary: Sacral fractures that result in spinopelvic dissociation are unstable injuries that are often treated surgically, with iliosacral screw fixation and/or lumbopelvic fixation from L4 to the pelvis. Open lumbopelvic fixation allows for direct fracture reduction and immediate postoperative weight bearing, but is associated with a relatively high wound complication rate. Open surgery often takes several hours and can be associated with significant blood loss, and therefore may not be well tolerated physiologically in these patients who often have multiple injuries. We developed a percutaneous lumbopelvic reduction and fixation technique to address these issues. PMID:26894767
Page, S M; Stern, P J
Eighty-two patients with 105 metacarpal and/or phalangeal fractures stabilized with plates were retrospectively reviewed to assess complications and outcomes. Despite stable fixation and early mobilization, major complications were encountered in 36% of fractures, especially with phalangeal and open fractures. Complications included stiffness, nonunion, plate prominence, infection, and tendon rupture. Forty-eight of 63 (76%) metacarpal fractures and 44 of 66 (67%) closed fractures had a final range of motion greater than 220 degrees; however, only 4 of 37 (11%) phalangeal fractures and 8 of 34 (24%) open fractures achieved this outcome. Despite technical advances in plate design and instrumentation, including lower-profile titanium plates, complications occur commonly with metacarpal and phalangeal fractures, leading to a high incidence of unsatisfactory results. We do not condemn plate fixation, and attribute many of our unsatisfactory results to the frequent use of plates in open and phalangeal fractures.
Lorich, Dean G; Warner, Stephen J; Schottel, Patrick C; Shaffer, Andre D; Lazaro, Lionel E; Helfet, David L
Patella fractures are challenging orthopaedic injuries. Many commonly used fixation techniques can be ineffective and lead to poor clinical outcomes even with satisfactory reductions and fracture healing. In this investigation, we present the technique of cage plate fixation of patella fractures and the clinical outcomes of 9 initial patients surgically treated at our institution. This technique allows direct visualization of the articular reduction, provides multiplanar fixation, effectively stabilizes inferior pole comminution, and reduces the risk of patella vascular disruption. Using this technique, we have achieved excellent functional and radiographic outcomes.
Hammond, Douglas; Parmar, Sat; Whitty, Justin; Pigadas, Nick
Whether to extract or retain wisdom teeth present in a fracture line is a controversial topic. This study reviewed the records of all patients who had mandibular wisdom teeth at the time of the injury, and had an open reduction and internal fixation procedure between January 2009 and January 2012. The cohort of patients who concomitantly had their wisdom tooth extracted at the time of fixation had a greater complication rate (24.3%) compared with patients who did not (14.9%). This suggests that if third molars in the line of a fracture have caries, are fractured, show signs of pericoronitis, are periodontally involved, or are interfering with the occlusion are extracted at the time of fixation, this will increase the incidence of complications.
Hammond, Douglas; Parmar, Sat; Whitty, Justin; Pigadas, Nick
Whether to extract or retain wisdom teeth present in a fracture line is a controversial topic. This study reviewed the records of all patients who had mandibular wisdom teeth at the time of the injury, and had an open reduction and internal fixation procedure between January 2009 and January 2012. The cohort of patients who concomitantly had their wisdom tooth extracted at the time of fixation had a greater complication rate (24.3%) compared with patients who did not (14.9%). This suggests that if third molars in the line of a fracture have caries, are fractured, show signs of pericoronitis, are periodontally involved, or are interfering with the occlusion are extracted at the time of fixation, this will increase the incidence of complications. PMID:26576231
Höch, Andreas; Schimpf, Richard; Hammer, Niels; Schleifenbaum, Stefan; Werner, Michael; Josten, Christoph; Böhme, Jörg
Cement augmentation of pedicle screws is the gold standard for the stabilization of osteoporotic fractures of the spine. In-screw cement augmentation, in which cement is injected through the cannula, is another option for fracture stabilization of fragility fractures of the sacrum. However, biomechanical superiority of this technique compared to conventional sacroiliac screw fixation has not been tested. The present study compares the stability of cement-augmented and non-cement-augmented sacroiliac screw fixation in osteoporotic sacrum fractures under cyclic loading. Eight human donor pelvises with intact ligaments and 5th lumbar vertebra were dissected. A vertical shear fracture was created as a combination of a sacrum fracture and cutting of the symphysis. Both sides were tested in a single-limb-stance setup with 10,000 loading cycles applied. Stiffness of the pelvis and displacement of the fracture were measured using a hydraulic testing machine and a 3D image correlation system. The augmented screw fixation failed in two of eight pelvises, and the non-augmented screws failed in three of eight pelvises. CT scans showed no leakage of cement. In-screw polymethylmethacrylate (PMMA) augmentation showed no advantage based on measured displacement of the sacrum fractures or stiffness for sacroiliac screw fixation of fragility fractures of the sacrum.
Egol, Kenneth; Howard, Daniel; Monroy, Alexa; Crespo, Alexander; Tejwani, Nirmal; Davidovitch, Roy
Introduction Operative fixation of displaced inferior pole patella fractures has now become the standard of care. This study aims to quantify clinical, radiographic and functional outcomes, as well as identify complications in a cohort of patients treated with non-absorbable braided suture fixation for inferior pole patellar fractures. These patients were then compared to a control group of patients treated for mid-pole fractures with K-wires or cannulated screws with tension band wiring. Methods In this IRB approved study, we identified a cohort of patients who were diagnosed and treated surgically for a displaced patella fracture. Demographic, injury, and surgical information were recorded. All patients were treated with a standard surgical technique utilizing non-absorbable braided suture woven through the patellar tendon and placed through drill holes to achieve reduction and fracture fixation. All patients were treated with a similar post-operative protocol and followed up at standard intervals. Data were collected concurrently at follow up visits. For purpose of comparison, we identified a control cohort with middle third patella fractures treated with either k-wires or cannulated screws and tension band technique. Patients were followed by the treating surgeon at regular follow-up intervals. Outcomes included self-reported function and knee range of motion compared to the uninjured side. Results Forty-nine patients with 49 patella fractures identified retrospectively were treated over 9 years. This cohort consisted of 31 females (63.3%) and 18 males (36.7%) with an average age of 57.1 years (range 26 - 88 years). Patients had an average BMI of 26.48 (range 19 - 44.08). Thirteen patients with inferior pole fractures underwent suture fixation and 36 patients with mid-pole fractures underwent tension band fixation (K-wire or cannulated screws with tension band). In the suture cohort, one fracture failed open repair (7.6%), which was revised again with sutures
Egol, Kenneth; Howard, Daniel; Monroy, Alexa; Crespo, Alexander; Tejwani, Nirmal; Davidovitch, Roy
Operative fixation of displaced inferior pole patella fractures has now become the standard of care. This study aims to quantify clinical, radiographic and functional outcomes, as well as identify complications in a cohort of patients treated with non-absorbable braided suture fixation for inferior pole patellar fractures. These patients were then compared to a control group of patients treated for mid-pole fractures with K-wires or cannulated screws with tension band wiring. In this IRB approved study, we identified a cohort of patients who were diagnosed and treated surgically for a displaced patella fracture. Demographic, injury, and surgical information were recorded. All patients were treated with a standard surgical technique utilizing non-absorbable braided suture woven through the patellar tendon and placed through drill holes to achieve reduction and fracture fixation. All patients were treated with a similar post-operative protocol and followed up at standard intervals. Data were collected concurrently at follow up visits. For purpose of comparison, we identified a control cohort with middle third patella fractures treated with either k-wires or cannulated screws and tension band technique. Patients were followed by the treating surgeon at regular follow-up intervals. Outcomes included self-reported function and knee range of motion compared to the uninjured side. Forty-nine patients with 49 patella fractures identified retrospectively were treated over 9 years. This cohort consisted of 31 females (63.3%) and 18 males (36.7%) with an average age of 57.1 years (range 26-88 years). Patients had an average BMI of 26.48 (range 19-44.08). Thirteen patients with inferior pole fractures underwent suture fixation and 36 patients with mid-pole fractures underwent tension band fixation (K-wire or cannulated screws with tension band). In the suture cohort, one fracture failed open repair (7.6%), which was revised again with sutures and progressed to union. Of the 36
Knutsen, Ashleen R; Sangiorgio, Sophia N; Liu, Chang; Zhou, Steve; Warganich, Tibor; Fleming, John; Harris, Thomas G; Ebramzadeh, Edward
The goal of this study was to evaluate the biomechanical performance of three distal fibula fracture fixation implants in a matched pair cadaveric fibula model: (1) a 5-hole compression plate with lag screw, (2) a 5-hole locking plate with lag screw, and (3) the 6-hole tabbed-plate with locking screws. Three-dimensional motions between the proximal and distal fibular segments were measured under cyclic valgus bending, cyclic compressive axial loading, and cyclic torsional external-rotation loading. During loading, strains were measured on the surfaces of each fibula near the simulated fracture site, and on the plate, to assess load transfer. Bone quality was quantified globally for each donor using bone mineral density (BMD) measured using Dual X-ray absorptiometry (DEXA) and locally at the fracture site using bone mineral content (BMC) measured using peripheral quantitative computed tomography (pQCT). Mean failure loads were below 0.2Nm of valgus bending and below 4Nm of external-rotational torque. Mean failure angulation was below 1degree for valgus bending, and failure rotation was below 7degrees for external-rotation. In the compression plate group, significant correlations were observed between bone quality (global BMD and local BMC) and strain in every one of the five locations (Pearson correlation coefficients >0.95, p<0.05). In contrast, in the locking and tabbed-plate groups, BMD and BMC correlated with far fewer strain locations. Overall, the tabbed-plate had similar construct stability and strength to the compression and locking plates. However, the distribution of load with the locking and tabbed-plates was not as heavily dependent on bone quality. Copyright © 2016 European Foot and Ankle Society. Published by Elsevier Ltd. All rights reserved.
Dunning, C E; Lindsay, C S; Bicknell, R T; Johnson, J A; King, G J; Patterson, S D
The in vitro stability of an Ilizarov hybrid external fixator was compared with that of a dorsal 3.5-mm AO T-plate in 8 unpaired, fresh-frozen upper extremities. A specially designed testing device that used computer-controlled pneumatic actuators was used to simulate active finger, wrist, and forearm motions by applying loads to relevant tendons. A comminuted extra-articular distal radius fracture was modelled using a dorsally based wedge osteotomy. Fracture stability was assessed using an electromagnetic tracking device to measure motion across the fracture site after randomized application of the plate and the hybrid fixator. During simulated finger and wrist motions with the forearm pronated or supinated, motion of the distal fragment with the hybrid fixator applied was comparable to or statistically less than with the AO plate applied. During simulated forearm rotation, the stability provided by the 2 fixation types was similar, although the plate allowed statistically less radial-ulnar deviation of the fragment. In this model of a 2-part extra-articular distal radius fracture, the clinically meaningful stability of the Ilizarov hybrid external fixator was comparable to that of the dorsal AO plate.
Giannoudis, Peter V; Kanakaris, Nikolaos K; Tsiridis, Eleftherios
Periprosthetic femoral fractures (PFF) are increasing as a result of changes in population demographics and the increase in the number of total hip replacements performed. The overall incidence has been reported to range from 0.1% to 6% of all total hip arthroplasties. Management of these fractures is often particularly demanding, complex and expensive. In many cases, the surgeon has to solve the simultaneous problems of implant loosening, bone loss and fracture. A thorough understanding of the unique characteristics of the different fracture types, the principles of PFF treatment and a familiarity with the various fixation devices, grafts and prosthetic implants are all of paramount importance. Internal fixation is used either alone or as an adjunct to stem revision. The stability of the original implant and the configuration of the fracture itself are the basic factors that influence the decision-making process. The current study reviews the existing literature on internal fixation of femoral periprosthetic fractures.
Ding, Haoliang; Qin, Hui; An, Zhiquan
Minimally invasive plate osteosynthesis(MIPO) has been considered as an alternative for fracture treatment. Previous study has demonstrated that MIPO technique has the advantage of less soft tissue injury compared with open reduction internal fixation (ORIF). However, the comparison of callus formation and mineralization between two plate osteosynthesis methods remains unknown. In this experiment, ulna fracture model was established in 42 beagle dogs. The fractures underwent reduction and internal fixation with MIPO or ORIF. Sequential fluorescent labeling and radiographs were applied to determine new callus formation and mineralization in two groups after operation. At 4, 8 and 12 weeks postoperatively, the animals were selected to be sacrificed and the ulna specimens were analyzed by Micro-CT. The sections were also treated with Masson staining for histological evaluation. More callus formation was observed in MIPO group in early stage of fracture healing. The fracture union rate has no significant difference between two groups. The results indicate that excessive soft tissue stripping may impact early callus formation. As MIPO technique can effectively reduce soft tissue injury with little incision, it is considered to be a promising alternative for fracture fixation. PMID:26444295
Greiner, Christopher L; Verstraete, Frank J M; Stover, Susan M; Garcia, Tanya C; Leale, Dustin; Arzi, Boaz
OBJECTIVE To evaluate biomechanical properties of intact feline mandibles, compared with those for mandibles with an experimentally created osteotomy that was stabilized with 1 of 2 internal fixation configurations. SAMPLE 20 mandibles from 10 adult feline cadavers. PROCEDURES An incomplete block study design was used to assign the mandibles of each cadaver to 2 of 3 groups (locking plate with locking screws [locking construct], locking plate with nonlocking screws [nonlocking construct], or intact). Within each cadaver, mandibles were randomly assigned to the assigned treatments. For mandibles assigned to the locking and nonlocking constructs, a simple transverse osteotomy was created caudal to the mandibular first molar tooth after plate application. All mandibles were loaded in cantilever bending in a single-load-to-failure test while simultaneously recording load and actuator displacement. Mode of failure (bone or plate failure) was recorded, and radiographic evidence of tooth root and mandibular canal damage was evaluated. Mechanical properties were compared among the 3 groups. RESULTS Stiffness, bending moments, and most post-yield energies for mandibles with the locking and nonlocking constructs were significantly lower than those for intact mandibles. Peak bending moment and stiffness for mandibles with the locking construct were significantly greater than those for mandibles with the nonlocking construct. Mode of failure and frequency of screw damage to tooth roots and the mandibular canal did not differ between the locking and nonlocking constructs. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that both fixation constructs were mechanically inferior to intact mandibles. The locking construct was mechanically stronger than the nonlocking construct.
Obata, Hiroyuki; Futamura, Kentaro; Obayashi, Osamu; Mogami, Atsuhiko; Tsuji, Hideki; Kurata, Yoshiaki; Kaneko, Kazuo
Recent reports suggest the presence of a rare fracture type for which reduction and fixation cannot be achieved with volar locking plate (VLP). In particular, it is difficult to achieve reduction and fixation with volar lunate facet (VLF) fragments present on the volar ulnar aspect of the lunate facet, because of the anatomical structure and biomechanics in this region. Herein, we report two challenging cases of difficulty in fixation of the VLF fragment in distal radius fracture. For this fracture type, it is most important to identify the volar ulnar bone fragment before surgery; it may also be necessary to optimize distal placement of the VLP via a dual-window approach and to apply additional fixations, such as a small plate, anchor, and/or external fixation. PMID:28255487
Leonidou, Andreas; Moazen, Mehran; Lepetsos, Panagiotis; Graham, Simon M; Macheras, George A; Tsiridis, Eleftherios
Optimal management of periprosthetic femoral fractures (PFF) around a well fixed prosthesis (Vancouver B1) remains controversial as adequate fixation needs to be achieved without compromising the stability of the prosthesis. The aim of this study was to highlight the effect of bone quality i.e. canal thickness ratio (CTR), and fracture topography i.e. fracture angle and its position in relation to the stem, on the biomechanics of a locking plate for a Vancouver B1 fracture. A previously corroborated simplified finite element model of a femur with a cemented total hip replacement stem was used in this study. Canal thickness ratio (CTR) and fracture topography were altered in several models and the effect of these variations on the von Mises stress on the locking plate as well as the fracture displacement was studied. Increasing the CTR led to reduction of the von Mises stress on the locking plate as well as the fracture movement. In respect to the fracture angle with the medial cortex, it was shown that acute angles resulted in lower von Mises stress on the plate as opposed to obtuse angles. Furthermore, acute fracture angles resulted in lower fracture displacement compared to the other fractures considered here. Fractures around the tip of the stem had the same biomechanical effect on the locking plate. However, fractures more distal to the stem led to subsequent increase of stress, strain, and fracture displacement. Results highlight that in good bone quality and acute fracture angles, single locking plate fixation is perhaps an appropriate management method. On the contrary, for poor bone quality and obtuse fracture angles alternative management methods might be required as the fixation might be under higher risk of failure. Clinical studies for the management of PFF are required to further support our findings.
Lareau, Craig R.; Daniels, Alan H.; Vopat, Bryan G.; Kane, Patrick M.
Unstable ankle fractures and impacted tibial pilon fractures often benefit from provisional external fixation as a temporizing measure prior to definitive fixation. Benefits of external fixation include improved articular alignment, decreased articular impaction, and soft tissue rest. Uniplanar external fixator placement in the Emergency Department (ED ex-fix) is a reliable and safe technique for achieving ankle reduction and stability while awaiting definitive fixation. This procedure involves placing transverse proximal tibial and calcaneal traction pins and connecting the pins with two external fixator rods. This technique is particularly useful in austere environments or when the operating room is not immediately available. Additionally, this bedside intervention prevents the patient from requiring general anesthesia and may be a cost-effective strategy for decreasing valuable operating time. The ED ex-fix is an especially valuable procedure in busy trauma centers and during mass casualty events, in which resources may be limited. PMID:25709258
Qiu, Meiguang; Shi, Zhanjun; Xiao, Jun; Zhang, Xuming; Ling, Shishui; Ling, Hao
The purpose of this study is to evaluate the potential benefits of rib fracture fixation in patients with flail chest and multiple non-flail rib fractures versus conventional treatment modalities. A retrospective reviewed study compared 86 cases which received surgical treatment between June 2009 and May 2013 to 76 cases which received conservative treatment between January 2006 and May 2009. The patients were divided into the flail chest (n = 38) and multiple non-flail rib fracture groups (n = 124). In the flail chest group, the mechanical ventilation time, ICU monitoring time, tracheostomies, thoracic deformity, and impaired pulmonary function and return to full-time employment were compared. In the multiple non-flail rib fracture group, fracture healing, visual analog scale (VAS) pain score, inpatient length of stay, atelectatic, pulmonary complications, and normal activity-returning time were compared. Patients in the flail chest operative fixation group had significantly shorter ICU stay, decreased ventilator requirements, fewer tracheostomies, less thoracic deformity and impaired pulmonary function, and more returned to full-time employment. Patients in the multiple non-flail rib fracture operative fixation had shorter hospital stay, less pain, earlier return to normal activity, more fracture healing, less atelectasis, and fewer pulmonary infections. This study demonstrates the potential benefits of surgical stabilization of flail chest and multiple non-flail rib fractures with plate fixation. When compared with conventional conservative management, operatively managed patients demonstrated improved clinical outcomes.
Forsythe, Raquel M; Peitzman, Andrew B; DeCato, Thomas; Rosengart, Matthew R; Watson, Gregory A; Marshall, Gary T; Ziembicki, Jenny A; Billiar, Timothy R; Sperry, Jason L
Venous thromboembolism is a major cause of morbidity and mortality after injury. Prophylactic anticoagulation is often delayed as a result of injuries or required procedures. Those patients at highest risk in this early vulnerable window postinjury are not well characterized. We sought to determine those patients at highest risk for an early pulmonary embolism (PE) after injury. A retrospective analysis using data derived from a large state wide trauma registry (1997-2007) was performed. Patients with a documented PE and time of occurrence were selected (n = 712). Patients with fat emboli and lower extremity vascular injuries were excluded. Patients with a PE within the first 72 hours of admission (EARLY, n = 122) were compared with those with DELAYED presentation. Kaplan-Meier survival analysis was used to characterize the timing of death between the two groups. Backward stepwise logistic regression was used to determine independent risk factors for EARLY PE relative to those with DELAYED PE. EARLY and DELAYED groups were similar in age, gender, Glasgow Coma Scale, emergency department systolic blood pressure, and injury mechanism. The EARLY PE group had a lower Injury Severity Score but injuries more commonly included femur fracture. Kaplan-Meier analysis revealed that EARLY PE patients have a significantly higher risk of early mortality relative to DELAYED PE patients (p = 0.012). Regression analysis revealed that the only independent risk factor for EARLY PE was lower extremity/pelvic orthopedic fixation (<48 hours from injury). The risk of EARLY PE was more than threefold higher (odds ratios, 3.85; 95% CI, 1.9-7.6; p < 0.001) for those who underwent early lower extremity orthopedic fixation versus those who did not. Early lower extremity/pelvis orthopedic fixation is the single independent predictor of EARLY PE in this patient cohort. Venous thromboembolism/PE prevention strategies should be made a priority in this group of patients, including early
Gao, Bo; Xiang, Zhou; Fang, Yue; Kong, Qing-Quan; Huang, Fu-Guo; Cen, Shi-Qiang; Zhong, Gang; Ma, Jun; Wang, Lei
To investigate the applications of fluoroscopy-based navigation in pelvic fractures and related surgical considerations. From May 2010 to December, 16 patients with pelvic fractures were treated with computerized navigation. There were 12 males and 4 females with an average age of 37 years (ranged from 20 to 54 years). Fractures were caused by traffic accident in 5 cases, crush injury in 5 cases and falling from height in 6 cases. Based on the Tile classification, there were 15 cases of Tile C type and 1 case of Tile B type. In these patients, 4 patients were treated with sacroiliac screw fixation; 2 patients were treated with sacroiliac screw fixation, screw fixation for pubic symphysis diastasis and pubic fractures; 8 patients were treated with sacroiliac screw fixation and screw fixation for pubic fractures; 2 patients were treated with screw fixation for pubic fractures. The index such as screw inserting time, accurance of inserting screws, intra-operative blood losing, injuries of nerve, vascular and other organs, reduction conditions were observed. A total of 36 screws were inserted. The average time was 20 min for each screw placement. The blood loss ranged from 10 to 20 ml. There were no wound infections, neurovascualr injuries and other organ injuries. The postoperative pelvic X-ray and three-dimensional CT showed that the fractures had good reduction and all the screws had good position. Percutaneous screw fixation of pelvic fractures with fluoroscopy-based navigation have advantages such as little trauma, less blood loss, little complication, reliable fixation and no blood transfusion, which can reconstruct the stability of the pelvic ring, but need adequate preoperative reperation and high requirements for the surgeon.
Loukota, R A
Following the introduction of a new technique for fixation of fractures of the condylar neck and base in our department, the operative times were compared with those for the traditional and frequently used method of open reduction and internal fixation. A distinct learning curve was seen.
Verstreken, Frederik; Meermans, Geert
The ideal position for a screw used for scaphoid fixation is central. The purpose of this study was to compare the current volar percutaneous approaches used for scaphoid fracture fixation, explore different options to improve central screw placement, and describe our experience with the transtrapezial approach.
Wood, Thomas; Thomas, Katie; Farrokhyar, Forough; Ristevski, Bill; Bhandari, Mohit; Petrisor, Bradley
Olecranon fractures represent 10% of upper extremity fractures. There is a growing body of literature to support the use of plate fixation for displaced olecranon fractures. The purpose of this survey was to gauge Canadian surgeons' practices and preferences for internal fixation methods for displaced olecranon fractures. Using an online survey tool, we administered a cross-sectional survey to examine current practice for fixation of displaced olecranon fractures. We received 256 completed surveys for a response rate of 31% (95% confidence interval [CI] 30.5-37.5%). The preferred treatment was tension band wiring (78.5%, 95% CI 73-83%) for simple displaced olecranon fractures (Mayo IIA) and plating (81%, 95% CI 75.5-85%) for displaced comminuted olecranon fractures (Mayo IIB). Fracture morphology with a mean impact of 3.31 (95% CI 3.17-3.45) and comminution with a mean impact of 3.34 (95% CI 3.21-3.46) were the 2 factors influencing surgeons' choice of fixation method the most. The major deterrent to using tension band wiring for displaced comminuted fractures (Mayo IIB) was increased stability obtained with other methods described by 75% (95% CI 69-80%) of respondents. The major deterrent for using plating constructs for simple displaced fractures (Mayo IIA) was better outcomes with other methods. Hardware prominence was the most commonly perceived complication using either method of fixation: 77% (95% CI 71.4-81.7%) and 76.2% (95% CI 70.6-81.0%) for tension band wiring and plating, respectively. Divergence exists with current literature and surgeon preference for fixation of displaced olecranon fractures.
Wood, Thomas; Thomas, Katie; Farrokhyar, Forough; Ristevski, Bill; Bhandari, Mohit; Petrisor, Bradley
Background Olecranon fractures represent 10% of upper extremity fractures. There is a growing body of literature to support the use of plate fixation for displaced olecranon fractures. The purpose of this survey was to gauge Canadian surgeons’ practices and preferences for internal fixation methods for displaced olecranon fractures. Methods Using an online survey tool, we administered a cross-sectional survey to examine current practice for fixation of displaced olecranon fractures. Results We received 256 completed surveys for a response rate of 31% (95% confidence interval [CI] 30.5–37.5%). The preferred treatment was tension band wiring (78.5%, 95% CI 73–83%) for simple displaced olecranon fractures (Mayo IIA) and plating (81%, 95% CI 75.5–85%) for displaced comminuted olecranon fractures (Mayo IIB). Fracture morphology with a mean impact of 3.31 (95% CI 3.17–3.45) and comminution with a mean impact of 3.34 (95% CI 3.21–3.46) were the 2 factors influencing surgeons’ choice of fixation method the most. The major deterrent to using tension band wiring for displaced comminuted fractures (Mayo IIB) was increased stability obtained with other methods described by 75% (95% CI 69–80%) of respondents. The major deterrent for using plating constructs for simple displaced fractures (Mayo IIA) was better outcomes with other methods. Hardware prominence was the most commonly perceived complication using either method of fixation: 77% (95% CI 71.4–81.7%) and 76.2% (95% CI 70.6–81.0%) for tension band wiring and plating, respectively. Conclusion Divergence exists with current literature and surgeon preference for fixation of displaced olecranon fractures. PMID:26204363
Özbek, Zühtü; Özkara, Emre; Önner, Hasan; Baş, Gültekin; Erman, İpek Canan; Özen, Hülya; Entok, Emre; Arslantaş, Ali
This study aimed to investigate the effect of fusion on short segment including fractured level (SSIFL) and long segment (LS) transpedicular fixation after acute thoracolumbar junction (TLJ) burst fractures. The two-year clinical and radiological follow-up results of the two groups were also compared. Seventy-four patients were randomized into one of two groups: SSIFL (n: 39) or LS (n: 35). The SSIFL group included one level above and one level below, including the fracture level, while the LS group included two levels above and two levels below, excluding the fracture level, for the transpedicular fixation. Fusion was assessed by technetium 99m-methylendiphosphonate (Tc-99m MDP), bone scintigraphy and single photon emission computerized tomography (SPECT). The 2-year follow-up results were compared clinically (Oswestry Disability Index-ODI and Visual Analogue Scale-VAS) and radiologically (kyphosis angle-KA, sagittal index-SI, anterior vertebral body height loss-AVBHL) at regular intervals. The clinical scores and radiological parameters of patients with and without fusion were also compared. The number of patients with fusion was significantly higher in the SSIFL group compared to the LS group. There was a significant reduction of the clinical scores of patients who had fusion compared to the fusion-free group; however, there was no radiologically significant difference. Furthermore, there was no significant difference between the SSIFL and LS groups in terms of the two-year radiological and clinical follow-up results. Fusion occurred sooner and patients experienced earlier clinical recovery in the SSIFL group compared to the LS group. Copyright © 2017 Elsevier Inc. All rights reserved.
Fuechtmeier, Bernd; Egersdoerfer, Stefan; Tuma, Georg; Monkman, Gerit J; Nerlich, Michael
The use of robotics in surgery is nothing new. However, there are areas of surgery, such as in fracture fixation, where robots have yet to be implemented. This paper considers the choice of robot, gripper and ancillary equipment together with navigation systems necessary for their application. Hitherto robots have seen operation in surgery only in cases where relatively low manipulation forces are required. Nothing yet exists with the capability of handling forces in excess of 200 Newton as would be required in the above scenario. Another encumbrance to robots which are already in medical use is the difficulty in programming. Unfortunately most of these robots are programmed by specialists for a particular application. However, there exists a number of robot programming languages, like Unimation VA-LII (recently superceded by Stäubli V+), which do not require specialist knowledge. The application of industrial robots to the "heavier" side of modern surgery is without doubt technically realisable. The remainder of this research project aims to determine exactly which robots and what ancilliary equipment are needed and then to implement them, first on plastic models and later on cadavers. A second phase is expected to deal with type approval and a final third phase with operations on live patients.
Smith, T O; Hedges, C; MacNair, R; Schankat, K
The less invasive surgical stabilisation (LISS) plate fixation method is an orthopaedic procedure for the fixation of distal femoral fractures. Early physiotherapy treatments of motion and mobilisation have been advocated following this procedure. This article critically appraises the evidence base assessing the early rehabilitation of patients following LISS fixation for distal femoral fractures. A review of EMBASE, Medline, CINAHL and AMED, and a hand search were undertaken. Two independent reviewers identified all eligible articles. Two reviewers extracted the data, which were verified by a third reviewer. All included articles were critically appraised by two independent reviewers using the Critical Appraisal Skills Programme tool. Seventeen case series assessing 508 patients with 535 fractures were reviewed. No clinical trials comparing physiotherapy programmes were identified. The review identified that following LISS fixation for distal femoral fractures, patients begin range-of-motion exercises immediately and are initially required to restrict weight-bearing following surgery. It remains unclear whether casts, braces or immobilisation aids are applied during the initial postoperative period. The efficacy of different physiotherapy protocols following LISS fixation for distal femoral fractures remains unclear. Further well-designed randomised controlled trials are required to compare different postoperative physiotherapy rehabilitation programmes for patients following LISS fixation of distal femoral fractures in order to determine the optimal postoperative management for this complex patient group.
Mehmood, Seemab; Ali, Murtaza Najabat; Ansari, Umar; Mir, Mariam; Khan, Munezza Ata
Injuries cover about 11% of World's Disease Burden depicting fractures to be the leading severe consequence of trauma. Fractures occur due to force impact or osteoporosis. Fracture healing is a complicated process. Fracture fixation techniques focus on imparting reduction to fractured fragments and induce healing. When considering possible fixation methods, the aspect of micro-movement is an important one, as this induces callus formation which tends to be a crucial step for fracture healing. Internal fixation of long bone fractures using metallic plates has been carried out since decades and recently advancements have been in synthesizing biodegradable plates as well. The purpose of this research was to fabricate an Auxetic Polymeric Bone Plate that can be used as an internal fixator for long bone fracture; this bone plate renders micro-movement due to its counter intuitive behavior, has the potential to reduce the effect of stress shielding and allow the same range of motion as that of natural bone. Polyurethane was chosen as a material for the fabrication of the Auxetic device because of its biocompatibility and non-toxic effects. The plate was then tested for mechanical properties such as Tensile and Compression testing to determine the strength. The tensile testing of the Auxetic polyurethane specimens showed that the mean of the Poisson's ratio of the samples lies between -0.68 and -0.87 at different uni-axial tensile load values. The Auxetic structure of our device has the potential to allow for efficient fixation because its negative Poisson's ratio offers micro-movement, thereby causing fixation with relative stability rather than absolute stability. The Auxetic bone plate can be superior to contemporary plate fixation systems, as it demands meaningfully small contact points. The suitable mechanical properties might lessen stress shielding effects that are normally caused by rigid bone plates. The Auxetic nature of the bone will help align and sustain the
Farah, N; Nassar, L; Farah, Z; Schuind, F
Loss of reduction remains an important problem after treatment of distal radius fractures, whatever the type of bone fixation. We assessed retrospectively the rate of secondary displacement after external fixation of distal radius fractures in order to identify possible risk factors for instability. We reviewed the pre-operative and serial post-operative radiographs of a retrospective series of 35 distal radius fractures treated by bridging external fixation. When classified according to the Société Française d'Orthopédie et Traumatologie (SOFCOT) criteria, the rate of secondary displacement was 48.5%. At final follow up, the reduction was anatomical in 12% and acceptable in 83%. There was malunion in 5%. The loss of reduction concerned primarily the distal radius palmar tilt and was moderate. No correlation was found with age, gender, type of fracture, degree of initial displacement, associated ulnar fracture, or seniority of the treating surgeon.
Wu, Chih-Lung; Chang, Hui-Chin; Lu, Ko-Hsiu
Clavicular fractures account for nearly 10 % of all fractures, and the majority of those fractures involve the midshaft. Historically, these fractures were treated nonoperatively; however, recent data suggest an increased risk of nonunion and symptomatic malunion for displaced, comminuted midshaft clavicular fractures treated conservatively. Surgical intervention via plate osteosynthesis or intramedullary fixation with pins, nails, or screws has been shown to reduce, but not eliminate, this risk. Identification of risk factors predictive of nonunion would improve the overall management of displaced, comminuted midshaft clavicular fractures. The medical records of 337 consecutive patients who underwent Knowles pin fixation and supplemental cerclage for the treatment of displaced, comminuted midshaft clavicular fractures between April 2007 and March 2009 were retrospectively reviewed. The records of the mechanism of injury, side of injury, Robinson fracture classification, presence of associated injuries, cerclage material, and patient-related variables, including diabetes mellitus, hypertension and smoking, were analyzed. Variables were assessed by univariate and multivariate analysis to identify those factors significantly associated with the development of fracture nonunion. A total of 19 nonunions occurred. Increasing age and use of wire for supplemental cerclage fixation were significantly associated with an increased risk for fracture nonunion (p < 0.001). Although suggested as predictors of nonunion in other studies, female gender and fracture severity were not significantly associated with nonunion. Nonunion remains a significant complication in the treatment of displaced, comminuted midshaft clavicular fractures even with intramedullary fixation. Use of absorbable suture in place of wire for cerclage fixation and careful selection of treatment strategy in the elderly may reduce the risk for nonunion.
Lin, Jeff Chien-Fu; Liang, Wen-Miin
This study compared the rates of mortality, medical complication, and reoperation after fixation surgery for displaced femoral neck fracture with those after hemiarthroplasty surgery for undisplaced femoral neck fracture using competing risk analysis in inpatients aged 60 years and above from a population database in Taiwan. We identified 13,772 subjects who underwent fixation for undisplaced cervical fracture and 13,772 matched controls who underwent hemiarthroplasty for displaced cervical fracture from 1998 to 2007, and followed them up until the end of 2009. The outcomes of patients who received internal fixation for undisplaced fracture and those of patients who received hemiarthroplasty for displaced fracture were compared. The 3-month, 2-year, and 10-year mortality rates were 4.9%, 22.1%, and 67.1% for fixation, and 5.6%, 23.8%, and 71.0% for hemiarthroplasty, respectively. The 3-month, 2-year, and 10-year cumulative incidence rates of the first reoperation were 7.4%, 18.1%, and 27.7% for fixation and 6.3%, 12.0%, and 22.3% for hemiarthroplasty, respectively. The 3-month cumulative incidence rates of the first medical complication were 14.4% for fixation and 15.4% for hemiarthroplasty, respectively. Hemiarthroplasty had a 1.09 times (95% CI: 1.05-1.12) higher hazard ratio for overall death than fixation. However, fixation had a 1.36 times (95% CI: 1.29-1.43) higher subdistribution hazard ratio for first reoperation than hemiarthroplasty after adjusting for gender, age, and comorbidities. The short-term overall mortality and medical complication rate of fixation for undisplaced fracture were slightly lower than those of hemiarthroplasty for displaced fracture. However, the short-term cumulative incidence of first reoperation after fixation was significantly higher than that for hemiarthroplasty. Further prospective studies or clinical trials based on the competing risk model, and which include important risk factors, are necessary to quantify the adjusted
Lawyer, Tracye J; Jankowski, Jaclyn; Russell, George V; Stronach, Benjamin M
Morbid obesity and osteoarthritis are conditions that place a significant burden on the US healthcare system. Acetabular fracture is a known cause of post-traumatic osteoarthritis (PTOA) and morbid obesity contributes to the development of osteoarthritis. This study aimed to determine the prevalence of PTOA in morbidly obese patients who underwent acetabular fracture fixation. A retrospective review of morbidly obese patients who underwent acetabular fracture repair was performed. Patient information included demographics, body mass index, patient age, and length of hospital stay. The prevalence of PTOA was determined by radiographic review with a minimum follow-up of 4 years. There were 299 acetabular fracture fixations performed from 2007 to 2012 at our institution and 39 of these were in morbidly obese patients. One patient was excluded due to preoperative osteoarthritis of the hip. Of the 38 patients, 26 (68%) went on to develop PTOA after acetabular fracture fixation. This is significantly higher than previously reported rates of PTOA after acetabular fracture fixation. There was a higher rate of PTOA in morbidly obese males compared with females (P=0.008). Morbid obesity appears to pose a significantly increased risk for the development of PTOA after fixation of acetabular fractures.
Zhuang, Ping; Hong, Jiayuan; Chen, Wei; Wu, Jin
Introduction Open crus fracture is still difficult in clinical treatment because of the delayed fracture union and high rate of nonunion after the operation. A consensus has been reached that mechanical stress can promote fracture healing. We independently developed a stress stimulator, which can provide longitudinal pressure for the fixed fracture end of the lower legs to promote fracture healing. The purpose of this study is to explore the advantages and clinical effect of the rap stress stimulator applied for open crus fracture after skeletal external fixation. Material and methods One hundred and sixty-five patients (183 limbs) who suffered from open tibia and fibula fracture received skeletal external fixation, of which 108 limbs were treated with the rap stress stimulator after external fixation and 75 limbs were treated with regular functional exercises of muscle contraction and joint activity only. Then the fracture healing time and rate of nonunion were compared between the two groups. Results The mean fracture healing time and rate of nonunion in the group treated with the rap stress stimulator were 138.27 ±4.45 days and 3.70% respectively, compared to 153.43 ±4.89 days and 10.67% in the group treated without the stimulator. Conclusions The rap stress stimulator significantly shortened the fracture healing time and reduced the rate of nonunion for treating open tibia and fibula fractures. PMID:26170856
Zhuang, Ping; Hong, Jiayuan; Chen, Wei; Wu, Jin; Ding, Zhenqi
Open crus fracture is still difficult in clinical treatment because of the delayed fracture union and high rate of nonunion after the operation. A consensus has been reached that mechanical stress can promote fracture healing. We independently developed a stress stimulator, which can provide longitudinal pressure for the fixed fracture end of the lower legs to promote fracture healing. The purpose of this study is to explore the advantages and clinical effect of the rap stress stimulator applied for open crus fracture after skeletal external fixation. One hundred and sixty-five patients (183 limbs) who suffered from open tibia and fibula fracture received skeletal external fixation, of which 108 limbs were treated with the rap stress stimulator after external fixation and 75 limbs were treated with regular functional exercises of muscle contraction and joint activity only. Then the fracture healing time and rate of nonunion were compared between the two groups. The mean fracture healing time and rate of nonunion in the group treated with the rap stress stimulator were 138.27 ±4.45 days and 3.70% respectively, compared to 153.43 ±4.89 days and 10.67% in the group treated without the stimulator. The rap stress stimulator significantly shortened the fracture healing time and reduced the rate of nonunion for treating open tibia and fibula fractures.
Feng, Yongzeng; Shui, Xiaolong; Wang, Jianshun; Cai, Leyi; Wang, Gang; Hong, Jianjun
The aim of the present study was to compare the clinical outcomes of hybrid fixation using elastic stable intramedullary nailing (ESIN) for the radius and plate screw fixation for the ulna (Hybrid group) with dual ESIN fixation (D-ESIN group) for both-bone forearm fractures in children between 10 and 16 years of age. Fifty patients with both-bone forearm fractures (28 patients in the Hybrid group and 22 patients in the D-ESIN group) were reviewed. Functional outcomes were evaluated according to the criteria of Price et al. Radiological results were assessed by fracture union at three and six months and bone union time. Postoperative complications were also recorded. The times of fluoroscopy intraoperatively and duration of immobilization postoperatively were significantly lower in the Hybrid group (P < 0.05). The union rate of the ulna at three months postoperatively in the hybrid group was significantly higher than that in the D-ESIN group (P < 0.05). The average time of bone union was significantly shorter in the hybrid group than that in the D-ESIN group (P < 0.05). There were no differences according to the satisfactory rate and degree, the major and minor complications between the groups. Hybrid fixation is superior in terms of the times of fluoroscopy intraoperatively, duration of immobilization postoperatively, delayed union rate of the ulna and the average time of bone union. Therefore, hybrid fixation is an alternative treatment for both-bone forearm fractures in children between 10 and 16 years of age. Copyright © 2016 IJS Publishing Group Ltd. Published by Elsevier Ltd. All rights reserved.
Kim, Jung-Han; Gwak, Heui-Chul; Lee, Chang-Rack; Choo, Hye-Jeung; Kim, Jeon-Gyo; Kim, Dae-Yoo
The present study compared the quality of reduction and the clinical assessment between screw fixation and suture-button fixation with an ankle fracture accompanied by syndesmosis injury. We studied the clinical and radiologic findings 1 year postoperatively through retrospective examination of 24 patients who had undergone screw fixation from January 2011 to December 2012 and prospective examination of 20 patients who had undergone suture button fixation from January 2013 to May 2014. Regarding the tibiofibular clear space, tibiofibular overlap, and medial clear space, the screw fixation group had improvement from a preoperative mean of 6.97 (range 2.79 to 15.81) mm, 4.43 (range 0 to 7.87) mm, 7.90 (range 4.24 to 19.50) mm to a postoperative mean of 4.95 (range 2.72 to 9.08) mm, 6.29 (range 0 to 10.37) mm, and 4.32 (range 1.98 to 6.57) mm, respectively. The corresponding improvement for the suture-button fixation group was from a preoperative mean of 6.65 (range 3.94 to 13.73) mm, 5.39 (range 0 to 9.44) mm, 7.27 (range 4.04 to 16.00) mm to a postoperative mean of 5.15 (range 2.93 to 7.30) mm, 7.21 (range 2.15 to 10.30) mm, and 4.25 (range 2.97 to 5.71) mm. No statistically significant difference was found between the 2 techniques. Both suture-button and metal screw fixation are effective treatment methods for an ankle fracture accompanied by syndesmosis injury. However, a long-term and prospective analysis is needed. Copyright © 2016 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Campbell, Nicole; Richardson, Martin; Antippa, Phillip
An intramedullary screw (Portland Orthopaedics, St. Clair, MI) and Inion (Tampere, Finland) Orthopaedic Trauma Plating System (OTPS) mesh for use for internal fixation of fractured ribs have not previously undergone biomechanical testing. The aim of this study is to compare the biomechanics of intact ribs undergoing four-point bending to the biomechanics of fractured ribs fixed with each of the two devices to determine which device provides superior fixation. Thirty fresh-frozen porcine ribs (ribs 6-8) were submitted to four-point bending to failure, at a rate of 2.5 mm/min, to determine stiffness and force at failure. The ribs were then randomized to receive fixation with either Inion OTPS mesh or an intramedullary screw. The fixated ribs were again submitted to four-point bending to failure. Ribs fixated with OTPS mesh were significantly stiffer and failed at a significantly higher load than ribs fixated with intramedullary screws (p = 0.0001). Ribs fixated with OTPS mesh were less stiff than intact ribs but failed at a similar force to intact ribs. The Inion OTPS mesh system provides superior fixation of fractured ribs compared with an intramedullary screw when tested with four-point bending. The OTPS mesh system also has the added advantage of being absorbable. The intramedullary screw needs to undergo modification and further testing before use in humans. Future studies should focus on more physiologic methods of loading.
Zilkens, Christoph; Graf, Markus; Anastasiadis, Alexandros; Smajic, Samir; Muhr, Gert; Kälicke, Thomas
This is a retrospective analysis of the clinical and radiological outcome in 24 patients with acute or chronic posttraumatic elbow instability, who were treated with open reduction, internal fixation and a hinged external fixator. The instability was acute after elbow fracture dislocation in 11 cases; the other 13 had chronic posttraumatic instability of the elbow. Concentric stability and a sufficient range of motion of the elbow joint were achieved in all cases. The addition of a hinged external fixator in noncompliant patients, who underwent open reduction and internal fixation of an acute or chronic posttraumatic unstable elbow, allows early intensive mobilisation and can improve the clinical outcome after these complex elbow injuries.
Berg, Andrew James; Bhatia, Chandra
While neck of femur fractures are common it is rare to see this injury in a bilateral leg amputee. Special consideration needs to be given to the management of these patients. We report the case of a 58-year-old man with bilateral leg amputation who presented to the emergency department with left hip pain following a fall. A fracture of the left neck of femur with extension into the femoral shaft was diagnosed. Internal fixation was planned with a dynamic hip screw. Standard fracture table setup, which allows for traction of the fractured limb and positioning of the contralateral limb such that anteroposterior and lateral X-rays can be obtained, was not possible in this case due to the amputations. We highlight considerations that need to be made in positioning a bilateral amputee for neck of femur fracture fixation and also highlight an improvised technique that can be utilised by other surgeons.
Uzun, Metin; Bilen, Fikri Erkal; Eralp, Levent
Objectives: The aim of the treatment of tibial plateau fractures is to obtain a pain-free and fully functional knee with closed reduction, percutaneous cannulated screw fixation and hexapodal external fixator reconstruction for high energy compound upper tibial fractures. Methods: Patients with comminuted tibial plateau fractures underwent closed reduction, percutaneous fixation with cannulated screws, and reconstruction with hexapodal external fixator. The follow-up period was 24 months. Results: The clinical and radiological results were good or excellent. The average knee flexion was 125°. Conclusion: Our results are successful in the initial stage, however, it should be pointed out that during the long term follow-up osteoarthritis may develop leading to worsening of the condition. Level of Evidence IV, Case Series. PMID:24644420
Surgical repair of a fractured tibiotarsus in a scarlet macaw (Ara macao) is described. The forces imposed on the fracture site are discussed and the unique features of avian bone emphasised. Advantages of external skeletal fixation and specific details of the frame construction are highlighted.
Huang, Minqiang; Ding, Huanwen; Huang, Miaojun; Wang, Hong; Teng, Qiang
To explore a new method of treating serious tibiofibula comminuted fracture by using three-dimensional (3-D) printing personalized external fixator. In April 2015, a male patient (aged 18 years with a height of 171 cm and a weight of 67 kg) with left tibiofibula comminuted fracture was included in the study. Computer-assisted reduction technique combined with 3-D printing was used to develop a customised personalized external fixator for fracture reduction. The effectiveness was observed. The operation time was about 10 minutes without fluoroscopy, and successful reduction was obtained. The patient had equal limb length after operation. X-ray films showed that the posterior angulation of distal fracture was corrected 37 degrees, and the eversion angle was corrected 4 degrees. The tibial fractures had good paraposition or alignment, and the lower limb force line was corrected completely. No new fracture displacement occurred. The clinical healing time of fracture was 3.5 months and the bone union was achieved after 8 months. The function of affected limb recovered well after operation. A personalized external fixator for serious tibiofibula comminuted fracture reduction made by 3-D printing technique has the merits of easy manipulation, high individuation, accurate reduction, stable fixation, and no need of fluoroscopy.
Nowak, Tobias E; Burkhart, Klaus J; Andres, Torsten; Dietz, Sven O; Klitscher, Daniela; Mueller, Lars P; Rommens, Pol M
Intramedullary nailing and locked plating for fixation of olecranon fractures has recently gained popularity. However, these two new technologies have not been compared for their biomechanical efficacy. The aim of this study was to evaluate the biomechanical stability of two newly designed fracture fixation devices for treating olecranon fractures during dynamic continuous loading: the ION intramedullary locking nail and the LCP precontoured locking compression plate. Simulated oblique olecranon fractures were created in eight pairs of fresh-frozen cadaver ulnae and stabilised using either the LCP or ION. Specimens were then subjected to continuous dynamic loading (from 25 to 200 N), with a continuous angle alteration between 0° and 90° of flexion, to perform a matched-pairs comparison. Significant differences in the distance between markers surrounding the fracture gap was determined using the Wilcoxon test after four and 300 loading cycles. The ION resulted in significantly less displacement in the fracture gap at 0° extension (P = 0.036), 45° flexion (P = 0.035) and 90° flexion (P = 0.017) after 300 cycles of continuous loading. The measured displacements were small and were probably not of clinical significance. No mechanical failure or hardware migration was seen with either fixation technique. This study shows significantly less micromotion for the ION than for the LCP in treating oblique olecranon fractures after 300 cycles of dynamic loading. Both implant types could be appropriate surgical techniques for fixation of selected olecranon fractures and osteotomies.
Berkes, Marschall; Obremskey, William T; Scannell, Brian; Ellington, J Kent; Hymes, Robert A; Bosse, Michael
The development of a deep wound infection in the presence of hardware after open reduction and internal fixation presents a clinical dilemma, and there is scant literature to aid in decision-making. The purpose of the present study was to determine the prevalence of osseous union with maintenance of hardware after the development of postoperative infection within six weeks after internal fixation of a fracture. The present study included 121 patients from three level-I trauma centers, retrospectively identified from billing and trauma registries, in whom 123 postoperative wound infections with positive intraoperative cultures had developed within six weeks after internal fixation of acute fractures. The incidence of fracture union without hardware removal was calculated, and the parameters that predicted success or failure were evaluated. Eighty-six patients (eighty-seven fractures; 71%) had fracture union with operative débridement, retention of hardware, and culture-specific antibiotic treatment and suppression. Predictors of treatment failure were open fracture (p = 0.03) and the presence of an intramedullary nail (p = 0.01). Several variables were not significant but trended toward an association with failure, including smoking, infection with Pseudomonas species, and involvement of the femur, tibia, ankle, or foot. Deep infection after internal fixation of a fracture can be treated successfully with operative débridement, antibiotic suppression, and retention of hardware until fracture union occurs. These results may be improved by patient selection based on certain risk factors and the specific bacteria and implants involved.
Thelen, Simon; Betsch, Marcel; Schneppendahl, Johannes; Grassmann, Jan; Hakimi, Mohssen; Eichler, Christian; Windolf, Joachim; Wild, Michael
This biomechanical study is the first to compare 3 fixation methods-bilateral fixed-angle plate, modified anterior tension wiring, and cannulated lag screws with anterior tension wiring-in multifragmentary distal patella fractures. A T-shaped 3-part fracture simulating a multifragmentary articular distal patella fracture (AO/OTA 34-C2.2) was created in 18 human cadaver knee specimens. Three groups were created using homogenous ages and bone mineral densities based on the fixation method received. Repetitive testing over 100 cycles was performed by moving the knee against gravity from 90° flexion to full extension. Failure was defined as fracture displacement greater than 2 mm. In all patellae using fixed-angle plates, an anatomical fracture reduction could be maintained throughout cyclic testing, whereas anterior tension wiring and lag screws with tension wiring showed significant fracture displacement after 100 cycles, with mean fracture gaps of 2.0±1.3 and 1.9±1.6 mm, respectively. The differences in fracture gaps between the fixed-angle plate group and the other 2 groups were statistically significant. In both groups using tension wiring, half of the constructs (3 of 6 in each group) failed due to a fracture displacement greater than 2 mm. The bilateral fixed-angle plate was the only fixation method that sustainably stabilized a multifragmentary articular distal patella fracture during cyclic loading when compared with modified anterior tension wiring and cannulated lag screws with anterior tension wiring.
Yian, E H; Banerji, I; Matthews, L S
To quantitatively determine the minimal screw number needed for stable side plate fixation to the femoral shaft in treating unstable intertrochanteric hip fractures. Laboratory/biomedics study. Orthopaedic biomechanics laboratory. The convenience sample was made up of one saw bone, one steel pipe, and ten human cadaveric femur specimens. Human specimens were selected by ruling out pathology and excess osteopenia. Ten specimens were tested to completion. Telescoping hip screw and hip screw side plate secured with various numbered combinations of side plate screws. Decreases in tension experienced by all previously inserted screws when an additional screw was applied were recorded and labeled as "protection." Protection offered by a third screw on all previous screws was 787.3 newtons in the steel pipemodel, 71.2 newtons in the sawbone model, and 158.3 newtons in the human model (p < 0.005). A fourth bone screw did not decrease tension in previous screws by more than 11 newtons. The protective effect of the fourth screw on screw #3 increased with decreasing screw application torque by a maximum of 21.8 newtons (p < 0.005). This study suggests that three bone screws provide an optimal distribution of tensile forces. The insertional torque used to place screws, once screw-plate contact has been established, does not play a significant role in screw protection. Additional studies are needed to assess the role of cortical bone density, and cyclical loading and bending forces experienced by the side plate screws, before definite clinical recommendations can be made.
Reoperation rates are high after surgery for hip fractures. We investigated the effect of a sliding hip screw versus cancellous screws on the risk of reoperation and other key outcomes. For this international, multicentre, allocation concealed randomised controlled trial, we enrolled patients aged 50 years or older with a low-energy hip fracture requiring fracture fixation from 81 clinical centres in eight countries. Patients were assigned by minimisation with a centralised computer system to receive a single large-diameter screw with a side-plate (sliding hip screw) or the present standard of care, multiple small-diameter cancellous screws. Surgeons and patients were not blinded but the data analyst, while doing the analyses, remained blinded to treatment groups. The primary outcome was hip reoperation within 24 months after initial surgery to promote fracture healing, relieve pain, treat infection, or improve function. Analyses followed the intention-to-treat principle. This study was registered with ClinicalTrials.gov, number NCT00761813. Between March 3, 2008, and March 31, 2014, we randomly assigned 1108 patients to receive a sliding hip screw (n=557) or cancellous screws (n=551). Reoperations within 24 months did not differ by type of surgical fixation in those included in the primary analysis: 107 (20%) of 542 patients in the sliding hip screw group versus 117 (22%) of 537 patients in the cancellous screws group (hazard ratio [HR] 0·83, 95% CI 0·63-1·09; p=0·18). Avascular necrosis was more common in the sliding hip screw group than in the cancellous screws group (50 patients [9%] vs 28 patients [5%]; HR 1·91, 1·06-3·44; p=0·0319). However, no significant difference was found between the number of medically related adverse events between groups (p=0·82; appendix); these events included pulmonary embolism (two patients [<1%] vs four [1%] patients; p=0·41) and sepsis (seven [1%] vs six [1%]; p=0·79). In terms of reoperation rates the sliding hip
Jamjoom, Bakur A; Jamjoom, Abdulhakim B
We present a review of the published evidence on the optimal timing for long bone fracture fixation in severe traumatic brain injury (TBI); a matter that remains under debate. Fifteen retrospective articles (level II-3 evidence) were considered suitable for the review. We conclude that the published evidence does not provide a definitive answer to the optimal timing of long bone fracture surgery in severe TBI, and a randomized controlled trial is required. We recommend a safe strategy that combines damage control surgery with a period of monitoring of intracranial pressure, cerebral perfusion pressure, and if available brain tissue oxygen until the patient is considered fit for the fracture fixation.
Sabat, Dhananjaya; Dabas, Vineet; Dhal, Anil
Late rupture of extensor pollicis longus (EPL) tendon after Galeazzi fracture dislocation fixation is an unknown entity though it is a well-established complication following distal radius fractures. We report the case of a 55-year old male who presented with late EPL tendon rupture 4 months following internal fixation of Galeazzi fracture dislocation with a Locking Compression Plate (LCP). He was managed with extensor indicis proprius (EIP) transfer to restore thumb extension. At 4 years followup, functional result of the transfer was good. We identify possible pitfalls with this particular patient and discuss how to avoid them in future.
Castelli, Alberto; D'amico, Salvatore; Combi, Alberto; Benazzo, Francesco
Elbow fracture-dislocation is always demanding to manage due to the considerable soft-tissue swelling or damage involved, which can make an early open approach and ligamentous reconstruction impossible. The purpose of this study was to evaluate the role of elbow hinged external fixation (HEF) as a definitive treatment in patients with elbow dislocations associated with Regan-Morrey (R-M) type I and II coronoid fractures and soft-tissue damage. We treated 11 patients between 2010 and 2012 with HEF. Instability tests and standard X-ray examinations were performed before surgery and 1-3 to 3-6 months after surgery, respectively. All patients underwent a preoperative CT scan. Outcomes were assessed with a functional assessment scale (Mayo Elbow Performance Score, MEPS) that included 4 parameters: pain, ROM, stability, and function. The results were good or excellent in all 11 patients, and no patient complained of residual instability. Radiographic examination showed bone metaplasia involving the anterior and medial sides of the joint in 5 patients. HEF presented several advantages: it improves elbow stability and it avoids long and demanding surgery in particular in cases with large soft tissue damage. We therefore consider elbow HEF to be a viable option for treating R-M type I and II fracture-dislocations.
Ochman, S; Vordemvenne, T; Paletta, J; Raschke, M J; Meffert, R H; Doht, S
Introduction. Osteotomy or fracture models can be used to evaluate mechanical properties of fixation techniques of the hand skeleton in vitro. Although many studies make use of osteotomy models, fracture models simulate the clinical situation more realistically. This study investigates monocortical and bicortical plate fixation on metacarpal bones considering both aforementioned models to decide which method is best suited to test fixation techniques. Methods. Porcine metacarpal bones (n = 40) were randomized into 4 groups. In groups I and II bones were fractured with a modified 3-point bending test. The intact bones represented a further control group to which the other groups after fixation were compared. In groups III and IV a standard osteotomy was carried out. Bones were fixated with plates monocortically (group I, III) and bicortically (group II, IV) and tested for failure. Results. Bones fractured at a mean maximum load of 482.8 N ± 104.8 N with a relative standard deviation (RSD) of 21.7%, mean stiffness was 122.3 ± 35 N/mm. In the fracture model, there was a significant difference (P = 0.01) for maximum load of monocortically and bicortically fixed bones in contrast to the osteotomy model (P = 0.9). Discussion. In the fracture model, because one can use the same bone for both measurements in the intact state and the bone-plate construct states, the impact of inter-individual differences is reduced. In contrast to the osteotomy model there are differences between monocortical and bicortical fixations in the fracture model. Thus simulation of the in vivo situation is better and seems to be suitable for the evaluation of mechanical properties of fixation techniques on metacarpals.
Roccia, Fabio; Rossi, Paolo; Gallesio, Cesare; Boffano, Paolo
The current study evaluated the success and the possible complication of intermaxillary fixation with self-tapping and self-drilling screws (STSDSs) in nondislocated or slightly dislocated mandibular fractures.Forty patients with mandibular fractures, treated with intermaxillary fixation using STSDSs, were clinically assessed by means of a dental vitality test and evaluation of tooth mobility adjacent to the cortical screw holes, and radiologically by means of a panoramic dental radiograph upon removal of the screws.The main complication was screw loss in 4.4% of cases, followed by coverage by oral mucosa in 1.2% of cases. However, no dental root damage, screw breakage, malocclusion, or poor consolidation of mandibular fractures was observed.The use of STSDSs for intermaxillary fixation is a useful alternative to the use of arch bars in the treatment of some types of mandibular fractures. In addition, there is no risk of dental lesions as with self-tapping screws.
Kato, Shuichi; Tatebe, Masahiro; Yamamoto, Michiro; Iwatsuki, Katsuyuki; Nishizuka, Takanobu; Hirata, Hitoshi
The purpose of this study was to determine whether volar locking plate fixation for distal radius fracture benefits the fragility fracture population as much as it benefits the non-fragility fracture population. This matched case-control study was conducted based on a multi-center clinical prospective cohort. A comparison of treatment outcomes after volar locking plate fixation was made between females 55 years of age and older (fragility fracture population) and males less than 75 years of age (non-fragility fracture population) by evaluating clinical, radiological, and subjective outcomes using Hand20, a validated patient-rated disability instrument. A total of 170 patients were enrolled in this study. The two cohorts were matched in terms of AO fracture type. The fragility fracture population group and the non-fragility fracture population group each consisted of 50 patients. All objective measurements including wrist range of motion and radiological evaluations, but excluding grip strength, were not significantly different between the two groups. However, the Hand20 at 18 months after surgery was worse in the fragility fracture population group than in the non-fragility fracture population group. Carpal tunnel syndrome was the most frequently encountered complication in the fragility fracture population group, with one case (2%) in the non-fragility fracture population group and six cases (12%) in the fragility fracture population group, but the difference was not significant. In conclusion, there was a significant deficit in the improvement in disability despite favorable radiological and functional outcomes in fragility fracture population patients. Therefore, the fragility fracture population, especially middle-aged or older women, needs to be informed about prolonged disability and the higher risk of upper extremity disorders prior to surgery.
Sali, Eric; Serane, Julien; Lefèvre, Edouard; Amsallem, Lior
An articular glenoid fracture is an uncommon injury. Usually significantly displaced intra-articular glenoid fractures are treated with open reduction surgery. Conventional open surgery techniques involve high morbidity. Here we describe an arthroscopy-assisted reduction and fixation method of an Ideberg type III glenoid fracture. This method provides good articular reduction without extensive exposure or soft tissue dissection and without nerve and/or vascular lesion. PMID:28386498
Khiabani, Kazem S.; Mehmandoost, Meghdad Khanian
Background and Objectives The ideal line of osteosynthesis in mandibular angle fractures indicates that a plate might be placed either along or just below the external oblique ridge. Some authors believe that using one miniplate at this line at the mandibular angle region provides sufficient strength to stabilize the fracture but others imply a second plate is required. Such controversies exist in the use of maxillomandibular fixation (MMF). The intention of the present study was to compare efficiency and complications of using one miniplate with and without MMF in mandibular angle fractures. Methods and Materials Forty patients with facial trauma with mandibular angle fractures including displaced and unfavorable fractures were categorized into two groups of 20 persons. In all patients, one miniplate was placed on the external oblique ridge. In the first group, patients had light maxillomandibular elastic bands just after surgery but no rigid MMF. In the second group, patients had rigid MMF for 2 weeks after surgery. Patients were followed to evaluate complications and treatment efficiency. Conclusions Our study showed that use of a single miniplate in the external oblique ridge is a functionally stable treatment for all types of angle fractures (including displaced and unfavorable fractures) except comminuted and long oblique fractures, which were not included in our study. Use of postoperative MMF did not improve the results. PMID:24436745
Martini, A K
Unstable distal radius fractures cannot be immobilized in a plaster cast: mal-unions (and later arthrosis of the wrist) are the result. Most symptoms are attributable to the shortening of the radius. Retention by means of an external fixator is the therapy of choice in such cases. Various fixator systems have become known. In this paper, a new fixator is presented which has the following advantages: It is very mobile and adaptable, and corrections are possible after attachment of the fixator. The screws can be inserted depending on the anatomical situation. The fixator is handy and light. The fixator has proved its effectiveness for a long time and is also suitable for complicated wrist injuries.
Ji, Jong-Hun; Kim, Weon-Yoo; Ra, Ki-Hang
In cases of displaced greater tuberosity fractures, treatments by arthroscopic-assisted reduction and percutaneous screw fixation have been reported. However, in cases in which there is a comminuted fracture or a minimally displaced fracture combined with concomitant lesions such as rotator cuff tear or labral pathology, it is difficult to reduce the fracture and to treat other pathologies by use of a percutaneous screw. Recently, many surgeons have used the double-row repair method in rotator cuff repair, which provides a tendon-bone interface better suited for biologic healing and restoring normal anatomy. In accordance with this method, we used the arthroscopic technique of double-row suture anchor fixation for a minimally displaced greater tuberosity fracture without additional incision. Initially, debridement was performed on the fracture surface by use of a shaver, and the medial-row anchor was inserted through the anterior portal or the intact cuff. Two lateral-row anchors were inserted just anterior and posterior to the lower margin of the fractured fragment under C-arm guidance. The medial-row sutures and lateral-row sutures were then placed. Arthroscopic double-row suture anchor fixation of a displaced greater tuberosity fracture restores the original footprint of the rotator cuff and normal tendon-bone interface of the displaced greater tuberosity fracture.
Mancini, Júlio Cezar M A; Garcia, Márcio Ricardo Taveira; de Oliveira, Ilka Regina Souza; de Freitas, Ronaldo Rodrigues; Luz, João Gualberto C
This study assessed the arterial blood supply to the mandible of edentulous patients treated for mandibular fractures using colour Doppler ultrasound. The blood supply of edentulous patients surgically treated for mandibular fractures (group A) and edentulous fracture-free individuals (group B) was assessed. Only the fractured sides were evaluated in the first group (N = 17), whereas each side was evaluated in the second group (N = 20). The arterial flow of six sites was assessed. The systolic-peak maximum velocity (SPV), final diastolic velocity (FDV), resistive index (RI), pulsatility index (PI), acceleration and flow direction of each artery were obtained. Additionally, the presence of local vascular obstructive factors was evaluated. The differences between groups were analysed using the Kruskal-Wallis test, which was complemented by the Mann-Whitney test, for correlations between the degree of alveolar atrophy and the study factors (p < 0.050). There was a significant decrease in the flow of certain arteries, especially the submental (SPV, p = 0.007, PI, p = 0.022, and acceleration, p = 0.015), in the fracture group. The facial artery in both groups showed lower values related to local obstructive factors (SPV, p = 0.001, FDV, p = 0.040, and PI, p = 0.030). The submental artery flow was higher (SPV, p = 0.006, and FDV, p = 0.009) in non-atrophic individuals. There was a decreased flow mainly in the submental artery, but there were no cases of major vascular injury in edentulous patients treated for mandibular fractures.
Kaempffe, F A; Walker, K M
Few studies have examined the potential adverse effects of excess distraction and prolonged duration of external fixation for the treatment of distal radius fractures. In this study, 19 patients with distal radius fractures treated with external fixation and supplemental Kirschner wire fixation between August 1991 and November 1997 were studied retrospectively. Patients were evaluated by questionnaire, chart review, radiographs, and clinical examination an average of 161 weeks after injury. Although no significant correlation was found between amount of distraction, as measured by carpal height index, and scores for pain, function, radiographs, motion, grip, strength, and final result, a negative correlation was found of all categories with increasing carpal height index. A significant negative correlation was seen between duration of external fixation and scores for pain, motion, and total score, with motion scores being most affected. New York Orthopaedic Hospital grades of good or excellent were attained by 89% of the patients. The data suggest that external fixation with supplemental pin fixation is a satisfactory method of treating severe fractures of the distal radius. Outcome likely is improved with shorter duration of external fixation.
Zhang, X F; Huang, J W; Mao, H X; Chen, W B; Luo, Y
Although there have been a small number of studies reporting single bone fixation of either radius or ulna as well as hybrid fixation, the paucity of data for the hybrid fixation method still remains. Hybrid fixation with plate and IM nailing would achieve good fixation and functional outcome, minimal damage to soft tissues and lower re-fracture risk. Forty cadavers (20 males, 20 females; mean age 68.06, SD 1.58years) were selected in biomechanical study under axial loading, bending loading, and torsional loading. Eighty-seven patients (47 males, 40 females; mean age 38.03±0.88years) were enrolled in the clinical study and randomly received different fixation: both-bone plate fixation or both-bone intramedullary nailing, plate fixation of ulna and intramedullary nailing of radius and intramedullary nailing of ulna and plate fixation of radius. In the biomechanical study, intramedullary nailing of ulna and plate fixation of radius had similar results with that using both-bone plate method under axial, bending and torsional loading (All P>0.05), suggesting the more stable fixation compared with the other two groups (All P<0.05). In clinical research, both-bone intramedullary nailing was related to shortest operative time, smallest wound size and periosteal stripping area compared with other three groups (P<0.05). Patients receiving intramedullary nailing of ulna and plate fixation of radius showed the lowest incidence of postoperative complications and the best functional recovery outcome comparing with other three groups of patients (Both P<0.05). The hybrid fixation method of intramedullary nailing of ulna and plate fixation of radius showed good stability in biomechanics, fewer complications and better functional clinical outcomes. Level II, prospective randomised study. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Hoshino, C Max; Tran, Wesley; Tiberi, John V; Black, Mary Helen; Li, Bonnie H; Gold, Stuart M; Navarro, Ronald A
Displaced patellar fractures are commonly stabilized with a modified anterior tension-band construct. The goal of the current study was to compare the incidence of complications after tension-band fixation of the patella with Kirschner wires as compared with cannulated screws. We performed a retrospective cohort study of consecutive, surgically treated patellar fractures. Patients were divided into two cohorts: fractures fixed with use of Kirschner wires and fractures fixed with use of cannulated screws. The primary outcome measure was early loss of fixation that necessitated revision surgery. Secondary outcomes included early postoperative infection and the need for implant removal. Four hundred and forty-eight patellar fractures were studied. Kirschner wires were used for fixation in 315 (70%), and cannulated screws were used for fixation in 133 (30%). The incidence of fixation failure was 3.5% in the Kirschner-wire group and 7.5% in the screw group (p = 0.065). A postoperative infection occurred in 4.4% of patients in the Kirschner-wire group and 1.5% of patients in the screw group (p = 0.17). One hundred sixteen (37%) patients in the Kirschner-wire group and 30 (23%) in the screw group underwent elective implant removal (p = 0.003). After adjusting for confounding variables, a trend toward increased incidence of fixation failure with screws as compared with Kirschner wires was present (p = 0.083). Patients treated with Kirschner wires were twice as likely to undergo implant removal compared with those treated with screws (p = 0.002). Serious complications are uncommon following treatment of patellar fractures with a modified tension-band technique, with use of either Kirschner wires or cannulated screws. In both groups the rate of fixation failure was low, as was the rate of postoperative infection. Symptomatic implants, the most common complication observed, were twice as frequent in patients treated with Kirschner wires.
Xu, Jiaming; Zhang, Changqing; Wang, Tao
Proximal humeral fractures are common lesions of the elderly, but there are no established treatment guidelines. A surgical treatment for comminuted and displaced fractures of the proximal humerus was developed and is still evolving. The aim of this study was to perform a quantitative review to evaluate the risk of avascular necrosis (AVN) in patients with proximal humeral fractures who were treated by operative fixation compared with conservative treatment. We searched the PubMed, MEDLINE, Springer, Elsevier Science Direct, Cochrane Library, Google Scholar, China National Knowledge Infrastructure (in Chinese), and Wanfang database (in Chinese) up to December 2013 to identify studies related to operative fixation and AVN in patients with proximal humeral fractures. Seven studies with a total of 291 patients (142 operative fixation cases and 149 conservative treatment cases) with proximal humeral fractures were considered in the meta-analysis. The overall meta-analysis showed no significant difference in the incidence of AVN between the two groups [odds ratio (OR) 1.42, 95% confidence interval (CI) 0.33-6.11, p = 0.64]. The subgroup meta-analysis by study design (retrospective/prospective), sample size (≤40/>40), and ethnicity (European/Asian) demonstrated similar results. However, the subgroup analysis by specific operative approach (plate fixation/tension band wiring fixation/others) indicated that plate fixation was associated with a higher rate of AVN than conservative treatment (OR 0.20, 95% CI 0.05-0.76, p = 0.019). Plate fixation was associated with a higher risk of AVN development than conservative treatment in patients with proximal humeral fractures.
Wenninger, Jerome J; Dannenbaum, Joseph H; Branstetter, Joanna G; Arrington, Edward D
Military service members have increased requirements of shoulder weight bearing to perform duties. Operative intervention has increased for treatment of displaced middle one-third clavicle fractures. Complications of operatively treated clavicle fixation have not been extensively studied. A retrospective, longitudinal cohort chart evaluation was conducted of all active duty members undergoing fixation of middle one-third clavicle fractures, for complications between intramedullary pin fixation and plate constructs. This review found 62 patients meeting inclusion criteria. Thirty-three patients underwent intramedullary pin fixation with Hagie pins and 31 patients underwent precontoured superior clavicle plate fixation of their middle one-third clavicle fractures. Complications included wound infection, skin and/or soft tissue irritation, and need for unplanned hardware removal. The overall complication rate was 31% in the plate fixation group versus 9% in the intramedullary pin group (p = .024). All patients achieved fracture union with return to duty; however, increased overall complications were seen in the plate fixation group.
Ibrahim, Mohammad; Terai, Hidetomi; Yamada, Kentaro; Suzuki, Akinobu; Toyoda, Hiromitsu; Nakamura, Hiroaki
Patients with long bone metastasis have many therapeutic options, including surgery. However, the appropriate time for surgical intervention and the use of internal fixation prior to impending fracture remains controversial. The purpose of this study was to establish a long bone metastatic model with internal fixation, and to determine whether prophylactic internal fixation for long bone metastasis prior to impending fracture would affect bone destruction, tumor progression, and mortality. We implanted VX2 tumor cells into the tibiae of 45 rabbits divided equally into three groups: internal fixation, control, and sham groups. Rabbits were monitored by X-ray and computed tomography, and blood serum levels were examined every 2 weeks. Computed tomography data revealed significantly higher bone destruction in rabbit tibiae in the sham and control groups compared with those in the fixation group; there were volumetric bone losses of 0.2, 0.4, and 2.3% in the fixation, sham, and control groups, respectively, at 3 weeks, which increased to 1.2, 2.5, and 6.1% at 5 weeks. Rabbits in the fixation group showed significantly prolonged survival (64.5 ± 13.5 days) in comparison with rabbits in the sham group (50.3 ± 11.6 days) and control group (38.2 ± 4.9 days). Our results suggest that prophylactic internal fixation may hinder bone destruction and tumor progression, thus extending the survival period for patients with long bone metastasis.
Covey, Jennifer L; Farese, James P; Bacon, Nicholas J; Schallberger, Sandra P; Amsellem, Pierre; Cavanaugh, Ryan P; Milner, Rowan J
To evaluate clinical outcome of dogs with appendicular osteosarcoma (OSA) treated with stereotactic radiosurgery (SRS) and subsequent internal fixation of a pathologic fracture. Retrospective case series. Dogs with spontaneous-occurring appendicular OSA (n = 6). Medical records (May 2002-January 2008) of dogs that had SRS for appendicular OSA were reviewed. Dogs were included if they had a pathologic fracture either before or after SRS and were treated with internal fixation. Signalment, history, physical examination findings, clinicopathologic data, diagnostic imaging findings, biopsy results, surgical complications, number of surgeries, adjuvant therapy, development of metastatic disease and cause of death were recorded. Six dogs met the inclusion criteria. Two dogs had a pathologic fracture at admission and 4 dogs developed a fracture after SRS with a mean ± SD time to fracture development of 6.25 ± 1.65 months. The first 3 fractures were repaired using an open approach and the latter three using minimally invasive percutaneous osteosynthesis (MIPO). Infection occurred in 5 dogs and implant failure in 3. Limb function was subjectively assessed as good in all dogs when the implants were stable and infections were subclinical. Survival times ranged from 364-897 days; 1 dog was lost to follow-up. Fracture repair using internal fixation should be considered a viable limb-sparing alternative for pathologic fractures that have been treated with SRS. © Copyright 2014 by The American College of Veterinary Surgeons.
Kazemian, Gholam Hossein; Emami, Mohammad; Manafi, Alireza; Najafi, Farideh; Najafi, Mohammad Amin
Background Hip fractures are one of the causes of disability amongst elderly patients. External fixator and skeletal traction are two modes of treatment. Objectives The aim of this study is to compare two different treatment modes for intertrochanteric fractures in elderly patients. Patients and Methods Sixty elderly patients with intertrochanteric fractures were randomized for treatment with either skeletal traction (Group A) or an external fixation (Group B). In this study patients at least 60 years of age, with AO/OTA A1 or A2 type fracture and intertrochanteric fracture as a result of minor trauma, were enrolled. Results Acceptable reduction was achieved in eight and 26 patients of group A and B, respectively. The mean duration of hospitalization in Group A and Group B was 14.3 ± 1.1 and 2.2 ± 0.6 days, respectively. Significant differences between the two groups were observed, regarding acceptable reduction and duration of hospitalization. Less pain was observed in group B, at five days and twelve months after surgery; the average HHS was 57 and 66, in group A and B, respectively (P > 0.05). Conclusions Treatment with an external fixator is an effective treatment modality for intertrochanteric fractures in elderly high-risk patients. The advantages include rapid and simple application, insignificant blood loss, less radiation exposure, adequate fixation, pain reduction, early discharge from the hospital, low cost and more favorable functional outcome. PMID:27218039
Kazemian, Gholam Hossein; Emami, Mohammad; Manafi, Alireza; Najafi, Farideh; Najafi, Mohammad Amin
Hip fractures are one of the causes of disability amongst elderly patients. External fixator and skeletal traction are two modes of treatment. The aim of this study is to compare two different treatment modes for intertrochanteric fractures in elderly patients. Sixty elderly patients with intertrochanteric fractures were randomized for treatment with either skeletal traction (Group A) or an external fixation (Group B). In this study patients at least 60 years of age, with AO/OTA A1 or A2 type fracture and intertrochanteric fracture as a result of minor trauma, were enrolled. Acceptable reduction was achieved in eight and 26 patients of group A and B, respectively. The mean duration of hospitalization in Group A and Group B was 14.3 ± 1.1 and 2.2 ± 0.6 days, respectively. Significant differences between the two groups were observed, regarding acceptable reduction and duration of hospitalization. Less pain was observed in group B, at five days and twelve months after surgery; the average HHS was 57 and 66, in group A and B, respectively (P > 0.05). Treatment with an external fixator is an effective treatment modality for intertrochanteric fractures in elderly high-risk patients. The advantages include rapid and simple application, insignificant blood loss, less radiation exposure, adequate fixation, pain reduction, early discharge from the hospital, low cost and more favorable functional outcome.
Tan, Jacqueline S W; Foo, Anthony T L; Chew, Winston C Y; Teoh, Lam Chuan
To retrospectively review the outcomes of intra-articularly placed interfragmentary screws for fixation of difficult condylar fractures of the metacarpal and proximal phalangeal heads. We placed interfragmentary screws intra-articularly in 10 patients with 11 fractures to achieve a rigid fixation construct in which the non-articular portion of the bone fragment is too small to allow a stable fixation, or where the bone fragment is entirely osteochondral. The mean duration of follow-up was 15.9 months (range, 6-45 mo). All fractures united within 16 weeks (average, 8.1 wk). We observed subsidence in 1 case; another patient had screw protrusion that required removal. The range of motion of the involved metacarpophalangeal joints for the metacarpal head fractures was 79° (range, 60° to 90°). The range of motion of the involved proximal interphalangeal joints for the proximal phalangeal head fractures was 86° (range, 80° to 90°). Intra-articularly placed interfragmentary screw fixation is a good technique for treating difficult condylar fractures of the hand. Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Hsu, Andrew R; Lee, Simon
Stress fractures of the tarsal navicular are high-risk injuries that can result in displacement, avascular necrosis, malunion, and nonunion. Delayed diagnosis and improper treatment can lead to long-term functional impairments and poor clinical outcomes. Increased shear stress and decreased vascularity in the central third of the navicular can complicate bony healing with often unpredictable return times to activity using conservative management in a non-weight-bearing cast. There recently has been increasing debate regarding the effectiveness of treatment options with a trend toward surgical management to anatomically reduce and stabilize navicular stress fractures in athletes. However, anatomic reduction and fixation of the navicular can be difficult despite direct visualization and intraoperative fluoroscopy. We report a case of a chronic navicular stress fracture in a high-level teenage athlete treated with open reduction internal fixation (ORIF) and calcaneus autograft using intraoperative computed tomography (CT) (O-arm®, Medtronic, Minneapolis, MN) for real-time evaluation of fracture reduction and fixation. Intraoperative CT was fast, reliable, and allowed for confirmation of guide wire orientation, alignment, and length across the fracture site. Anatomic fixation of navicular stress fractures can be challenging, and it is important for surgeons to be aware of the potential advantages of using intraoperative CT when treating these injuries. Therapeutic, Level IV: Case Report. © 2014 The Author(s).
Miramini, Saeed; Zhang, Lihai; Richardson, Martin; Mendis, Priyan; Ebeling, Peter R
Mechano-regulation plays a crucial role in bone healing and involves complex cellular events. In this study, we investigate the change of mechanical microenvironment of stem cells within early fracture callus as a result of the change of fracture obliquity, gap size and fixation configuration using mechanical testing in conjunction with computational modelling. The research outcomes show that angle of obliquity (θ) has significant effects on interfragmentary movement (IFM) which influences mechanical microenvironment of the callus cells. Axial IFM at near cortex of fracture decreases with θ, while shear IFM significantly increases with θ. While a large θ can increase shear IFM by four-fold compared to transverse fracture, it also result in the tension-stress effect at near cortex of fracture callus. In addition, mechanical stimuli for cell differentiation within the callus are found to be strongly negatively correlated to angle of obliquity and gap size. It is also shown that a relatively flexible fixation could enhance callus formation in presence of a large gap but could lead to excessive callus strain and interstitial fluid flow when a small transverse fracture gap is present. In conclusion, there appears to be an optimal fixation configuration for a given angle of obliquity and gap size. Copyright © 2016 IPEM. Published by Elsevier Ltd. All rights reserved.
Sobhan, Mohammad R.; Abrisham, Seyed Mohammad J.; Vakili, Mahmood; Shirdel, Saeed
Background: Pelvic ring injuries and sacroiliac dislocations have significant impacts on patient’s quality of life. Several techniques have been described for posterior pelvic fixation. The current study has been designed to evaluate the spinopelvic method of fixation for sacroiliac fractures and fracture-dislocations. Methods: Between January 2006 and December 2014, 14 patients with sacroiliac joint fractures, dislocation and fracture-dislocation were treated by Spinopelvic fixation at Shahid Sadoughi Training Hospital, Yazd, Iran. Patients were seen in follow up, on average, out to 32 months after surgery. Computed tomographic (CT) scans of patients with sacral fractures were reviewed to determine the presence of injuries. A functional assessment of the patients was performed using Majeed’s score. Patient demographics, reduction quality, loss of fixation, outcomes and complications, return to activity, and screw hardware characteristics are described Results: The injury was unilateral in 11 (78.5%) patients and bilateral in 3 (21.5%). Associated injuries were present in all patients, including fractures, dislocation and abdominal injuries. Lower limb length discrepancy was less than 10 mm in all patients except two. Displacement, as a measure of quality of reduction was less than 5 mm in 13 patients. The mean Majeed score was 78/100. Wound infection and hardware failure were observed in 3 (21.4%) and 1 (7.1%) cases, respectively. In this study most patients (85%) return to work postoperatively. Conclusion: According to the findings, spinopelvic fixation is a safe and effective technique for treatment of sacroiliac injuries. This method can obtain early partial to full weight bearing and possibly reduce the complications. PMID:27847854
Weber-Spickschen, T S; Oszwald, M; Westphal, R; Krettek, C; Wahl, F; Gosling, T
Robot assisted fracture reduction of femoral shaft fractures provides precise alignment while reducing the amount of intraoperative imaging. The connection between the robot and the fracture fragment should allow conventional intramedullary nailing, be minimally invasive and provide interim fracture stability. In our study we tested three different reduction tools: a conventional External Fixator, a Reposition-Plate and a Three-Point-Device with two variations (a 40 degrees and a 90 degrees version). We measured relative movements between the tools and the bone fragments in all translation and rotation planes. The Three-Point-Device 90 degrees showed the smallest average relative displacement and was the only device able to withstand the maximum applied load of 70 Nm without failure of any bone fragment. The Three-Point-Device 90 degrees complies with all the stipulated requirements and is a suitable interface for robot assisted fracture reduction of femoral shaft fractures.
Aluko-Olokun, Bayo; Olaitan, Ademola A; Aluko-Olokun, Oluseun A
This study analyzed the cosmetic and functional outcome of cases involving reconstruction of tooth-bearing portion of the lower jaw, using a polyglactin 910 suture for fixation. This prospective intervention study documented the treatment outcome in 25 consecutive adult patients, who underwent immediate mandibular reconstruction following segmental resection of tooth-bearing portion of mandible. Cortico-cancellous bone graft was taken from the inner table of iliac bone, sparing the crest. Use of post-surgical inter-maxillary fixation was avoided. Twenty-five patients were recruited for the study. Seventeen were males and eight were females. Their ages ranged from 18 to 50 years, with a mean of 30.0 years. Average length of grafted bone was 9.8 cm. Following surgery, all 25 (100%) patients were judged to have satisfactory facial symmetry. One (4.0 %) had altered dental occlusion. Twenty-five (100%) had satisfactory bone union. All of the patients claimed to masticate satisfactorily. Assessment was carried out at the last post-operative follow-up visit for each patient who ranged between 22 and 83 months. Use of polyglactin 910 suture material for fixation in mandibular reconstruction following segmental resection of tooth-bearing portion has proven to be a cosmetic and functional success. It may serve as alternative for those among whom conventional treatment methods may be contraindicated. This method of bone fixation may serve as a reliable and much cheaper alternative in low-income countries. Level IV, therapeutic study.
Ali, A; Douglas, H; Stanley, D
Sixteen patients who underwent a revision operation for nonunion of fractures of the distal humerus following previous internal fixation were reviewed at a mean follow-up of 39 months (8 to 69). The Mayo elbow performance score was excellent in 11, good in two, fair in two and poor in one. In 15 patients union was achieved and in one with an infected nonunion a subsequent bone graft was necessary in order to obtain union.Age, gender, a history of smoking, mechanism of the injury and the AO classification of the initial fracture did not correlate with the development of nonunion. In 12 patients (75%), the initial fixation was assessed as being suboptimal. The primary surgery was regarded as adequate in only three patients. Our findings suggest that the most important determinant of nonunion of a distal humeral fracture after surgery is the adequacy of fixation.
Docker, Charles; Starks, Ian; Wade, Roger; Wynn-Jones, Charles
We present the case of a woman diagnosed with simultaneous displaced intracapsular femoral neck fractures following the birth of her second child. No traumatic event was identified. Diagnosis was delayed as the cause of her pain was thought to be non-skeletal in origin. Radiological and serological investigations were diagnostic of osteomalacia. Surgical fixation of her fractures was further delayed due to profound hypocalcaemia. Despite the delays, fixation with bilateral dynamic hip screws resulted in union with no evidence of avascular necrosis at 2 years follow-up. We believe this to be the first report of atraumatic bilateral femoral neck fractures and it shows that a good result can be achieved even in the presence of delayed fixation.
Klatte, Till O; O’Loughlin, Padraigh F; Citak, Mustafa; Rueger, Johannes M; Gehrke, Thorsten; Kendoff, Daniel
Background and purpose Mechanically failed internal fixation following hip fracture is often treated by salvage arthroplasty. If deep wound infection is present, a 2-stage procedure is often used. We have used a 1-stage procedure in infected cases, and we now report the outcome. Patients and methods We reviewed 16 cases of deep wound infection after mechanically failed hip fracture fixation, treated between 1994 and 2010. In all patients, a joint prosthesis was implanted in a 1-stage procedure. Results After an average follow-up period of 12 (2–18) years, no reinfection was detected. In 4 cases, a hip dislocation occurred and 3 of these needed further surgery. Interpretation A 1-stage procedure for arthroplasty of an infected, mechanically failed hip fracture fixation is feasible and carries a low risk of infection. PMID:23799345
Ramlee, Muhammad Hanif; Kadir, Mohammed Rafiq Abdul; Murali, Malliga Raman; Kamarul, Tunku
Pilon fractures are commonly caused by high energy trauma and can result in long-term immobilization of patients. The use of an external fixator i.e. the (1) Delta, (2) Mitkovic or (3) Unilateral frame for treating type III pilon fractures is generally recommended by many experts owing to the stability provided by these constructs. This allows this type of fracture to heal quickly whilst permitting early mobilization. However, the stability of one fixator over the other has not been previously demonstrated. This study was conducted to determine the biomechanical stability of these external fixators in type III pilon fractures using finite element modelling. Three-dimensional models of the tibia, fibula, talus, calcaneus, navicular, cuboid, three cuneiforms and five metatarsal bones were reconstructed from previously obtained CT datasets. Bones were assigned with isotropic material properties, while the cartilage was assigned as hyperelastic springs with Mooney-Rivlin properties. Axial loads of 350 N and 70 N were applied at the tibia to simulate the stance and the swing phase of a gait cycle. To prevent rigid body motion, the calcaneus and metatarsals were fixed distally in all degrees of freedom. The results indicate that the model with the Delta frame produced the lowest relative micromovement (0.03 mm) compared to the Mitkovic (0.05 mm) and Unilateral (0.42 mm) fixators during the stance phase. The highest stress concentrations were found at the pin of the Unilateral external fixator (509.2 MPa) compared to the Mitkovic (286.0 MPa) and the Delta (266.7 MPa) frames. In conclusion, the Delta external fixator was found to be the most stable external fixator for treating type III pilon fractures. Copyright © 2014 IPEM. Published by Elsevier Ltd. All rights reserved.
Tafazal, Suhayl; Madan, Sanjeev S; Ali, Farhan; Padman, Manoj; Swift, Simone; Jones, Stanley; Fernandes, James A
The use of circular fixators for the treatment of tibial fractures is well established in the literature. The aim of this study was to compare the Ilizarov circular fixator (ICF) with the Taylor spatial frame (TSF) in terms of treatment results in consecutive patients with tibial fractures that required operative management. A retrospective analysis of patient records and radiographs was performed to obtain patient data, information on injury sustained, the operative technique used, time duration in frame, healing time and complications of treatment. The minimum follow-up was 24 months. Ten patients were treated with ICF between 2000 and 2005, while 15 patients have been treated with TSF since 2005. Two of the 10 treated with ICF and 5 of the 15 treated with TSF were open fractures. All patients went on to achieve complete union. Mean duration in the frame was 12.7 weeks for ICF and 14.8 weeks for the TSF group. Two patients in the TSF group had delayed union and required additional procedures including adjustment of fixator and bone grafting. There was one malunion in the TSF group that required osteotomy and reapplication of frame. There were seven and nine pin-site infections in the ICF and TSF groups, respectively, all of which responded to antibiotics. There were no refractures in either group. In an appropriate patient, both types of circular fixator are equally effective but have different characteristics, with TSF allowing for postoperative deformity correction. Of concern are the two cases of delayed union in the TSF group, all in patients with high-energy injuries. We feel another larger study is required to provide further clarity in this matter. Level II-comparative study.
El-Mowafi, Hani; El-Hawary, Ahmed; Kandil, Yasser
Pilon fractures usually result from high energy trauma, and are commonly associated with extensive soft tissue damage which prevents the use of open reduction and internal fixation. This study was designed to evaluate the use of the Ilizarov external fixator in the treatment of pilon fractures of the ankle, and to determine whether arthroscopy of the ankle could improve the outcome. From February 2011 to May 2013 a total of 23 patients with unilateral closed pilon fractures were divided into two groups treated with and without arthroscopy during fixation with the Ilizarov external fixator. The fractures were classified according to the AO Rüdi and Allgőwer classification. Follow up ranged from 10 to 37 months with a mean of 18 months. All cases were evaluated at follow up by the AOFAS and the Bone et al. grading system. According to Bone et al. there were 3 cases excellent, 4 cases good, 2 cases fair, and 2 cases poor in Group A (without arthroscopy), whereas there were 4 cases excellent, 6 cases good, 2 cases fair in Group B (with arthroscopy). The AOFAS score for Group A was 77.8±5.8, and for Group B was 78.4±6.9. We concluded that the Ilizarov external fixator is an excellent method in treating pilon fractures as it minimizes the need for extensive surgery. We also conclude that the use of arthroscopy during pilon fracture fixation did not add statistically significant improvement to our results and it needs longer term investigation to assess its advantage - if any - to the final outcome. level 2. Copyright © 2015 Elsevier Ltd. All rights reserved.
Springer, M A; van Binsbergen, E A; Patka, P; Bakker, F C; Haarman, H J
A prospective randomized clinical trial was performed to evaluate the use of self-reinforced absorbable composites (Biofix) in the fixation of ankle fractures. The aim of this study was to demonstrate that fixation with Biofix rods and screws is as good as the standard A.O. fixation. The benefits of Biofix rods and screws are: a reduction in costs since no secondary operation is needed, prevention of stress-shielding and thereby diminishing the risk of bone porosity. Patients aged between 16 and 75 years old with closed, non-comminuted fractures of the lateral and/or medial malleolus and dislocation of the fracture fragments greater than 2 mm were included in the study. 22 patients were treated with Biofix rods and screws and the control group of 19 patients with a standard technique. After 3, 6 and 12 months, rontgenograms were taken. At the same time functional results were evaluated following the criteria of Olerud and Molander. Two patients were withdrawn from the trial for non-medical reasons. 22 patients (12 from the Biofix group, 10 from the AO group) operated two or more years ago were contacted to see if any complications had occurred since they were last seen. In 4 cases a Biofix screw broke down just beneath the head during insertion. This did not result in an insufficient fixation of the fracture. There were no early post-operative complications. The functional and rontgenological results in both groups were equal. In three cases a sterile sinus developed at the site of screw insertion. Biofix rods and screws, made of polylactic acid, are a good alternative for the fixation of fractures of the ankle. The use of resorbable fracture fixation material has the advantage that a second operation to remove osteosynthesis material is not necessary. The long term results are good. There is, however, a possibility of development of tissue reaction to the resorbable material.
Platzer, Patrick; Thalhammer, Gerhild; Krumboeck, Anna; Schuster, Rupert; Kutscha-Lissberg, Florian; Zehetgruber, Isabella; Braunsteiner, Thomas; Vécsei, Vilmos
Surgical treatment of odontoid fractures that do not allow interfragmentary fracture compression involves either posterior atlantoaxial arthrodesis or additional anterior stabilization using a plate construct. The purpose of this study was to determine the clinical and radiographic outcome after anterior plate fixation of odontoid fractures that were not suitable for anterior screw fixation. We reviewed the clinical and radiographic records of 9 patients with an average age of 54 years at the time of surgery who had undergone anterior plate fixation of an odontoid fracture. Indications for using a plate construct were odontoid fractures with anterior oblique fracture lines, fractures with comminution or major displacement, and pathological fractures. Eight patients returned to their preinjury activity level and were satisfied with their treatment. One patient reported chronic pain symptoms and a notable decrease in cervical spine motion. Using the Smiley-Webster Scale to quantify their clinical outcome, we achieved an overall outcome score of 1.6. Bony fusion was achieved in all patients. Reduction or fixation failed in 2 patients. Reoperation for technical failures was not necessary in any of the patients. We had promising results using anterior plate fixation for surgical treatment of odontoid fractures that did not allow interfragmentary fracture compression. Because this method avoids the rigid fixation of the atlantoaxial joint in contrast to techniques of posterior cervical arthrodesis, it seems to be a practical option for the management of fracture types that require additional stabilization of the odontoid.
Parker, Martyn J; Handoll, Helen H G
Many different surgical techniques have been described for the internal fixation of extracapsular hip fractures. To compare different aspects of surgical technique used in operations for internal fixation of extracapsular hip fractures in adults. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (January 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1), MEDLINE, EMBASE, CINAHL, Current Controlled Trials, orthopaedic journals, conference proceedings and reference lists of articles. Date of last search was January 2008. No language restriction was applied. All randomised and quasi-randomised trials investigating operative techniques used in operations for the treatment of extracapsular hip fractures in adults. Two review authors independently selected trials, assessed trial quality and extracted data. Wherever appropriate, data were pooled. Predominantly older people with trochanteric fractures were treated in the 11 included trials.One trial (65 participants undergoing fixation with a fixed nail-plate) found no statistically significant differences between osteotomy versus anatomical reduction. Four trials, involving 465 participants undergoing fixation with a sliding hip screw (SHS), compared osteotomy versus anatomical reduction. Osteotomy was associated with an increased operative blood loss and length of surgery. There were no statistically significant differences for mortality, morbidity or measures of anatomical deformity.Two trials (138 participants) compared SHS fixation of a trochanteric hip fracture augmented with cement against a standard fixation. There were no reoperations even for the four cases of fixation failure in the cement group. The cement group had significantly better quality of life scores at six months. One trial (200 participants) comparing compression versus no compression of a trochanteric fracture in conjunction with SHS fixation found no significant
Wang, S D; Li, X L; Liu, H P
To compare fracture healing therapies, the gene expression profiles of rat fracture samples treated with nail and plate fixation were analyzed at 1 day, 3 days, 1 week, 2 weeks, 4 weeks, and 6 weeks after surgery. The gene expression profiles GSE1685, which include 19 samples, were downloaded from the Gene Expression Omnibus database. After preprocessing, the gene expression profiles were subjected to time series analysis using the Short Time-series Expression Miner software, and the significantly differentially expressed gene (DEG) sets were selected. Further, the distributions of those DEG sets on the corresponding chromosomes were identified using the functional classification tool. Finally, the DEGs were subjected to function and pathway enrichment analysis. DEG analysis indicated that the number of DEGs (854 genes) from nail fixation was significantly lower than that of DEGs (1029 genes) from plate fixation. The DEGs were mainly enriched in cell proliferation, cellular localization, and response to wounding functions. Several critical DEGs expressed during the fracture healing process were screened, and 2 common pathways were enriched for the DEGs in the nail fixation and plate fixation. These DEGs and pathways may be potential targets or predictive markers during fracture healing.
Matzon, Jonas L; Reb, Christopher W; Danowski, Ryan M; Lutsky, Kevin
Trapezium fractures comprise approximately 3% to 5% of all hand fractures. Although operative management of intra-articular trapezium fractures can result in good functional outcomes, there is very little literature addressing specific operative techniques. We describe a technique for open reduction and internal fixation of severely comminuted, intra-articular trapezium fractures, utilizing autogenous cancellous bone graft from the distal radius.
Xue, Zichao; Qin, Hui; Ding, Haoliang; Xu, Haitao; An, Zhiquan
Background Failed patellar fracture fixation is rare, and is usually attributed to technical errors. There are no specific details available on how to address this problem. We present our two-tension-band technique for fixing patellar fractures. Material/Methods Between March 2010 and March 2013, 4 men and 2 women with failed fixation patellar fractures were treated in our department. Their average age was 34 years (range 23–49 years). The initial fracture type was C1 in 3, C2 in 1, and C3 in 2, according to the AO classification. The initial fracture patterns included 3 transverse and 3 comminuted fractures. There were no open fractures. All patients underwent internal fixation with a modified anterior tension band (MATB) supplemented with cerclage wiring. All failures were caused by tension bands sliding past the tip of the Kirschner wires. The mean time between the primary and revision operations was 16.2 months (range 2–63 months). We revised the fractures by two-separate-tension-band technique. Results The mean follow-up was 52 months (range 31–67 months). All patients healed radiographically without complications at an average of 14.7 weeks (range 8–20 weeks). The Bostman knee score was excellent in 3 and good in 3. All patients regained full extension and the mean range of flexion was 147.5° (135–155°). Conclusions Use of this two-tension-band technique can avoid technical errors and provide more secure fixation. We recommend it for both primary and revision surgery of patellar fractures. PMID:27485104
Ali, A M; Yang, L; Hashmi, M; Saleh, M
The two main challenges in the management of bicondylar tibial plateau fractures are: Firstly, the compromised skin and soft tissue envelope which invite a high rate of complications following attempted open reduction and dual plating. Secondly, poor bone quality and comminuted fracture patterns, which create difficulty in achieving stable fixation. Although dual plating is considered to be the best mechanical method of stabilizing these complex fractures, there remains concern regarding the high rate of complications associated with extensive soft tissue dissection, required for the insertion of these plates in an already compromised knee. The Sheffield Hybrid fixator (SHF) technique offers a solution to the two main problems of these difficult fractures by minimizing soft tissue dissection, since bone fragments are reduced and fixed percutaneously, and providing superior cancellous bone purchase with beam loading stabilization for comminuted fractures. Our biomechanical testing showed the SHF with four tensioned wires to be as strong as dual plating and able to provide adequate mechanical stability in the fixation of bicondylar tibial plateau fractures. This was confirmed clinically by a prospective review of the use of the SHF at our centre, for managing complex and high-energy tibial plateau fractures with a good final outcome and no cases of deep infection or septic arthritis.
Inal, Sermet; Inal, Canan
Pediatric comminuted talar fractures are reported to be rare, and treatment options such as minimal internal K-wire fixation without using a tourniquet to prevent avascular necrosis have not previously been investigated. We report a case of a comminuted talar body and a non-displaced neck fracture with dislocation of the tibiotalar, talonavicular and subtalar joints with bimalleolar epiphyseal fractures in an 11-year-old boy due to a fall from height. We present radiological findings, the surgical procedure and clinical outcomes of minimal internal K-wire fixation without using a tourniquet. Avascular necrosis rates are reported to be between 0 % and 66 % after fractures of the neck of the talus and the talar body in children. The likelihood of developing avascular necrosis increases with the severity of the fracture. To avoid avascular necrosis in a comminuted talar fracture accompanied by tibiotalar, talonavicular, subtalar dislocations and bimalleolar epiphyseal fractures, a minimal internal K-wire fixation without the use of a tourniquet was performed. The outcome was evaluated by the American Orthopedic Foot and Ankle Society score (AOFAS). A score of 90 (excellent) was found at the end of the second year of follow up. Radiology revealed preservation of the joint with no evidence of avascular necrosis, and clinical findings revealed a favorable functional outcome after two years. 4.
Bellil, Mehdi; Hadhri, Khaled; Sridi, Maamoun; Kooli, Mondher
Traumatic atlantoaxial rotatory fixation is a very rare injury in adults which is often misdiagnosed initially. Its combination with C2 fractures is predominated by dens lesions. Therapeutic management is challenging because of the difficulty to achieve optimal reduction and permanent stability. We report a rare case of traumatic atlantoaxial rotatory fixation in a 56-year-old women associated with C2 articular facet fracture successfully treated by conservative means after patient-awake manual reduction with optimal functional and radiographic outcome. PMID:25558147
Clohessy, James William; Chang, Frank; Subramaniam, Shiva S.
Intermaxillary fixation (IMF) is an integral technique utilized by maxillofacial surgeons to appropriately reduce and relate maxillary and mandibular fractures to both one another and the facial skeleton. This case report reviews the management of a comminuted mandibular fracture including inoperable bilateral condylar fractures that precluded the use of convention IMF techniques necessitating an alternative technique. This was achieved in the form of modified bony plates extending intraorally. Postoperative review showed favorable results with occlusion and range of motion comparable to the premorbid function and no unforeseen complications.
Byun, Chun Sung; Park, Il Hwan; Hwang, Wan Jin; Lee, Yeiwon; Cho, Hyun Min
Background Sternal fractures are relatively rare, and caused mainly by blunt anterior chest wall trauma. In most cases, sternal fractures are treated conservatively. However, if the patient exhibits problematic symptoms such as intractable chest wall pain or bony crepitus due to sternal instability, surgical correction is indicated. But no consensus exists regarding the most appropriate surgical method. We analyzed the results of surgical fixation in cases of sternal fracture in order to identify which surgical method led to the best outcomes. Methods We retrospectively reviewed the medical records of patients with sternal fractures from December 2008 to December 2011, and found 19 patients who underwent open reduction and internal fixation of the sternum with a longitudinal plate (L-group) or a T-shaped plate (T-group). We investigated patients’ characteristics, clinical details regarding each case of chest trauma, the presence of other associated injuries, the type of open reduction and fixation, whether a combined operation was performed, and postoperative complications. Results Of the 19 patients, 10 patients (52.6%) were male, and their average age was 56.8 years (range, 32 to 82 years). Seven patients (36.8%) had isolated sternal fractures, while 12 (63.2%) had other associated injuries. Seven patients (36.8%) were in the L-group and 12 patients (63.2%) were in the T-group. Three patients in the L-group (42.9%) showed a loosening of the fixation. In all patients in the T-group, the fracture exhibited stable alignment. Conclusion Open reduction and internal fixation with a T-shaped plate in sternal fractures is a safer and more efficient treatment method than treatment with a longitudinal plate, especially in patients with a severely displaced sternum or anterior flail chest, than a longitudinal plate. PMID:27733996
Wee, Hwabok; Reid, J Spence; Chinchilli, Vernon M; Lewis, Gregory S
Internal fixation of bone fractures using plates and screws involves many choices-implant type, material, sizes, and geometric configuration-made by the surgeon. These decisions can be important for providing adequate stability to promote healing and prevent implant mechanical failure. The purpose of this study was to develop mathematical models of the relationships between fracture fixation construct parameters and resulting 3D biomechanics, based on parametric computer simulations. Finite element models of hundreds of different locked plate fixation constructs for midshaft diaphyseal fractures were systematically assembled using custom algorithms, and axial, torsional, and bending loadings were simulated. Multivariate regression was used to fit response surface polynomial equations relating fixation design parameters to outputs including maximum implant stresses, axial and shear strain at the fracture site, and construct stiffness. Surrogate models with as little as three regressors showed good fitting (R (2) = 0.62-0.97). Inner working length was the strongest predictor of maximum plate and screw stresses, and a variety of quadratic and interaction terms influenced resulting biomechanics. The framework presented in this study can be applied to additional types of bone fractures to provide clinicians and implant designers with clinical insight, surgical optimization, and a comprehensive mathematical description of biomechanics.
Elmi, Asghar; Tabrizi, Ali; Rouhani, Alireza; Mirzatolouei, Fardin
Background Femoral neck fractures are urgent injuries that require precise reduction and stable fixation. In some cases, however, early treatment is not possible. Objectives The present study aimed to evaluate long-term results of delayed fixation of femoral neck fractures using cannulated screws. Patients and Methods This retrospective descriptive-analytical study was conducted on 26 patients with femoral neck fractures. The patients were treated through a closed reduction and fixation method using cannulated screws. Patients were followed up for at least five years and the rate of complications was determined. Results In this study, 26 patients with mean age of 34.3 years were assessed. Average time interval from injury to surgery was 46.4 ± 12.2 hours; 18 patients (69%) were operated on with more than 36 hours of delay. Incidence of AVN and nonunion was reported in 10 (38.4%) and 3 (11.5%) patients, respectively. Conclusions Time plays an important role in treatment results of femoral neck fractures. To treat the fractures, closed reduction and fixation using cannulated screws may still be the best option. PMID:24350142
Khan, Moin; Aleem, Ilyas S; Poolman, Rudolf W
Hip fractures are among the most common debilitating injuries in the elderly and are a significant cause of morbidity and mortality worldwide. Despite the ever-increasing literature on the topic of hip fractures, optimal treatment remains uncertain. Trials with small sizes, methodological limitations, strict inclusion criteria and wide confidence intervals leave the optimal approach to treating hip fractures unknown and controversial. In 2005, the International Hip Fracture Research Collaborative was officially established with the mandate of resolving controversies in hip fracture management. Presently, two multicenter randomized trials, FAITH and HEALTH, are underway. The FAITH trial (Fixation Using Alternative Implants for the Treatment of Hip Fractures) will compare Sliding Hip Screws and Cancellous Screws; the HEALTH trial (Hip Fracture Evaluation with Alternatives of Total Hip Arthroplasty versus Hemi-Arthroplasty) will compare total hip arthroplasty and hemi-arthroplasty. The present paper reviews current controversies in hip fracture care. Ultimately, only large randomized trials, such as FAITH and HEALTH, will resolve the longstanding controversy of whether primary replacement or fixation is the preferred treatment modality in this common fracture. Subsequent trials need to focus on surgical strategies in the cognitively impaired patient.
Kottmeier, Stephen A; Watson, J Tracy; Row, Elliot; Jones, Clifford B
A critical assessment of radiographic and clinical outcomes after complex articular fractures of the proximal tibia demonstrates several aspects worthy of reevaluation and potential modification. These include a refined understanding of fracture pathoanatomy, injury classification, operative exposure, surgical timing, and preferred fixation constructs in addition to implant design modifications. Evolving trends include increasing appreciation of the importance of the fracture morphology in the axial plane and the role that the fracture pattern has on the choice of surgical approach. This focused review will highlight the attributes and limitations of classification schemes (both conventional and contemporary) as well as the role that posterior surgical approaches performed in the prone position may offer in select clinical scenarios. The merits of staged fixation (prone followed by supine patient positioning), its technique, indications, and potential liabilities are described and case examples offered. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.
Rhee, Woo-Tack; You, Seung-Hoon; Jang, Yeon-Gyu; Lee, Sang-Youl
Fractures of lumbo-sacral junction involving bilateral sacral wings are rare. Posterior lumbo-sacral fixation does not always provide with sufficient stability in such cases. Various augmentation techniques including divergent sacral ala screws, S2 pedicle screws and Galveston rods have been reported to improve lumbo-sacral stabilization. Galveston technique using iliac bones would be the best surgical approach especially in patients with bilateral comminuted sacral fractures. However, original Galveston surgery is technically demanding and bending rods into the appropriate alignment is time consuming. We present a patient with unstable lumbo-sacral junction fractures and comminuted U-shaped sacral fractures treated by lumbo-sacro-pelvic fixation using iliac screws and discuss about the advantages of the iliac screws over the rod system of Galveston technique.
Sahoo, N K; Mohan, Ritu
Intermaxillary fixation (IMF) is conventionally used for treatment of fractures involving maxillomandibular complex both for closed reduction and as an adjuvant to open reduction. To overcome the cumbersome procedure of tooth borne appliances cortical bone screws were introduced in the year of 1989 to achieve IMF which is essentially a bone borne appliance. In our institution we treated 45 cases of mandibular fracture both single and multiple fractures by open reduction over a period of 24 months. IMF screws were used to achieve dental occlusion in all the cases. Various advantages, disadvantages and complications are discussed. In our institutional experience we found that the IMF screws are an ideal device for temporary intermaxillary fixation for the cases having only mandibular fracture.
Sun, Doohoon; Park, Byeong-Seop; Jang, Gun-Il
Purpose We conducted a study on patients who underwent hip joint arthroplasty because of unstable femur intertrochanteric fractures with greater trochanter bony fragments. After dividing patients into three groups depending on their fracture patterns, we evaluated the clinical and radiological outcomes of different operation methods applied to each of these groups. Materials and Methods Using Evan's classification, we defined an unstable intertrochanteric fracture as those characterized as stage 4 or 5. Of the 137 patients presenting with an intertrochanteric fracture with osteoporosis (bone mineral density, <−2.5) between March 2014 and October 2015, 63 met the eligibility criteria and were included in this study. Next, patients were divided into three groups based on their greater trochanter fracture patterns (discerned with three-dimensional computed tomography images); different fixation methods were applied to each group by a single orthopaedic surgeon. Results Taken as a whole, 50 out of 63 patients experienced no reduction in walking distance in their daily lives. Harris hip score increased from 74.8 to 85.7 point and we considered this a relatively good result. Radiologically, we observed complete bone union in 62 cases (98.4%); the lone exception was in a patient who experienced osteolysis. There were also 3 cases who removed greater trochanter reattachment device due to broken implant and 1 case of dislocation. Conclusion The different fixation methods applied to three distinct groups with varying fractures patterns were successful in achieving proper reduction and fixation of greater trochanteric fractures. We also observed reduced bone union periods when arthroplasty was performed in patients with unstable intertrochanteric fractures. Lastly, we believe these approaches may also aid in achieving early ambulation and early rehabilitations. PMID:28316964
Kain, Michael S; Marcantonio, Andrew J; Iorio, Richard
Femoral neck fractures are a major public health problem. Multiple-screw fixation is the most commonly used surgical technique for the treatment of stable femoral neck fractures. We determined (1) the proportion of hips that had conversion surgery to THA, and (2) the proportion of hips that underwent repeat fracture surgery after percutaneous screw fixation of stable (Garden Stages I and II) femoral neck fractures in patients older than 65 years and the causes of these reoperations. We performed a retrospective study of all patients older than 65 years with stable femoral neck fractures secondary to low-energy trauma treated surgically at our institution between 2005 and 2008. We identified 121 fractures in 120 patients older than 65 years as stable (Garden Stage I or II); all were treated with percutaneous, cannulated screw fixation in an inverted triangle without performing a capsulotomy or aspiration of the fracture hematoma at the time of surgery. The average age of the patients at the time of fracture was 80 years (range, 65-100 years). Radiographs, operative reports, and medical records were reviewed. Fracture union, nonunion, osteonecrosis, intraarticular hardware, loss of fixation, and conversion to arthroplasty were noted. Followup averaged 11 months (range, 0-5 years) because all patients were included, including those who died. The mortality rate was 40% for all patients at the time of review. Twelve patients (10%) underwent conversion surgery to THA at a mean of 9 months after the index fracture repair (range, 2-24 months); the indications for conversion to THA included osteonecrosis, nonunion, and loss of fixation. Two others had periimplant subtrochanteric femur fractures treated by surgical repair with cephalomedullary nails and two patients had removal of hardware. Revision surgery after osteosynthesis for stable femoral neck fractures was more frequent in this series than previously has been reported. The reasons for this higher frequency
Mulders, Marjolein A M; Walenkamp, Monique M J; Goslings, J Carel; Schep, Niels W L
Of all distal radius fractures, 25 % are complete articular fractures (AO/OTA type C fractures). Two thirds of those fractures are displaced and require reduction. According to several International Guidelines, adequately reduced intra-articular distal radius fractures are best treated non-operatively with plaster immobilisation, while surgical fixation is suggested only when the articular step exceeds 2 mm after reduction. However, these recommendations are based on studies that did not differentiate between intra- and extra-articular distal radius fractures. Thus, no clear consensus about the best treatment for patients with displaced intra-articular distal radius fractures can be reached. Despite the lack of evidence, an increase in internal fixation of intra-articular distal radius fractures has been observed over the last decade. The aim of this study is to determine the difference in functional outcome following open reduction and plate fixation compared with non-operative treatment with closed reduction and plaster immobilisation in patients with a displaced intra articular distal radius fracture. This multicentre randomised controlled trial will randomise between open reduction and internal plate fixation (intervention group) and closed reduction and plaster immobilisation (control group). All consecutive adult patients from 18 to 65 years with a displaced intra-articular distal radius fracture (AO/OTA type C), which has been adequately reduced at the Emergency Department according to the Dutch National Guidelines, are eligible for inclusion in this study. The primary outcome is function and pain of the wrist assessed with the Patient-Rated Wrist Evaluation score (PRWE). Secondary outcomes are the Disability of the Arm, Shoulder and Hand score (DASH), pain, quality of life (SF-36), range of motion, grip strength, radiological parameters, complications, crossovers and cost-effectiveness of both treatments. A total of 90 patients will be included in this
Faralli, Mario M; Calenti, Claudio C; Ibba, Maria Cristina M; Ricci, Gianpietro G; Frenguelli, Antonio A
Our study examined the posture of 15 patients who had sustained a simple unilateral or bilateral fracture of the condylar head of the mandible as a result of sports or traffic accidents. Following preliminary testing of vestibular function, the patients underwent balance testing: Romberg test with eyes closed (EC), Romberg EC and bite test (ECBT), EC and head retroflexed (ECR). The study parameters were: surface (S) of the statokinesigram, stomatognathic influence index related to S (SSI), and postural oscillations on the frontal plane (X). In keeping with the literature, we felt that the following pattern in static balance suggested a posture destabilised by the stomatognathic system: SSI values of less than 60, reduction of S in the transition from EC to ECR, pathological increase of postural oscillations on the X plane. The study was completed by obtaining a list of new symptoms reported by the patients (altered bite, fullness, tinnitus, pain, loss of balance). The most significant patterns were observed in patients with vestibular dysfunctions and neck pain. It seems that a fracture of the condylar head can affect postural behaviour, although proprioceptive changes alone are not enough to cause true loss of balance and there must be concomitant vestibular dysfunction. The stabilometric pattern is not conditioned by the extent of the trauma or the related treatment. In terms of proprioceptive elements, the presence of muscle pain seems to point to cervical muscle tension as the main culprit in the onset of posttraumatic instability.
Abu Halaweh, Sami A; Aloweidi, Abdelkareem S; Qudaisat, Ibraheem Y; Al-Kazaleh, Fawaz A
We report a case of a mandibular dentoalveolar fracture caused by severe iatrogenic hyponatremia-induced grand mal seizure in a 31-year-old pregnant lady who underwent normal vaginal delivery. She had oxytocin augmentation of her labor, and the seizure happened in the immediate postpartum period. The seizure was thought to be because of severe hyponatremia and prompt management controlled the metabolic disorder. The fracture was reduced and fixed successfully, and she was discharged after 48 hours, healing was uneventful.
Bischoff, R; Buechler, U; De Roche, R; Jupiter, J
We report 100 cases in which a tension-band technique was used to secure fixation of avulsion fractures within the digits. Included are 51 bony mallet fractures that were subluxed or irreducible, 38 displaced bony gamekeeper's fractures of the thumb, 8 fractures of the lateral phalangeal base, and 3 avulsion fractures that involved the base of the dorsal aspect of the middle phalanx. We evaluated results on the basis of clinical and x-ray film criteria. Excellent or satisfactory results were found in all 38 bony gamekeeper's injuries. All but one gamekeeper's fracture healed; the one nonunion was asymptomatic. All eight patients with lateral avulsion fractures had an excellent or satisfactory result on clinical examination. Seven of the eight had an excellent result on x-ray film evaluation; the one malnuion was asymptomatic. Two of the three fractures with dorsal avulsions of the base of the middle phalanx had a satisfactory result on clinical and x-ray film examination; the one poor result was due to the severity of the comminution of the fracture. However, 21 of the 51 bony mallet injuries had a poor result both clinically and radiographically. We noted numerous postoperative complications including dorsal skin breakdown, superficial and deep infection, and secondary displacement of the fragment. Tension-band fixation is an excellent method for treating various avulsion fractures of the hand such as bony gamekeeper's thumb, lateral avlusion injuries, and dorsal avulsions of the middle phalanx. However, the treatment of bony mallet fingers with tension band fixation is less predictable and should be used with caution.
Reichel, Lee M; Milam, Graham S; Reitman, Charles A
The coronoid process has been shown to play a critical role in ulnohumeral stability. Coronoid process fractures can occur in isolation or as part of a complex injury pattern. The most common complex pattern, known as the "terrible triad," includes a radial head fracture and elbow dislocation along with the coronoid fracture. Failure to address these fractures and ligamentous injuries can result in recurrent instability and progression to painful arthrosis. Both medial and lateral approaches to the coronoid have been popularized in recent literature, but there is no universally accepted approach. Common fixation techniques include suture lasso, suture anchors, lag screws, and plating all of which have various drawbacks. We describe a direct anterior approach to address coronoid process fractures made in addition to a lateral approach to address radial head and lateral collateral ligament injuries. Coronoid fractures addressed through the anterior approach were stabilized with anterior to posterior screw fixation combined with buttress plating, which allowed anatomic reduction and stable internal fixation at short-term follow-up.
Larangeira, Joao Alberto; Bellenzier, Liliane; Rigo, Vanessa da Silva; Ramos Neto, Elias Josue; Krum, Francisco Fritsch Machry; Ribeiro, Tiango Aguiar
Patella fracture is relatively uncommon and the vertical trace fracture represents almost 12-17%. The open patella fracture expresses 6-30%. The association of these two uncommon conditions was the aim of this case report even as the treatment and the moment of fixation (definitive surgical treatment). A 27-year-old man after a motorcycle accident showed an open patella fracture classified as a Gustilo and Anderson type IIIA lesion. The patient was immediately treated with precocious surgery fixation with a modified tension band which consists of two parallel K-wires positioned orthogonal to the fracture line and a cerclage wire shaped anteriorly at patella as an eight. The premature fixation benefited the infection prevention and provided earlier joint motion, which increased the nutrition of articular cartilage. Six months postoperatively, the patient had a satisfactory joint motion with full extension and 116° of joint flexion and returned to his daily life activities without restriction. Twelve months postoperatively, the patient had full extension and 120° of knee flexion without pain, joint effusion and instability. Muscle strength force was considered normal at grade V. In conclusion, early chirurgic treatment and precocious articular mobilization improve prognosis, suggesting that the employment of these practices should be adopted whenever possible in most of the open fractures.
Larangeira, Joao Alberto; Bellenzier, Liliane; Rigo, Vanessa da Silva; Ramos Neto, Elias Josue; Krum, Francisco Fritsch Machry; Ribeiro, Tiango Aguiar
Patella fracture is relatively uncommon and the vertical trace fracture represents almost 12-17%. The open patella fracture expresses 6-30%. The association of these two uncommon conditions was the aim of this case report even as the treatment and the moment of fixation (definitive surgical treatment). A 27-year-old man after a motorcycle accident showed an open patella fracture classified as a Gustilo and Anderson type IIIA lesion. The patient was immediately treated with precocious surgery fixation with a modified tension band which consists of two parallel K-wires positioned orthogonal to the fracture line and a cerclage wire shaped anteriorly at patella as an eight. The premature fixation benefited the infection prevention and provided earlier joint motion, which increased the nutrition of articular cartilage. Six months postoperatively, the patient had a satisfactory joint motion with full extension and 116° of joint flexion and returned to his daily life activities without restriction. Twelve months postoperatively, the patient had full extension and 120° of knee flexion without pain, joint effusion and instability. Muscle strength force was considered normal at grade V. In conclusion, early chirurgic treatment and precocious articular mobilization improve prognosis, suggesting that the employment of these practices should be adopted whenever possible in most of the open fractures. PMID:25436033
Ding, Liang; He, Zhimin; Xiao, Haijun; Chai, Leizi; Xue, Feng
Although aseptic nonunion of humeral diaphyseal fracture is rare, it often is debilitating for the patient. Treatment is challenging for the surgeon when nonunion occurs. The purpose of this study was to analyze and identify independent risk factors for aseptic nonunion among patients with humeral diaphyseal fracture undergoing surgical fixation. The medical records of all humeral diaphyseal fracture patients who underwent surgical fixation from January 2005 to January 2011 were reviewed to identify those who developed aseptic nonunion. We performed univariate and multivariate logistic regression to identify independent associations of potential risk factors for aseptic nonunion among patients with surgical humeral diaphyseal fracture. A total of 686 patients were identified, with 659 meeting our inclusion criteria. Among these 659 cases there were 24 cases of septic nonunion, an incidence of 3.6%. The patients were followed for 9-24 months, with an average follow-up period of 14.8 months. In the final regression model, advanced age (odds ratio, 1.09; 95% CI: 1.03-1.14, P = 0.001), smoking (odds ratio, 5.34; 95% CI: 1.05-27.00, P = 0.043), use of NSAIDs (odds ratio, 2.51; 95% CI: 1.80-3.50, P < 0.001), and ASA score (odds ratio, 3.04; 95% CI: 1.06-8.74, P = 0.039) were risk factors for aseptic nonunion of humeral diaphyseal fracture after surgical fixation. This analysis confirms advanced age, smoking, use of NSAIDs, and ASA score were related to an increased risk of aseptic nonunion of humeral diaphyseal fracture after surgical fixation. Patients who have the risk factors identified in this study should be counseled about the possibility of aseptic nonunion occurring after surgical fixation.
Torbert, Jesse T; Joshi, Manjari; Moraff, Adrienne; Matuszewski, Paul E; Holmes, Amanda; Pollak, Andrew N; OʼToole, Robert V
Infection after fracture fixation is a major source of morbidity. Information regarding bacterial speciation and antibiotic resistance is lacking. We attempted to determine the speciation and drug resistance profiles associated with fracture fixation infections. Retrospective study. Level I trauma center. Two hundred eleven patients with 214 infections underwent surgery for postoperative infection from December 2006 to December 2010. Deep postoperative infections within 12 months of fixation were included. None. Incidence of each bacterial species and rate of clinically relevant resistance in Staphylococcus aureus, gram-negative rod (GNR), and Enterococcus species. The effect of timing of infection presentation and location of fracture on bacterial speciation was also investigated. Fifty-six percent of infections had S. aureus present, with 58% of those (32% of all infections) being methicillin-resistant S. aureus. Thirty-two percent of infections had at least one GNR present, with only 4% of those being multidrug resistant. We found a marked increase in the rate of GNR infections of the pelvis, acetabulum, and proximal femur (63%) compared with other locations (27%), which was statistically significant (P = 0.0002). At our center, S. aureus and GNR are most often found in deep postoperative infections after fixation. Methicillin-resistant S. aureus is common in this population. Our GNR rate is high, but resistance in this group was low. The proportion of GNR infections in the pelvis, acetabulum, and proximal femur was high even in closed fractures. These data provide a modern snapshot of orthopaedic infections after fracture fixation and might be useful in designing future studies and protocols for antibiotic prophylactic treatment. We are considering the use of aminoglycosides in the treatment of closed fractures of the pelvis, acetabulum, and proximal femur. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Platzer, Patrick; Thalhammer, Gerhild; Ostermann, Roman; Wieland, Thomas; Vécsei, Vilmos; Gaebler, Christian
A retrospective, comparative study. Anterior screw fixation has become an accomplished treatment option for the management of odontoid fractures. In younger patients, it has shown encouraging results with low complication rates; whereas in geriatric trauma victims, it remains the subject of controversy. The purpose of this study was to determine functional and radiographic results after anterior screw fixation of Type II odontoid fractures, with the particular interest to compare the outcome between younger and elderly patients. We reviewed clinical and radiographic records of 110 patients with an average age of 54 years at the time of surgery after anterior double screw fixation of their odontoid fractures between 1990 and 2004. To compare functional and radiographic results between nongeriatric and geriatric patients, they were divided by age into 2 groups: Group A included patients 65 years of age or younger and Group B contained patients older than 65 years. A total of 95 patients had returned to their preinjury activity level and were satisfied with their treatment. The Smiley-Webster scale showed an overall outcome score of 1.42 with similar results in both groups (Group A, 1.34; Group B, 1.50). Bony fusion was achieved in 102 patients, failures of reduction or fixation occurred in 12 patients. Comparing between the 2 groups, we had a nonunion rate of 4% in younger individuals and a significantly higher rate of 12% in geriatric patients. Reoperation due to nonunion or technical failures was necessary in 8 patients. We had encouraging results using anterior screw fixation for surgical treatment of odontoid fractures and favor this method as preferred management strategy for stabilization of these fractures. Comparing between age groups, we had similar results on cervical spine function. With regards to fracture healing as well as morbidity and mortality, younger patients had a superior outcome.
Park, Jun Hyung
Background Ultrasound-aided fixation is a recently developed alternative method of treatment of zygomatico-maxillary (ZM) fracture, and it can resolve the problems of excessive torsion force and subsequent fractures of screws. We conducted this study to evaluate the clinical usefulness of ultrasound-aided fixation as compared with the conventional fixation method using a drill and an expander in patients with ZM fracture. Methods We conducted a retrospective study in 35 patients with ZM fracture who had been treated at our hospital during a period ranging from March of 2008 to December of 2010. We divided them into two groups: an ultrasound-aided fixation group, comprising 13 patients who underwent ultrasound-aided fixation (SonicWeld Rx, KLS Martin), and a conventional group, comprising 22 patients who underwent conventional fixation (Biosorb FX, Linvatec Biomaterials Ltd.). We compared such variables as sex, direction, age at operation, follow-up period, operation duration, number of fixed holes, and time to discharge between the two groups. Results The ultrasound-aided fixation reduced the operation duration by about 30 minutes as compared with that of conventional fixation. There was no significant difference in follow-up period, number of fixed holes, or time to discharge between the two groups. Furthermore, there were no complications in either group. Conclusions The ultrasound-aided fixation of fractured ZM bone using an absorbable implant system is safe and effective in promptly reducing the bone fracture and providing satisfactory cosmetic outcomes over time. PMID:23898427
Gehr, Jonas; Friedl, Wilhelm
Reconstruction of the anatomy of the ankle joint while protecting the soft tissue, and osteosynthesis to maintain stability for function and weight bearing. Distal fractures of the fibula, bimalleolar fractures, and isolated fractures of the medial malleolus. Very small (< 5 mm) distal fragments (if fixation of the fragments is not possible using a small XXS nail) and very narrow (< 2.5 mm) medullary cavity (conversion to plate fixation). With displaced fibula fractures, open reduction should be performed with fracture retention using wide-armed reduction forceps, insertion of a central guide wire into the medullary cavity, use of a cannulated drill bit, introduction of the nail using an aiming arm and locked fixation with threaded wire. After checking the position using X-ray, the wire should be shortened using the bolt cutters. POSTOPERATIVE MANAGEMENT (Depending on the Weber classification): Full weight bearing for all isolated distal fractures of the fibula (Weber types A and B) and isolated fractures of the medial malleolus. For distal fractures of the fibula (Weber types A and B) with additional fracture of the medial malleolus or involvement of the medial ligament partial weight bearing of 20 kp for 4 weeks, followed by full weight bearing. For all Weber C fractures and/or additional Volkmann fracture only 10 kp of partial weight bearing with a rocker-sole orthosis should be allowed for 6 weeks followed by full weight bearing. No weight bearing for 6 weeks until the screws are removed is only recommended, if positioning screws have been used for Weber C fractures. In the period from 05/2000 to 01/2002, 194 ankle fractures were treated with the IP-XS-Nail((R)). Follow-up examinations were conducted on 162 patients with an average age of 51.2 years after an average of 15 months. 62 Weber B fractures (38.3%) and 45 Weber C fractures (27.7%) were evaluated. There were bimalleolar fractures in 55 cases (34.0%). According to the Olerud Score (clinical and
A majority of proximal humeral fractures are preferably treated conservatively. However, surgical management may be beneficial in proximal humeral fractures with significant displacement or angulation. Unfortunately, the complication rates associated with current surgical procedures for fracture fixation, ORIF and IM devices, can be unacceptably high. A new technology, termed the PH Cage, addresses the technical limitations associated with current technologies available for fixation of proximal humeral fractures. It allows for intramedullary fixation of a PH fracture and provides direct load bearing support to the articular surface and buttresses the medial column during healing. We are presenting our first experience with the PH Cage for the fixation of a PH fracture, which had previously failed conservative management. PMID:28255485
Mitković, Milan M; Mitković, Milorad B; Bumbasirević, Marko; Mitković, Marija M
Biomechanical features of long bones indicate that external fixation of long bone fractures have to be balanced according to general transversal stability as more as possible. The aim of this work was to investigate the influence of orientation pins to the general transversal stability of external fixation of fractures of long bones. In this study we have used the model of fractured long bone made of wood which was treated by Mitkovic external fixator with 4 pins, in 3 different situations: (1) all pins are in one axial plane, (2) each 2 pins are in 2 axial planes with angle distances of 60 degrees, (3) each 2 pins are in 2 axial planes wich are normal to each other. Means of relations of measured movements of long bone model fragments during the use of perpendicular force from 2 directions, normal to each other, after grouping of results in 3 grous: 0.17, 0.46 and 0.72. Statistical analyses showed that the differences between each of 3 grous were significant (p < 0.05). It can be concluded that it is better if pins are oriented in different axial planes, with pretension that both planes are normal to each other, during external fixation of long bone fractures.
symptoms, failed fixation, and further surgery (5). Treatment for severe AVN in the talus is initially arthrodesis , followed by talectomy (1). It is unknown...posttraumatic arthritis (p D .11). Two of 17 fractures underwent subtalar fusions. Average follow-up was 16 months postoperatively (range, 4–53). FIGURE 1
Ferreira, N; Marais, L C
Bicondylar tibial plateau fractures are serious injuries to a major weight-bearing joint. These injuries are often associated with severe soft tissue injuries that complicate surgical management. We reviewed 54 consecutive patients who sustained bicondylar tibial plateau fractures that were treated with limited open reduction and cannulated screw fixation combined with fine-wire circular external fixation. Forty-six patients met the inclusion criteria of this retrospective review. Eight patients were excluded because they did not complete a minimum of 1-year follow-up. Thirty-six patients had Schatzker type-VI, and ten patients had Schatzker type-V fractures. All fractures were united without loss of reduction; there were no incidences of wound complications, osteomyelitis or septic arthritis. The average Knee Society Clinical Rating Score was 81.6, translating to good clinical results. Minor pin track infection was the most common complication encountered. This review concludes that fine-wire circular external fixation, combined with limited open reduction and cannulated screw fixation, consistently produces good functional results without serious complications.
Zhang, Yiling; Shen, Jing; Mao, Zhi; Long, Anhua; Zhang, Lihai; Tang, Peifu
To analyze the associated risk factors of hidden blood loss in the internal fixation of intertrochanteric fracture. A retrospective analysis was made on the clinical data of 317 cases of intertrochanteric fractures which were treated by internal fixation between January 1993 and December 2008. There were 154 males and 163 females with an average disease duration of 4.58 days (range, 7 hours to 33 days); the age was (69.86 +/- 15.42) years; the average height was 1.64 m (range, 1.50-1.84 m); and the average weight was 62.26 kg (range, 39-85 kg). Of them, intramedullary fixation was used in 203 patients and extramedullary fixation in 114 patients. The operation time was (61.99 +/- 18.25) minutes. The red blood cell transfusion was given to 84 patients, and the transfusion amount was 200-1 000 mL. The drainage volume was 0-750 mL (mean, 61.85 mL). Hidden blood loss was calculated through change of hematocrit level before and after operation. The multiple linear regression was performed to analyse the risk factors of hidden blood loss. The total blood loss was (918.60 +/- 204.44) mL, the hidden blood loss was (797.77 +/- 192.58) mL, and intraoperative visible blood loss was (257.32 +/- 271.24) mL. Single factor analysis showed hidden blood loss was significantly higher in variables as follows: gender, age, injury cause, fracture type, American anesthesiologists grading, anesthesia mode, hypertension, diabetes, disease duration, operation time, intraoperative transfusion of red blood cells, and fixation type. Multiple linear regression showed age, fracture type, anesthesia mode, and fixation type were significant risk factors. The risk factors of hidden blood loss are advanced age (> 60 years), unstable fracture, general anesthesia, and imtramedullary fixation. Especially in elder patients with unstable fracture treated by intramedullary fixation under general anesthesia, hidden blood loss is more significant.
Aldelaimi, Tahrir N
Surgical treatment of nasal bone fractures in children is a complex and challenging task not only to maxillofacial surgeons but exceeding to ears, nose, and throat and plastic surgeons. Twelve child patients including 9 boys (75%) and 3 girls (25%) with nasal bone fractures were seen at the Maxillofacial Surgery Department at Ramadi Teaching Hospital during the period of December 2009 to December 2010. Fractured nasal bone is reduced to its anatomic position with Walsham forceps, and the dislocated or disrupted nasal septum with Asch forceps. The most common cause of the injury was road traffic accident and motorcycle accident 5 (42%); nasal deviation was found in 9 cases (75%), and depression in 2 (17%). In 9 patients (75%), injuries were isolated, and 3 (25%) were associated with other facial bone fractures. Significant advances have been made in the management of these injuries, decreasing the incidence of secondary deformities.
Olsson, O; Ceder, L; Lunsjö, K; Hauggaard, A
The twin hook, which has 2 oppositely directed apical hooks, is an alternative to the lag screw for use with a 'dynamic plate' in the fixation of trochanteric hip fractures. In this prospective study lasting 1 year, 102 consecutive patients with trochanteric hip fractures were treated by 19 surgeons with either a twin hook or a lag screw combined with a conventional sliding hip screw plate or a Medoff sliding plate. Seven intraoperative errors were made with the twin hook but postoperative migration did not differ significantly between the 2 groups. Postoperative fixation failures were equally distributed between the 2 groups. The twin hook provides adequate fixation, which is comparable to that produced by a lag screw.
Huang, Jiangfa; Pan, Jianke; Xu, Mingtao; Xu, Shuchai
Abstract Rationale: Osteopetrosis is a rare disease that predominantly occurs in descendants of inbreeding families. In the case of fractures happen in patients with osteopetrosis, the choice between operative or conservative treatment is still controversial. Open reduction and internal fixation (ORIF) is a conventional treatment for fractures, and it possesses more applicability than conservative treatment. During this surgical treatment, ensure that bone union in the right way is pivotal to success and simultaneously prevents refracture and displacement after the operation. Herein, we present a case of femoral fracture of a patient with osteopetrosis via open reduction and internal fixation. To illustrate successful factors during the treatment process, we discuss experience combined with literature review following case report. Patient concerns: A 67-year-old man who has diagnosed with osteopetrosis over 20 years ago suffered from pain in the left hip last for more than 1 month and he was incapable of walking recently. Before this incident, he had sustained 4 femoral fractures that treated insufficiently by open reduction surgery. Diagnosis: Physical, radiological, and biological examinations indicated a femoral subtrochanteric fracture that was overlapping displacement between fracture ends. Interventions and outcomes: Treated with surgery by open reduction with internal fixation and osteotomy, the fracture united in 12 months, and he returned to walk with full weight bearing, during which no complication occurred. Lessons: Open reduction and internal fixation is also suitable for the patient with osteopetrosis, and they have similar union ability to the normal. To guarantee successful treatment, specific strategies of operation and rehabilitation program are necessary. PMID:28816960
Kadar, Assaf; Sherman, Haggai; Glazer, Yael; Katz, Eldad; Steinberg, Ely Liviu
The most common major complications following surgical fixation of patellar fractures are infection, nonunion and reoperation. In this study, we sought to define the predisposing factors to the development of these complications. Open reduction and internal fixation surgeries for patellar fractures that were performed in a single institution between 2006 and 2011 were retrospectively reviewed. Patients' demographic data (age, gender, comorbidities), injury and fracture data (associated injuries, type of fracture, open or closed fracture), surgical data (type of surgery and interval between fracture occurrence and surgery) and major postoperative complications (infection, nonunion, symptomatic hardware and revision surgery) were collected from the medical records and verified by a telephone survey. Correlation analysis identified the major variables influencing the development of these complications. The cohort of 188 patients had an average follow-up of 908 days. Thirteen (6.9 %) patients developed infection, 3 (1.6 %) had fracture nonunion and 42 (22.3 %) required a second operation. A history of cerebrovascular accident (CVA) correlated significantly with the development of infection (OR 6.18, CI 1.1-35.6, p = 0.041) and nonunion (OR 14.9, CI 1.2-188.1; p = 0.037). A history of diabetes significantly increased the risk of a second operation (OR 8.69, CI 95 % 1.8-41.9, p = 0.007). Open fracture did not increase the risk of any of these complications. A history of CVA and diabetes mellitus significantly increased the risk of complications following patellar fracture fixation. Patients with these comorbidities should be informed of their increased risk of these complications and be followed up more rigorously.
Zhang, Yuntong; Zhao, Xue; Tang, Yang; Zhang, Chuncai; Xu, Shuogui; Xie, Yang
Posterior wall fractures are one of the most common acetabular fractures. However, only 30% of these fractures involve a single large fragment, and comminuted acetabular posterior wall fractures pose a particular surgical challenge. The purpose of this study was to compare outcomes between patients who received fixation for comminuted posterior wall fracture using the Acetabular Tridimensional Memory Fixation System (ATMFS) and patients who underwent fixation with conventional screws and buttress plates (Plates group). Between April 2003 and May 2007, 196 consecutive patients who sustained a comminuted posterior wall fracture of acetabulum were treated with ATMFS or conventional screws and buttress plates. Operative time, fluoroscopy time, blood loss, and any intra-operative complications were recorded. Plain AP and lateral radiographs were obtained at all visits (Matta's criteria). Modified Merle d' Aubigne-Postel score, and Mos SF-36 score were compared between groups. Fifty patients were included in the analysis with 26 in the ATMFS group and 24 in the Plates group. The mean follow-up time was 57.5 months, ranging from 31 to 69 months. All patients had fully healed fractures at the final follow-up. There was no difference in clinical outcomes or radiological evaluations between groups. Patients with comminuted posterior wall fractures of the acetabulum treated with the ATMFS or conventional screws and buttress plate techniques achieve a good surgical result. Both techniques are safe, reliable, and practical. Use of the ATMFS technique may reduce blood loss and improve rigid support to marginal bone impaction. The use ATMFS may need additional support when fractures involve the superior roof. Copyright © 2013 Elsevier Ltd. All rights reserved.
Kish, Alexander J; Hennrikus, William L
The AAOS guidelines suggest operative fixation of all type 2 supracondylar humerus fractures. Not all type 2 fractures are the same. Wilkins type 2a fractures have intrinsic stability. The purpose of this paper is to report closed reduction and single-pin fixations for Wilkins 2a fractures. Fifteen consecutive type 2a fractures treated with single-pin fixation were prospectively evaluated. Procedure notes, age, sex, side involved, duration of immobilization, and complications were recorded. Radiographs were measured for the lateral humerocapitellar line and the humeral ulna angle. At final follow-up the carrying angle, range of motion, and the Flynn criteria were recorded. The average age of patients was 5 years (age range, 1 to 9 y). Three females and 12 males were studied. Eight right elbows and 7 left elbows were injured. A 0.0625 K-wire was used in 2 cases and a 2 mm K-wire was used in 13 cases. On preoperative lateral radiographs, the anterior humeral line did not intersect the capitellum. On postoperative radiographs, the anterior humeral line intersected the middle third of the capitellum. Following pinning, the elbow was immobilized in a long-arm cast in pronation with elbow at 75 degrees of flexion. The cast and pin were removed at an average of 27 days (range, 25 to 31 d). One patient was lost to follow-up. The remaining 14 patients were followed for at least 3 months. At final follow-up, the carrying angle was within 2 degrees of the opposite elbow and ROM was within 3 degrees of the opposite elbow in all cases. Final Flynn criteria were excellent in all 14 patients. There were no complications. Treatment of supracondylar fractures has evolved from selective pinning of type 2 fractures to pinning all type 2 fractures. The results of the current study demonstrate the efficacy of using a single lateral entry pin for stabilization of type 2a fractures in children. Level III.
Lovald, Scott T; Wagner, Jon D; Baack, Bret
To design and optimize a bone plate for fractures of the mandibular body that will provide maximum fracture stability with minimal implanted volume and patient intrusion. The design will be driven by the unique biomechanics specific to this fracture location. A finite element model of a fractured human mandible was created using tomography scans. Material properties were assigned to the cortical bone, cancellous bone, and dental region. Boundary conditions included simulating a unilateral molar clench and incisal loading. The bone plate design process included a shape optimization routine and design parameter analysis using the model. The optimized bone plate design was finally compared with standard bone plate configurations based on stress and strain measures. For incisal loading, the newly designed InterFlex II plate has 69% of the fracture strain and only 34% of the plate stress of an 8-hole strut plate. For unilateral molar loading, those numbers improve even further to 59% and 27%, respectively. InterFlex II plate stresses are less than or equal to the paired plate configuration, and fracture strain is within 10% of the corresponding paired plate strain under both loading scenarios. In terms of mechanical performance, InterFlex II is in the same class as the commonly used paired plate configuration, despite having only 55% of the implanted volume. A design process focused on shape and design variable optimization can produce bone plates that provide maximum fracture stability with minimum implanted volume.
Kazemian, G H; Manafi, A R; Najafi, F; Najafi, M A
Although the use of a dynamic hip screw (DHS) is considered to be the preferred treatment for intertrochanteric fractures, the external fixation device could produce clinical outcomes comparable to the outcomes obtained with conventional treatment. Furthermore, because external fixation is minimally invasive, we expected a lower rate of morbidity. Therefore, we compared the two treatments in a clinical trial of elderly patients with intertrochanteric fracture. 60 elderly high-risk patients with an average age of 78 years were treated for intertrochanteric fracture, resulting from a low energy trauma. Patients were randomly divided in two groups regarding to treatment. In Group A the patients were treated with DHS, while in Group B were treated with external fixator. The fixator was well accepted and no patient had significant difficulties while sitting or lying. The average intraoperative time was 73 min in Group A and 15 min in Group B (p<0.05). 27 patients of Group A need blood transfusion postoperatively and none in Group B (p<0.05). The mean duration of hospitalization in Group A and Group B was 8.4 and 2.2 days, respectively (p<0.05). 9 of patients Group B had pin-track infection grade 2 that all were treated by oral antibiotics. There were no differences in comorbidities, quality of reduction, screw cut out, bed sore and HHS between the two groups. Treatment with external fixator is an effective treatment for intertrochanteric fractures in elderly highrisk patients. The advantages include quick and simple application, minimal blood loss, less radiation exposure, adequate fixation, pain reduction, early discharge from hospital, low costs and favourable functional outcomes. Copyright © 2013 Elsevier Ltd. All rights reserved.
Cho, Won-Tae; Cho, Jae-Woo; Yoon, Yong-Cheol; Kim, Youngwoo; Oh, Chang-Wug; Oh, Jong-Keon
During nailing of intertrochanteric fractures, there is always a risk of reduction loss despite achieving an acceptable reduction status after a percutaneous procedure. Most surgeons usually attempted to maintain the reduction with a manual endeavor. However, we experienced varying amounts of intraoperative reduction loss and had to perform readjustments several times. These struggles motivated us to attempt provisional pin fixation as an alternative method. The purpose of this study was to analyze the factors affecting intraoperative reduction loss, especially in comparison between two methods. Sixty-eight patients with intertrochanteric fractures were included. They were divided into two groups based on the method, by retrospective analysis of the intraoperative c-arm image. In the manual maintenance group, an assistant maintained the instruments during the procedure. In the provisional pin fixation group, the reduction was temporaryily held by a 3.2mm guide pin fixation across the fracture. A displacement of more than one cortical thickness in any plane or angular deformity during any point in the procedure after acceptable reduction was judged as an intraoperative reduction loss. Multivariate logistic regression was used for statistical analysis. The number of cases with intraoperative reduction loss was 18 (18 of 38, 46.1%) in the manual maintenance group and 6 (6 of 30, 20.0%) in the provisional pin fixation group. The odds ratio of intraoperative reduction loss in the manual maintenance group was 5.182 (95% confidence interval, 1.455-18.452) compared with the provisional pin fixation group as the reference. As a reasonable approach for maintaining reduction, provisional pin fixation can significantly decrease intraoperative reduction loss after percutaneous reduction of intertrochanteric fractures during nailing.
Zielinski, Stephanie M.; Keijsers, Noël L.; Praet, Stephan F.E.; Heetveld, Martin J.; Bhandari, Mohit; Wilssens, Jean Pierre; Patka, Peter; Van Lieshout, Esther M.M.
Objectives To determine patient independency, health-related and disease-specific quality of life (QOL), gait pattern, and muscle strength in patients after salvage arthroplasty for failed internal fixation of a femoral neck fracture. Design Secondary cohort study to a randomized controlled trial. Setting Multicenter trial in the Netherlands, including 14 academic and non-academic hospitals Patients Patients after salvage arthroplasty for failed internal fixation of a femoral neck fracture were studied. A comparison was made with patients who healed uneventfully after internal fixation. Intervention None (observatory study) Main outcome measurements Patient characteristics, SF-12, and WOMAC scores were collected. Gait parameters were measured using plantar pressure measurement. Maximum isometric forces of the hip muscles were measured using a handheld dynamometer. Differences between the fractured and contralateral leg were calculated. Groups were compared using univariate analysis. Results Of 248 internal fixation patients (median age 72 years), salvage arthroplasty was performed in 68 patients (27%). Salvage arthroplasty patients had a significantly lower WOMAC score (median 73 versus 90, P=0.016) than patients who healed uneventfully after internal fixation. Health-related QOL (SF-12) and patient independency did not differ significantly between the groups. Gait analysis showed a significantly impaired progression of the center of pressure in the salvage surgery patients (median ratio −8.9 versus 0.4, P=0.013) and a significant greater loss of abduction strength (median −25.4 versus −20.4 N, P=0.025). Conclusion Despite a similar level of dependency and QOL, salvage arthroplasty patients have inferior functional outcome than patients who heal after internal fixation of a femoral neck fracture. PMID:24835623
Zielinski, Stephanie M; Keijsers, Noël L; Praet, Stephan F E; Heetveld, Martin J; Bhandari, Mohit; Wilssens, Jean Pierre; Patka, Peter; Van Lieshout, Esther M M
To determine patient independency, health-related and disease-specific quality of life (QOL), gait pattern, and muscle strength in patients after salvage arthroplasty for failed internal fixation of a femoral neck fracture. Secondary cohort study to a randomized controlled trial. Multicenter trial in the Netherlands, including 14 academic and nonacademic hospitals. Patients after salvage arthroplasty for failed internal fixation of a femoral neck fracture were studied. A comparison was made with patients who healed uneventfully after internal fixation. None (observatory study). Patient characteristics, SF-12, and Western Ontario McMaster osteoarthritis index scores were collected. Gait parameters were measured using plantar pressure measurement. Maximum isometric forces of the hip muscles were measured using a handheld dynamometer. Differences between the fractured and contralateral leg were calculated. Groups were compared using univariate analysis. Of 248 internal fixation patients (median age, 72 years), salvage arthroplasty was performed in 68 patients (27%). Salvage arthroplasty patients had a significantly lower Western Ontario McMaster osteoarthritis index score (median, 73 vs. 90; P = 0.016) than patients who healed uneventfully after internal fixation. Health-related QOL (SF-12) and patient independency did not differ significantly between the groups. Gait analysis showed a significantly impaired progression of the center of pressure in the salvage surgery patients (median ratio, -8.9 vs. 0.4, P = 0.013) and a significant greater loss of abduction strength (median, -25.4 vs. -20.4 N, P = 0.025). Despite a similar level of dependency and QOL, salvage arthroplasty patients have inferior functional outcome than patients who heal after internal fixation of a femoral neck fracture. Therapeutic level III.
Yıldırım, Azad; Kapukaya, Ahmet; Mertsoy, Yılmaz; Yiğit, Şehmus; Çaçan, Mehmet Akif; Atiç, Ramazan
The treatment of open fractures leads to major problems which may be due to various reasons. It mainly causes soft tissue problems due to the absorption of a large amount of energy by the soft tissues and bone tissues. Although some recent treatment protocols have eliminated many problems regarding delayed soft tissue closure, it still remains a big challange. This study uses a method called the internal fixator technique with noncontact locking plate (NC-LP) which involves the use of a combination of advantages of open and closed fixation techniques. 42 patients (32 men and 10 women) having a mean age of 34.11 years (range 17-56 years) with open fractures operated using internal fixator technique between 2007 and 2012 were included in this study. A retrospective chart review was conducted to record the following: age, gender, anatomic region of fractures, fracture etiology, classification of open fractures by Gustilo-Anderson and AO classification, surgeries, length of hospitalization, location and pattern of fracture, length of followup, and complications. The fractures were caused by traffic accidents, shotgun injuries, falls from heights, and industrial crush injuries. Based on the Gustilo-Anderson classification, 31 fractures were Type III and 11 were Type II, where 23 were localized in the tibia and 19 in the femur. Patients delay for a mean of 13.5 h (range 6-24 h) for operation and the mean followup interval was 27.8 months (range 16-44 months). The mean union time was 19.7 weeks (range 16-29 weeks). One patient had delayed union and implant failure, one patient had osteomyelitis, five suffered from surface skin necrosis, and one patient had an angulation of 17° in the sagittal plane, for which no additional intervention was performed. This case series demonstrates that an "internal fixator technique" is an acceptable alternative to the management of open fractures of the femur or tibia in adult patients. The NC-LP method provided opportunities to achieve
Macdonald, J.; Robinson, A.; Brown, I.
This case report involves a 56-year-old female (Mrs X) with a traumatic intertrochanteric hip fracture with subtrochanteric extension below a previous Birmingham hip resurfacing. Periprosthetic fractures following hip resurfacing are usually subcapital and treated with a revision or conservative management. We present an unusual surgical problem with an interesting solution stabilising the fracture using a proximal femoral locking compression plate (LCP). Eight months following surgery the patient is able to walk pain free and there is good fixation and stability. PMID:24995142
Terai, Haruhiko; Shimahara, Masashi
We report a new intermaxillary fixation (IMF) method for condylar fractures using a thermoforming plate. Fifteen cases of condylar fracture were selected and thermoforming plates were applied. The patient's recover was uneventful in all 15 cases, and the period of IMF ranged from 7 to 17 days, (mean 12) for the following 7 days IMF was used only at night together with functional jaw training during the day. The outcome was good. IMF using a thermoforming plate may be a useful technique for selected condylar fractures.
Gupta, Yogendra; Jha, Ranjib Kumar; Karn, Navin Kumar; Sah, Sanjaya Kumar; Mishra, Bibhuti Nath; Bhattarai, Manoj Kumar
Klippel-Trenaunay syndrome (KTS) is a rare complex malformation characterized by the clinical triad of capillary malformations, soft tissue and bone hypertrophy, and venous/lymphatic malformation. Fractures of long bones in such cases are challenging to treat. A 12-year-old female with this syndrome presented with femoral shaft fracture of right thigh. She was initially kept on skeletal traction for two weeks and then she underwent closed reduction and immobilization with external fixator with uneventful intraoperative and postoperative period. Fracture united at four and half months. PMID:26885423
El-Alfy, Barakat; Ali, Ayman M; Fawzy, Sallam I
Comminuted diaphyseal fractures in the pediatric age group represent a major orthopedic problem. It is associated with a high incidence of complications and poor outcomes because of the instability and difficulty in treatment. The aim of this study was to evaluate the efficacy of combined external skeletal fixation and flexible intramedullary nails in reconstruction of comminuted diaphyseal fracture in skeletally immature patients. Combined external fixator and elastic stable intramedullary nails were used in the management of 27 pediatric patients (15 males and 12 females) with unstable comminuted diaphyseal fractures of the tibia and femur. There were 19 fractures of the femur and eight fractures of the tibia. The average age of the patients was 8.7 years (range 7-14 years) for the femur and 10.8 years (range 6-15 years) for the tibia. Fractures were classified according to the system of Winquist and Hansen as grade II (five cases), grade III (nine cases), and grade IV (13 cases). All cases were operated within 6 days (range 0-6 days) after injury. The mean follow-up period was 2.8 years (range 2-3.5 years). The average duration of the external fixation was 1.6 months for fractures of the tibia, whereas it was 1.4 months for fractures of the femur. The average time for tibia fracture union was 2.8 months for fractures of the tibia, whereas it was 1.9 months for fractures of the femur. Malalignment in varus less than 5° was noted in one patient. One patient had a limb-length discrepancy of 1.5 cms. There were five cases (18.5%) with pin-tract infection. According to the Association for the Study and Application of the Methods of Ilizarov evaluation system, bone results were excellent in 23 cases (85.2%), good in three cases (11.1%), and poor in one case (3.7%). Functional results were excellent in 22 (81.5%) cases and good in five (18.5%) cases. Combined use of external fixators and elastic intramedullary nails is a good method for the treatment of comminuted
Gillett, N; Brown, S A; Dumbleton, J H; Pool, R P
Thermoplastic plates of Nylon 6-10 and Polybutylene terephthalate reinforced with 30% short randomly oriented carbon fibres were tested for internal fixation of canine femoral transverse midshaft fractures. The elastic modulus of the plates was one-half that of bone: however, ultimate strength and strain in bending were comparable to bone. The fractures healed with moderate callus formation which was completely remodelled by 8 to 12 wk post surgery. Although a moderate inflammatory reaction to occasional particulate debris was noted, the materials appeared to possess the proper elastic moduli to allow sufficient support for the healing fracture without protecting the remodelling process.
Toro, Giuseppe; Calabrò, Giampiero; Toro, Antonio; de Sire, Alessandro; Iolascon, Giovanni
Summary Distal femoral fractures have typically a bimodal occurrence: in young people due to a high-energy trauma and in older people related to a low-energy trauma. These fractures are associated to a very high morbidity and mortality in elderly. Distal femoral fractures might be treated with plates, intramedullary nails, external fixations, and prosthesis. However, difficulties in fracture healing and the rate of complications are important clinical issues. The purpose of this retrospective review was to present our experience in treatment of distal femoral fracture in a sample of older people in order to evaluate the technical pitfalls and strategies used to face up the fractures unsuccessfully treated with locking plates. We included people aged more than 65 years, with a diagnosis of distal femoral fracture, treated with locking plates. We considered ‘unsuccessfully treated’ the cases with healing problems or hardware failures. Of the 12 patients (9 females and 3 males; mean aged 68.75 ± 3.31 years) included, we observed 3 ‘unsuccessfully cases’, 2 due to nonunions and 1 due to an early hardware failure, all treated using a condylar blade plate with a bone graft. One patient obtained a complete fracture healing after 1 year and in the other cases there was a nonunion. We observed as most common technical pitfalls: inadequate plate lengthening, fracture bridging, and number of locking screws. The use of locking plates is an emerging technique to treat these fractures but it seems more challenging than expected. In literature there is a lack of evidences about the surgical management of distal femoral fractures that is still an important challenge for the orthopaedic surgeon that has to be able to use all the fixation devices available. PMID:27134634
Saidpour, Seyed H
In the internal fixation of fractured bone by means of bone-plates fastened to the bone on its tensile surface, an on-going concern has been the excessive stress shielding of the bone by the excessively-stiff stainless-steel plate. The compressive stress shielding at the fracture-interface immediately after fracture-fixation delays callus formation and bone healing. Likewise, the tensile stress shielding in the layer of bone underneath the plate can cause osteoporosis and decrease in tensile strength of this layer. In this study a novel forearm internal fracture fixation plate made from short carbon fibre reinforced plastic (CFRP) was used in an attempt to address the problem. Accordingly, it has been possible to analyse the stress distribution in the composite plates using finite-element modelling. A three-dimensional, quarter-symmetric finite element model was generated for the plate system. The stress state in the underlying bone was examined for several loading conditions. Based on the analytical results the composite plate system is likely to reduce stress-shielding effects at the fracture site when subjected to bending and torsional loads. The design of the plate was further optimised by reducing the width around the innermost holes.
Liu, Jingchen; Li, Ye; Wu, Yuntao
The present study aimed to evaluate the effect of using one-stage posterior C2 and C3 pedicle screw fixation or combined anterior C2-C3 fusion in the treatment of unstable hangman's fracture. A total of 13 patients with unstable hangman's fractures underwent C2 and C3 pedicle screw fixation, lamina interbody fusion or combined anterior C2-C3 fusion and imaging examinations to evaluate the fracture fixation and healing condition at three days and three months following surgery. Postoperative X-ray and computed tomography (CT) results showed high fracture reduction, good internal fixation position and reliable fracture fixation. The three-month postoperative CT showed good vertebral fracture healing. C2 and C3 pedicle screw fixation has a good curative effect in the treatment of unstable hangman's fracture. The direct fixation of the fracture enables early ambulation by the patients.
Korompilias, Anastasios V; Lykissas, Marios G; Kostas-Agnantis, Ioannis P; Beris, Alexandros E; Soucacos, Panayiotis N
The purpose of this study was to classify Galeazzi type injuries and determine the association of residual instability after rigid fixation with the fracture pattern of the shaft of the radius, using a system that is based on anatomic landmarks of the radial shaft. The clinical records of 95 patients (72 men and 23 women) with Galeazzi type injuries requiring open reduction and internal fixation of the fractures were retrospectively reviewed. The mean follow-up was 6.8 years (range, 18 mo to 11 y) after injury. Sixty-nine fractures occurred in the distal third of the radial shaft (type I), 17 fractures were in the middle third (type II), and 9 fractures were in the proximal third of the shaft of the radius (type III). Gross instability of the distal radioulnar joint (DRUJ) was determined intraoperatively by manipulation after radial fixation as compared to the uninjured side. Forty patients had DRUJ instability after internal fixation and were treated with temporary pinning with a K-wire placed transversely proximal to the sigmoid notch. Distal radioulnar joint instability after internal fixation was recorded in 37 type I fractures, 2 type II fractures, and 1 type III fracture. Distal radioulnar joint instability following radial shaft fracture fixation is significantly higher in patients with type I fractures than in patients with type II or type III fractures. The location of the radius fracture can be sufficiently used for preoperative estimation of percentage chance of potential DRUJ instability after fracture fixation. Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Vander Have, Kelly L; Ganley, Theodore J; Kocher, Mininder S; Price, Charles T; Herrera-Soto, Jose A
Tibial eminence fractures are rare injuries in children and adolescents. Displaced fractures require reduction and fixation. Operative stabilization can be accomplished with either open or arthroscopic reduction and fixation. Whereas loss of extension has been reported, there are no reports in the literature that quantify loss of motion or provide guidance for treatment. To report a series of patients who developed knee stiffness after operative treatment for displaced tibial eminence fractures. Case series; Level of evidence, 4. Review of medical records and imaging studies of pediatric patients with displaced tibial eminence fractures who developed arthrofibrosis after surgical intervention. Thirty-two patients were identified. Twenty-four required reoperation for loss of flexion (n = 9), loss of extension (n = 4), or both (n = 11). Manipulation under anesthesia resulted in distal femoral fractures and subsequent growth arrest in 3 patients. Twenty-nine patients were able to achieve near full knee motion at final follow-up. Children with tibial spine fractures are at risk for arthrofibrosis. Stabilization of the fracture is important to allow early postoperative rehabilitation. Should stiffness occur, manipulation of the knee should be performed only in conjunction with lysis of adhesions.
Behera, Prateek; Aggarwal, Sameer; Kumar, Vishal; Kumar Meena, Umesh; Saibaba, Balaji
Fractures of the tibia are one of the most commonly seen orthopedic injuries. Most of them result from a high velocity trauma. While intramedullary nailing of tibial diaphyseal fractures is considered as the golden standard form of treatment for such cases, many metaphyseal and metaphyseal-diaphyseal junction fractures can also be managed by nailing. Maintenance of alignment of such fractures during surgical procedure is often challenging as the pull of patellar tendon tends to extend the proximal fragment as soon as one flexes the knee for the surgical procedure. Numerous technical modifications have been described in the literature for successfully nailing such fractures including semi extended nailing, use of medial plates and external fixators among others. In this study, it was aimed to report two cases in which we used our ingenious method of applying external fixator for maintaining alignment of the fracture and aiding in the entire process of closed intramedullary nailing of metaphyseal tibial fractures by the conventional method. We were able to get good alignment during and after the closed surgery as observed on post-operative radiographs and believe that further evaluation of this technique may be of help to surgeons who want to avoid other techniques.
Chan, Yuen; Selvaratnam, Veenesh; Garg, Neeraj
Use of Kirschner wires (K-wires) is the most common method of fracture stabilisation in lateral condyle fracture fixation in children. We report a case of toxic shock syndrome (TSS) following an open reduction and internal fixation using K-wires for a humeral lateral condyle fracture in a 5-year-old girl. TSS is a toxin-mediated multisystem illness. It typically presents with shock and it is most often attributed to toxin-producing strains of Staphylococcus aureus and Streptococcus pyogenes. It can lead to multiorgan failure and, ultimately, death. It is important to be aware of TSS, as it can present within any setting. Patients often have non-specific symptoms and their condition can worsen rapidly. TSS postorthopaedic surgery is rare; however, due to the serious nature of this disease, it is important to promptly recognise and diagnose TSS, and to ensure appropriate treatment is started without delay. PMID:26264942
de Jesus, G P; Vaz, L G; Gabrielli, M F R; Passeri, L A; V Oliveira, T; Noritomi, P Y; Jürgens, P
The surgical treatment of mandibular condyle fractures currently offers several possibilities for stable internal fixation. In this study, a finite element model evaluation was performed of three different methods for osteosynthesis of low subcondylar fractures: (1) two four-hole straight plates, (2) one seven-hole lambda plate, and (3) one four-hole trapezoidal plate. The finite element model evaluation considered a load applied to the first molar on the contralateral side to the fracture. Results showed that, although the three methods are capable of withstanding functional loading, the lambda plate displayed a more homogeneous stress distribution for both osteosynthesis material and bone and may be a better method when single-plate fixation is the option.
Lee, Jung-Ho; Choi, Yoon-Seok; Oh, Deuk-Young; Rhie, Jong-Won; Han, Ki-Taik; Ahn, Sang-Tae
The ultimate goal in treating zygomatic complex fracture is to obtain an accurate, stable reduction while minimizing external scars and functional deformity. The present authors present our experiences with a single transconjunctival incision and two-point (inferior orbital rim and frontozygomatic suture) fixation in 53 patients with zygomatic complex fracture which were not comminuted. All patients had transconjunctival approaches with lateral canthal extensions, and six out of 53 patients also had an additional small (about less than 2 cm) gingivobuccal incision to achieve an accurate reduction. There were 3 minor complications, and the overall esthetics and functional results were satisfactory with a long term follow-up. Our method has the following advantages in the reduction of zygomatic complex fracture; It leaves only an inconspicuous lateral canthal scar. In addition, it provides excellent simultaneous visualization of the inferior orbital rim and frontozygomatic suture area. Hence, two-point fixation through a single incision can be performed with a satisfactory stability. PMID:17179691
Gwinn, David E; O'Toole, Robert V; Eglseder, W Andrew
Galeazzi fractures traditionally are treated in long arm casts with the wrist fully supinated for 6 weeks after open reduction and internal fixation. Recent literature suggests that early motion can be permitted for a subset of Galeazzi fractures. Defining a safe postoperative protocol that allows immediate elbow motion, immediate platform weight bearing, and early wrist motion might decrease elbow morbidity, increase range of motion, and improve outcomes. A retrospective review of a prospectively collected database of 26 patients at a level I trauma center was conducted. Early motion protocol was assigned to patients who were radiographically and clinically stable after plate and screw fixation. Elbow flexion and platform weight bearing were allowed immediately; increased wrist rotation was allowed at 2-week intervals. Early motion of elbow and wrist seems to be safe during postoperative rehabilitation of repaired Galeazzi fractures. The postoperative protocol might maximize elbow and wrist range of motion.
Park, Young-Seop; Hyun, Seung-Jae; Choi, Ho Yong; Kim, Ki-Jeong; Jahng, Tae-Ahn
OBJECTIVE The aim of this study was to investigate the risk of upper instrumented vertebra (UIV) fractures associated with UIV screw fixation (unicortical vs bicortical) and polymethylmethacrylate (PMMA) augmentation after adult spinal deformity surgery. METHODS A single-center, single-surgeon consecutive series of adult patients who underwent lumbar fusion for ≥ 4 levels (that is, the lower instrumented vertebra at the sacrum or pelvis and the UIV of the thoracolumbar spine [T9-L2]) were retrospectively reviewed. Age, sex, follow-up duration, sagittal UIV angle immediately postoperatively including several balance-related parameters (lumbar lordosis [LL], pelvic incidence, and sagittal vertical axis), bone mineral density, UIV screw fixation type, UIV PMMA augmentation, and UIV fracture were evaluated. Patients were divided into 3 groups: Group U, 15 patients with unicortical screw fixation at the UIV; Group P, 16 with bicortical screw fixation and PMMA augmentation at the UIV; and Group B, 21 with bicortical screw fixation without PMMA augmentation at the UIV. RESULTS The mean number of levels fused was 6.5 ± 2.5, 7.5 ± 2.5, and 6.5 ± 2.5; the median age was 50 ± 29, 72 ± 6, and 59 ± 24 years; and the mean follow-up was 31.5 ± 23.5, 13 ± 6, and 24 ± 17.5 months in Groups U, P, and B, respectively (p > 0.05). There were no significant differences in balance-related parameters (LL, sagittal vertical axis, pelvic incidence-LL, and so on) among the groups. UIV fracture rates in Groups U (0%), P (31.3%), and B (42.9%) increased in sequence by group (p = 0.006). UIV bicortical screw fixation increased the risk for UIV fracture (OR 5.39; p = 0.02). CONCLUSIONS Bicortical screw fixation at the UIV is a major risk factor for early UIV compression fracture, regardless of whether a thoracolumbosacral orthosis is used. To reduce the proximal junctional failure, unicortical screw fixation at the UIV is essential in adult spinal deformity correction surgery.
Kistler, Brian J; Smithson, Ian R; Cooper, Seth A; Cox, Jacob L; Nayak, Aniruddh N; Santoni, Brandon G; Sagi, H Claude
Several construct options exist for transverse acetabular fracture fixation. Accepted techniques use a combination of column plates and lag screws. Quadrilateral surface buttress plates have been introduced as potential fixation options, but as a result of their novelty, biomechanical data regarding their stabilizing effects are nonexistent. Therefore, we aimed to determine if this fixation method confers similar stability to traditional forms of fixation. We biomechanically compared two acetabular fixation plates with quadrilateral surface buttressing with traditional forms of fixation using lag screws and column plates. Thirty-five synthetic hemipelves with a transverse transtectal acetabular fracture were allocated to one of five groups: anterior column plate+posterior column lag screw, posterior column plate+anterior column lag screw, anterior and posterior column lag screws only, infrapectineal plate+anterior column plate, and suprapectineal plate alone. Specimens were loaded for 1500 cycles up to 2.5x body weight and stiffness was calculated. Thereafter, constructs were destructively loaded and failure loads were recorded. After 1500 cycles, final stiffness was not different with the numbers available between the infrapectineal (568±43 N/mm) and suprapectineal groups (602±87 N/mm, p=0.988). Both quadrilateral plates were significantly stiffer than the posterior column buttress plate with supplemental lag screw fixation group (311±99 N/mm, p<0.006). No difference in stiffness was identified with the numbers available between the quadrilateral surface plating groups and the lag screw group (423±219 N/mm, p>0.223). The infrapectineal group failed at the highest loads (5.4±0.6 kN) and this was significant relative to the suprapectineal (4.4±0.3 kN; p=0.023), lag screw (2.9±0.8 kN; p<0.001), and anterior buttress plate with posterior column lag screw (4.0±0.6 kN; p=0.001) groups. Quadrilateral surface buttress plates spanning the posterior and anterior
Li, Changhua; Xie, Bingju; Chen, Shanxi; Lin, Guangmao; Yang, Guojing; Zhang, Lei
The aim of this prospective study was to investigate the effect of local hip bone density on mechanical failure after fixation of pertrochanteric fractures and to establish possible risk factors for the failures. A total of 136 consecutive patients presenting a closed unilateral pertrochanteric fracture were enrolled. The patients were treated with a sliding hip screw or an intramedullary nail. Dual energy X-ray absorptiometry measurements for bone density of the contralateral hip were made within 4 weeks postoperatively. Follow-up evaluations on the standard radiographs were documented for any mechanical failure including loss of reduction, screw or blade cut-out, lateral migration of the screw or blade, and implant breakage. Secondary outcomes were also recorded including patient characteristics and fixation construct variables as possible predictors for mechanical failure. At a minimum of 2 years of follow-up, 38 patients were reported with mechanical failure at an estimated risk of 27.9 %. The local bone density measurements for the study population showed no difference between patients with (0.710 g/cm(2)) and without (0.726 g/cm(2)) mechanical failure (P = 0.180). We also observed no significant correlation between local bone density and failure in patients with good fracture reduction (P = 0.862). The multivariate regression analysis identified fracture type (P < 0.001) and quality of fracture reduction (P < 0.001) as being independent predictors for mechanical failure, whereas local bone density was not (P = 0.658). Local hip bone density does not appear to have a significant influence on mechanical failure after internal fixation of pertrochanteric fractures. Stable fractures and fractures with good reduction are expected to obtain satisfactory outcomes.
Lawrence, Tom M; Ahmadi, Shahryar; Morrey, Bernard F; Sánchez-Sotelo, Joaquín
This study set out to accurately determine the incidence of wound complications after distal humerus fracture fixation, to assess risk factors, and to determine their implications on outcome. Eighty-nine distal humerus fractures (mean patient age, 58 years) were treated with internal fixation at an average of 4 days after injury. Mean follow-up time was 15 months (range, 6-72 months). Twenty-nine (33%) fractures were open. Medical records and radiographs were reviewed to determine wound complications. Logistic regression analysis was carried out to determine associated risk factors. Fourteen patients (15.7%) developed a major wound complication requiring on average 2.5 (range, 1-6) additional surgical procedures. Six patients required plastic surgical soft tissue coverage. All 14 fractures complicated by wound problems united. The final mean range of motion in the major wound complication group was 100° (range, 65°-130°), compared with 100° (range, 10°-140°) in those with no or minor wound problems. Grade III open fractures and the use of a plate to stabilize the olecranon osteotomy were identified as significant risk factors for development of major wound complications. The incidence of major wound complications after fixation of distal humerus fractures is substantial. The presence of a grade III open fracture and the use of an olecranon osteotomy stabilized with a plate are significant risk factors for major wound complications. Fracture healing rates and functional elbow range of motion do not appear to be affected by major wound complications when they are handled with proper soft tissue coverage techniques. Copyright © 2014 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.
Nishizuka, Takanobu; Kurahashi, Toshikazu; Hara, Tatsuya; Hirata, Hitoshi; Kasuga, Toshihiro
Almost all of the currently available fracture fixation devices for metaphyseal fragility fractures are made of hard metals, which carry a high risk of implant-related complications such as implant cutout in severely osteoporotic patients. We developed a novel fracture fixation technique (intramedullary-fixation with biodegradable materials; IM-BM) for severely weakened long bones using three different non-metallic biomaterials, a poly(l-lactide) (PLLA) woven tube, a nonwoven polyhydroxyalkanoates (PHA) fiber mat, and an injectable calcium phosphate cement (CPC). The purpose of this work was to evaluate the feasibility of IM-BM with mechanical testing as well as with an animal experiment. To perform mechanical testing, we fixed two longitudinal acrylic pipes with four different methods, and used them for a three-point bending test (N = 5). The three-point bending test revealed that the average fracture energy for the IM-BM group (PLLA + CPC + PHA) was 3 times greater than that of PLLA + CPC group, and 60 to 200 times greater than that of CPC + PHA group and CPC group. Using an osteoporotic rabbit distal femur incomplete fracture model, sixteen rabbits were randomly allocated into four experimental groups (IM-BM group, PLLA + CPC group, CPC group, Kirschner wire (K-wire) group). No rabbit in the IM-BM group suffered fracture displacement even under full weight bearing. In contrast, two rabbits in the PLLA + CPC group, three rabbits in the CPC group, and three rabbits in the K-wire group suffered fracture displacement within the first postoperative week. The present work demonstrated that IM-BM was strong enough to reinforce and stabilize incomplete fractures with both mechanical testing and an animal experiment even in the distal thigh, where bone is exposed to the highest bending and torsional stresses in the body. IM-BM can be one treatment option for those with severe osteoporosis. PMID:25111138
Kim, Min Bom; Cho, Jae-Woo; Lee, Young Ho; Shon, Won-Yong; Park, Jung Wee; Kim, Jinil; Oh, Jong-Keon
Periprosthetic fractures are difficult to manage. Plating technique has been considered a reliable form of management of periprosthetic fractures with a well-fixed stem, but a dependable and stable method of plate fixation to the bone is lacking. This study reports the clinical results using a locking attachment plate (LAP) instead of cable fixation to fix locking plates to a periprosthetic femoral shaft fracture. Nineteen patients with periprosthetic femoral shaft fractures around well-fixed stemmed implants were studied between August 2012 and December 2014. Patients were followed up for at least 1 year postoperatively. Median age was 74 years (range 56-96 years). Fractures were classified according to the Unified Classification System, Vancouver classification, and Su classification. Open reduction was performed under minimal incision and the locking plate was fixed to the lateral cortex of the femoral shaft. The part of the shaft without a stem was fixed to the plate using 5.0-mm locking screws, and the part with an underlying stem was fixed using 3.5-mm locking screws through the LAP instead of cables. Postoperatively, patients were managed using general principles for femoral shaft fractures. Average follow-up was 16 months (range 12-36 months). All cases achieved fracture healing without loss of reduction. There were no cases of implant breakage or stem loosening at final follow-up. The average number of LAPs per fixation construct was 2.1 (range 1-4), and the average number of 3.5-mm locking screws through each LAP was 3.3 (range 2-4). The average value of plate screw density was 0.55 (range 0.37-0.8), and the average working length was four holes (range 2-8). Using the LAP to manage periprosthetic fractures with a well-fixed stem could obviate the need for cable around the stem area and yield acceptable outcomes.
Lv, Hongzhi; Chang, Wenli; Yuwen, Peizhi; Yang, Na; Yan, Xiaoli; Zhang, Yingze
Implant breakage after the fixation of traumatic fractures is rare; however, when it occurs, it is debilitating for the patients and a challenge for surgeons. The purpose of this study was to analyze and identify the independent risk factors for implant breakage of traumatic fractures treated with plate osteosynthesis. We reviewed the medical records of patients with a fracture to any part of their four extremities, clavicle, hand or foot, who underwent surgical plate osteosynthesis from January 2005 to January 2015, and who sustained a subsequent implant breakage. Kaplan-Meier univariate and multivariate Cox regressions were performed to identify independent associations of potential risk factors for implant breakage in this cohort. We identified 168 patients who underwent plate osteosynthesis surgery and had subsequent internal fixator breakage. The mean patient age was 40.63 ± 16.71 years (range, 3 to 78 years), with 72.0% (121) males and 28.0% (47) females. The average time between surgery and implant breakage was 12.85 ± 12.42 months (range, 1 to 60 months). In the final regression model, we show that inserting screws close to the fracture line is an independent predictive risk factor for implant breakage (HR, 2.165, 95%CI, 1.227 to 3.822; P = 0.008). We found that inserting screws close to the fracture line is related to an increased risk of internal fixator breakage in patients treated with plate osteosynthesis after fracture. Plates with additional holes likely lead to an increased risk of implant breakage, presumably because surgeons cannot resist inserting extra screws into the holes adjacent to the fracture line, which reduces the stiffness of the plate. We have addressed this problem by designing a plate without holes adjacent to the fracture line.
Zelle, Boris A; Boni, Guilherme
Statically locked, reamed intramedullary nailing remains the standard treatment for displaced tibial shaft fractures. Establishing an appropriate starting point is a crucial part of the surgical procedure. Recently, suprapatellar nailing in the semi-extended position has been suggested as a safe and effective surgical technique. Numerous reduction techiques are available to achieve an anatomic fracture alignment and the treating surgeon should be familiar with these maneuvers. Open reduction techniques should be considered if anatomic fracture alignment cannot be achieved by closed means. Favorable union rates above 90 % can be achieved by both reamed and unreamed intramedullary nailing. Despite favorable union rates, patients continue to have functional long-term impairments. In particular, anterior knee pain remains a common complaint following intramedullary tibial nailing. Malrotation remains a commonly reported complication after tibial nailing. The effect of postoperative tibial malalignment on the clinical and radiographic outcome requires further investigation.
Ghafil, Dior; Ackerman, Pieter; Baillon, Renaud; Verdonk, Rene; Delince, Philippe
Interlocking intramedullary nailing is currently the preferred treatment for most tibial fractures requiring operative treatment, with good results and a relatively low complication rate as reported in large clinical series. However, vascular and neurological complications caused by interlocking screws have been reported. In addition, insertion of distal interlocking screws can be technically demanding and may entail substantial exposure. We present the results with an expandable self-locking nail in the management of 52 AO type A and B tibial shaft fractures. The mean time to union was 15.8 weeks and the rate of union was 98%. The average surgical time was 60 minutes. Complications were those usually seen in diaphysis nailing and no complication was noted during nail expansion. Interlocking screws are not necessary, which reduces the risk of iatrogenic lesions. The expandable nail allows effective management of AO type A and B diaphyseal fractures of the tibia, a lower radiation exposure and shorter operative time.
Yavuz, Umut; Sökücü, Sami; Demir, Bilal; Yıldırım, Timur; Ozcan, Cağrı; Kabukçuoğlu, Yavuz Selim
In this study, we aimed to compare the functional and radiological results of intramedullary nailing and plate fixation techniques in the surgical treatment of distal tibia diaphyseal fractures close to the ankle joint. Between 2005 and 2011, 55 patients (32 males, 23 females; mean age 42 years; range 15 to 72 years) who were treated with intramedullary nailing (21 patients) or plate fixation (34 patients) due to distal tibia diaphyseal fracture were included in the study. The average follow-up period was 27.6 months (range, 12-82 months). The patients were evaluated with regard to nonunion, malunion, infection, and implant irritation. The AOFAS (American Orthopaedic Foot and Ankle Society) scale was used for the clinical evaluation. No statistically significant difference was found between the two surgical methods with respect to unification time, AOFAS score, accompanying fibula fracture, material irritation, and malunion. Nine patients had open fractures, and these patients were treated with plate fixation (p=0.100). Nonunion developed in three patients who were treated with plates. Infection occurred in one patient. Anterior knee pain was significantly higher in patients who were treated with intramedullary nails. There was no malunion in any patient. As the distal fragment is not long enough, plate fixation technique is usually preferred in the treatment of distal tibia diaphyseal fractures. In this study, we observed that if the surgical guidelines are followed carefully, intramedullary nailing is an appropriate technique in this kind of fracture. The malunion rates are not significantly increased, and it also has the advantages of being a minimally invasive surgery with fewer wound problems.
Qi, Lei; Li, Mu; Zhang, Shuai; Si, Haipeng; Xue, Jingsong
Nonunion and C1-C2 instability of odontoid fractures usually result from delayed diagnosis and inappropriate treatment. However, the available treatment options for odontoid fractures remain controversial. The authors evaluated the effectiveness of internal screw fixation via the C1 and C2 pedicle in cases of old odontoid fractures. This retrospective study included 21 patients with old odontoid fractures (13 men and 8 women; mean age, 46.5 years; range, 24-69 years). Internal screw fixation via the C1 and C2 pedicle was performed in all patients. Fracture reduction and C1-C2 fusion were assessed with imaging. The neck pain visual analog scale score and cervical spinal cord functional Japanese Orthopaedic Association score (for those who had cervical spinal cord injury) were used to evaluate the effectiveness of treatment. Postoperative complications were recorded. Postoperative imaging showed that the C1-C2 dislocation was satisfactorily repositioned in all patients. Bone fusion was observed 1 year after surgery in all patients. No loosening or breaking of internal fixation occurred. The preoperative neck pain visual analog scale score was 5.9±1.5 and improved significantly to 1.8±0.8 after surgery (P<.001). The Japanese Orthopaedic Association score in patients with cervical spinal injury (n=14) was 9.2±1.9 and also significantly improved to 13.8±1.9 at the last follow-up examination (P<.001), with an average improvement rate of 61.0%. No iatrogenic vertebral artery injury or severe spinal cord injury occurred. Screw fixation via the C1 and C2 pedicle was found to be an effective and safe surgical approach for the treatment of old odontoid fractures with C1-C2 dislocation or instability.
Matejčić, Aljoša; Ivica, Mihovil; Jurišić, Darko; Ćuti, Tomislav; Bakota, Bore; Vidović, Dinko
Comminution of the patellar apex is amenable to internal fixation by standard techniques and usually requires partial patellectomy. In our institution, multifragmentary fractures of the distal pole are treated with the basket plate, which is shaped to fit the geometry of the patellar apex. This implant has been used in our institution for over 25 years. The aim of this study was to evaluate long-term results of internal fixation of comminuted fractures of the patellar apex with the basket plate. A total of 142 patients with fracture of the distal pole of the patella were treated with the basket plate between 1988 and 2013. Functional evaluation was conducted using the modified Cincinnati knee rating system. A total of 98 patients were available for late functional evaluation. There were no infections or implant-related problems during the follow-up period. All fractures healed within 8 to 10 weeks. There were three cases of early revision because of improper use of the implant and incorrect indication. Functional outcome following internal fixation with the basket plate was excellent in 80 patients and good in 18; there were no poor results. Internal fixation with the basket plate is recommended for management of multifragmentary fractures of the patellar apex because this method enables early, unrestricted knee motion, and provides reliable healing and good functional outcome. This method is an alternative to partial patellectomy and is considered a patella-saving procedure; therefore, the use of the basket plate is strongly recommended for the treatment of distal pole fractures. Copyright © 2015 Elsevier Ltd. All rights reserved.
Tuomilehto, Noora; Kivisaari, Reetta; Sommarhem, Antti; Nietosvaara, Aarno Y
Background and purpose - The quality of pin fixation of displaced supracondylar humerus fractures in children has not been assessed, and the clinical value of radiographic examinations after pin fixation is unclear. We evaluated pin configuration, quality of osteosynthesis, and outcome in 264 supracondylar fractures. The clinical significance of postoperative radiographs was analyzed. Patients and methods - 252 Gartland-III and 12 flexion-type supracondylar humerus fractures were pin-fixed in the periods 2002-2006 and 2012-2014. During 2012-2014, staff were intructed that postoperative radiographs should not be taken. Quality of reduction was assessed by measuring Baumann and lateral capitellohumeral angles (LCHA) and also by recording the crossing point of the anterior humeral line (AHL) with bony capitellum. Rotatory alignment was registered as normal or abnormal. Pin configuration and quality of osteosynthesis were evaluated. The clinical significance of postoperative radiographs was analyzed. Results - Postoperatively, Baumann angle was normal in 66% of the fractures, AHL crossed the capitellum in 84%, and no malrotation was evident in 85% of the fractures. Crossed pins were used in 89% of the cases. 2 or more pins fixed both fracture fragments in 66%. Radiographic examinations were inadequate for assessment of LCHA in 13%, of Bauman angle in 8%, of AHL in 2%, of rotation in 1%, and of pin fixation in 2% of the cases. Postoperative radiographs did not give useful information except in 1 patient who had corrective osteotomy. All 94 patients with follow-up (97%) who were treated during 2012-2014 were satisfied with the outcome. Interpretation - Despite pin fixation being deemed unsatisfactory in one-third of the cases, significant malunion was rare. Postoperative radiography did not alter management or outcome.
Tuomilehto, Noora; Kivisaari, Reetta; Sommarhem, Antti; Nietosvaara, Aarno Y
Background and purpose — The quality of pin fixation of displaced supracondylar humerus fractures in children has not been assessed, and the clinical value of radiographic examinations after pin fixation is unclear. We evaluated pin configuration, quality of osteosynthesis, and outcome in 264 supracondylar fractures. The clinical significance of postoperative radiographs was analyzed. Patients and methods — 252 Gartland-III and 12 flexion-type supracondylar humerus fractures were pin-fixed in the periods 2002–2006 and 2012–2014. During 2012–2014, staff were intructed that postoperative radiographs should not be taken. Quality of reduction was assessed by measuring Baumann and lateral capitellohumeral angles (LCHA) and also by recording the crossing point of the anterior humeral line (AHL) with bony capitellum. Rotatory alignment was registered as normal or abnormal. Pin configuration and quality of osteosynthesis were evaluated. The clinical significance of postoperative radiographs was analyzed. Results — Postoperatively, Baumann angle was normal in 66% of the fractures, AHL crossed the capitellum in 84%, and no malrotation was evident in 85% of the fractures. Crossed pins were used in 89% of the cases. 2 or more pins fixed both fracture fragments in 66%. Radiographic examinations were inadequate for assessment of LCHA in 13%, of Bauman angle in 8%, of AHL in 2%, of rotation in 1%, and of pin fixation in 2% of the cases. Postoperative radiographs did not give useful information except in 1 patient who had corrective osteotomy. All 94 patients with follow-up (97%) who were treated during 2012–2014 were satisfied with the outcome. Interpretation — Despite pin fixation being deemed unsatisfactory in one-third of the cases, significant malunion was rare. Postoperative radiography did not alter management or outcome. PMID:27774833
Wei, Jie; Yang, Tu-Bao; Luo, Wei; Qin, Jia-Bi; Kong, Fan-Jing
A meta-analysis to compare complication rates following volar or dorsal surgical fixation of distal radius fracture. A detailed search of PubMed®/MEDLINE® was undertaken to identify randomized and nonrandomized controlled trials published before 25 August 2012 that compared volar with dorsal fixation, in patients with distal radius fracture. A quantitative meta-analysis of 12 trials (952 patients) was performed. There was no between-group difference in the overall rate of complications. Volar fixation was associated with significant increases in neuropathy (relative risk [RR] 2.19; 95% confidence intervals [CI] 1.27, 3.76) and carpal tunnel syndrome (RR 4.56; 95% CI 1.02, 20.44), and a reduction in tendon irritation, compared with the dorsal approach (RR 0.38; 95% CI 0.17, 0.86). Dorsal fixation offers a lower risk of neuropathy and carpal tunnel syndrome than the volar approach, but a higher risk of tendon irritation. Patients with a distal radius fracture can expect similar outcomes after volar or dorsal surgery.
Wagner, Scott C; Chi, Benjamin B; Gordon, Wade T; Potter, Benjamin K
The technique of retrograde intramedullary fixation of fractures through open traumatic amputations has not been previously described. We performed a retrospective case series at a tertiary-care military hospital setting. Ten patients met inclusion criteria. All were male, and all were injured through improvised explosive device. Outcome measures included the incidence of fracture nonunion, osteomyelitis or acute infection, heterotopic ossification (HO), as well as successful prosthesis fitting and ambulation. Average time to fixation after injury and amputation closure was 11.7 and 12.2 days, respectively. Follow-up averaged 20.2 months. The radiographic union rate was 100%, and time to osseous union averaged 7.5 months. One patient had an amputation site infection requiring revision, but none of the nails was removed for infectious reasons. HO occurred in 7 patients, and 2 patients required revision for symptomatic HO. All patients were successfully fitted with prostheses and able to ambulate. To our knowledge, this is the only series in the literature to specifically describe retrograde intramedullary fixation of long bone fractures through the zone of traumatic amputation sites. The infectious risk is relatively low, whereas the union rate (100%) and successful prosthesis fitting are high. For patients with similar injuries, retrograde intramedullary fixation through the zone of amputation is a viable treatment option.
Carluzzo, Fulvio; Longo, G.F.
Introduction: The following is an original case report in the literature of a patient with post-traumatic bilateral calcaneum fracture, both type III of Sanders’ classification, that was treated, by the same surgeon, in the left foot with open reduction and internal fixation and in the right foot with closed reduction and application of an external fixator. Case Report: Patient 43 y.o., male, high fall accident, with bilateral calcaneum fracture, both type III of Sanders’ classification. we have chosen to treat the left foot with ORIF (Fig. 3) and the right one with closed reduction and application of an external fixator. Patient was followed up radiologically with radiographs at 2, 12 and 24 months, and clinically at 15 days, 1, 3, 6, 12, 18 and 24 months with the Maryland Foot Score, as suggested by Sanders et al. Conclusion: In our patient, the one year clinical outcomes post-surgery was better in the foot treated with external fixation, regardless complex fracture and the not good status of soft tissue, due to open surgical treatment and hardwere inside. Long-term clinical follow-up given best outcomes in patients treated with ORIF, due to better reduction of subtalar joint facet and Böhler’s angle. PMID:27299071
Claes, L E; Wilke, H-J; Augat, P; Rübenacker, S; Margevicius, K J
We asked whether dynamization of externally fixed diaphyseal fractures could improve bone healing in comparison to rigid fixation of fractures having similar remaining gap sizes. To answer this question we evaluated metatarsal osteotomies in 12 sheep. The osteotomy with a 0.6-mm gap was stabilized with a specially designed high bending and torsional stiffness external ring fixator. Osteotomies in six sheep were stabilized rigidly (axial movement < 0.06 mm) or dynamically (axial movement 0.15-0.34 mm). The cyclical axial interfragmentary movement was caused by the load-bearing of the operated limb. With increasing healing time, the initially allowed movement was decreased by callus formation around the osteotomy. The reduction in interfragmentary movement was measured and monitored by a linear variable displacement transducer at the external fixator and a telemetry system. After 9 weeks the sheep were sacrificed and the healed bones were investigated biomechanically and histomorphologically. Compared to the rigidly fixed osteotomies, the dynamized osteotomies showed significantly (P < 0.05) greater (+41%) callus formation and 45% greater tensile strength of the newly formed bone in the cortical osteotomy gap. Histological analysis indicated that the effect of dynamization occurred mainly after the 5th week. RELEVANCE: From these results we conclude that dynamic fixation of diaphyseal gaps is advantageous in comparison to stable external fixation.
Madey, Steven M.; Tsai, Stanley; Fitzpatrick, Daniel C.; Earley, Kathleen; Lutsch, Michael
Abstract Background Rigid locked plating constructs can suppress fracture healing by inhibiting interfragmentary motion required to stimulate natural bone healing by callus formation. Dynamic fixation with active locking plates reduces construct stiffness, enables controlled interfragmentary motion, and has been shown to induce faster and stronger bone healing in vivo compared to rigid locking plates. This prospective observational study represents the first clinical use of active locking plates. It documents our early clinical experience with active plates for stabilization of humeral shaft fractures to assess their durability and understand potential complications. Methods Eleven consecutive patients with humeral shaft fractures (AO/OTA types 12 A-C) were prospectively enrolled at a level I and a level II trauma center. Fractures were stabilized by using active locking plates without supplemental bone graft or bone morphogenic proteins. The screw holes of active locking plates are elastically suspended in elastomer envelopes inside the plate, enabling up to 1.5 mm of controlled interfragmentary motion. Progression of fracture healing and integrity of implant fixation was assessed radiographically at 3, 6, 12, and 24 weeks post surgery. Patient-reported functional outcome measures were obtained at 6, 12, and 24 weeks post surgery. The primary endpoint of this study was plate durability in absence of plate bending or breakage, or failure of the elastically suspended locking hole mechanism. Secondary endpoints included fracture healing, complications requiring revision surgery, and functional outcome scores. Results The eleven patients had six simple AO/ OTA type 12A fractures, three wedge type 12B fractures, and two comminuted type 12C fracture, including one open fracture. All active locking plates endured the 6-month loading period without any signs of fatigue or failure. Ten of eleven fractures healed at 10.9 ± 5.2 weeks, as evident by bridging callus and pain
Abd-Almageed, Emad; Marwan, Yousef; Esmaeel, Ali; Mallur, Amarnath; El-Alfy, Barakat
Arbeitsgemeinschaft für Osteosynthesefragen (AO) type 43-C tibial plafond/pilon fractures represent a challenge for the treating orthopedic surgeon. We assessed the outcomes of using hybrid external fixation for this fracture type. The present prospective cohort study was started in August 2009 and ended by July 2012. Thirty consecutive patients (mean age 37.4 ± 10.7 years) with a type C tibial plafond fracture who had presented to our tertiary care orthopedic hospital were included. Motor vehicle accidents and fall from height were the cause of the fracture in 14 (46.7%) and 13 (43.3%) patients, respectively. A type C3 fracture was present in 25 patients (83.3%), and type C1 and C2 fractures were present in 2 (6.7%) and 3 (10.0%) patients, respectively. Nine fractures (30.0%) were open. Hybrid external fixation was used for all fractures. All fractures were united; clinical healing was achieved by a mean of 18.1 ± 2.2 weeks postoperatively and radiologic healing at a mean of 18.9 ± 1.9 weeks. The fixator was removed at a mean of 20.4 ± 2.0 weeks postoperatively. At a mean follow-up point of 13.4 ± 2.6 months, the mean modified Mazur ankle score was 84.6 ± 10.4. It was not associated with wound classification (p = .256). The most commonly seen complication was ankle osteoarthritis (17 patients; 56.7%); however, it was mild in >50.0% of the affected patients. In conclusion, using hybrid external fixation for type C tibial plafond fractures resulted in good outcomes. However, this should be investigated further in studies with a higher level of evidence. Copyright © 2015 American College of Foot and Ankle Surgeons. Published by Elsevier Inc. All rights reserved.
Haller, Justin M; Holt, David; Rothberg, David L; Kubiak, Erik N; Higgins, Thomas F
High-energy tibial plateau and tibial plafond fractures have a high complication rate and are frequently treated with a staged approach of spanning external fixation followed by definitive internal fixation after resolution of soft tissue swelling. A theoretical advantage to early spanning external fixation is that earlier fracture stabilization could prevent further soft tissue damage and potentially reduce the occurrence of subsequent infection. However, the relative urgency of applying the external fixator after injury is unknown, and whether delay in this intervention is correlated to subsequent treatment complications has not been examined. Is delay of more than 12 hours to spanning external fixation of high-energy tibial plateau and plafond fractures associated with increased (1) infection risk; (2) compartment syndrome risk; and (3) time to definitive fixation, length of hospitalization, or risk of secondary surgeries? We further stratified our results based on injury site: plateau and plafond. In practical clinical terms, many of these high-energy C-type articular fractures will arrive at the regional trauma center in the evening and this investigation attempted to explore if these injuries need to be placed in temporizing fixators that evening or if they may be safely addressed in a dedicated trauma room the next morning. We performed a retrospective review of all patients at a Level I university trauma center with high-energy tibial plateau and plafond fractures who underwent staged treatment with a spanning external fixation followed by subsequent definitive internal fixation between 2006 and 2012. Patients who received a fixator within 12 hours of recorded injury time were classified as early external fixation; those who received a fixator greater than 12 hours from injury were classified as delayed external fixation. There were 80 patients (42 plateaus and 38 plafonds) in the early external fixation cohort and 79 patients (45 plateaus and 34 plafonds
Background The objective of this study was to determine whether one can achieve stable fixation of a two column (transverse) acetabular fracture by only fixing a single column with a locking plate and unicortical locking screws. We hypothesized that a locking plate applied to the anterior column of a transverse acetabular fracture would create a construct that is more rigid than a non-locking plate, and that this construct would be biomechanically comparable to two column fixation. Methods Using urethane foam models of the pelvis, we simulated transverse acetabular fractures and stabilized them with 1) an anterior column plate with bicortical screws, 2) an anterior locking plate with unicortical screws, 3) an anterior plate and posterior column lag screw, and 4) a posterior plate with an anterior column lag screw. These constructs were mechanically loaded on a servohydraulic material testing machine. Construct stiffness and fracture displacement were measured. Result and Discussion We found that two column fixation is 54% stiffer than a single column fixation with a conventional plate with bicortical screws. There was no significant difference between fixation with an anterior column locking plate with unicortical screws and an anterior plate with posterior column lag screw. We detected a non-significant trend towards more stiffness for the anterior locking plate compared to the anterior non-locking plate. Conclusion In conclusion, a locking plate construct of the anterior column provides less stability than a traditional both column construct with posterior plate and anterior column lag screw. However, the locking construct offers greater strength than a non-locking, bicortical construct, which in addition often requires extensive contouring and its application is oftentimes accompanied by the risk of neurovascular damage. PMID:20459688
Khajavi, Kiarash; Lee, Arthur T; Lindsey, Derek P; Leucht, Philipp; Bellino, Michael J; Giori, Nicholas J
The objective of this study was to determine whether one can achieve stable fixation of a two column (transverse) acetabular fracture by only fixing a single column with a locking plate and unicortical locking screws. We hypothesized that a locking plate applied to the anterior column of a transverse acetabular fracture would create a construct that is more rigid than a non-locking plate, and that this construct would be biomechanically comparable to two column fixation. Using urethane foam models of the pelvis, we simulated transverse acetabular fractures and stabilized them with 1) an anterior column plate with bicortical screws, 2) an anterior locking plate with unicortical screws, 3) an anterior plate and posterior column lag screw, and 4) a posterior plate with an anterior column lag screw. These constructs were mechanically loaded on a servohydraulic material testing machine. Construct stiffness and fracture displacement were measured. We found that two column fixation is 54% stiffer than a single column fixation with a conventional plate with bicortical screws. There was no significant difference between fixation with an anterior column locking plate with unicortical screws and an anterior plate with posterior column lag screw. We detected a non-significant trend towards more stiffness for the anterior locking plate compared to the anterior non-locking plate. In conclusion, a locking plate construct of the anterior column provides less stability than a traditional both column construct with posterior plate and anterior column lag screw. However, the locking construct offers greater strength than a non-locking, bicortical construct, which in addition often requires extensive contouring and its application is oftentimes accompanied by the risk of neurovascular damage.
Bigsby, Ewan; Acharya, Mehool R; Ward, Anthony J; Chesser, Timothy Js
To determine if the routine use of intraoperative blood cell salvage in acetabular fracture internal fixation reduces the need for allogenic blood transfusion, is cost effective, and whether it is influenced by the acetabular fracture pattern. A retrospective study. Tertiary pelvic and acetabular reconstructive center. Patients undergoing internal fixation for acetabular fractures. Eighty consecutive patients were reviewed, comprising 26 elementary fracture (EF) and 54 associated fracture (AF) types. The mean volume of autologous blood transfused was 484 mL. The mean volume of 561 mL of autologous blood transfused in patients with AF types was significantly greater than the mean volume of 325 mL transfused in the EF group (P = 0.007). Additional allogenic blood transfusion was required in 5 (19%) patients with EFs and 15 (28%) patients with AFs (P = 0.418). The mean cost of the blood cell salvage and additional blood products in our study was $223 (£135) for all fracture types ($174/£105 for EF and $246/£149 for AF).When treating AF types, the mean cost of using blood cell salvage was $246 (£149) as compared with the mean predicted cost of not using blood cell salvage and transfusing the equivalent of 1.7 units of allogenic blood instead, which was $463 (£281). These distributions are significantly different (P = 0.01). The use of blood cell salvage for internal fixation surgery for acetabular fracture is cost effective, particularly when treating AF types, and its routine use is advocated to limit the need for allogenic blood transfusion.
Jazini, Ehsan; Weir, Tristan; Nwodim, Emeka; Tannous, Oliver; Saifi, Comron; Caffes, Nicholas; Costales, Timothy; Koh, Eugene; Banagan, Kelley; Gelb, Daniel; Ludwig, Steven C
Complex sacral fractures with vertical and anterior pelvic ring instability treated with traditional fixation methods are associated with high rates of failure and poor clinical outcomes. Supplemental lumbopelvic fixation (LPF) has been applied for additional stability to help with fracture union. The study aimed to determine whether minimally invasive LPF provides reliable fracture stability and acceptable complication rates in cases of complex sacral fractures. This is a retrospective cohort study at a single level I trauma center. The sample includes 24 patients who underwent minimally invasive LPF for complex sacral fracture with or without associated pelvic ring injury. Reoperation for all causes, loss of fixation, surgical time, transfusion requirements, length of hospital stay, postoperative day at mobilization, and mortality were evaluated. Patient charts from 2008 to 2014 were reviewed. Of the 32 patients who underwent minimally invasive LPF for complex sacral fractures, 24 (12 male, 12 female) met all inclusion and exclusion criteria. Outcome measures were assessed with a retrospective chart review and radiographic review. The authors did not receive external funding for this study. Acute reoperation was 12%, and elective reoperation was 29%. Two (8%) patients returned to the operating room for infection, one (4.2%) required revision for instrumentation malposition, and seven (29%) underwent elective removal of instrumentation. No patient experienced failure of instrumentation or loss of correction. Average surgical time was 3.6 hours, blood loss was 180 mL, transfusion requirement was 2.1 units of packed red blood cells, and postoperative mobilization was on postoperative day 5. No mortalities occurred as a result of the minimally invasive LPF procedure. Compared with historic reports of open LPF, our results demonstrate reliable maintenance of reduction and acceptable complication rates with minimally invasive LPF for complexsacral fractures. The
Lindsey, R W; Dick, W; Nunchuck, S; Zach, G
The Fixateur Interne has been proposed for limited pedicle fixation of thoracolumbar spine fractures with the assumption that motion in the nontraumatized spinal segments could be maintained. To date, no data exist that both localize and quantitate spinal mobility about the fractured vertebra. Voluntary maximum lateral flexion and extension radiographs were obtained on patients with unstable thoracolumbar spine fractures at a minimum of 2 years after Fixateur Interne instrumentation (implant was removed after 1 year). Residual intersegmental motion was measured at levels adjacent to both the vertebra fracture and the fixation. Fifty-nine patients were reviewed, and the posterior vertebral body angle demonstrated a mean total sagittal motion of 2.98 degrees. Cephalad and caudal to the fractured vertebra, a mean of 1.34 degrees and 3.08 degrees, respectively, of residual motion was noted; cephalad and caudal to the previously instrumented segment a mean of 3.22 degrees and 6.88 degrees, respectively, was measured. The authors conclude that residual mobility is most evident at the caudal end of the instrumented segment, removed from the fractured vertebra. The level with end plate disruption becomes essentially ankylosed, with or without a fusion.
Kaneko, Kazuo; Murotani, Rentaroh; Mogami, Atsuhiko; Okahara, Hitoshi; Ohbayashi, Osamu; Iwase, Hideaki; Fujita, Hidemine; Kurosawa, Hisashi
The authors report an unusual case of hip subluxation after internal fixation without associated sepsis. We report one recently treated case in which a 75-year-old female experienced subluxation of her hip joint after open reduction and internal fixation for a trochanteric fracture. In this paper, we describe a case of progressive, spontaneous subluxation of the hip joint over several weeks. Most previously reported cases are associated with cerebral palsy. This entity has not been reported previously. Our patient was treated by hemi-arthroplasty and repair of the disrupted capsule, and achieved a good long-term functional result. The cause of this particular condition is discussed.
Maniscalco, P; Pizzoli, A L; Renzi Brivio, L; Caforio, M
The authors report their experience of treating complex elbow fracture-dislocations in elderly people, using a minimally-invasive approach with a new articulated external fixator that is associated with minimal internal fixation. The clinical results for 19 patients are presented according to outcome factors, such as range of motion, pain and function, rate and type of complications, and reoperation rate. The results indicate that this treatment strategy should be considered as a good alternative to other treatment options reported in the literature, including conservative treatment, ORIF with angular stable plates and total elbow arthroplasty.
Li, Zhangao; Zhou, Zhongwei; Li, Peng; Zeng, Wei; Qing, Hai; Tang, Wei
To retrospectively investigate infection by multidrug-resistant bacteria (MDRB) after rigid internal fixation (RIF) of mandibular fracture and determine risk factors and cure methods. From 2009 through 2014, 933 patients with mandibular fracture were enrolled in the study. Fifteen variables were statistically analyzed using univariate and multivariate logistic regression methods to investigate risk factors for MDRB infection after RIF of mandibular fracture. Sixteen of 933 patients (1.71%) developed MDRB infection. Of these, 6 were infected with methicillin-resistant Staphylococcus aureus (MRSA), 6 with multidrug-resistant Pseudomonas aeruginosa (MDR-PA), 1 with extended spectrum β-lactamase-producing Klebsiella pneumonia, 1 with extended spectrum β-lactamase-producing Escherichia coli, 1 with multidrug-resistant Acinetobacter baumannii, and 1 with multidrug-resistant Enterobacter cloacae. Univariate analysis showed that risk factors of MDRB infection after RIF of mandibular fracture were age, obesity (body mass index ≥25 kg/m(2) for Asians), polytrauma (Injury Severity Score >16), preoperative infection, open fractures, comminuted fractures accompanied by other facial fractures, and teeth involving the fracture line. Multivariate logistic regression analysis showed that obesity, preoperative infection, and open fractures were independent risk factors of MDRB infection. After systemic anti-infection treatments with vancomycin, piperacillin, tazobactam, local drainage, and debridement, the infections were under control. Fourteen patients achieved clinical healing at an average time of 8.71 months, and 2 did not achieve clinical healing. The overall mean follow-up was 18.81 months. MDRB infections occurring after RIF of mandibular fracture were caused mainly by MRSA and MDR-PA. Obesity, preoperative infection, and open fractures were the main risk factors. To lower risk, surgical debridement should be performed sooner once acute infection has been controlled
Momaya, Amit M; Hlavacek, Jimmy; Etier, Brian; Johannesmeyer, David; Oladeji, Lasun O; Niemeier, Thomas E; Herrera, Nicholas; Lowe, Jason A
Tibial plateau fractures are challenging to treat due to the high incidence of postoperative infections. Treating physicians should be aware of risk factors for postoperative infection in patients who undergo operative fixation. A retrospective review was undertaken to identify all patients with tibial plateau fractures over a 10 year period (2003-2012) who underwent open reduction internal fixation. A total of 532 patients were identified who met the inclusion criteria. Several patient and clinical characteristics were recorded, and those variables with a significant association (p<0.05) with postoperative infection after a univariate analysis were further analyzed using a multivariate analysis. Fifty-nine (11.1%) of the 532 patients developed a deep infection. The average length of follow-up for patients was 19.5 months. Methicillin-resistant Staphylococcus aureus was the most common species, and it was isolated in 26 (44.1%) patients. Open fractures, the presence of compartment syndrome, and a Schatzker type IV-VI were found to be independent risk factors for deep infection. The rate of deep infection remains high after operative fixation of tibial plateau fractures. Patients with risk factors for infection should be counseled on the possibility of reoperation, and surgeons should consider MRSA prophylaxis in those patients who are at higher risk. Copyright © 2016 Elsevier Ltd. All rights reserved.
Ramírez, J M; Macías, C
To describe the outcome of bone plate fixation of distal radius and ulna fractures in toy breed dogs treated with conventional bone plates. Records of 15 toy breed dogs with distal radius and ulna fractures were retrospectively reviewed for signalment, method of fixation, complications and clinical and radiographic assessments. A telephone-based owner questionnaire was conducted to determine long-term function and client satisfaction. Age ranged from 4 months to 6 years. Body weight ranged from 1 to 4 kg. Dynamic compression plates were used in 13 dogs and veterinary cuttable plates were used in 2 dogs as the means of fixation. Full radiographic and clinical follow-up data were available for 10 dogs and follow-up was performed between 6 and 8 weeks postoperatively. At that time, all fractures had healed and return to function was considered excellent in all 10 dogs. Five dogs did not return for hospital evaluation because they were judged by their owners to be free of lameness. In two cases, owners could not be contacted by telephone, but the referring veterinarians reported the dogs to be asymptomatic. No major complications occurred. Conventional bone plates are suitable choices for stabilisation of distal radius and ulna fractures in toy breed dogs and are not necessarily correlated with high rates of complication. © 2016 Australian Veterinary Association.
Tang, Jiaguang; Liu, Yishan; Cao, Zheng; Hu, Yuan; Lu, Xiang; Lin, Bin
This study aims to evaluate clinical efficacy of short segment pedicle screw fixation without bone fusion for unstable thoracolumbar burst fracture. Nineteen patients younger than 40 years old with unstable thoracolumbar burst fractures were included. The surgical procedure included postural reduction for 3 days and screw fixations at one level above, one level below and at the fractured level itself. The implants were removed 12 months after initial operation. Imaging and clinical findings were analyzed at preoperative, 12 months after surgery, just before implant removal, and at six months after implant removal. Results indicated that difference was statistically significant between preoperative period or postoperative 1 year follow-up, just before implant removal and 6 months after implant removal (P < 0.05). Results at postoperative 1 year follow-up, just before implant removal and 6 months after implant removal were better than preoperative period. There were no significant complications or neurological deterioration after screws insert and removal in any patient. The rate of clinical outcome with excellent and good was 94.7%. In conclusion, short segment pedicle screw fixation without bone fusion can be an effective and safe operative srategytechnique in the management of young patients suffering from unstable burst fracture.
Lin, J; Liu, H; Liu, P; Yang, H
To evaluate the efficacy of external fixators(EFs) for management of open fractures of tibia and fibula in patients with haemophilia A. EFs are commonly used in the clinical management of infected or open fractures when internal fixation is contraindicated and plaster immobilization is inadequate. However, EFs have not been frequently used for these indications in haemophilic patients for fear of pin tract infection and bleeding. This is a retrospective therapeutic study. We describe the use of EF (Orthofix uniplanar fixators) in five patients (mean age: 31.4 years; range: 10-52) with haemophilia A suffering from open fracture of tibia and fibula (Gustilo classification ranging from II to IIIA). The average time to union was 23 weeks (range: 18-30 weeks). Much lower levels were subsequently maintained till wound healing. The average total factor consumption was 358.30 IU kg(-1) (range: 272-421 IU kg(-1) ), administered over a period of 14.2 days (range 9-21). There were no major complications related to EF. In summary, EFs can be used safely and effectively in management of open fractures of tibia and fibula in patients with haemophilia A.
Chow, Roxanne M; Begum, Farhana; Beaupre, Lauren A; Carey, Jason P; Adeeb, Samer; Bouliane, Martin J
Locking plate constructs for proximal humeral fractures can fail due to varus collapse, especially in osteoporotic bone with medial cortex comminution. Augmentation, using a fibular allograft as an intramedullary bone peg, may strengthen fixation preventing varus collapse. This study investigated the ability of the augmented locking plate construct to withstand repetitive varus stresses relative to the nonaugmented construct. Proximal humeral fractures with medial comminution were simulated by performing wedge-shaped osteotomies at the surgical neck in cadaveric specimens. For each cadaver (n = 8), 1 humeral fracture was fixated with the locking plate construct alone and the other with the locking plate construct plus ipsilateral fibular autograft augmentation. The humeral head was immobilized and a repetitive, medially directed load was applied to the humeral shaft until construct collapse or until 25000 cycles were completed. No augmented construct collapsed. In comparison, 6 of 8 nonaugmented constructs collapsed (P < .05). Collapse in the 6 nonaugmented constructs occurred after an average ±SD of 6604 ± 1984 cycles. Screw penetration of the articular surface was found in only 1 of the nonaugmented constructs. Fibular allograft augmentation increased the ability of the locking plate to withstand repetitive varus loading. Clinically, this may assist proximal humeral fracture fixation in osteoporotic bone with medial cortex comminution. Crown Copyright © 2012. Published by Mosby, Inc. All rights reserved.
Siebenbürger, Georg; Van Delden, Dustin; Helfen, Tobias; Haasters, Florian; Böcker, Wolfgang; Ockert, Ben
Open reduction and internal fixation is one established method for treatment of displaced fractures of the proximal humerus. However, the timing of surgery and its effect on complications have not yet been investigated in the literature. Hence, aim of this study was to analyze the occurrence of complication following locked plating of proximal humeral fractures when surgery was delayed in comparison to early intervention. Between February 2002 and November 2010, 497 patients with displaced proximal humeral fractures were treated by open reduction and locked plating. 329 patients were available for follow-up with a minimum of 12 months after surgery. Outcome analysis included radiographic evidence of loss of fixation (> 10° of secondary displacement), screw-cutout and avascular head necrosis. Outcomes were analyzed with regards to age, gender and fracture pattern and were compared between time intervals in which the primary surgery had been conducted; early intervention (< 48 h), timely scheduled for surgery (3-5 days) and delayed intervention (>5 days). Of 329 patients (68.4% women; median age at time of surgery: 69.9 years, 95% Confidence Interval (CI) 68.2, 71.2) the median time between fracture incident and surgical intervention was 3.2 days (95%CI: 3.1, 3.3). Surgery was performed in a 2-part fracture at a median of 3.3 days (95%CI: 3.2, 3.4) after trauma, in a 3-part fracture after 3.3 days (95%CI: 3.1, 3.4), in a 4-part fracture 2.9 days (95%CI: 2.8, 3.0), in head split type fracture 2.2 days (95%CI: 2.0, 2.4) and in dislocation type fracture 0.8 days after trauma (95%CI: 0.7, 0.9, p = 0.40). Loss of fixation was observed in 12.8% (n = 42 patients), of which in 4.9% (n = 16) screw cutout was evident and in 6.8% of cases (n = 20) avascular head necrosis was diagnosed. Patients in which complication was observed were treated at median 2.5 days after trauma (95% CI, 1.8, 3.2), in comparison, patients without evidence of complications were treated at a median of
Gutowski, Christina J; Darvish, Kurosh; Ilyas, Asif M; Jones, Christopher M
Fixation of radial neck fractures can be achieved with a plate and screw construct or, in absence of comminution, with two obliquely-oriented screws. This study investigated the mechanical properties, specifically the stiffness and load to failure, of these two fixation strategies in a cadaver model. Ten matched-pair radii were removed from fresh cadaver arms. A transverse osteotomy was created at the neck of each radius. Right-sided radii were fixed with two oblique headless compression screws; left-sided radii were fixed with a radial neck plate. The distal aspect of each radius was potted in urethane casting resin. The radial head was loaded in shear in 4 different planes (medial to lateral, lateral to medial, posterior to anterior, and anterior to posterior) using an Instron machine. Stiffness and load to failure were recorded. The stiffness of both constructs was similar in all planes except for loading from medial to lateral where the screw construct was 1.8 times stiffer. Average ultimate failure occurred at 229N for the screws and 206N for the plate. Failure strength was not statistically different. However, mode of failure differed for both fixation constructs, the plate failed in bending while the screws failed by pullout and fracture. The two strategies provide similar strength and stiffness for the fixation of transverse, non-comminuted radial neck fractures. While plate and screw constructs are more appropriate for axially unstable or comminuted fractures, two oblique screws might be preferred for simple transverse neck fractures since this strategy requires less exposure and the implant is buried. Copyright © 2015 Elsevier Ltd. All rights reserved.
Hiatt, Stephen V; Begonia, Mark T; Thiagarajan, Ganesh; Hutchison, Richard L
To determine the relative importance of intramedullary wire (IMW) diameter and IMW number in conferring stability to a metacarpal fracture fixation construct. Our research hypothesis was that the stiffness of IMW fixation for metacarpal shaft fractures using a single 1.6-mm-diameter (0.062-in) wire would be greater than three 0.8-mm-diameter (0.031-in) wires. Our study compared the biomechanical stiffness between one 1.6-mm K-wire and three 0.8-mm K-wires in a composite, fourth-generation, biomechanical metacarpal construct under cantilever testing to treat transverse metacarpal shaft fractures. Six composite bone-wire constructs were tested in each group using constant-rate, nondestructive testing. Stiffness (load/displacement) was measured for each construct. All constructs demonstrated a linear load-displacement relationship. Wires were all tested in their elastic zone. The mean stiffness of the 1-wire construct was 3.20 N/mm and the mean stiffness of the 3-wire construct was 0.76 N/mm. These differences were statistically significant with a large effect size. The stiffness of IMW fixation for metacarpal shaft fractures using a single 1.6-mm-diameter wire was significantly greater than using three 0.8-mm-diameter wires. When IMW fixation is clinically indicated for the treatment of metacarpal fractures, the increased stiffness of a single large-diameter construct provides more stability in the plane of finger flexion-extension. Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.
Hoffmann, Martin F; Burgers, Travis A; Mason, James J; Williams, Bart O; Sietsema, Debra L; Jones, Clifford B
In the United States there are more than 230,000 total hip replacements annually, and periprosthetic femoral fractures occur in 0.1-4.5% of those patients. The majority of these fractures occur at the tip of the stem (Vancouver type B1). The purpose of this study was to compare the biomechanically stability and strength of three fixation constructs and identify the most desirable construct. Fifteen medium adult synthetic femurs were implanted with a hip prosthesis and were osteotomized in an oblique plane at the level of the implant tip to simulate a Vancouver type B1 periprosthetic fracture. Fractures were fixed with a non-contact bridging periprosthetic proximal femur plate (Zimmer Inc., Warsaw, IN). Three proximal fixation methods were used: Group 1, bicortical screws; Group 2, unicortical screws and one cerclage cable; and Group 3, three cerclage cables. Distally, all groups had bicortical screws. Biomechanical testing was performed using an axial-torsional testing machine in three different loading modalities (axial compression, lateral bending, and torsional/sagittal bending), next in axial cyclic loading to 10,000 cycles, again in the three loading modalities, and finally to failure in torsional/sagittal bending. Group 1 had significantly greater load to failure and was significantly stiffer in torsional/sagittal bending than Groups 2 and 3. After cyclic loading, Group 2 had significantly greater axial stiffness than Groups 1 and 3. There was no difference between the three groups in lateral bending stiffness. The average energy absorbed during cyclic loading was significantly lower in Group 2 than in Groups 1 and 3. Bicortical screw placement achieved the highest load to failure and the highest torsional/sagittal bending stiffness. Additional unicortical screws improved axial stiffness when using cable fixation. Lateral bending was not influenced by differences in proximal fixation. To treat periprosthetic fractures, bicortical screw placement should be
Thanni, Lateef O. A.; Aigoro, Nofiu O.
BACKGROUND: There is a dearth of data on surgical site infections (SSIs) complicating internal fixation of fractures from Nigeria. AIMS: To determine the incidence and risk factors for SSIs following internal fixation of fracture. METHODS: A cohort of 90 patients with long bone fractures that were stabilized internally with metallic devices was studied prospectively and retrospectively. RESULTS: The incidence of SSI was 12%. The isolated organisms were Staphylococcus aureus in four patients, Pseudomonas spp. in three, and Escherichia coli in one patient. Diabetes mellitus and perioperative transfusion with allogeneic blood were not predictive of SSI. Duration of operation longer than 120 minutes was a strong predictor (OR 2.25, 95% CL 0.48-10.16). Other risk factors were male sex (OR 2.01, 95% CL 0.44-10.45), injury-operation interval less than six months (OR 2.00, 95% CL 0.22-46.08), fracture fixation with plates and screws (OR 1.51, 95% CL 0.36-6.40), white blood cell count (WBC) less than 5,000 per cumm (OR 1.50, 95% CL 0.15-16.37), preoperative urinary catheterization (OR 1.48, 95% CL 0.00-16.19), and postoperative urinary catheterization (OR 1.24, 95% CL 0.29-5.00). CONCLUSION: The incidence of SSI after internal fixation of long bone fractures in our centers is 12%, and this is within the previously reported range. Use of plates and screws, WBC less than 5,000 per cumm, and perioperative urinary catheterization are important risk factors. PMID:15303412
Zhang, Zhi-Min; Liu, Jian; Huang, Chun-Xia; Zhao, Zhan-Fu; Wang, Gang; Qin, Cong-Cong
To investigate clinical efficacy and feasibility of double-plating fixation via anteriormiddle approach in treating type C3 distal femoral fractures. From August 2008 to August 2011, 12 cases with type C3 distal femoral fractures were treated, including 5 open fractures and 7 closed fractures. Among them, there were 8 males, 4 females with an average of 40 years (ranged, 25 to 55 years). There were 7 in left side, 5 in right side. Nine cases were caused by car accident, 3 cases by falling down. The duration from injury to hospital was form 20 minutes to 5 days (mean 135 min). After tibia bone traction for 5 to 8 days, the operation were performed by double-plating fixation via anteriormiddle approach, and autograft of iliac bone or allograft bone grafting were given to bone defect. Knee joint function was evaluated according to Merchanetal criteria. The operation time was from 110 to 160 min, with an average of 135 min, the blood loss was from 300 ml to 500 ml,with an average of 400 ml. Post-operative wound were stage I healing. All patients were followed up from 16 to 36 months (mean 24 months). No infection, reduction loss, nonunion, deep vein thrombosis occurred. Bone healing time was for 18 to 24 weeks with an average of 21 weeks. According to the Merchanetal criteria, 4 cases got excellent results, 6 good, 1 fair and 1 poor. Double-plating fixation via anteriormiddle approach for type C3 distal femoral fractures is an effective way, which has advantages of obvious exposure, simple manipulation, anatomical reduction, stable fixation. However,operation indications and operating instructions should be strictly followed.
Kinon, Merritt D; Desai, Rupen; Loriaux, Daniel; Houten, John K
Percutaneous iliosacral screw placement is a technically challenging procedure with a significant complication profile for misplaced screws. The use of stereotactic image guidance has been shown to provide superior accuracy in the placement of spinal instrumentation. Here, the authors describe a novel application of O-arm technology (Medtronic Sofamor Danek, Memphis, TN, USA) to help safely place iliosacral screws for the treatment of a traumatic sacral fracture. Copyright © 2015 Elsevier Ltd. All rights reserved.
Guo, Yongzhi; Tong, Liangyong; Li, Shaoguang; Liu, Zhi
Background The optimal treatment of type III pilon fractures remains controversial. Hence, we performed this study to investigate whether open reduction and internal fixation (ORIF) is superior to external fixations combined with limited internal fixations (EFLIF). Material/Methods From January 2012 to October 2013, a total of 78 patients were included. Twenty-six patients underwent EFLIF and 52 patients underwent ORIF. All subjects were followed up at 1, 3, 6, and 12 months postoperatively. All outcomes and complications were recorded. Results No statistical differences were observed in Mazur score or ROM between the 2 groups. There were significant differences between the 2 groups in hospital stay (P<0.001), reduction results (P=0.019), screw loosening (P=0.025), and traumatic arthritis (P=0.037). Conclusions Similar functional outcomes were achieved in EFLIF and ORIF groups. Due to several limitations of this study, a well-designed randomized controlled trial involving more patients and long-term follow-up is needed to find an optimal treatment protocol. PMID:26050786
Sternheim, A; Saidi, K; Lochab, J; O'Donnell, P W; Eward, W C; Griffin, A; Wunder, J S; Ferguson, P
We investigated the clinical outcome of internal fixation for pathological fracture of the femur after primary excision of a soft-tissue sarcoma that had been treated with adjuvant radiotherapy. A review of our database identified 22 radiation-induced fractures of the femur in 22 patients (seven men, 15 women). We noted the mechanism of injury, fracture pattern and any complications after internal fixation, including nonunion, hardware failure, secondary fracture or deep infection. The mean age of the patients at primary excision of the tumour was 58.3 years (39 to 86). The mean time from primary excision to fracture was 73.2 months (2 to 195). The mean follow-up after fracture fixation was 65.9 months (12 to 205). Complications occurred in 19 patients (86%). Nonunion developed in 18 patients (82%), of whom 11 had a radiological nonunion at 12 months, five a nonunion and hardware failure and two an infected nonunion. One patient developed a second radiation-associated fracture of the femur after internal fixation and union of the initial fracture. A total of 13 patients (59%) underwent 24 revision operations. Internal fixation of a pathological fracture of the femur after radiotherapy for a soft-tissue sarcoma has an extremely high rate of complication and requires specialist attention.
Dailiana, Z; Agorastakis, D; Varitimidis, S; Bargiotas, K; Roidis, N; Malizos, K N
To evaluate the outcome of hand fractures managed with mini-external fixators (MEFs) in order to assess their usefulness in different fracture types and to make recommendations regarding potential applications. Fifty-one patients with 59 metacarpal and phalangeal fractures were treated with MEFs. Fixators were used to reduce the fracture or to achieve volar plate arthroplasty when anatomical joint reconstruction was impossible. The mean period from injury to MEF application was 4.5 days. The procedure was performed using regional anesthesia and fluoroscopic control, and it lasted 20 to 45 minutes. MEFs were removed in a mean period of 6 weeks, and follow-up was 18 to 55 months. Forty-nine patients with 57 fractures remained in the follow-up group. In all cases the skeleton was successfully reconstructed, whereas the clinical outcome varied according to the type of the original injury: intra-articular fractures had worse outcome than extra-articular (p=.035 for grip strength and p=.0005 for total active motion), and open fractures had worse outcome than closed (p=.06 for grip strength and p=.001 for total active motion). In all cases, patients' satisfaction was high; the Disabilities of the Arm, Shoulder, and Hand score was <7.9 and the visual analog scale score was <0.5. The findings of this series demonstrate the efficacy of versatile MEFs to establish union and correct alignment of hand skeleton with minimal tissue trauma while retaining a good clinical outcome even in the most complex injuries. MEFs can be considered for all hand fractures requiring surgical treatment, and especially for the intra-articular and comminuted fractures. Therapeutic IV.
Chen, Shih-Hao; Tai, Ching-Lung; Yu, Tzai-Chiu; Wang, Chih-Wei; Lin, Chia-Wei; Chen, Chen-Yu; Liu, Keng-Chang
Distal femur fractures adjacent to total knee arthroplasty are a rare yet complex problem. Recently, extramedullary locking plate and retrograde intramedullary nail fixations have become popular options, but the complication rates associated with these procedures are 15-20 %. Modified fixations were assessed in an effort to reduce complications from unstable periprosthetic fractures. Using experimental and finite element methods, this study compared the construct behaviours of a locking plate, a retrograde intramedullary nail, and their modifications (a spiral-blade supplemented in an intramedullary nail or a locking plate/allograft hybrid) when subjected to various fracture types, locations, loading conditions, and bony strength. The implanted models were used to assess construct stiffness, fracture micromotion, and implant stress under different osteoporotic conditions. Finally, we collected 40 cases for radiological analysis to indicate the appropriate procedure for treating periprosthetic fractures following total knee arthroplasty. Regardless of the fracture type, femoral constructs fixed with a conventional or spiral-blade supplemented intramedullary nail exhibited higher axial but lower torsional stiffness than those fixed with a locking plate. Torsional deformation occurred if the lower-positioned fracture had no medial support. The locking plate/allograft construct exhibited the highest stiffness and the least micromotion. A review of 40 clinical cases confirmed the above findings regarding the locking plate/allograft construct. The spiral-blade supplement of retrograde intramedullary nail and locking plate/allograft modified constructs significantly stabilizes the unstable fractured gaps. The locking plate/allograft is recommended for the periprosthetic fractures with deficient bone stock and severe osteoporosis to improve alignment and healing potentials.
Lauxen, Daniel; Schwartsmann, Carlos Roberto; Silva, Marcelo Faria; Spinelli, Leandro de Freitas; Strohaecker, Telmo Roberto; Souza, Ralf Wellis de; Zimmer, Cinthia Gabriely; Boschin, Leonardo Carbonera; Gonçalves, Ramiro Zilles; Yépez, Anthony Kerbes
Objective: The objective of this paper is to measure the volume occupied by the most widely used internal fixation devices for treating femoral neck fractures, using the first 30, 40 and 50 mm of insertion of each screw as an approximation. The study aimed to observe which of these implants caused least bone aggression. Methods: Five types of cannulated screws and four types of dynamic hip screws (DHS) available on the Brazilian market were evaluated in terms of volume differences through water displacement. Results: Fixation with two cannulated screws presented significantly less volume than shown by DHS, for insertions of 30, 40 and 50 mm (p=0.01, 0.012 and 0.013, respectively), fixation with three screws did not show any statistically significant difference (p= 0.123, 0.08 and 0.381, respectively) and fixation with four cannulated screws presented larger volumes than shown by DHS (p=0.072, 0.161 and 0.033). Conclusions: Fixation of the femoral neck with two cannulated screws occupied less volume than DHS, with a statistically significant difference. The majority of screw combinations did not reach statistical significance, although fixation with four cannulated screws presented larger volumes on average than those occupied by DHS. PMID:27047886
Haddad, Behrooz; Khan, Wasim; Zaghloul, Ahmed; Grimes, Lisa; Schenk, Willem
Olecranon fractures are common skeletal injuries accounting for approximately 10% of upper extremity fractures in adults. Simple non-comminuted fractures are traditionally fixed using the tension band wiring technique. This technique, however, has several complications, most commonly prominence of the metalwork frequently requiring surgery for removal. We describe a retrospective review of a new method of fixation for these fractures using partially threaded screws in an attempt to avoid these complications. We used two 3.5 and/or 4 mm partially threaded screws to fix seven simple olecranon fractures and two olecranon osteotomies. Notes and clinic letters of all nine patients were reviewed for demographic data, operation details and complications. Radiographs were reviewed at final clinical follow-up. The Mayo Elbow Performance Score was completed during a telephone consultation. One patient injured her elbow postoperatively, which resulted in fragmentation of the proximal segment and loss of fixation. In one patient the tip of the screws broke after a fall but this did not result in loss of fixation. There were no problems with metalwork prominence or skin irritation in any of the patients. Two patients had low scores due to loss of fixation, and severely comminuted supracondylar fracture of the humerus. Six patients had good scores. We believe that use of AO compression screws is a valid method for the fixation of simple fractures of the olecranon. It is a safe technique and has several advantages over tension band fixation. There is minimal tissue dissection and operating time is decreased. There is minimal risk of metalwork prominence as screws obtain good purchase in the anterior cortex of ulna. Good interfragmentary compression is achieved as screws are perpendicular to the fracture line and two screws provide good rotational stability. Protection of fixation for 1014 days does not result in significant loss of range of motion. Further clinical and
Ibrahim, Fady Michael Fahmy; Abd El-Rady, Abd El-Rady Mahmoud
A prospective study to evaluate the results of monosegmental fixation; fixation of the fractured level with the adjacent vertebra sharing the same disc, in selected types of lumbar and thoracic fractures. This technique aims at saving motion levels by fusion of the only affected motion segment without sacrificing other levels. Forty patients enrolled in this study between August 2011 and October 2013. The inclusion criteria were recent thoracic or lumbar vertebral fractures (less than 2 weeks). The fracture involves only one of the end plates of the vertebrae (either the superior or the inferior). The other end plate and both pedicles should be intact. The exclusion criteria were cervical fractures, fractures that include both end plates or pedicles of the vertebra, fracture dislocation, and load sharing classification score more than seven. All patients underwent monosegmental fixation with pedicle screw fixation. Eight patients were supplemented with interbody grafts. Radiological evaluation was done to assess local kyphosis angle, degree of compression of the anterior column, the degree of comminution, retropulsed fragment, neural canal compromise, integrity of the affected end plate, exclusion of pedicle fracture, and most important to assure that only one end plate is affected. All patients were assessed neurologically according to Frankel grading system. Patient were assessed by Denis pain scale and Denis work scale. The age of the patients was of a mean of 34.5 years old. All patients were Frankle E at time of presentation and remained the same post-operative. The mean operative time from incision time to end of skin closure was 74.2 min. The mean blood loss was 230 ml. The pre-operative degree of local kyphosis; was of a mean 8.22°. This was improved to 2.25° at the immediate postoperative x-rays. At two years follow up, the loss of correction was of a mean 0.85° which was insignificant. The pre-operative percentage of height lost improved from a
Barnes, Jonathan; Webb, Mark; v Fearon, Paul
Distal radius fractures are common injuries in children. Those that affect the growth plate (physis) need to be managed carefully as inadequate management may lead to long-term deformity and a reduction in function. However, different management strategies all have drawbacks and controversy exists over how best to manage these cases. This is the case of a 13-year-old girl who presented with a Salter Harris II fracture, which was managed using a novel approach of utilising a T plate in a buttress mode to stabilise the fracture after anatomical reduction. This provided effective fracture fixation and should allow good bone healing without causing any iatrogenic growth plate damage and without fixing a plate across the physis, which may need removal in the future.
Barnes, Jonathan; Webb, Mark; Fearon, Paul v
Distal radius fractures are common injuries in children. Those that affect the growth plate (physis) need to be managed carefully as inadequate management may lead to long-term deformity and a reduction in function. However, different management strategies all have drawbacks and controversy exists over how best to manage these cases. This is the case of a 13-year-old girl who presented with a Salter Harris II fracture, which was managed using a novel approach of utilising a T plate in a buttress mode to stabilise the fracture after anatomical reduction. This provided effective fracture fixation and should allow good bone healing without causing any iatrogenic growth plate damage and without fixing a plate across the physis, which may need removal in the future. PMID:24488665
Dong, Zhiwei; Li, Qihong; Bai, Shizhu; Zhang, Li
Condyle fractures are common in children and are increasingly treated with open reduction. Three-dimensional printing has developed into an important method of assisting surgical treatment. This report describes the case of a 14-year-old patient treated for a right condyle fracture at the authors' hospital. Preoperatively, the authors designed a surgical guide using 3-dimensional printing and virtual surgery. The 3-dimensional surgical guide allowed accurate alignment of the fracture using Kirschner wire without additional dissection and tissue injury. Kirschner wire fixation augmented by 3-dimensional printing technology produced a good outcome in this adolescent condyle fracture. Copyright © 2015 American Association of Oral and Maxillofacial Surgeons. Published by Elsevier Inc. All rights reserved.
Capo, John T; Svach, David; Ahsgar, John; Orillaza, Nathaniel S; Sabatino, Christopher T
Radial head and neck fractures are common and at times require operative fixation. There is no consensus on the ideal fixation construct for unstable radial neck fractures. Using 7 fresh frozen cadaveric radii, fractures of the radial neck were created 2 cm from the articular surface. The fractures were stabilized with 5 different commonly used constructs: crossed K-wires; a 2.4-mm T-plate using screws in the head (T-plate and nonlocked screw construct); a T-plate using a screw and locked buttress pin in the head (T-plate and locked buttress pin construct); a T-plate with an interfragmentary screw from the shaft retrograde, through the plate into the head (retrograde interfragmentary screw construct); and a T-plate with an interfragmentary screw from a nonarticular portion of the head antegrade into the shaft (antegrade interfragmentary screw construct). All constructs were tested for bending and torsional rigidity using an Instron mechanical testing machine (Model 306; MTS Systems, Eden Prairie, Minnesota). The highest rigidity in both bending and torsion was the antegrade interfragmentary screw construct. During bending, the antegrade interfragmentary screw construct was significantly stronger than a T-plate and nonlocked screw construct. In torsion, the retrograde interfragmentary screw construct was significantly stiffer than K-wires and approached significance over a T-plate and locked buttress pin construct. Locking bolts vs screws into the head did not significantly increase rigidity in torsion or bending. In this model, plating showed an increase in stiffness in torsional loading as compared to K-wires. The addition of a lag screw across the neck fracture consistently showed an increase in torsional and bending stiffness of the constructs. These data may assist orthopedic surgeons in determining the best fixation for radial neck fractures.
Santosha; Singh, Arambam Mahendra; Waikhom, Sanjib; Pakhrin, Vishal; Mukherjee, Sagnik; Debbarma, Rajkumar; Prashant, Prabhu Shrinivas
Introduction Calcaneal fractures constitute the most common fractures in hindfoot. Lots of controversies exist in the management of calcaneal fractures but now-a-days, it is preferable to perform open reduction and internal fixation and early mobilizatation. Aim To evaluate the functional outcome after open reduction and internal fixation of displaced intra-articular fractures of the calcaneum by locking calcaneal plate. Materials and Methods The study was conducted in the Department of Orthopaedic Surgery from September 2013 to April 2016. Thirty intra-articular fractures of the calcaneum were treated by locking calcaneal plate. Patients were followed up for a period of 24 months. Bohler’s angle was measured in preoperative, immediate Post-operative period and after 2 years, follow-up was compared. Results were evaluated according to American Orthopaedic Foot and Ankle Society (AOFAS) Score. Results After 24 months of follow-up, all 24 patients were available for evaluation. Radiological union was achieved in a mean time of 12.5 weeks. Mean duration of hospital stay was 21 days. Bohler’s angle was significantly higher after 2 years of follow-up when compared with preoperative x-ray. According to the AOFAS, Ankle–Hind foot Scale outcome score results were excellent in 43.3% of the patients, good in 33.3%, fair in 10%, and poor in 13.3% of patients. The mean AOFAS score was 79.9 (Range 49-96). Conclusion Open reduction and internal fixation of intra-articular fractures of the calcaneum with locking calcaneal plate gives good results. Maintenance of calcaneal height and Bohler’s angle helps to decrease the incidence of subtalar arthritis. PMID:28208957
Background: Intramedullary nailing is an effective approach for treatment of diaphyseal tibial fractures. However, infrapatellar intramedullary nailing can easily cause angulation and rotation displacement at the fracture ends and increase risk of postoperative infection. Intramedullary nailing via the suprapatellar approach was proved with good reduction and fixation. We used locked intramedullary nailing for the treatment of tibial fractures via a suprapatellar approach in this study. Materials and Methods: 23 patients undergoing tibial fractures fixation by locked META intramedullary nailing via a suprapatellar approach were enrolled between June 2012 and October 2013. There were 18 males and 5 females. The average age was 35.5 years (range 18-60 years). The intraoperative data including operative time and blood loss and postoperative data consisting of hospital stays, fluoroscopy time, fracture healing time and complications were all recorded. Results: The average operative time, blood loss, fluoroscopy time and hospital stay were 78.2 ± 9.1 min, 90.4 ± 23.4 mL, 38.5 ± 6.5 s and 11 ± 3.4 days respectively. The mean followup period in all the patients was 15.5 months. Callus appeared in the patients at average 8 weeks after surgery. The mean knee and ankle range of motion were significantly improved at the last followup (P < 0.05). The average Hospital for Special Surgery and Olerud–Molander scores was 92 ± 4.3 points and 93.6 ± 3.9 points, respectively. No complications were observed. Conclusion: Locked META intramedullary nail fixation via a suprapatellar approach is safe and effective for patients suffering from tibial fractures and earlier functional recovery. PMID:27293289
Zielinski, Stephanie M; Heetveld, Martin J; Bhandari, Mohit; Patka, Peter; Van Lieshout, Esther M M
The effect of implant removal after internal fixation of a femoral neck fracture on physical functioning was analyzed. Characteristics of patients who had their implant removed were studied, as it is currently unknown from which type of patients implants are removed and what effect removal has on function. Secondary cohort study alongside a randomized controlled trial. Multicenter study in 14 hospitals. Patients who had their implant removed after internal fixation of a femoral neck fracture are compared with patients who did not. Patient characteristics and quality of life (Short Form 12, Western Ontario McMaster Osteoarthritis Index) were compared. Matched pairs were selected based on patient/fracture characteristics and prefracture physical functioning. Of 162 patients, 37 (23%) had their implant removed. These patients were younger (median age: 67 vs. 72 years, P = 0.024) and more often independently ambulatory prefracture (100% vs. 84%, P = 0.008) than patients who did not. They more often had evident implant back-out on x-rays (54% vs. 34%, P = 0.035), possibly related to a higher rate of Pauwels 3 fractures (41% vs. 22%, P = 0.032). In time, quality of life improved more in implant removal patients [+2 vs. -4 points, Short Form 12 (physical component), P = 0.024; +9 vs. 0 points, Western Ontario McMaster Osteoarthritis Index, P = 0.019]. Implant removal after internal fixation of a femoral neck fracture positively influenced quality of life. Implant removal patients were younger and more often independently ambulatory prefracture, more often had a Pauwels 3 fracture, and an evident implant back-out. Implant removal should be considered liberally for these patients if pain persists or functional recovery is unsatisfactory. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
Alves, Tim; Neal, John W; Weinhold, Paul S; Dahners, Laurence E
In light of recent reports that patients with femoral neck shortening following fracture fixation are dissatisfied with their outcomes, the objective of this study was to compare the compressive strength, or resistance to shortening, of 3 possible strategies for stabilization of the femoral neck that should resist shortening. The proximal portion of 21 synthetic composite femurs were prepared to isolate the femoral neck for study. A 4-mm segment of the femoral neck was removed to simulate a transcervical comminuted fracture that would be expected to shorten under standard treatment conditions. These simulated fractures were fixed by 1 of 3 methods: a 3-screw configuration using parallel partially threaded screws augmented with an injectable hydroxyapatite bone substitute in the fracture site; a 3-screw configuration using parallel fully threaded screws; or a nonparallel 3-screw configuration using partially threaded screws. The specimens were tested in compression along the axis of the femoral neck, and the mean stiffness and load to failure values were calculated.The hydroxyapatite bone substitute-augmented partially threaded screw fixation construct resulted in the highest stiffness (1928+/-135 N/mm) and load to failure (6529+/-674 N), followed by the fully threaded screw construct (1210+/-166 N/mm and 3987+/-419 N, respectively), and finally the nonparallel construct (518+/-176 N/mm and 592+/-295 N, respectively) (P<.001 for all groups). This study supports further evaluation of hydroxyapatite bone substitute augmentation at the fracture site to prevent femoral neck shortening in femoral neck fractures receiving internal fixation. Copyright 2010, SLACK Incorporated.
Despite advances in science and technology, the success rate for the treatment of displaced intracapsular femoral neck fractures in high-energy injuries remains disappointing. The blood supply system in the femoral head of humans does not favor recovery from these fractures. Once these fractures occur, osteonecrosis and nonunion rates may be as high as 30%, even if the newest technique is used. There are some surgical techniques used to supplement internal fixation to reestablish the blood supply in the femoral head, but none have been evidently successful. After analysis of related studies, the author concludes that immediate surgical treatment using improved techniques incorporating the principles of biomechanics can improve the success rate of treatment of these fractures. Using these principles, the fracture site can achieve sufficient stability. Consequently, the blood supply in the femoral head and neck can be reestablished earlier and loss of reduction of fragments during treatment can be minimized. Thus, the chance of full recovery from these complicated fractures can be maximized. In this study, the biomechanical characteristics of these fractures and the principles associated with the surgical techniques used for treating them are reviewed and clarified. Finally, a surgical technique which is ideal from the author's viewpoint is presented. The author believes that the recommended surgical technique may become the best method for treating these complicated fractures.
Zhang, Wenlong; Zhang, Xu; Zhao, Gang; Gao, Shunhong; Yu, Zhiliang
The aim of this study was to describe and evaluate a surgical technique for the treatment of mallet finger fractures using a K-wire stabilization of the distal interphalangeal (DIP) joint and another K-wire pressing the bone fragment. Between June 2007 and March 2014, 41 patients (28 men, 13 women) with isolated closed mallet finger fracture were treated using two K-wires. In the cohort, the mean joint surface involvement was 44.3% (range: 28-62%). With a mean period of 23.6 months, patient follow-up lasted 13-34 months. The fingers were evaluated for loss of extension and flexion of the (DIP) joints. The results were graded using Crawford's criteria. Union of all fractures took place at an average of 5.5 weeks after the surgical procedure. Average extension lag was 4°, and active flexion 71°. According to the Crawford rating scale, 35 fingers were excellent, four were good, one was fair, and one was poor. Pressing fixation of the bone fragment with the end of a K-wire was a useful technique in the treatment of mallet finger fractures. Therapeutic IV. Copyright © 2015. Published by Elsevier Ltd.
Vallier, Heather A
Displaced distal tibia shaft fractures are effectively treated with standard plates and intramedullary nails. Plate fixation performed with meticulous soft tissue handling results in minimal risks of infection and poor wound healing. Standard plates have high rates of primary union, whereas locking plates may delay union because of increased stiffness. Tibial healing may also be delayed after plating of the fibula, although fibula reduction and fixation may aid accuracy of reduction of the tibia. Malalignment occurs more often with infrapatellar intramedullary nailing versus plates, and early results of suprapatellar nailing appear promising in minimizing intraoperative malalignment. Long-term function after fixation of the distal tibia is good for most, with poor outcomes often associated with baseline social and mental health issues.
Asloum, Y; Bedin, B; Roger, T; Charissoux, J-L; Arnaud, J-P; Mabit, C
Open reduction and internal plate fixation of the fibula is the gold standard treatment for ankle fractures. The aim of this study was to perform a prospective randomized study to compare bone union, complications and functional results of two types of internal fixation of the fibula (plating and the Epifisa FH intramedullary nail). Inclusion criteria were: closed fractures, isolated displaced fractures of the lateral malleolus, inter- and supra-tubercular bimalleolar fractures, and trimalleolar fractures. This study included 71 patients (mean age 53 ± 19): plate fixation group (n=35) and intramedullary nail fixation group (n=36). In seven cases, intramedullary nailing was technically impossible and was converted to plate fixation (the analysis of this sub-group was performed independently). Two patients died and two patients were lost to follow-up. The final comparative series included 32 cases of plate fixation and 28 cases of intramedullary nail fixation. Union, postoperative complications and Kitaoka and Olerud-Molander functional scores were analyzed after one year of follow-up. There was no significant difference in the rate of union (P=0.5605) between the two types of fixation. There were significantly fewer complications (7% versus 56%) and better functional scores (96 versus 82 for the Kitaoka score; 97 versus 83 for the Olerud-Molander score) with intramedullary nailing than with plate fixation. Intramedullary nailing of the lateral malleolus in non-comminuted ankle fractures without syndesmotic injury is a reproducible technique with very few complications that provides better functional results than plate fixation. II (randomized prospective study). Copyright © 2014 Elsevier Masson SAS. All rights reserved.
Farid, Yasser R
Acetabular fractures with complete or incomplete quadrilateral plate separation frequently present with central displacement of the femoral head. Failure of stable fixation of medial wall fractures leaves residual subluxation despite reduction of other fracture components. Several fixation techniques may be either technically demanding or insufficient for stable fixation in conditions of comminution, osteoporosis, or neglected injuries. The proposed wire-plate composite uses a reconstruction spring plate over the pelvic brim for medial wall buttressing. One hole on its true pelvic limb provides a pulley to deviate a cerclage wire or cable passed through the greater sciatic notch into the true pelvis. This enhances buttressing against medial protrusion. Application through anterior approaches is simple and fixation is reliable in difficult fractures without the risk of joint penetration because all quadrilateral plate buttressing implants remain extraosseous.
Chan, Winnie Sze-wun; Kong, Siu-wah; Sun, Kin-wai; Tsang, Pui-ki; Chow, Hung-lit
We report the case of an 83-year-old woman who developed a pseudoaneurysm of the profunda femoris artery after dynamic hip screw fixation for an intertrochanteric femoral fracture. 23 days after the fixation, radiological investigations including colour Doppler ultrasonography and computed tomographic angiography identified a pseudoaneurysm surrounded by a large intramuscular haematoma close to the profunda femoris. The patient underwent emergency evacuation and was under intensive care for 3 days and was discharged 6 weeks later, with no complications. At one-year follow-up, the wound and fracture had healed, but the patient was confined to a wheelchair. A high index of clinical suspicion and radiological imaging are necessary for making the diagnosis.
Ramakrishna, Kotlanka; Sridhar, Idapalapati; Sivashanker, Sathiamoorthy; Khong, Kok Sun; Ghista, Dhanjoo N.
The objective of treating the fractured bone is to achieve painless functioning of the bone and undisturbed healing at the fracture. Internal fixation by stiff bone-plate is one of the standard methods to achieve these objectives. Recently, there is considerable interest in the usage of compliant plates to enhance bone healing with reduced stress shielding. Herein, first an analytical solution is developed to determine screw forces in the bone-plate assembly that conforms the plate and the bone under bending load. Based on the analytical calculations, an optimal fixator plate selection criterion for necessary and sufficient stress shielding is proposed. Second, effectiveness of employing a non-homogeneous stiffness graded (SG) plate rather than a homogeneous stainless steel (SS) plate for stress shielding is investigated using a finite element method. It is found that stress shielding on bone by SG plate is less compared to SS plate.
Hollevoet, Nadine; Vanhoutie, Tom; Vanhove, Wim; Verdonk, René
Different methods exist to treat distal radius fractures. A prospective randomized study was conducted to establish whether palmar plate fixation with locking screws gave better results than percutaneous K-wire fixation in patients over 50 years of age. Only fractures with dorsal displacement after a simple fall were included in the study. Twenty wrists were treated with K-wires and 20 with a plate. Radiological parameters were measured on preoperative radiographs and at five weeks postoperatively. Clinical results and DASH scores were determined at three months postoperatively and at more than one year. No significant difference in radial inclination, palmar tilt, clinical outcome and DASH score was found between plating and K-wires, but the mean difference in ulnar variance between pre- and postoperative radiographs was significantly better with plates. It can be concluded that plates were superior to K-wires in restoring ulnar variance, but functional outcome was similar with both techniques.
Queipo-de-Llano, A; Lombardo-Torre, M; Leiva-Gea, A; Delgado-Rufino, F B; Luna-González, F
In the treatment of unstable pelvic ring fractures, external fixators have the limitation of not adequately stabilizing the injured posterior elements. This article presents a novel and simple technique of temporary external fixation of the pelvic ring, able to produce compression of both the anterior and posterior pelvic elements. A curved flexible carbon-fiber rod is used, pre-tensioned before attachment to supra-acetabular Schanz screws. Although more extensive clinical experience is required, favorable preliminary results in a series of 13 patients with unstable pelvic fracture were encouraging: the aim of closing the posterior and anterior elements of the pelvic ring was achieved in all cases treated with this technique, and 12 patients survived. Radiological results were excellent in 3 cases and good in 9 cases. No major complications, such as secondary displacement, vertical re-displacement or deep infection, were observed. Mean operative time was 25min, compatible with emergency management.
Vesnaver, Ales; Gorjanc, Matija; Eberlinc, Andreja; Dovsak, David A; Kansky, Andrej A
Treatment of fractures of the mandibular condyle fractures varies among centres as there still is no general consensus. The aim of this paper was to determine the safety and efficiency of surgical treatment using a transparotid approach for direct plating. A prospective clinical study was conducted on 34 patients with 36 fractures of the condyle. All 36 fractures were displaced, and 14 (39%) of them were fracture dislocations. The fractures were treated surgically with a transparotid facelift or retromandibular approach using miniplates and screws for fixation. Patients were carefully followed up and were asked to answer a survey paper 2-39 months postoperatively. Occlusion practically identical to the pretraumatic condition was achieved in 31 out of 33 dentate patients (94%). Postoperative interincisal distance was 30-61 mm (mean 44 mm), 4 patients (12%) had postoperative deflection to the side of injury during mouth opening. Facial symmetry was achieved in all of the patients. Eight out of 36 cases (22%) had a transient weakness of certain ipsilateral facial muscle groups, lasting for 4-8 weeks. In one of these patients, a mild weakness of the upper lip and lower eyelid persisted after 13 months. There were 5 cases of miniplate fractures (14%), all of them in patients in whom 1.7 or thinner miniplates were used. There were 5 cases of salivary fistulae (14%), all of them in patients where the parotid capsule was not closed in a watertight fashion. According to the postoperative survey completed by 32 patients, 30 of them (94%) were very satisfied with the outcome of treatment. If conducted properly, the transparotid facelift approach offers a safe and effective approach for direct fixation of condylar fractures.
Azam, Quamar; Sherwani, MKA; Abbas, Mazhar; Gupta, Rahul; Asif, Naiyer; Sabir, AB
Objective: Patients often reach the hospital late after passage of golden hours (initial 6 hours) after sustaining high-velocity injuries. The decision of internal fixation in Gustilo's Type IIIA and IIIB fractures becomes a formidable challenge in patients reaching late. The purpose of the present study was to find out if internal fixation could be safely undertaken in these patients. Materials and Methods: Sixty-three patients, having 70 compound fractures (46 Type IIIA and 24 IIIB), which were internally fixed after 6h but within 24h after injury, were included in the present analysis. Follow-up ranged from 18 to 48 months with mean of 28 months. Result: Overall infection rate noted was (n = 11) 15.71% (8.7% in IIIA, and 29.16% in IIIB). The difference in deep infection rate between Type IIIA and Type IIIB was found to be statistically significant (P value < 0.01). Nonunion was seen in five fractures. Functional evaluation using Katenjian's criteria, showed 62.85% (44 fractures of 70) good to excellent results. Conclusion: Satisfactory results may be obtained in Gustilo's Type IIIA and IIIB fractures even if fixed after the golden period, provided strict protocol such as aggressive debridement, prophylactic antibiotic coverage, early soft tissue reconstruction and timely bone grafting is followed. The primary coverage of the wound is discouraged. PMID:21139745
Carvalho, Roni Azevedo; Filho, Nelson Franco; Neto, Antonio Batalha Castello; Reis, Giulyano Dias; Dias, Marcos Pereira
Objective: To analyze and present the surgical results from unstable supracondylar fractures of the humerus in children, treated by means of reduction and percutaneous fixation using two crossed Kirschner wires. Methods: A cross-sectional study was conducted on 20 children, taking into consideration sex, age at the time of the fracture, age at the time of the assessment, side affected, type and mechanism of trauma, postoperative complications and radiographic and clinic variables. Results: Ten fractures were observed in the left arm and ten in the right arm. The age at the time of the fracture ranged from 2 to 13 years (mean: 5.9 ± 2.48 years). Three fractures were classified as type II and 17 as type III. The length of follow-up ranged from four months to three years. Baumann's angle ranged from 69 to 100 (mean: 78.3) and cubitus varus was observed in four patients (values ranging from 84 to 100). According to the modified Flynn's criteria, 20 cases presented satisfactory outcomes: 17 excellent (85%), two good (10%) and one regular (5%). Two patients presented limited range of motion, two had paresthesia in the cubital region and one had transient neuropraxia of the ulnar nerve for six weeks. Conclusion: Percutaneous fixation with two crossed Kirschner wires leads to good results when carried out under direct viewing and with isolation of the ulnar nerve. PMID:27047887
Hochban, W; Ellers, M; Umstadt, H E; Juchems, K I
In a case series 54 patients with 61 subcondylar fractures had been treated by surgical repositioning and miniplate-fixation by an intraoral approach. Functional results with special regard to the function of the temporomandibular joint TMJ were registered not earlier than 1 year postoperatively and compared to a case series of 48 patients with 63 conservatively treated subcondylar fractures. Axiographic or pantographic investigation proved higher incidence of TMJ-disorders as it was the case for the common clinical functional examination. TMJ-function was worse in the conservatively treated cases especially in dislocated fractures. Therefore dislocated fractures especially with luxation of the TMJ should be surgically treated. Surgical repositioning and fixation by an intraoral approach is difficult and allows only limited access and view of the fracture, but avoids complications by scaring or facial nerve damage and seems to be sufficient for adequate repositioning. Minor dislocations showed no influence on TMJ-function. Of course surgical repair of disrupted TMJ-ligaments is not possible by an intraoral approach-disrupted TMJ-ligaments in luxated joints seem to be of major importance for the later TMJ-function.
Jang, Jae Hoon; Ahn, Jae Min; Lee, Hee Jin
Purpose This study aimed to evaluate the surgical outcomes of biologic plating using locking compression plate-distal femur (LCP-DF) in patients with subtrochanteric fracture of the femur. Materials and Methods Between January 2010 and December 2013, 28 consecutive patients with subtrochanteric fractures of the femur, treated with biologic fixation using LCP-DF, were enrolled. Preoperative values, including patient age, sex, body mass index, fracture type, type of lung injury, and surgical timing from injury to surgery, were retrospectively evaluated. Radiologic assessments included time to union, coronal alignment, rotational alignment, and complications such as implant breakage and screw breakage. Adverse events, including postoperative fat embolism and adult respiratory distress syndrome, infection during the follow-up period, and walking ability at the last follow-up visit, were assessed. Results Union was achieved in 27 patients (96.4%) after a mean duration of 5.4 months (range, 3-14 months). No patients developed fat embolism or adult respiratory distress syndrome during the hospitalization period of this study. Conclusion Biologic fixation using locking compression plates may represent a safe surgical option which can be utilized in patients with subtrochanteric fracture regardless of injury severity, surgical timing, fracture type, and presence of lung injury. PMID:28316965
Ng, Alan; Barnes, Esther S
The management of complications resulting from the open reduction and internal fixation of ankle fractures is discussed in detail. The initial radiographic findings of the most common postsurgical complications of ankle fracture reduction are briefly discussed, namely lateral, medial, and posterior malleolar malunion or nonunion, syndesmotic widening, degenerative changes, and septic arthritis with or without concomitant osteomyelitis. Emphasis is placed on the management of these complications, with a review of the treatment options proposed in the literature, a detailed discussion of the authors' recommendations, and an inclusion of different case presentations.
Teng, Lin; Zhong, Gang; Liu, Gang; Xiao, Cong; Liu, Guoming; Huang, Fuguo
To compare the biomechanical stability of Kirschner wire and tension band wiring, reconstruction plate combined with tension band wiring, and olecranon anatomical plate in fixing proximal ulna combined with olecranon fracture, so as to provide the theoretical evidence for clinical selection of internal fixation. Eight specimens of elbow joints and ligaments were taken from eight fresh male adult cadaveric elbows (aged 26-43 years, mean 34.8 years) donated voluntarily. The model of proximal ulna combined with olecranon fracture was made by an osteotomy in each specimen. Fracture end was fixed successively by Kirschner wire and tension band wiring (group A), reconstruction plate combined with tension band wiring (group B), and olecranon anatomical plate (group C), respectively. The biomechanical test was performed for monopodium compression experiments, and load-displacement curves were obtained. The stability of the fixation was evaluated according to the load value when the compression displacement of fracture segment was 2 mm. No Kirschner wire withdrawal, broken plate and screw, loosening and specimens destruction were observed. The load-displacement curves of 3 groups showed that the displacement increased gradually with increasing load, while the curve slope of groups B and C was significantly higher than that of group A. When the compression displacement was 2 mm, the load values of groups A, B, and C were (218.6 +/- 66.9), (560.3 +/- 116.1), and (577.2 +/- 137.6) N, respectively; the load values of groups B and C were significantly higher than that of group A (P < 0.05), but no significant difference was observed between groups B and C (t = 0.305, P = 0.763). The proximal ulna combined with olecranon fracture is unstable. Reconstruction plate combined with tension band wiring and olecranon anatomical plate can meet the requirement of fracture fixation, so they are favorable options for proximal ulna combined with olecranon fracture. Kirschner wire and tension
Hsu, Edward; Crombie, Anthony; To, Phong; Marquart, Louise; Batstone, Martin D
Open reduction of mandibular fractures before internal fixation is most commonly performed by 1 of 2 methods: intermaxillary fixation (IMF) or manual reduction. There are risks to both patient and clinician associated with using IMF. Furthermore, previous retrospective studies have failed to show any advantage in its use. The purpose of this study was to directly compare the use of manual reduction (experimental group) and IMF (control group) in open reduction-internal fixation of mandibular fractures. Patients who presented with isolated mandibular fractures at 2 hospitals in Queensland, Australia, from May 2009 to June 2010 were enrolled in a prospective controlled trial comparing IMF and manual reduction. The outcome measures were operative duration (primary outcome), as well as radiographic outcome, occlusal outcome, and complications (secondary outcomes). The patient and assessor were blinded to the type of reduction used before fixation. The study hypothesis is that manual reduction allows internal fixation in a shorter time than IMF with an equivalent outcome. We recruited 50 patients, 26 allocated to IMF and 24 allocated to manual reduction before internal fixation of mandibular fractures. IMF was associated with an increased duration of procedure (P < .001) and increased complication rate (P = .063), without any observable benefit with regard to either radiographic outcome or occlusal outcome. IMF is not required in open reduction-internal fixation of mandibular fractures that met our inclusion criteria. IMF is associated with increased costs to the health service and risks to both the patient and clinician. Copyright © 2012 American Association of Oral and Maxillofacial Surgeons. All rights reserved.
Mathew, G; Kowalczuk, M; Hetaimish, B; Bedi, A; Philippon, M J; Bhandari, M; Simunovic, N; Crouch, S; Ayeni, O R
The purpose of this study was to estimate the radiographic prevalence of CAM-type femoroacetabular impingement (FAI) in elderly patients (≥ 50 years) who have undergone internal fixation for femoral neck fracture. A total of 187 frog-leg lateral radiographs of elderly patients who underwent internal fixation for a femoral neck fracture were reviewed by two independent reviewers. The alpha angle, beta angle, and femoral head-neck offset ratio were calculated. The presence of two abnormal radiographic parameters was deemed to be diagnostic of radiographic CAM-type impingement. Radiographic CAM-type FAI was identified in 157 out of 187 (84 %) patients who underwent internal fixation for fractures of the femoral neck. Moderate-to-good inter-observer reliability was achieved in the measurement of radiographic parameters. With reference to fracture subtypes and prevalence of radiographic features of CAM-type morphology, 97 (72 %) out of 134 patients were positive for CAM in Garden subtypes I and II, whereas 49 (85.9 %) out of 57 patients had radiographic CAM in Garden III and IV subtypes. There was a high prevalence of CAM-type FAI in patients that underwent surgical fixation of femoral neck fractures. This is significantly higher than the reported prevalence in non-fracture patient populations. The high prevalence of CAM morphology could be related to several factors, including age, fracture morphology, quality of reduction, type of fixation, and fracture healing.
Wang, Chun-Hao; Chang, Peng-Yuan; Wu, Jau-Ching; Tu, Tsung-Hsi; Wu, Ching-Lan; Huang, Wen-Cheng; Cheng, Henrich
Odontoid fracture is not uncommon and surgical treatment that uses posterior screw/rod fixation is an acceptable option. This is the first report of delayed hydrocephalus due to subarachnoid fat migration as a complication of posterior atlanto-axial (AA) fixation. A 27-year-old man underwent posterior C1 lateral mass and C2 pedicle screw fixation for a recent Anderson-D'Alonzo type 2 odontoid fracture. Autologous bone graft was wired for onlay fusion. The surgery was smooth, except that there was an incidental durotomy intraoperatively. The patient had significant relief of his neck pain, although computed tomography (CT) demonstrated a medial breach of the left C1 screw postoperation; however, he gradually developed headache and dizziness after discharge. Five weeks after operation, magnetic resonance imaging demonstrated a large pseudo-meningocele at the surgical site, which was managed conservatively. Nine weeks after the AA fixation, the patient was sent to the emergency department for altered consciousness. A brain CT demonstrated hydrocephalus and multiple fat emboli in the subarachnoid and intraventricular space. A ventriculoperitoneal shunt was inserted to manage the hydrocephalus and pseudo-meningocele. The patient recovered well and was followed up to 13 months after operation. To date, this was the first report of delayed hydrocephalus caused by fat embolism after AA fixation surgery. Incidental durotomy in posterior AA fixation may predispose the patient to a serious complication of fat-cerebrospinal fluid embolism and subsequent hydrocephalus. There should be a heightened awareness for such a complication. Both CT and magnetic resonance imaging are useful for the diagnosis of subarachnoid fat droplets. Copyright © 2016 Elsevier Inc. All rights reserved.
During fixation of a femoral neck fracture in a 23-year-old male patient with cannulated screws, a broken guide wire fragment inadvertently advanced through the hip joint and protruded into the pelvis. A second surgical approach was needed to remove the broken fragment from the pelvis. Awareness of such a potentially devastating complication will make surgeons more cautious during implementation of orthopedic instruments and increases patient’s safety during surgery.
Serrano-Mateo, L; Lopiz, Y; León-Serrano, C; García-Fernández, C; López-Durán-Stern, L; Marco, F
Distal humerus fractures in the elderly frequently associated with poor bone quality and comminution, making it harder to achieve proper osteosynthesis. Our aim is to evaluate the radiological and functional results of open reduction and internal fixation of these fractures. Retrospective study of 26 patients treated by open reduction and internal fixation between the years 2005-2010. Mean follow-up was 42 months. At final follow-up, a radiography evaluation (Knirk and Jupiter score) and clinical examination using Mayo Elbow Performance Score and Quick-Disabilities of the Arm, Shoulder and Hand Score was performed. Mean age of the group was 76.8 years (65-89), with 83% of the patients being female. Sixteen patients suffered type C fractures and 8 type A by AO classification. All underwent posterior surgical approach. Mean elbow flexion reached 118.86°, with a mean extension deficit of 25°. More than 3-quarters (79.1%) of the patients showed 0-1 grade degenerative changes on the X-ray films at final follow-up. Functional results reached an average 19.87 points on Quick-Disabilities of the Arm, Shoulder and Hand Score, and 85 points on Mayo Elbow Performance Score scores. Non-union occurred in 2 cases: distal humerus in one patient and olecranon osteotomy in another. Ulnar nerve neuropraxia was recorded in 2 cases, and radial nerve in one. All 3 recovered uneventfully. Revision surgery was required, with 2 patients needing hardware removal and one a new fixation. Treatment by open reduction and internal fixation with plating in elderly people for type A and C distal humerus fractures gives good functional results regarding this population, and thus scarcely disturbs their quality of life. Copyright © 2012 SECOT. Published by Elsevier Espana. All rights reserved.
Abousayed, Mostafa M; Toussaint, Rull James; Kwon, John Y
We describe a simple technique using dual C-arms (large and mini C-arm together) for open reduction internal fixation of calcaneal fractures in the lateral decubitus position that (1) decreases the difficulty of obtaining proper intraoperative imaging; (2) limits C-arm movement, which decreases risk of contamination and operative time; and (3) minimizes the drawbacks of each imaging fluoroscopic modality. Level V, Technical tip, Expert opinion.
O’Shea, Kieran; Burke, Tom
Displaced fractures of the lateral malleolus are typically treated with plate osteosynthesis with or without the use of lag screws, and immobilisation in a plaster cast for up to 6 weeks. Fixation through a smaller incision with less metal, such as lag screw only fixation, would theoretically lead to decreased infection rates and less irritation caused by hardware. The purpose of this study was to evaluate the benefits and success of lag screw only fixation of the lateral malleolus in non-comminuted oblique fractures of the lateral malleolus. A total of 25 patients who had non-comminuted unstable oblique fractures of their lateral malleolus that had been surgically fixed with lag screws only were retrospectively evaluated. All patients were younger than 60 years of age. Evaluation of the success of fixation, complications, resultant mobility and patient satisfaction was based on information gathered from chart reviews, X-ray findings and a standardised questionnaire based on the AOFAS Foot and Ankle Outcomes Questionnaire. These results were compared to an age-matched group of 25 consecutive patients treated with plate osteosynthesis. Of the 25 patients fixed with lag screws, nine had an unstable fracture of the lateral malleolus only, ten were bimalleolar fractures and six were trimalleolar. Eighteen patients were treated with two lag screws, and seven were treated with three lag screws. The bi- and trimalleolar fractures were treated with standard partially threaded cancellous screws. None of the lag screw-only group lost reduction. There were no documented wound infections in the lag screw group as compared to three deep infections in the plate group. Lag screw-only patients reported no palpable hardware as compared to 50% of the plate group. AOFAS scores at a mean of 12 months post-operative were similar in both groups. Lag screw only fixation of the lateral malleolus is a safe and effective method that has a number of advantages over plate osteosynthesis
Posterior pedicle screw fixation has become a popular method for treating thoracolumbar burst fractures. However, it remains unclear whether additional fixation of more segments could improve clinical and radiological outcomes. This meta-analysis was performed to evaluate the effectiveness of fixation levels with pedicle screw fixation for thoracolumbar burst fractures. MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Springer, and Google Scholar were searched for relevant randomized and quasirandomized controlled trials that compared the clinical and radiological efficacy of short versus long segment for thoracolumbar burst fractures managed by posterior pedicle screw fixation. Risk of bias in included studies was assessed using the Cochrane Risk of Bias tool. Based on predefined inclusion criteria, Nine eligible trials with a total of 365 patients were included in this meta-analysis. Results were expressed as risk difference for dichotomous outcomes and standard mean difference for continuous outcomes with 95% confidence interval. Baseline characteristics were similar between the short and long segment fixation groups. No significant difference was identified between the two groups regarding radiological outcome, functional outcome, neurologic improvement, and implant failure rate. The results of this meta-analysis suggested that extension of fixation was not necessary when thoracolumbar burst fracture was treated by posterior pedicle screw fixation. More randomized controlled trials with high quality are still needed in the future. PMID:28243383
Cisneros, Luis Natera; Gómez, Mireia; Alvarez, Carlos; Millán, Angélica; De Caso, Julio; Soria, Laura
Background: Tibial platfond fractures are usually associated with massive swelling of the foot and ankle, as well as with open wounds. This swelling may cause significant decrease of the blood flow, so the state of the soft tissue is determinant for the surgical indication and the type of implant. This retrospective study compares the union times in cases of tibial plafond fractures managed with a hybrid external fixation as a definitive procedure versus those managed with a two stage strategy with final plate fixation. Materials and Methods: A retrospective study in a polytrauma referral hospital was performed between 2005 and 2011. Patients with a tibial plafond fracture, managed with a hybrid external fixation as a definitive procedure or managed with a two stage strategy with the final plate fixation were included in the study. Postoperative radiographs were evaluated by two senior surgeons. Fracture healing was defined as callus bridging of one cortex, seen on both lateral and anteroposterior X-ray. The clinical outcome was evaluated by means of 11 points Numerical Rating Scale for pain and The American Orthopedic Foot and Ankle Society ankle score, assessed at the last followup visit. Thirteen patients had been managed with a hybrid external fixation and 18 with a two-stage strategy with the final plate fixation. There were 14 males and 17 females with a mean age of 48 years (range 19–82 years). The mean followup was 24 months (range 24–70 months). Results: The mean time from surgery to weight bearing was 7 ± 6.36 days for the hybrid fixation group and 57.43 ± 15.46 days for the plate fixation group (P < 0.0001); and the mean time from fracture to radiological union was 133.82 ± 37.83) and 152.8 ± 72.33 days respectively (P = 0.560). Conclusion: Besides the differences between groups regarding the baseline characteristics of patients, the results of this study suggest that in cases of tibial plafond fractures, the management with a hybrid external
Khoshbin, Amir; Leroux, Timothy; Wasserstein, David; Wolfstadt, Jesse; Law, Peggy W; Mahomed, Nizar; Wright, James G
The epidemiology of paediatric supracondylar fracture (SCF) fixation has not been evaluated at a population level. The purpose of this study was to: (1) determine the incidence density rate (IDR) of SCF fixation and (2) determine the rate of and risk factors for re-operation. Using administrative databases, all patients who underwent SCF fixation (closed reduction percutaneous pinning (CRPP) or open reduction (OR)) in Ontario between April 2002 and March 2010 were identified. Exclusion criteria included age (>12 years), a prior or concurrent non-SCF elbow fracture or previous humeral osteotomy. The overall IDR of SCF fixation and for subgroups of age, sex and season were calculated. A multivariate regression (immediate and short-term re-operation) and a Cox proportional hazards model (long-term re-operation) were used to identify patient, injury and provider factors that influenced re-operation risk and were reported as odds ratios or hazard ratios (HRs) with 95% confidence intervals (CIs), respectively. A total of 3235 patients with a median age of 6.0 years (interquartile range (IQR): 3.0) underwent SCF fixation. The median follow-up was 6.0 years (IQR: 3.7). The majority underwent a CRPP (78.7%) which were performed after hours (75.6%). The overall IDR was 20.7/100,000 person-years (py), but it varied significantly by season and age. Re-operation was uncommon in the immediate (1.0%), short-term (1.4%) and long-term (0.3%) follow-up period. As compared to CRPP, patients who underwent OR were more likely to undergo early nerve exploration (odds ratio: 7.8 (CI: 3.0-20.6)) and re-operation in the long term (HR: 3.0 (CI: 1.0-8.7)). Increased surgeon volume of SCF fixation was protective against repeat fixation (odds ratio: 0.9 (CI: 0.9-1.0)) and re-operation in the long term (HR: 0.9 (CI: 0.8-1.0)). While SCF fixation is common, the rate of re-operation is low. No differences existed between the sexes and a higher volume of fixations occurred during the summer months
Huegli, R. W. Messmer, P.; Jacob, A. L.; Regazzoni, P.; Styger, S.; Gross, T.
Delayed or non-union of a sacral fracture is a serious clinical condition that may include chronic pain, sitting discomfort, gait disturbances, neurological problems, and inability to work. It is also a difficult reconstruction problem. Late correction of the deformity is technically more demanding than the primary treatment of acute pelvic injuries. Open reduction, internal fixation (ORIF), excision of scar tissue, and bone grafting often in a multi-step approach are considered to be the treatment of choice in delayed unions of the pelvic ring. This procedure implies the risk of neurological and vascular injuries, infection, repeated failure of union, incomplete correction of the deformity, and incomplete pain relief as the most important complications. We report a new approach for minimally invasive treatment of a delayed union of the sacrum without vertical displacement. A patient who suffered a Malgaigne fracture (Tile C1.3) was initially treated with closed reduction and percutaneous screw fixation (CRPF) of the posterior pelvic ring under CT navigation and plating of the anterior pelvic ring. Three months after surgery he presented with increasing hip pain caused by a delayed union of the sacral fracture. The lesion was successfully treated percutaneously in a single step procedure using CT navigation for drilling of the delayed union, autologous bone grafting, and screw fixation.
Jacob, Augustinus Ludwig; Suhm, Norbert; Kaim, Achim; Regazzoni, Pietro; Steinbrich, Wolfgang; Messmer, Peter
Purpose: To demonstrate the technical feasibility of the anterior approach to the coronal roof component of carefully selected acetabular fractures in computed tomography (CT)-navigated closed reduction and percutaneous fixation (CRPF).Methods: Four patients with nondisplaced or slightly displaced coronal fractures of the acetabular roof were treated with percutaneous screw fixation. Screws were implanted over guidepins placed under CT navigation. Mean clinical and radiological follow-up was 16 months.Results: All screws could be placed as intended. There were no peri- or postoperative complications. Radiological follow-up showed primary osseous union. Clinical results were excellent according to a median Merle-d'Aubigne score of 18.Conclusion: Nondisplaced or slightly displaced coronally oriented fractures of the acetabular roof can be treated by minimally invasive percutaneous CT-navigated fixation through an anterior approach that does not endanger the sciatic nerve. Early clinical results are encouraging. Close cooperation between trauma surgeons and radiologists and careful selection of cases is mandatory.
Lei, Jianyin; Dong, Pengfei; Li, Zhiqiang; Zhu, Feng; Wang, Zhihua; Cai, Xianhua
The aim of this study was to evaluate the biomechanical properties of common fixation systems for complex acetabular fractures. A finite element (FE) pelvic model with anterior column and posterior hemi-transverse acetabular fractures was created. Three common fixation systems were used to fix the posterior wall acetabular fractures: 1. Anterior column plate combined with posterior column screws (group I), 2. Anterior column plate combined with quadrilateral area screws (group II) and 3. Double-column plates (group III). And 600 N, representing the body weight, was loaded on the upper surface of the sacrum to simulate the double-limb stance. The amounts of total and relative displacements were compared between the groups. The total amount of displacement was 2.76 mm in group II, 2.81 mm in group III, and 2.83 mm in group I. The amount of relative displacement was 0.0078 mm in group II, 0.0093 mm in group III and 0.014 mm in group I. Our results suggested that all fixation systems enhance biomechanical stability significantly. Anterior column plate combined with quadrilateral area screws has quite comparable results to double column plates, they were superior to anterior column plate combined with posterior screws. Copyright © 2017 Turkish Association of Orthopaedics and Traumatology. Production and hosting by Elsevier B.V. All rights reserved.
Bouletreau, Pierre; Konsem, Tarcissus; Traoré, Ibraïma; Coulibaly, Antoine Toua; Ouédraogo, Dieudonné
In some developing countries wire is still widely used in facial fractures internal fixation. This study presents the effectiveness and complications of wire osteosynthesis in a university teaching hospital in Burkina Faso and discusses some of its other benefits and disadvantages. Notes of 227 patients with facial fractures treated by wire internal fixation at department of stomatology and maxillofacial surgery of CHU Souro Sanou, Burkina Faso between 2006 and 2010 are reviewed retrospectively. A satisfactory treatment outcome was recorded in 91.2% of the 227 patients. Complications occurred in 8.8% of the patients who had operative site infection (3.1%), malocclusion (1.8%), sensory disturbance (1.8), facial asymmetry (1.3%), delayed bone union (0.9%) or enophtalmos (0.4%). The overall complications rate was 7.4% after mandibular osteosynthesis, 6.9% after Le Fort osteosynthesis and 6.5% after zygoma osteosynthesis. Post operative infections occurred irrespective to the surgical site. The other complications were more specific to the surgical site. Wire internal fixation may be a reasonable alternative for the surgical treatment of non-comminuted facial fractures and those without bone substance loss, in the setting of limited resources. PMID:25237416
Cervantes, Thomas M; Slocum, Alexander H; Seldin, Edward B
Conventional bone plates are commonly used for surgical mandibular fracture fixation. Improper alignment between bone segments, however, can result in malocclusion. Current methods of fixation require a surgeon to visually align segments of bone and affix a metal plate using bone screws, after which little can be done to adjust alignment. A method of adjusting fracture alignment after plate placement, without screw removal, presents an improvement over costly and risky revision surgery. A modified bone plate has been designed with a deformable section to give surgeons the ability to reduce misalignments at the fracture site. The mechanics of deformation for various adjustment mechanisms was explored analytically, numerically, and experimentally to ensure that the adjustable plate is comparable to conventional bone plates. A static force of 358.8 N is required to deform the adjustable bone plate, compared with predicted values of 351 N using numerical simulation and 362 N using a simple beam theory. Dynamic testing was performed to simulate in vivo loading conditions and evaluate load-capacity in both deformed and un-deformed bone plates. Results indicate that bending stiffness of a rectangular bone plate is 709 N/mm, compared with 174 N/mm for an octagonal plate and 176 N/mm for standard plates. Once deformed, the rectangular and octagonal plates had a stiffness of 323 N/mm and 228 N/mm, respectively. Un-deformed and deformed adjustable bone plates have efficacy in bone segment fixation and healing.
Background To compare two different techniques of proximal pin placement for the treatment of intertrochanteric fractures in elderly patients utilizing the Orthofix Pertrochanteric Fixator. Methods Seventy elderly high-risk patients with an average age of 81 years were treated surgically for intertrochanteric fracture, resulting from a low energy trauma. Patients were randomly divided in two groups regarding to the proximal pin placement technique. In Group A the proximal pins were inserted in a convergent way, while in Group B were inserted in parallel. Results All fractures healed uneventfully after a mean time of 98 days. The fixator was well accepted and no patient had significant difficulties while sitting or lying. The mean VAS score was 5.4 in group A and 5.7 in group B. At 12 months after surgery, in group A the average Harris Hip Score and the Palmer and Parker mobility score was 67 and 5.8, respectively. In group B, the average Harris Hip Score and the Palmer and Parker mobility score was 62 and 5.6, respectively. No statistically significant difference was found regarding the functional outcome. The mean radiographic exposure during pin insertion in Group A and Group B was 15 and 6 seconds, respectively. The difference between the two groups, regarding the radiographic exposure, was found to be significant. Conclusion Proximal screw placement in a parallel way is simple, with significant less radiation exposure and shorter intraoperative duration. In addition, fixation stability is equal compared to convergent pin placement. PMID:21939534
Kang, Seung-Hoon; Jeong, Min; Lim, Hae-Seong
Background Distal humerus intercondylar fractures are intra-articular and comminuted fractures involving soft tissue injury. As distal humerus is triangle-shaped, parallel plating coupled with articular fixation would be suitable for bicolumn restoration in treatment of distal humerus intercondylar fracture. Methods This study included 38 patients (15 males and 23 females) who underwent olecranon osteotomy, open reduction and internal fixation with the triangle-shaped cannulated screw and parallel locking plates (triangular fixation technique). Functional results were assessed with the visual analog scale (VAS) scores, Mayo elbow performance (MEP) scores and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires. Anteroposterior and lateral elbow radiographs were assessed for reduction, alignment, fracture union, posttraumatic arthrosis, and heterotopic ossification, and computed tomography (CT) scans were used to obtain more accurate measurements of articular discrepancy. Results All fractures healed primarily with no loss of reduction. The mean VAS, MEP, and DASH scores of the affected elbow were not significantly different from those of the unaffected elbow (p = 0.140, p = 0.090, and p = 0.262, respectively). The mean degree of flexion was significantly lower in the affected elbow than in the unaffected elbow, but was still considered as functional (p = 0.001, > 100° in 33 of 38 patients). Two cases of articular step-offs (> 2 mm) were seen on follow-up CT scans, but not significantly higher in the affected elbow than in the unaffected elbow (p = 0.657). Binary logistic regression analysis revealed that only Association for Osteosynthesis (AO) type C3 fractures correlated with good/excellent functional outcome (p = 0.012). Complications occurred in 12 of the 38 patients, and the overall reoperation rate for complications was 10.5% (4 of 38 patients). Conclusions Triangular fixation technique for bicolumn restoration was an effective and reliable
Wang, Tao; Sun, Jun-Ying; Zha, Guo-Chun; Jiang, Tao; You, Zhen-Jun; Yuan, De-Jing
Femoral head necrosis is a rare but devastating complication following femoral neck fracture. The reported incidence of avascular necrosis after femoral neck fracture fixation varies widely, and there is no consensus regarding its risk factors. The aim of this study was to analyze the risk factors for femoral head necrosis after internal fixation in femoral neck fracture. This retrospective study included 166 patients with femoral neck fractures treated with surgical reduction and internal fixation at the authors' institution from January 2004 to December 2008. Eight patients died for reasons unrelated to the surgery, and 12 patients were lost to follow-up. The remaining 146 patients (146 fractures) were followed until union or until conversion to total hip arthroplasty. The patients included 61 males and 85 females with an average age of 47.5 years (range, 18-68 years). The authors analyzed the following factors: age, sex, Garden classification, reduction quality, surgical methods, injury-to-surgery interval, preoperative traction, weight-bearing time, and implant removal. All patients were followed for a mean of 52 months (range, 6-90 months). The incidence of femoral head necrosis was 14.4% (21/146). Garden classification (P=.012), reduction quality (P=.008), implant removal (P=.020), and preoperative traction (P=.003) were significantly associated with femoral head necrosis. Patient age (P=.990), sex (P=.287), injury-to-surgery interval (P=.360), weight-bearing time (P=.868), and surgical methods (P=.987) were not significantly associated with femoral head necrosis. In multivariate logistic regression analysis, implant removal was not a significant risk factor for femoral head necrosis development (P=.498). Garden classification, reduction quality, and preoperative traction had a significant effect on femoral head necrosis development. Copyright 2014, SLACK Incorporated.
Xu, Jian-Guang; Zeng, Bing-Fang; Zhou, Wei; Kong, Wei-Qing; Fu, Yi-Shan; Zhao, Bi-Zeng; Zhang, Tao; Lian, Xiao-Feng
A retrospective study. To evaluate the clinical outcome, effectiveness, and security of the surgical management of acute thoracolumbar burst fracture with corpectomy, titanic mesh autograft, and Z-plate fixation by anterior approach. Many surgical methods were adopted to treat acute burst thoracolumbar fracture. But the optimal surgical management remains controversial. A retrospective review of a consecutive series of 48 patients with thoracolumbar burst fracture treated with anterior corpectomy, titanic mesh autograft, and Z-plate internal fixation was carried out. Preoperative clinical and radiographic data of all cases were originally collected. Surgical indications were motor neurologic deficit and thoracolumbar column instability. Twenty-two patients (45.8%) with acute thoracolumbar burst fractures presented with a neurologic deficit. The postoperative recovery of neural function, restoration of anterior cortex collapse, kyphotic angle, and spinal canal compromise were observed. The preoperative kyphotic angle was improved to a mean of 5.6°, radiographic height restored to 95.8% of the adjacent normal levels, and canal compromise was 0%. None of the patients had neurologic deterioration. Mean follow-up time was 32.4 months (range, 24-47 months). All 22 patients with neurologic deficit demonstrated at least one Frankel grade improvement on final observation, with 16 (73%) patients had accomplished complete neurologic recovery. Forty-six (96%) patients reported minimal or no pain at final follow-up observation, and 40 (83%) patients who had been working before injury returned to original work. The authors considered spinal cord decompression with anterior corpectomy and stability reconstruction with titanic mesh autograft and Z-plate fixation at same time in one incision as an effective technique for unstable thoracolumbar burst fracture with and without neurologic deficit.
Chen, Alvin Chao-Yu; Chou, Ying-Chao; Cheng, Chun-Ying
Background: Controversy still exists regarding the current treatment modalities for unstable distal radius fractures. There are yet few articles investigating the efficacy of bicolumnar dorsal plating technique, which is designed to minimize tissue dissection while providing sufficiently secure fixation. A clinical study was performed to evaluate the feasibility of the minimally invasive plate osteosynthesis (MIPO) technique using a modified dorsal approach for the treatment of distal radius fractures. Materials and Methods: Thirty patients with unilateral distal radius fracture who underwent bicolumnar plate fixation with a minimally invasive dorsal approach between September 2008 and December 2010 were included in this retrospective study. Twenty four patients (8 men and 16 women) with a mean age of 53 years (range 18-85 years) were available for followup of at least 1 year or more were included in final study. Herein, we report the functional radiological outcomes of the study. There were three cases of AO Type A fracture, five cases of AO Type B fracture, and 16 cases of AO Type C fracture. Results: The union was achieved in all the patients. The functional results at one-year followup, assessed using the modified Gartland and Werley scoring system, were excellent in 14 patients, good in seven patients, and fair in three patients. The average correction of deformity was 4.1 mm for radial height, 7.6° for radial inclination, and 20.7° for volar tilt. Conclusions: MIPO with a dorsal approach is a feasible option for the management of displaced distal radius fractures and can result in favorable surgical outcomes. PMID:28216757
Fok, Margaret W M; Klausmeyer, Melissa A; Fernandez, Diego L; Orbay, Jorge L; Bergada, Alex Lluch
Background Intra-articular fractures of the distal radius represent a therapeutic challenge as compared with the unstable extra-articular fractures. With the recent development of specifically designed internal fixation materials for the distal radius, treatment of these fractures by fragment-specific implants using two or more incisions has been advocated. Purpose The purpose of this study was to investigate the efficacy of a fixed-angle locking plate applied through a single volar approach in maintaining the radiographic alignment of unstable intra-articular fractures as well as to report the clinical outcomes. We only excluded those with massive comminution, as is discussed in greater detail in the text. Patients and Methods This is a multicentered, retrospective study involving three hospitals situated in Spain, Switzerland, and the United States. In the period between January 2000 and March 2006, 97 patients with 101 intra-articular distal radius fractures, including 13 volarly displaced and 88 dorsally angulated fractures were analyzed. Over 80% were C2/C3 fractures, based on the AO classification. 16 open fractures were noted. Results With an average follow-up of 28 months (range 24-70 months), the range of movement of the wrist was very satisfactory, and the mean grip strength was 81% of the opposite wrist. The Disabilities of the Arm, Shoulder, and Hand (DASH) score was 8. The complications rate was < 5%, including loss of reduction in two patients. All fractures healed by 3 months postinjury. Conclusions Irrespective of the direction and amount of initial displacement, a great majority of intra-articular fractures of the distal radius can be managed with a fixed-angle volar plate through a single volar approach. Level IV retrospective case series.
Sezek, Sinan; Aksakal, Bunyamin; Gürger, Murat; Malkoc, Melih; Say, Y
Total deformation and stability of straight and helical compression plates were studied by means of the finite element method (FEM) and in vitro biomechanical experiments. Fixations of transverse (TF) and oblique (45°) bone (OF) fractures have been analyzed on sheep tibias by designing the straight compression (SP) and Helical Compression Plate (HP) models. The effects of axial compression, bending and torsion loads on both plating systems were analyzed in terms of total displacements. Numerical models and experimental models suggested that under compression loadings, bone fracture gap closures for both fracture types were found to be in the favor of helical plate designs. The helical plate (HP) fixations provided maximum torsional resistance compared to the (SP) fixations. The fracture gap closure and stability of helical plate fixation for transverse fractures was determined to be higher than that found for the oblique fractures. The comparison of average compression stress, bending and torsion moments showed that the FEM and experimental results are in good agreement and such designs are likely to have a positive impact in future bone fracture fixation designs.
de Azevedo, Marcos Coelho; de Azevedo, Gualter Maldonado; Hayashi, Alexandre Yoshio; Dourado Nascimento, Paulo Emilio
To evaluate the results obtained from treatment of humeral shaft fractures and their complications using the Osteoline® uniplanar external fixator. Methods: The radiographic and functional results from 78 patients with humeral shaft fractures treated using the uniplanar external fixation technique were retrospectively assessed. The patients' ages ranged from 23 to 71 years, with a mean of 47 years. Male patients predominated (79%). Out of the 78 patients, 45 presented open fractures, 14 presented pseudarthrosis and six presented synthesis failure. There were no losses during the follow-up and all the patients were discharged after fracture consolidation and functional recovery. The results were evaluated based on the studies by Catagni, as good, fair or poor. Results: Fracture consolidation was observed in 98% of the cases treated with uniplanar external fixation. Only one pseudarthrosis case required conversion to rigid internal fixation and autologous bone grafting. At the end of the treatment, all the patients were discharged with consolidated fractures, without pain, and good limb function. Conclusion: The external fixation described in this paper was shown to be an efficient and safe method for treating humeral shaft fractures and their complications. It preserved the local biological status and enabled passive and active movement immediately after surgery. PMID:27027026
Dexel, Julian; Fritzsche, Hagen; Beyer, Franziska; Harman, Melinda K; Lützner, Jörg
Open-wedge high tibial osteotomy (HTO) is an established treatment for young and middle-aged patients with medial compartment knee osteoarthritis and varus malalignment. Although not intended, a lateral cortex fracture might occur during this procedure. Different fixation devices are available to repair such fractures. This study was performed to evaluate osteotomy healing after fixation with two different locking plates. Sixty-nine medial open-wedge HTO without bone grafting were followed until osteotomy healing. In patients with an intact lateral hinge, no problems were noted with either locking plate. A fracture of the lateral cortex occurred in 21 patients (30.4 %). In ten patients, the fracture was not recognized during surgery but was visible on the radiographs at the 6-week follow-up. Lateral cortex fracture resulted in non-union with the need for surgical treatment in three out of eight (37.5 %) patients using the newly introduced locking plate (Position HTO Maxi Plate), while this did not occur with a well-established locking plate (TomoFix) (0 out of 13, p = 0.023). With regard to other adverse events, no differences between both implants were observed. In cases of lateral cortex fracture, fixation with a smaller locking plate resulted in a relevant number of non-unions. Therefore, it is recommended that bone grafting, another fixation system, or an additional lateral fixation should be used in cases with lateral cortex fracture. III.
Jiang, Y; Rong, X X; Chen, P; Xu, Y J; Zhu, G X
Objective: To explore the treatment of senile osteoporotic femoral fractures after using internal fixation of bone cement dry prosthetic. Methods: Twelve patients aged from 74 to 94 years with mean age of (84.0±2.5) years with internal fixation of bone cement dry prosthetic surgery who were treated at Department of Orthopaedics in Nanjing Medical University Affiliated Wuxi Second Hospital between May 2013 and May 2015 were retrospectively analyzed. There were 8 male and 4 female, 10 cases of tumble and 2 cases of traffic injury. The fracture types with AO type included 1 case of A1 type, 5 cases of A2 type, 3 cases of A3 type, 1 case of B1 type, 2 cases of B2 type. The steel plate internal fixation with bone cement dry prosthetic method was chosen to treat senile severe femoral fracture. Postoperative observation of postoperative pain assessment, hip joint activity and walking ability were evaluated. Paired simple t test and Wilcoxon rank sum test were used to compare the differences of pain score and the ability to walk. Results: Twelve cases received an average of (16.0±3.6) months follow-up. The average hospitalization days are (9.0±1.4) days and average of intraoperative time was (68.0±10.6) minutes. Intraoperative blood loss compared to normal was (106.0±24.2) ml. Patients began walking load and activities in two weeks. The gait and joint activities gradually restored and there were no obvious deformity and no loose internal fixation. All of the patients didn't have fracture shift with breaking plates or screws deformation and have no bone cement reaction. The walking ability was (4.1±0.9) points, the hip joint activities were 98.5°±7.7° and pain scores were 1.22±0.58 by Holden grading standards. The differences of walking ability (Z=-3.126, P<0.05) and pain scores (t=23.047, P<0.001) between pre- and post-operative were statistically significant. One patient had contralateral hip pain, 2 patients had lateral thigh pain, 10 patients returned to
Ebraheim, Nabil A; Sochacki, Kyle R; Liu, Xiaochen; Hirschfeld, Adam G; Liu, Jiayong
The number of patients requiring knee and hip arthroplasty has been steadily increasing, and periprosthetic fractures are on the rise. Locking plates are the most common treatment for periprosthetic fractures, but the use of cerclage wires with locking plate fixation has been controversial. Forty-seven patients with periprosthetic femur fractures were reviewed retrospectively. Twenty-four patients received locking plate alone and twenty-three patients were treated with locking plate and cerclage wires. Patients were evaluated for clinical and radiographic signs of union at two, six, twelve, twenty-four, and forty-eight weeks postoperatively. The average follow-up time in the plate group was 9.4 ± 6.7 months, while it was 6.0 ± 4.2 months in the cerclage wire group. The time to union in the cerclage wire group (3.6 ± 1.0 months) was significantly less than the plate group (4.8 ± 2.6 months). The group with the cerclage wires had a significantly lower revision rate of 0% compared to 20.8%. There was no statistical significance of union rate and complication rate between the two groups. Cerclage wires used with locking plate fixation successfully treats periprosthetic fractures of the femur with faster time to union, less complication, and fewer revisions. © 2013 Chinese Orthopaedic Association and Wiley Publishing Asia Pty Ltd.
Komura, Shingo; Yokoi, Tatsuo; Nonomura, Hidehiko
Fracture-dislocations of the proximal interphalangeal joint are challenging to treat, since it is difficult to achieve both rigid fixation and early joint motion simultaneously. Palmar fracture-dislocations of the proximal interphalangeal joint are less frequent injuries and a small number of treatment methods have been reported. We describe here a patient with a chronic palmar fracture-dislocation of the proximal interphalangeal joint, who was treated with a new surgical technique. In the surgery, a mini hook plate that was made by adapting a 1.5 mm AO hand modular system straight plate was used. Despite the thinness of the fragment, rigid fixation was achieved, resulting in early active motion. At final follow up, the active ranges of motion were 0°-100° at the proximal and 0°-80° at the distal interphalangeal joint, and there were no complications. This technique may become a useful surgical method to treat palmar fracture-dislocations of the proximal interphalangeal joint.
Esmailiejah, Ali Akbar; Abbasian, Mohammad Reza; Safdari, Farshad; Ashoori, Keyqobad
Background: The optimal technique for operative fixation of humeral shaft fractures remains controversial and warrants research. Objectives: The purpose of the current study was to compare the functional and clinical outcomes of conventional open reduction and internal fixation (ORIF) with minimally invasive plate osteosynthesis (MIPO) in patients with fractures in two-third distal humeral shaft. Patients and Methods: In the current prospective case-control study, 65 patients with humeral shaft fractures were treated using ORIF (33 patients) or MIPO (32 patients). Time of surgery, time of union, incidence of varus deformity and complications were compared between the two groups. Also, the university of California-Los Angeles (UCLA) shoulder rating scale and Mayo Elbow performance score (MEPS) were used to compare the functional outcomes between the two groups. Results: The median of union time was shorter in the MIPO group (4 months versus 5 months). The time of surgery and functional outcomes based on the UCLA and MEPS scores were the same. The incidence of varus deformity was more than 5° and was higher and the incidence of nonunion, infection and iatrogenic radial nerve injury were lower in the MIPO group; however, the differences were not significant. Conclusions: Due to the shorter union time, to some extent less complication rate and comparable functional and clinical results, the authors recommend to use the MIPO technique in treating the mid-distal humeral shaft fracture. PMID:26543844
Zhu, Junkun; Pan, Zhijun; Zheng, Rongzong; Lan, Shuhua
Objective : To describe the surgical technique and preliminary clinical outcomes in a series of open reduction internal fixation of basal acromion process fractures applying a double-plating technique. Methods : Nine consecutive patients, mean age 33.4 years old (range, 23-61 years old) with unilateral acromion fracture (Type 3 AO/OTA) with more than 1cm displacement who underwent fixation utilizing a locked double-plating technique, were evaluated on average at 7.8 months (range, 3-15 months) for outcomes related to pain, shoulder function, and surgical complications. Results : Eight patients recovered with complete radiographic union and favorable shoulder function. One case failed to be fully evaluated for more than 3 months follow-up. The overall scores of Constant, Shoulder Pain and Disability Index (SPADI) and DASH for the eight patients reviewed were 91.9± 6.31, 3.11± 3.79 and 5.2± 6.35, respectively. No post-operative infection or surgical hardware irritation was identified at final follow-up of these eight patients. Conclusion : While more evidence is needed to justify its advantages over traditional implants, perpendicular double-plate with a locking system may be indicated for acromion pedicle fracture treatment, since it performed well for fracture healing and joint function rehabilitation. Level of Evidence IV, Therapeutic Study. PMID:26981047
Ong, J C Y; Kennedy, M T; Mitra, A; Harty, J A
The goal of this study was to determine differences in fracture stability and functional outcome between synthetic bone graft and natural bone graft with internal fixation of tibia plateau metaphyseal defects. Hydroxyapatite calcium carbonate synthetic bone graft was utilised in 14 patients (six males and eight females). Allograft/autograft were utilised in the remaining 10 patients (six males and four females). All the 24 patients had clinical, radiological and subjective functional score assessments. There was no significant statistical difference between the groups for post-operative articular reduction, long-term subsidence, and WOMAC scores. The degree of subsidence was not related to age or fracture severity. Maintenance of knee flexion was found to be better in the allograft/autograft group (p = 0.048) when compared between the groups. Multivariate analysis compared graft type, fracture severity, post-operative reduction, subsidence rate, range of movement and WOMAC score. The only finding was a statistical significant association with the graft type related to the 6-month range of movement figures. Use of autologous or allogenic bone graft allows better recovery of long-term flexion, possibly due to reduced inflammatory response compared with synthetic bone composites. However, all other parameters, such as maintenance of joint reduction and subjective outcome measures were comparable with the use of hydroxyapatite calcium carbonate bone graft. This study shows that synthetic bone graft may be a suitable alternative in fixation of unstable tibia plateau fractures, avoiding risk of disease transmission with allograft and donor site morbidity associated with autograft.
Introduction We present a case of a patient with a previously undescribed complication: intertrochanteric femoral neck insufficiency fracture after long-segment instrumented spinopelvic fusion to the ilium for Charcot spine. Case presentation A 42-year-old Caucasian man with post-traumatic complete T6 paraplegia presented to our institution after developing Charcot spinal arthropathy at L3 and L4 and symptoms of autonomic dysreflexia 21 years after his original spinal cord injury. Multiple anterior and posterior surgeries were required to eventually achieve stabilization of his thoracolumbar spine to his pelvis and resolution of symptoms. The most distal fixation point was two iliac wing screws bilaterally. At 10 weeks after the final spinal surgery and after posterior spinal bony consolidation had occurred, he sustained an intertrochanteric femoral neck fracture, distal to the iliac fixation, whilst bending forward in his wheelchair. His proximal femoral fracture was internally fixed with an intramedullary device. Conclusions Spinal Charcot’s arthropathy is a rare condition that may occur in patients with post-traumatic spinal cord injury. Although associated with high risk of complications, circumferential instrumented fusion in Charcot spine can restore spinal stability. Insufficiency fractures of the proximal femur are possible complications of long spinopelvic fusions. PMID:24378187
Landes, Constantin; Ballon, Alexander; Ghanaati, Sharam; Tran, Andreas; Sader, Robert
To evaluate the internal fixation of malar and midfacial fractures, long-term results, and biocompatibility of osteoconductive internal fixation devices composed of a forged composite of unsintered hydroxyapatite and poly-L-lactide (F-u-HA/PLLA). From January 2006 to June 2010, 29 patients (24 males and 5 females; age 33 ± 15 years) were included in the present prospective study. The fracture type was malar in 24 patients, midfacial in 5, isolated orbital floor blowout in 2, and frontal sinus, cranial base in 2 patients. The fractures were fixed with internal fixation devices; these were plates and screws composed of F-u-HA/PLLA. The 24 patients with malar fractures were treated with a single 4-hole L-plate or a straight plate at the infrazygomatic crest. All fractures with internal fixation using devices composed of F-u-HA/PLLA healed well. All malar and midfacial fractures had satisfactory long-term stability. The follow-up examinations at 12 to 67 months after surgery showed that most patients had no complaints, although 2 patients (15%) had a foreign body reaction that was treated by implant removal, with complete symptom resolution. At 5 years after fracture fixation, 2 patients had ultrasound and 2 had radiographic evidence of residual material. An exemplar biopsy showed direct bone growth into the material. In patients with malar and midfacial fractures, hardware composed of the F-u-HA/PLLA composite provided reliable and satisfactory internal fixation, intraoperative handling, long-term stability, and biocompatibility. Direct bone growth into the material could be histopathologically exemplified, in contrast to previous polymer fixations that were resorbed and surrounded by a connective tissue layer. This finding indicates that long-term F-u-HA/PLLA residual material will be included into the remodeled bone, which was confirmed on long-term follow-up radiographs. Copyright © 2014 American Association of Oral and Maxillofacial Surgeons. Published by
Kočiš, J; Kelbl, M; Veselý, R; Kočiš, T
PURPOSE OF THE STUDY In the management of dens axis fractures in patients older than 65 years of age the posterior approach is preferred due to osteoporosis and the risk of a failure of anterior osteosynthesis. The posterior approach, however, is associated with a higher incidence of complications. A combination of anterior transarticular fixation of C1/2 (ATS) with compression osteosynthesis of dens axis significantly increases the stability of osteosynthesis. MATERIAL AND METHODS In the period from 2009 to 2015 our hospital admitted 13 patients older than 65 years of age with a diagnosed type III dens axis fracture based on AO classification. 8 patients sustained a dens axis fracture combined with a stable atlas fracture. The cohort consisted of 13 women aged 67 to 90 years, with the mean age of 82.3 years. None of the female patients were affected neurologically. The dens axis fracture was treated by anterior approach. Once the screw was inserted in the dens axis, two more screws were added, the entrance points of those screws were medial and lateral to the odontoid screw and direction was divergently via C1/2 joints in order to reinforce stability. The patients were monitored at 6-week, 3-, 6- and 12-month follow-ups. Bone healing was confirmed by CT scan. RESULTS No complications were recorded during the surgery in any of the 13 patients. In one female patient the stabilization failed in the early postoperative period. A reoperation from anterior approach with the use of the same method was necessary. In eleven patients bone healing occurred after 6 to 12 months. In two patients pseudoarthrosis was formed with no clinical symptoms. No neurological deterioration or a patient s death was reported in the monitored period within 12 months after the treatment. DISCUSSION Where dens axis fractures in elderly patients are managed operatively, the posterior approach and transarticular fixation of C1/2 with sublaminar loop are preferred. This procedure is considered
Little, Milton M T; Berkes, Marschall B; Schottel, Patrick C; Garner, Matthew R; Lazaro, Lionel E; Birnbaum, Jacqueline F; Helfet, David L; Lorich, Dean G
To compare radiographic and clinical outcomes of supination external rotation type IV equivalent (SER IV E) ankle fractures (AO/OTA classification 44-B2.1) treated with transsyndesmotic screw fixation with those treated with deltoid and posterior inferior tibiofibular ligament (PITFL) repair. Case series and single-surgeon retrospective analysis of a prospective database. Academic level I trauma center. Forty-five SER IV E ankle fractures fulfilled all inclusion/exclusion criteria with at least 12 months of radiographic follow-up. Deltoid and PITFL repair in addition to lateral malleolus fixation compared with transsyndesmotic screw fixation. Syndesmotic reduction compared with contralateral extremity on a postoperative computed tomography scan and maintenance of reduction based on final postoperative radiographs [medial clear space (MCS) and tibiofibular clear space (TCS)]. There was no significant difference in mean postoperative TCS, MCS, or change in TCS or MCS between the cohorts. The anatomic treatment group had significantly better postoperative syndesmotic reduction compared with the transsyndesmotic cohort (7.4% vs. 33.3%; P = 0.02). Fourteen patients in the transsyndesmotic screw cohort underwent removal compared with 3 patients in the anatomic cohort who required secondary procedures. The transsyndesmotic screw cohort had statistically significant better mean dorsiflexion of ankle (mean 20 vs. 17 degrees; P = 0.02). This comparison of treatment strategies for SER IV E ankle fractures has shown an improvement in immediate postoperative syndesmotic reduction and the elimination of reoperation for removal of transsyndesmotic screws in patients treated with PITFL repair. Previous research has shown a good correlation between functional outcomes and syndesmotic reduction; however, further investigation into the functional outcomes of these patients is necessary to determine the future clinical impact of this anatomic fixation strategy. Therapeutic Level III
Toolan, B C; Koval, K J; Kummer, F J; Sanders, R; Zuckerman, J D
Fifty embalmed human tibias were osteotomized to create a simulated vertical shear (supination-adduction) fracture of the medial malleolus and were stabilized using one of five internal fixation techniques. In offset axial testing, which simulated supination-adduction loading, the fixation strength of tibias stabilized with either cortical or cancellous lag screws placed perpendicular to the osteotomy was over five times greater than the strength of those treated with an antiglide plate and nearly two and a half times greater than those treated with cancellous lag screws placed oblique to the osteotomy. The tibias stabilized with cancellous lag screws placed perpendicular to the osteotomy exhibited twice the fixation strength of the tibias stabilized with an antiglide plate and distal lag screw. The tibias stabilized with an antiglide plate and distal lag screw and perpendicularly placed cortical or cancellous lag screws demonstrated three times greater resistance to displacement to the applied supination-adduction load than those stabilized with an antiglide plate alone. In offset transverse testing, to simulate loading in external rotation, the mean failure load of the tibias stabilized with cancellous lag screws placed perpendicular to the osteotomy was over two and a half times greater than those stabilized with an antiglide plate and distal lag screw. No significant differences were observed in the resistance to displacement for these tests. These results support the use of lag screws placed perpendicular to the fracture surface for stabilization of vertical shear fractures of the medial malleolus and indicate that the use of an antiglide plate, with or without a distal lag screw, does not offer any advantage over lag screw fixation.
Pakarinen, Harri J; Flinkkilä, Tapio E; Ohtonen, Pasi P; Hyvönen, Pekka H; Lakovaara, Martti T; Leppilahti, Juhana I; Ristiniemi, Jukka Y
This study was designed to assess whether transfixion of an unstable syndesmosis is necessary in supination-external rotation (Lauge-Hansen SE/Weber B)-type ankle fractures. A prospective study of 140 patients with unilateral Lauge-Hansen supination-external rotation type 4 ankle fractures was done. After bony fixation, the 7.5-Nm standardized external rotation (ER) stress test for both ankles was performed under fluoroscopy. A positive stress examination was defined as a difference of more than 2 mm side-to-side in the tibiotalar or tibiofibular clear spaces on mortise radiographs. If the stress test was positive, the patient was randomized to either syndesmotic transfixion with 3.5-mm tricortical screws or no syndesmotic fixation. Clinical outcome was assessed using the Olerud-Molander scoring system, RAND 36-Item Health Survey, and Visual Analogue Scale (VAS) to measure pain and function after a minimum 1-year of followup. Twenty four (17%) of 140 patients had positive standardized 7.5-Nm ER stress tests after malleolar fixation. The stress view was positive three times on tibiotalar clear space, seven on tibiofibular clear space, and 14 times on both tibiotalar and tibiofibular clear spaces. There was no significant difference between the two randomization groups with regards to Olerud-Molander functional score, VAS scale measuring pain and function, or RAND 36-Item Health Survey pain or physical function at 1 year. Relevant syndesmotic injuries are rare in supination-external rotation ankle fractures, and syndesmotic transfixion with a screw did not influence the functional outcome or pain after the 1-year followup compared with no fixation.
Hohloch, Lisa; Konstantinidis, Lukas; Wagner, Ferdinand C; Strohm, Peter C; Südkamp, Norbert P; Reising, Kilian
Currently, closed reduction and percutaneous pinning are considered the treatment of choice for displaced supracondylar humerus fractures. However, indications exist for the use of external fixation with Schanz screws. In this in vitro study, we evaluate the biomechanical properties of a new variation for external fixation and compare them to an established construct. Twenty distal cadaver humeri (10 pairs) were allocated to 2 groups. The humeri of the first group were fixed by an external fixator consisting of Schanz screws and an oblique K-wire inserted from the distal radial cortex of the humerus, those of the second group were fixed by a new variation with the oblique K-wire inserted from the distal ulnar cortex of the humerus. Displacement and stiffness in static loading in internal and external rotation, as well as in extension and flexion were evaluated and compared. The variation of the external fixator of the second group proved to be statistically significantly superior to the variation of the first group in internal rotation loading (p>0.05). In sagittal loading conditions and external rotation loading, the variations were equally stable (p>0.05). There was no significant effect of the samples' bone density on displacement and stiffness values in any direction of loading. In cases of pediatric supracondylar humerus fractures when an external fixator is used for osteosynthesis, the insertion of an additional ulnarly inserted anti-rotation K-wire should be preferred to a radially inserted one as it reduces secondary displacement of the distal fragment. Copyright © 2015 Elsevier Ltd. All rights reserved.
Hsu, Andrew R; Lareau, Craig R; Anderson, Robert B
Infolding and retraction of an avulsed deltoid complex after ankle fracture can be a source of persistent increased medial clear space, malreduction, and postoperative pain and medial instability. The purpose of this descriptive case series was to analyze the preliminary outcomes of acute superficial deltoid complex avulsion repair during ankle fracture fixation in a cohort of National Football League (NFL) players. We found that there is often complete avulsion of the superficial deltoid complex off the proximal aspect of the medial malleolus during high-energy ankle fractures in athletes. Between 2004 and 2014, the cases of 14 NFL players who underwent ankle fracture fixation with open deltoid complex repair were reviewed. Patients with chronic deltoid ligament injuries or ankle fractures more than 2 months old were excluded. Average age for all patients was 25 years and body mass index 34.4. Player positions included 1 wide receiver, 1 tight end, 1 safety, 1 running back, 1 linebacker, and 9 offensive linemen. Average time from injury to surgery was 7.5 days. Surgical treatment for all patients consisted of ankle arthroscopy and debridement, followed by fibula fixation with plate and screws, syndesmotic fixation with suture-button devices, and open deltoid complex repair with suture anchors. Patient demographics were recorded with position played, time from injury to surgery, games played before and after surgery, ability to return to play, and postoperative complications. Return to play was defined as the ability to successfully participate in at least 1 full regular-season NFL game after surgery. All NFL players were able to return to running and cutting maneuvers by 6 months after surgery. There were no significant differences in playing experience before surgery versus after surgery. Average playing experience before surgery was 3.3 seasons, 39 games played, and 22 games started. Average playing experience after surgery was 1.6 seasons, 16 games played, and
The present study proposes an integrated computer-aided approach combining femur surface modeling, fracture evidence recover plate creation, and plate modification in order to conduct a parametric investigation of the design of custom plate for a specific patient. The study allows for improving the design efficiency of specific plates on the patients' femur parameters and the fracture information. Furthermore, the present approach will lead to exploration of plate modification and optimization. The three-dimensional (3D) surface model of a detailed femur and the corresponding fixation plate were represented with high-level feature parameters, and the shape of the specific plate was recursively modified in order to obtain the optimal plate for a specific patient. The proposed approach was tested and verified on a case study, and it could be helpful for orthopedic surgeons to design and modify the plate in order to fit the specific femur anatomy and the fracture information. PMID:28203270
Holland, P; Highcock, A; Bruce, C
Introduction This study investigates the influence of incomplete reduction of supracondylar fractures on the incidence of loss of reduction requiring reoperation Materials and methods A review of 107 consecutive patients presenting with supracondylar fractures treated with closed reduction and Kirschner wire stabilisation, between January 2011 and March 2013, was conducted. The mean age was 5 years (range 10 months to 12 years). Pre-, intra- and postoperative radiographs were reviewed. All patients who had failure of fixation requiring revision surgery were identified. Results Ninety-nine patients had an initial adequate radiographic reduction. Of these, one (1%) required revision surgery. Eight patients had an initial incomplete radiographic reduction and, of these, six (75%) required revision surgery (P < 0.0001). Discussion Supracondylar fractures treated with closed reduction and K wire stabilisation require adequate intraoperative reduction. Incomplete reduction should not be accepted, as despite the bones potential to remodel, the risk of further loss of reduction is high, requiring reoperation.
Wurm, Simone; Augat, Peter; Bühren, Volker
To analyze the mechanical stability of locked plating in comparison with tension-band wiring for the fixation of fractures of the patella. Biomechanical tests were performed on artificial foam patella specimens comparing an angular stable plate and monocortical screws with tension-band wiring. Tests were performed under combined tension and bending until failure simulating physiological loading of the tibia during walking. Tension-band wiring failed at 66% of the failure load of plating (1052 N, P = 0.002) and had 5 times larger fracture gap displacements (P = 0.002). Based on the biomechanical advantages, locked plating of the patella may constitute a reasonable alternative in the treatment of patella fractures.
Brown, S A; Hastings, R S; Mason, J J; Moet, A
This study focuses on determining the effects of clinically relevant procedures on the flexural and fracture toughness properties of three short-fibre thermoplastic composites for potential application as fracture fixation devices. The procedures included sterilization, heat contouring and saline soaking. The three materials tested were polysulphone, polybutylene terephthalate and polyetheretherketone, all reinforced with 30% short carbon fibres. The polysulphone composite showed significant degradation in mechanical properties due to saline soaking. The polybutylene terephthalate exhibited significant degradation of mechanical properties following both contouring and saline soaking. The polyetheretherketone composite, however, exhibited no degradation in mechanical properties. The results demonstrated that flexion and fracture toughness testing were effective for determining the response of the composites to different applied conditions and demonstrated the stability of polyetheretherketone subjected to these treatments. Scanning electron microscopy demonstrated the most effective fibre-matrix bonding to be in the polyetheretherketone.
Jettoo, P; de Kiewiet, Gp
We report a rare case of delayed distal radio-ulnar joint instability with malunion of a Galeazzi-type radius fracture in a 10- year-old boy. He underwent operative intervention with flexible intramedullary nailing of the radius. He had careful clinical and intra-operative evaluation under image intensifier, and regular clinical and radiological assessments subsequently in clinic, and his distal radio-ulnar joint (DRUJ) was stable. He nonetheless developed DRUJ instability with malunion of radial midshaft fracture at 4 months. Corrective osteotomy for forearm fracture malunion is an uncommon procedure in children. He underwent a corrective radial osteotomy at the site of malunion, held with a Pennig external fixator, with reconstruction of the DRUJ subluxation. He made a good recovery with full restoration of wrist and forearm function, which was maintained at 17 months.
Chen, Xiaozhong; He, Kunjin; Chen, Zhengming
The present study proposes an integrated computer-aided approach combining femur surface modeling, fracture evidence recover plate creation, and plate modification in order to conduct a parametric investigation of the design of custom plate for a specific patient. The study allows for improving the design efficiency of specific plates on the patients' femur parameters and the fracture information. Furthermore, the present approach will lead to exploration of plate modification and optimization. The three-dimensional (3D) surface model of a detailed femur and the corresponding fixation plate were represented with high-level feature parameters, and the shape of the specific plate was recursively modified in order to obtain the optimal plate for a specific patient. The proposed approach was tested and verified on a case study, and it could be helpful for orthopedic surgeons to design and modify the plate in order to fit the specific femur anatomy and the fracture information.
Berlusconi, M; Busnelli, L; Chiodini, F; Portinaro, N
The role of stabilisation of the fibula in distal two-bone fractures of the leg is controversial. Some studies indicate the need for fibular stabilisation in 43 AO fractures, but few studies consider the role of the fibula in 42 AO fractures. The aim of the current paper is to explain the role of stabilisation of the fibula in 42 AO fractures, correlating the rates of healing and non-union between patients with and without fibula fixation. A total of 60 patients with 42 AO (distal) shaft fracture of the tibia with associated fracture of the fibula were selected. Patients were divided into two groups according to whether or not the fibula was fixed: Group I (n=26) comprised patients who had their fibula fixed while Group II (n=34) comprised patients who did not. The fibular fracture was classified according to the AO and related to the level of the tibial fracture. Other parameters examined were the union rate of the two groups correlated to the fracture pattern and position of the fibular fracture; the demographic data, such as age and gender; the presence of an open fracture, and the type of tibial fixation device used (nail or plate). None of the parameters considered (open injury, AO classification, device used and level of the fibular fracture relative to the tibial) were shown to have an influence on the development of a non-union. This study showed a higher non-union rate when the fracture of the tibia and fibula were at the same level, the tibia was fixed with a bridging plate and the fibula left untouched. For this reason, we recommend fibular fixation in all 42 distal fractures when both fractures lie on the same plane and the tibial fracture is relatively stabilised. Copyright © 2013 Elsevier Ltd. All rights reserved.
Liu, Xi-Ming; Pan, Chang-Wu; Wang, Guo-Dong; Cai, Xian-Hua; Chen, Lei; Meng, Cheng-Fei; Huang, Jin-Cheng
Objective: This study aims to explore the mechanical stability of combined plate internal fixation in posterior wall fractures of the acetabulum. Methods: The fracture and internal fixation models were established in this study and they were divided into four kinds of internal fixation models, finite element analysis was performed. The four groups were 2 mini-plates and 1 reconstruction plate fixation (A), Reconstruction plate internal fixation group (B), 2 screws internal fixation group (C) and mini-plates internal fixation group (D). The displacement of each node was measured and evaluated. Results: There was no distortion in the geometric shape of the finite element model. The results of stress showed that it was less in the anterior pelvic ring and distributed uniform in labrum acetabulare; the stress was bigger in the upper and middle of sacroiliac joint and sciatic notch in sitting position. Conclusions: Combined plate internal fixation for posterior wall fractures of acetabular were stable and reliable, it is better than the other three methods. PMID:26550272
Bonnevialle, Nicolas; Ibnoulkatib, Aissa; Mansat, Pierre; Bonnevialle, Paul
The Kapandji pinning was initially described for the treatment of surgical neck fractures of the humerus in young patients. The aim of our study was to evaluate functional and radiological outcomes of the Kapandji modified technique in displaced complex three- and four-part fractures. From 2005 to 2009, 32 patients (23 three-part and nine four-part fractures) were included retrospectively. The mean age was 63 years old (range, 22-86), and the dominant shoulder was involved in 40% of the cases. At a mean follow up of 25 months (12-72), the mean absolute Constant score achieved 68 points (35-98) and adjusted score 80% (47-100). Patients had an average forward elevation of the shoulder of 132° (80°-180°), an average external rotation of 36° (0°-90°), and an average internal rotation to the level of L1 (sacrum to the level of T6). The older the patients were the worst was the active anterior elevation recovery (r = -0.3; p = 0.01). Reduction and fixation of initial varus-displaced fractures was not as reliable as in valgus. In eight cases (25%), K-wire migrations were observed and were correlated with age over 70 years old (p = 0.001). Two partial osteolysis of the greater tuberosity and two avascular necrosis of the humeral head (one was associated with a non-union) were identified. Moreover, three patients developed adhesive capsulitis. The Kapandji technique with fixation of tuberosities provides satisfactory results for the treatment of complex proximal fractures of the humerus. However, we do not recommend this technique for patients older than 70 years and in cases of varus displaced fractures.
AIM: To report ankle fracture configurations and bone quality following arthroscopic-assisted reduction and internal-fixation (ARIF) or open reduction and internal-fixation (ORIF). METHODS: The patients of ARIF (n = 16) or ORIF (n = 29) to treat unstable ankle fracture between 2006 and 2014 were reviewed retrospectively. Baseline data, including age, sex, type of injury, immediate postoperative fracture configuration (assessed on X-rays and graded by widest gap and largest step-off of any intra-articular site), bone quality [assessed with bone mineral density (BMD) testing] and arthritic changes on X-rays following surgical treatments were recorded for each group. RESULTS: Immediate-postoperative fracture configurations did not differ significantly between the ARIF and ORIF groups. There were anatomic alignments as 8 (50%) and 8 (27.6%) patients in ARIF and ORIF groups (P = 0.539) respectively. There were acceptable alignments as 12 (75%) and 17 (58.6%) patients in ARIF and ORIF groups (P = 0.341) respectively. The arthritic changes in follow-up period as at least 16 wk following the surgeries were shown as 6 (75%) and 10 (83.3%) patients in ARIF and ORIF groups (P = 0.300) respectively. Significantly more BMD tests were performed in patients aged > 60 years (P < 0.001), ARIF patients (P = 0.021), and female patients (P = 0.029). There was no significant difference in BMD test t scores between the two groups. CONCLUSION: Ankle fracture configurations following surgeries are similar between ARIF and ORIF groups, suggesting that ARIF is not superior to ORIF in treatment of unstable ankle fractures. PMID:27114933
Tarallo, Luigi; Mugnai, Raffaele; Adani, Roberto; Catani, Fabio
We analyzed the efficiency of a new plate DiPhos-RM in CFR-PEEK [carbon-fiber-reinforced poly (etheretherketone)] for the volar fixation of distal radius fractures. The new plate's composition has the advantage of x-ray absolute transparency, therefore allowing to monitor the healing of the fracture. The desired combination of high strength and low rigidity is obtained through the use of the polymer composites CFR-PEEK. In this preliminary study (from March 2012 to June 2012), 10 cases of intra-articular distal radius fractures were treated with DiPhos-RM produced by Lima Corporate (Italy). The fractures were classified according to the AO classification, 4 fractures were type C1, 3 type C2, and 3 were A2. A preoperative computed tomography scan was carried out in all patients. One patient also underwent a postoperative computed tomography scan. Grip strength, range of motion, and DASH score were evaluated at follow-up. There were no cases of hardware failure. Specifically, no loss of position or alignment of fixed-angle locking screws or breakage of the plate were observed. Radiographic union was present at an average of 6 weeks (range, 5 to 8 wk). The overall preliminary experience with this new plate is favorable. The new plate is easy to apply and provides the surgeon dual options of fixed-angle or variable-angle screws. It was rigid enough to maintain the reduction also in AO type C articular fractures.
Parikh, Shital N; Myer, David; Eismann, Emily A
Arthrofibrosis is a major complication of tibial spine fracture treatment in children, potentially resulting in knee pain, quadriceps weakness, altered gait, decreased function, inability to return to sports, and long-term osteoarthritis. Thus, prevention rather than treatment of arthrofibrosis is desirable. The purpose of this study was to evaluate an aggressive postoperative rehabilitation and early intervention approach to prevent permanent arthrofibrosis after tibial spine fracture treatment and to compare epiphyseal and transphyseal screws for fixation. A consecutive series of 24 patients younger than age 18 with displaced type II and III tibial spine fractures who underwent arthroscopic reduction and screw fixation between 2006 and 2011 were retrospectively reviewed. Final range of motion was compared between patients with epiphyseal (n=12) and transphyseal (n=9) screws. One-third (4 of 12) of patients with epiphyseal screws underwent arthroscopic debridement and screw removal approximately 3 months postoperatively; 3 patients lacked 5° to 15° of extension, 1 experienced pain with extension, and 1 had radiographic evidence of screw pullout, loss of reduction, and resultant malunion. In the transphyseal screw group, 3 patients had 10° loss of extension, and all corrected after arthroscopic debridement and screw removal. The two groups did not significantly differ in time to hardware removal or return to sports or final range of motion. No growth disturbances were identified in patients after transphyseal screw removal. An aggressive approach of postoperative rehabilitation and early intervention after arthroscopic reduction and screw fixation of tibial spine fractures in children was successful in preventing permanent arthrofibrosis.
Abrams, Geoffrey D; Bellino, Michael J; Cheung, Emilie V
Postoperative heterotopic ossification (HO) about the elbow may occur after surgical fixation of fractures and can contribute to dysfunction. Factors associated with HO formation after surgical fixation of elbow trauma are not well understood. All patients who underwent surgery for elbow trauma at our institution from October 2001 through August 2010 were retrospectively reviewed. Patients with prior injury or deformity to the involved elbow were excluded. Demographic data; fracture type; surgical treatment; and presence, location, and size of HO were recorded. The Fisher exact test, χ(2) test, and multivariate logistic regression were used with an α value of .05 used for significance. A total of 159 patients were identified, with 89 (37 men and 52 women) meeting inclusion and exclusion criteria. The mean age was 54.4 years (range, 18-90 years), and the mean follow-up time was 180 days. Age, male gender, lateral collateral ligament repair, and dual-incision approach were not associated with increased ectopic bone formation. Distal humeral fractures were a significant predictor of heterotopic bone. In patients in whom HO ultimately developed, it was visible on radiographs obtained 2 weeks postoperatively in 86% of cases. This investigation found predictors for the development of HO after surgical fixation of intra-articular elbow fractures. Furthermore, HO went on to develop at the time of final follow-up in only 14% of patients without HO on radiographs obtained 2 weeks postoperatively. This may suggest that absence of HO on radiographs obtained 2 weeks postoperatively may predict a more favorable outcome. Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.
Soong, Maximillian; van Leerdam, Roderick; Guitton, Thierry G; Got, Christopher; Katarincic, Julia; Ring, David
To identify risk factors for complications after volar locking plate fixation of distal radius fractures. We assessed early postoperative complications in 594 patients with fracture of the distal radius repaired with a volar locking plate and a minimum 1-month evaluation in the medical record. Later complications were assessed among 321 patients as a subset of the original cohort with a minimum 6 months' evaluation. We compared patient demographics, fracture characteristics, and aspects of management between patients with and without complications in bivariate analysis. Multivariable logistic regression analysis was applied to identify the factors independently associated with complications. A total of 47 complications were documented in the medical record. Early complications occurred in 24 of 594, including 8 intra-articular screws and 7 patients with loss of fixation. Late complications occurred in 23 of 321, including 14 patients diagnosed with tendon irritation (one rupture of the flexor pollicis longus tendon) and 5 patients who had subsequent surgery to address dysfunction of the distal radioulnar joint (malunion, synostosis, and arthrofibrosis). Of the 47 complications, 26 were attributed to the plate, of which 9 were considered major (intra-articular screws and tendon rupture; 1.3% (8 out of 594) and less than 1% (1 out of 321) of the early and late groups, respectively). In the logistic regression models, fall from a height and an ipsilateral elbow injury were positive independent predictors of early complications, whereas high-volume surgeons and plates other than the most commonly used plate were positive independent predictors of later complications. Volar locking plate fixation of distal radius fractures was associated with relatively few plate-related complications in our institutions. Factors indicating higher energy or complexity predicted early complications. The most common late complication was tendon irritation, which is less discrete and
Chen, Qin; Zhou, Zheng; Guan, Long
To evaluate the surgical efficiency of treating the intertrochanteric hip fracture with the Gamma nail fixation and to compare two operating methods of the Gamma nail fixation. From August 2000 to August 2006, 69 patients (32 males, 37 females; age, 43-98 years;average, 72.3 years) with the intertrochanteric hip fracture but with no associated injury were treated with the Gamma nail fixation. The patients' average illness course was 5. 6 days (range, 3-14 days). Among the 69 patients, 36 were treated with the traditional method of the Gamma nail fixation (Group A) and 33 were treated with an improved method of the Gamma nail fixation (Group B). According to the Association for the Study of Internal Fixation (AO-ASIF) classification, in Group A, 5 patients had a disease of Type A1, 23 of Type A2, and 8 of Type A3; in Group B, 8 patients had a disease of Type A1, 21 of Type A2, and 4 of Type A3. The data from the two groups were analyzed, and the statistical analysis was made on the following aspects: incision length, operating time, intraoperative bleeding, X-ray exposure frequency, drainage amount, blood transfusion volume, postoperative infection of the lungs, superficial infection of the incision, duration of antibiotic use, standing with the walking stick after operation, complication due to internal fixation, healing time for the fracture, and the hip function recovery half a year after operation assessed with the Harris scoring system. All the 69 patients were followed up for 8-80 months (average, 42 months). We studied the indexes such as incision length, operating time, intraoperative bleeding, X-ray exposure frequency, drainage amount, and blood transfusion volum; above indexes in Group A were 9.5 +/- 4.7 cm, 85 +/- 35 min, 186.0 +/- 87.3 ml, 9.0 +/- 5.1 times, 102.7 +/- 49.8 ml, 325.0 +/- 169.5 ml; and those were 5.3 +/- 1.2 cm, 46 +/- 10 min, 65.0 +/- 26.0 ml, 3.0 +/- 2.1 times, 52.5 +/- 16.2 ml, 203.0 +/- 61.2 ml in Group B. The above indexes showed that
Gao, Yan; Chen, Wei; Liu, Yue-Jv; Li, Xu; Wang, Hai-Li; Chen, Zhao-Yu
Background. Plate fixation and intramedullary fixation are the most commonly used surgical treatment options for mid-shaft clavicle fractures; the latter method has demonstrated better performance in some studies. Objectives. Our aim was to critically review and summarize the literature comparing the outcomes of mid-shaft clavicle fracture treatment with plate fixation or intramedullary fixation to identify the better approach. Search Methods. Potential academic articles were identified from the Cochrane Library, MEDLINE (1966-2015.5), PubMed (1966-2015.5), EMBASE (1980-2015.5) and ScienceDirect (1966-2015.5). Gray studies were identified from the references of the included literature. Selection Criteria. Randomized controlled trials (RCTs) and non-RCTs comparing plate fixation and intramedullary fixation for mid-shaft clavicle fracture were included. Data Collection and Analysis. Two reviewers performed independent data abstraction. The I (2) statistic was used to assess heterogeneity. A fixed- or random-effects model was used for the meta-analysis. Results. Six RCTs and nine non-RCTs were retrieved, including 513 patients in the intramedullary fixation group and 521 patients in the plating group. No significant differences in terms of the union rate and shoulder function were found between the groups. Patients in the intramedullary fixation group had a shorter operative time, less blood loss, smaller wound size, and shorter union time than those in the plating group. With respect to complications, significant differences were identified for all complications and major complications (wound infection, nonunion, implant failures, transient brachial plexopathy, and pain after 6 months). Similar secondary complications (symptomatic hardware, hardware irritation, prominence, numbness, hypertrophic callus) were observed in both groups. Conclusions. Intramedullary fixation may be superior to plate fixation in the treatment of mid-shaft clavicle fractures, with similar
Background Ankle fractures in patients with diabetes mellitus have long been recognized as a challenge to orthopedic surgeons. Nonunion and lengthy wound healing in high-risk patients with diabetes, particularly patients with peripheral arterial disease and renal failure, occur secondary to several clinical conditions and are often fraught with complications. Whether diabetic ankle fractures are best treated noninvasively or surgically is controversial. Case presentation A 53-year-old Japanese man fractured his right ankle. The fractured ankle was treated nonsurgically with a plaster cast. Although he remained non-weight-bearing for 3 months, radiography at 3 months showed nonunion. The nonunion was treated by Ilizarov external fixation of the ankle. The external fixator was removed 99 days postoperatively, at which time the patient exhibited anatomical and functional recovery and was able to walk without severe complications. Conclusion In patients with diabetes mellitus, severe nonunion of ankle fractures with Charcot arthropathy in which the fracture fragment diameter is very small and the use of internal fixation is difficult is a clinical challenge. Ilizarov external fixation allows suitable fixation to be achieved using multiple Ilizarov wires. PMID:25103697
Cho, Yongsuk; Kim, Junhyun; Kim, Dong-Won
Purpose Femoral intertrochanteric fractures are common in the elderly. Appropriate surgical fixation of trochanteric fracture fragments can restore normal anatomical structure and ambulation, and can aid in the recovery of biomechanical function of the hip. We evaluated clinical outcomes of bipolar hemiarthroplasty using a wiring technique for trochanteric fracture fragment fixation. Materials and Methods From September 2006 to February 2015, a total of 260 cases underwent simultaneous bipolar hemiarthroplasty and wire fixation. A total of 65 patients (69 hips) with an average age of 78 years and more than one year of follow-up was included in the study. Using pre-, postoperative and follow-up radiograms, we evaluated wire fixation failure and also assessed changes in walking ability. Results Loosening or osteolysis around the stem was not observed; however, we did observe bone growth around the stem (54 cases), cortical hypertrophy (6 cases), a wide range of sclerotic lines but no stem subsidence (1 case), wire breakage (9 cases), and fracture fragment migration with no significant functional deficiency (2 cases). Conclusion Our study showed that additional wiring for trochanteric fracture fragment fixation following bipolar hemiarthroplasty can help restore normal anatomy. The added stability results in faster rehabilitation, and good clinical and radiographic outcomes. We recommend this procedure in this type of fracture. PMID:28316962
Ya'ish, F; Bailey, C A; Kelly, C P; Craigen, M A
The vast majority of devices used for internal fixation of the scaphoid are metallic. This two-center study aimed to report the results of scaphoid fixation using a cannulated, bioabsorbable device made from a hydroxyapatite and poly-L-lactide composite in 29 consecutive patients. Fixation was performed for seven acute fractures and twenty-two established non-unions. Union was achieved in 72.4% of patients. Six of the acute fractures and fifteen of the non-unions united successfully. Modified Mayo Wrist Score ranged between good to excellent in all patients who successfully united, whereas patients who failed to unite ranged between poor to excellent, with one poor and two moderate scores. No adverse biocompatibility reactions were seen. Two failures with broken screws were re-explored and one of these was thought to be due to screw mal-placement. The device used is an alternative to conventional metal implants and produces comparable union rates to metallic devices in the short term.
Hardy, A; Casabianca, L; Grimaud, O; Meyer, A
In comminuted fractures of the intercondyloid eminence of the tibial spine, the quality of the reduction and the arthroscopic fixation, notably adjustable suture button fixation, is sometimes disappointing with reduction defects of the anterior bone block. In the Speed-Bridge technique, the two traction sutures of the adjustable button fixation are replaced with two braided sutures of different colors. After the button is placed above the eminence, reduction is obtained by tightening the loop of the button. The accessory communitive fragments are then packed in the depression around the main fragment. A second row provides bone suturing for these accessory fragments; traction sutures of the button are attached anteromedially and laterally with knotless anchors to obtain a Speed-Bridge-type inverted-V bone suture. The Speed-Bridge arthroscopic reinsertion technique of the tibial eminence effectively completes the adjustable button bone suture technique for communitive fractures to obtain better reduction and good stability. Copyright © 2016 Elsevier Masson SAS. All rights reserved.
Azam, Md Quamar; Iraqi, AA; Sherwani, MKA; Abbas, M; Alam, Afzal; Sabir, Amir Bin; Asif, Naiyer
Background: Time from injury to fixation of femoral neck fractures has been postulated as a vital determinant for rate of complications; however, no prospective study is available in the English literature. Delay, unfortunately, is inevitable in developing countries. The aim of the present study is to retrospectively review the outcome after delayed fixation of displaced type II and III femoral neck fractures in children. Materials and Methods: Using a standard assessment chart, we retrospectively reviewed medical records of all pediatric patients having femoral neck fractures presenting to our institution from June 1999 to May 2006. Inclusion criteria were children between 5 and 15 years of age sustaining displaced Delbet type II and III femoral neck fractures having a complete follow-up of at least 2 years. Patients with known metabolic disease, poliomyelitis or cerebral palsy, were excluded from the study. After application of inclusion and exclusion criteria, 22 patients having 22 fractures (13 type II and 9 type III) were studied. Surgery could be performed after a mean delay of 11.22 days (ranging from 2 to 21 days). Closed reduction was achieved in 14 cases and 8 cases required open reduction through anterolateral approach. Result: Osteonecrosis was noted in eight patients (36.37%) who included two of nine patients (22.22%) operated in the first week, three of eight patients (37.51%) operated in the second week, and three of five patients (60%) operated in the third week of injury. Nonunion was seen in four (18.18%) cases, and two of them were associated with failure of implants. One was treated by valgus osteotomy and the other by Meyer's procedure. Fractures united in both children but the latter developed avascular necrosis. Functional results, as assessed using Ratliff's criteria, were good in 14 (63.63%), fair in 2 (9%), and poor in 6 (27.27%) patients. Conclusion: Delay in fixation, type of fracture, and ability to achieve and maintain reduction are
Hamilton Jr, David A; Reilly, Danielle; Wipf, Felix; Kamineni, Srinath
AIM: To determine whether use of a precontoured olecranon plate provides adequate fixation to withstand supraphysiologic force in a comminuted olecranon fracture model. METHODS: Five samples of fourth generation composite bones and five samples of fresh frozen human cadaveric left ulnae were utilized for this study. The cadaveric specimens underwent dual-energy X-ray absorptiometry (DEXA) scanning to quantify the bone quality. The composite and cadaveric bones were prepared by creating a comminuted olecranon fracture and fixed with a pre-contoured olecranon plate with locking screws. Construct stiffness and failure load were measured by subjecting specimens to cantilever bending moments until failure. Fracture site motion was measured with differential variable resistance transducer spanning the fracture. Statistical analysis was performed with two-tailed Mann-Whitney-U test with Monte Carlo Exact test. RESULTS: There was a significant difference in fixation stiffness and strength between the composite bones and human cadaver bones. Failure modes differed in cadaveric and composite specimens. The load to failure for the composite bones (n = 5) and human cadaver bones (n = 5) specimens were 10.67 nm (range 9.40-11.91 nm) and 13.05 nm (range 12.59-15.38 nm) respectively. This difference was statistically significant (P ˂ 0.007, 97% power). Median stiffness for composite bones and human cadaver bones specimens were 5.69 nm/mm (range 4.69-6.80 nm/mm) and 7.55 nm/mm (range 6.31-7.72 nm/mm). There was a significant difference for stiffness (P ˂ 0.033, 79% power) between composite bones and cadaveric bones. No correlation was found between the DEXA results and stiffness. All cadaveric specimens withstood the physiologic load anticipated postoperatively. Catastrophic failure occurred in all composite specimens. All failures resulted from composite bone failure at the distal screw site and not hardware failure. There were no catastrophic fracture failures in the cadaveric
Gordon, Katharina; Winkler, Martin; Hofstädter, Thomas; Dorn, Ulrich; Augat, Peter
With increasing life expectancy and number of total hip arthroplasties (THA), the need for revision surgery is increasing too. The aim of this study was to evaluate the optimal fracture treatment for a clinically characteristic Vancouver B1 fracture. We hypothesized that locking plate fixation has biomechanical advantages over fixation with a simple cerclage system. Additionally, we hypothesized that removal of the primary short stem and revision with a long stem would show biomechanical benefit. The biomechanical testing was performed with a static and a dynamic loading protocol on twenty 4th Generation sawbones. These were divided into four different groups (n = 5 each). In group 1, the primary uncemented short stem remained and the fracture was stabilized with a locking plate. In group 2, the primary stem remained and the fracture was stabilized with a cerclage stabilization system containing two stabilizers and four cerclages. In group 3, the primary stem was replaced by an uncemented long revision stem and the fracture was fixed with a locking plate. In group 4, the short stem was replaced by a long revision stem and the fracture was fixed with the cerclage system. Static testing revealed that the revision of the short stem with the long stem caused a 2-fold (p < 0.001, ANOVA) increase of axial stiffness. In dynamic testing, the number of cycles to failure was 4 times (p < 0.001, ANOVA) higher with the long revision stem. Compared to locked plating cerclage wiring demonstrated a 26% more cycles to failure (p = 0.031, ANOVA). The load to failure was 91% larger (p < 0.001, ANOVA) with the long revision stem and 11% smaller with locked plating (p < 0.001, ANOVA). In conclusion, the present biomechanical study indicates that periprosthetic Vancouver B1 fractures can be sufficiently fixed by simple cerclage systems. Revision with a long replacement stem provides a superior mechanical stability regardless of type of osteosynthesis fixation and is therefore a viable
Lin, Da-sheng; Guo, Lin-xin; Ding, Zhen-qi; Chen, Chang-qing; Lian, Ke-jian; Hong, Jia-yuan
To investigate the feasibility and safety of the treatment for thoracolumbar fractures with transpedicular intracorporeal hydroxyapatite grafting and pedicle screw fixation via paraspinal approach. From June 2007 to December 2008, 19 cases of thoracolumbar fractures were treated with transpedicular intracorporeal hydroxyapatite grafting and pedicle screw fixation via paraspinal approach. There were 7 female and 12 male, ranging from 21 to 57 years of age (mean 40.8 years) at surgery. The time from injury to surgery varied from 1 d to 5 d (mean 2.9 d). Nineteen patients all suffered from single thoracolumbar fracture with the distribution of injury level being T(11) in 1, T(12) in 5, L(1) in 9, and L(2) in 4. According to Denis fracture classification, there were 5 compression fractures and 14 burst fractures. The mean preoperative ratio of the anterior height of the body was 57.2%, kyphosis angle was 17.6° and occupation of spinal canal was 27.7%. The mean preoperative load-sharing classification of spine fractures was 5.2. Based on the ASIA neurologic grading system, preoperative neurological function was grade B in 2 cases, C in 9 and D in 8. Median operating time was 83.8 min (range 60-95 min) and median blood loss was 133 ml (range 90 - 200 ml). Infection did not occur in any of the patients and the operative incisions were healing well. Average follow-up time was 19.2 months (range 12 - 36 months). At the latest follow-up, the height of the anterior border was corrected to 88.4%, the kyphosis angle was 6.1°, and the occupation of spinal canal was 8.2% on average. The postoperative neurologic function of all 19 patients was improved with grade D in 2 cases and E in 17. There were no instances of instrumentation failure and no patient had persistent postoperative back pain. Transpedicular intracorporeal hydroxyapatite grafting and pedicle screw fixation via paraspinal approach could provide reliable neurologic improvement in patients with incomplete neurologic
Jeevannavar, Santosh Somayya; Shenoy, Keshav Someshwar; Daddimani, Ravi M
A 20-year-old woman presented 6 months after an initial injury to her left elbow with pain and restricted movements. She was diagnosed with a type I malunited (Hahn-Steinthal) type of capitellum fracture through radiographic studies. Classically, the treatment has been excision of the fragment, which carries a risk of valgus instability of the elbow and late osteoarthrosis. We report a case of malunited type I capitellum fracture, for which corrective osteotomy through fracture site, open reduction and internal fixation was done 6 months following missed trauma. At 24 months follow-up the capitellum fracture had united and the patient has a stable elbow and excellent range of motion. Our case demonstrates that for type I malunited capitellum fractures corrective osteotomy through fracture site and internal fixation rather than excision of the fragment in young can result in successful union and stable elbow. PMID:23709538
Jeevannavar, Santosh Somayya; Shenoy, Keshav Someshwar; Daddimani, Ravi M
A 20-year-old woman presented 6 months after an initial injury to her left elbow with pain and restricted movements. She was diagnosed with a type I malunited (Hahn-Steinthal) type of capitellum fracture through radiographic studies. Classically, the treatment has been excision of the fragment, which carries a risk of valgus instability of the elbow and late osteoarthrosis. We report a case of malunited type I capitellum fracture, for which corrective osteotomy through fracture site, open reduction and internal fixation was done 6 months following missed trauma. At 24 months follow-up the capitellum fracture had united and the patient has a stable elbow and excellent range of motion. Our case demonstrates that for type I malunited capitellum fractures corrective osteotomy through fracture site and internal fixation rather than excision of the fragment in young can result in successful union and stable elbow.
Glass, Nina E; Burlew, Clay Cothren; Hahnhaussen, Jens; Weckbach, Sebastian; Pieracci, Fredric M; Moore, Ernest E; Stahel, Philip F
To investigate the safety and feasibility of performing definitive fracture fixation in multiply injured patients in the presence of an open abdomen after laparotomy. Retrospective observational cohort study. Level-I academic trauma center. Adult polytrauma patients with presence of an open abdomen after "damage control" laparotomy and associated major fractures of long bones, acetabulum, pelvis or spine, requiring surgical repair (n=81). Timing of definitive fracture fixation in relation to the timing of abdominal wall closure. Incidence of orthopedic surgical site infections. In During a 15-year time-window from January 1, 2000 until December 31, 2014, we identified a cohort of 294 consecutive polytrauma patients with an open abdomen after laparotomy. Surgical fixation of associated fractures was performed after the index laparotomy in 81 patients. In group 1 (n=32), fracture fixation occurred significantly sooner despite a concurrent open abdomen, compared to group 2 (n=49) with abdominal wall closure prior to fixation (mean 4.4 vs 11.8 days; P=0.01). The incidence of orthopaedic surgical site infections requiring a surgical revision was significantly lower in group 1 (3.1%) compared to group 2 (30.6%; P=0.002). Definitive fracture fixation in the presence of an open abdomen is performed safely and associated with a significant decrease in clinically relevant surgical site infections, compared to delaying fracture fixation until abdominal wall closure. These data suggest that the strategy of imposing a time delay in orthopaedic procedures while awaiting abdominal wall closure is unjustified. Therapeutic level III.
Feerick, Emer M; Kennedy, Jim; Mullett, Hannan; FitzPatrick, David; McGarry, Patrick
A computational investigation of proximal humeral fracture fixation has been conducted. Four devices were selected for the study; a locking plate, intramedullary nail (IM Nail), K-wires and a Bilboquet device. A 3D model of a humerus was created using a process of thresholding based on the grayscale values of a CT scan of an intact humerus. An idealised three part fracture was created in addition to removing a standard volume from the humeral head as a representation of bone voids that occur as a result of the injury. All finite element simulations conducted represent 90° arm abduction. Simulations were conducted to investigate the effect of filling this bone void with calcium phosphate cement for each device. The effect of constructing devices from carbon fibre polyetheretherketone (CFPEEK) was investigated. Simulations of cement reinforced devices predict greater stability for each device. The average unreinforced fracture line opening (FLO) is reduced by 48.5% for metallic devices with a lesser effect on composite devices with FLO reduced by 23.6%. Relative sliding (shear displacement) is also reduced between fracture fragments by an average of 58.34%. CFPEEK device simulations predict reduced stresses at the device-bone interface. Copyright © 2012 IPEM. Published by Elsevier Ltd. All rights reserved.
Ramseier, Leonhard Erich; Bhaskar, Atul R; Cole, William G; Howard, Andrew W
Open femur fractures in children are uncommon and usually associated with other injuries. In adults, there is a current trend to treat open fractures with intramedullary (IM) devices. The goal of this study was to compare external fixator (EF) to IM devices in the treatment of open femur fractures in children. Diaphyseal femur fractures without growth plate involvement were included. Thirty-five patients (12 IM; 23 EF) were identified. Age, hospital stay, polytrauma, mechanism of injury, and Gustilo-Anderson grade were recorded. Follow-up was at least until the fracture was clinically and radiographically healed. Patients with EFs were 5.2 times more likely (95% confidence interval, 1.05-25.5) to have any complication. Excluding pin track infections, patients with EFs were 2.7 times as likely (95% confidence interval, 0.567-13.2) to have a complication. Refractures occurred only in the EF group (6/23, 26%) and not in the IM nailing group (P = 0.062, Fischer exact test). These were associated with varus malunions-all 3 of the EF group with more than 15 degrees of varus at fracture union suffered a refracture. Treatment of open femur fractures in children is a challenging problem. Treatment with IM devices had fewer complications than the EF. We think that whenever possible, the use of IM devices for the treatment of open femur fracture in children should be considered, especially grade 1 open injuries. If EFs are used, avoiding varus malunion may decrease the refracture rate, and secondary change to an IM device should be considered. Comparative cohort study. Grade 3 level of evidence.
Aquilina, Peter; Chamoli, Uphar; Parr, William C H; Clausen, Philip D; Wroe, Stephen
The most stable pattern of internal fixation for fractures of the mandibular condyle is a matter for ongoing discussion. In this study we investigated the stability of three commonly used patterns of plate fixation, and constructed finite element models of a simulated mandibular condylar fracture. The completed models were heterogeneous in the distribution of bony material properties, contained about 1.2 million elements, and incorporated simulated jaw-adducting musculature. Models were run assuming linear elasticity and isotropic material properties for bone. This model was considerably larger and more complex than previous finite element models that have been used to analyse the biomechanical behaviour of differing plating techniques. The use of two parallel 2.0 titanium miniplates gave a more stable configuration with lower mean element stresses and displacements over the use of a single miniplate. In addition, a parallel orientation of two miniplates resulted in lower stresses and displacements than did the use of two miniplates in an offset pattern. The use of two parallel titanium plates resulted in a superior biomechanical result as defined by mean element stresses and relative movement between the fractured fragments in these finite element models. Copyright © 2012 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Xie, Zong-Ping; Zhang, Chang-Qing; Yi, Cheng-Qing; Qiu, Jian-Jun; Wang, Jian-Qiang; Zhou, Juan
There are many in vitro experiments showing that particulate bioactive glasses have a broad and certain antibacterial effect, but there is no report about this antibacterial effect in vivo so far. The aim of this study is to examine the efficacy of particulate Bioglass in reducing the rate of infection with Staphylococcus aureus after the fixation of open tibial fractures in rabbits. The test in vivo was carried out with male rabbits split into two groups infected with Staphylococcus aureus at the right tibial fracture sites fixed with plate and screw, either with or without bioactive glass respectively. Culture results show that six of ten rabbits from the control group had a positive culture for the strain of Staphylococcus aureus ATCC25923, compared with six of the nine rabbits from the Bioglass group. The median radiographic score is 4.5 points for the rabbits from the control group and 4 points for the rabbits from the Bioglass group. The median histopathological score was 2.5 points for the rabbits in the control group and 3 points for the rabbits in the Bioglass group. In conclusion, this study showed no significant difference between the rates of infection of two groups. Particulate Bioglass did not reduce the rate of infection with Staphylococcus aureus after the fixation of open tibial fractures in rabbits.
Goldstein, Rachel Y; Montero, Nicole; Jain, Sudheer K; Egol, Kenneth A; Tejwani, Nirmal C
To compare postoperative pain control in patients treated surgically for ankle fractures who receive popliteal blocks with those who received general anesthesia alone. Institutional Review Board approved prospective randomized study. Metropolitan tertiary-care referral center. All patients being treated with open reduction internal fixation for ankle fractures who met inclusion criteria and consented to participate were enrolled. Patients were randomized to receive either general anesthesia (GETA) or intravenous sedation and popliteal block. Patients were assessed for duration of procedure, total time in the operating room, and postoperative pain at 2, 4, 8, 12, 24, and 48 hours after surgery using a visual analog scale. Fifty-one patients agreed to participate in the study. Twenty-five patients received popliteal block, while 26 patients received GETA. There were no anesthesia-related complications. At 2, 4, and 8 hours postoperatively, patients who underwent GETA demonstrated significantly higher pain. At 12 hours, there was no significant difference between the 2 groups with regard to pain control. However, by 24 hours, those who had received popliteal blocks had significantly higher pain with no difference by 48 hours. Popliteal block provides equivalent postoperative pain control to general anesthesia alone in patients undergoing operative fixation of ankle fractures. However, patients who receive popliteal blocks do experience a significant increase in pain between 12 and 24 hours. Recognition of this "rebound pain" with early narcotic administration may allow patients to have more effective postoperative pain control.
Wild, Jason R; Askam, Brad M; Margolis, David S; Geffre, Christopher P; Krupinski, Elizabeth A; Truchan, Lisa M
To describe a method of suture augmentation of locking plate fixation (PF) of proximal olecranon fractures and to evaluate the biomechanical effectiveness of the suture augmentation using a human cadaveric model. Six matched pairs of cadaveric elbows were used. Proximal one-third fractures of the olecranon were simulated via a transverse osteotomy. Identical locking PF was performed on each elbow using olecranon locking plates. One elbow of each pair was assigned to suture augmentation of the construct. The choice of left/right specimen for augmentation was performed in an alternating fashion. Augmentation was performed using a no. 2 ultra-high-molecular weight polyethylene-braided suture attaching the triceps to the plate via a modified Krackow stitch. The elbows were mounted into a custom jig and linearly loaded to failure using a hydraulic testing machine. Load to and modes of failure were recorded for each sample. The data were analyzed using the Wilcoxon signed-rank test for nonparametric distributions. Suture augmentation improved the single load-to-failure strength in all pairs. One pair was excluded due to failure of the triceps attachment to the test machine. A median 398 N (P = 0.04 range, 197-633 N) or a median 48% (range, 30%-130%) improvement in strength was seen. The most common mode of failure was loss of fixation of the proximal olecranon fragment. Suture augmentation can significantly increase the single load-to-failure strength of locking PF for proximal olecranon fractures.
Zielinski, Stephanie M; Keijsers, Noël L; Praet, Stephan F E; Heetveld, Martin J; Bhandari, Mohit; Wilssens, Jean Pierre; Patka, Peter; Van Lieshout, Esther M M
This study assesses femoral neck shortening and its effect on gait pattern and muscle strength in patients with femoral neck fractures treated with internal fixation. Seventy-six patients from a multicenter randomized controlled trial participated. Patient characteristics and Short Form 12 and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were collected. Femoral neck shortening, gait parameters, and maximum isometric forces of the hip muscles were measured and differences between the fractured and contralateral leg were calculated. Variables of patients with little or no shortening, moderate shortening, and severe shortening were compared using univariate and multivariate analyses. Median femoral neck shortening was 1.1 cm. Subtle changes in gait pattern, reduced gait velocity, and reduced abductor muscle strength were observed. Age, weight, and Pauwels classification were risk factors for femoral neck shortening. Femoral neck shortening decreased gait velocity and seemed to impair gait symmetry and physical functioning. In conclusion, internal fixation of femoral neck fractures results in permanent physical limitations. The relatively young and healthy patients in our study seem capable of compensating. Attention should be paid to femoral neck shortening and proper correction with a heel lift, as inadequate correction may cause physical complaints and influence outcome. Copyright 2013, SLACK Incorporated.
Panteli, Michalis; Rodham, Paul; Giannoudis, Peter V
Femoral neck fractures represent a relatively uncommon injury in the non-elderly population often resulting from high-energy trauma. The cornerstone of their management is anatomic reduction and stable internal fixation of the femoral neck in an attempt to salvage the femoral head. Complications including avascular necrosis of the femoral head, non-union and post-traumatic osteoarthritis are not uncommon. The clinical outcomes of these patients can be improved with good pre-operative planning, optimization of surgical procedures and introduction of new improved implants and techniques. In the herein study, we attempt to describe the biomechanical properties of the hip and compare the performance of the most commonly used devices. Experimental evidence suggests that in Pauwels type III fracture patterns a cephalomedullary nail was significantly stronger in axial loading. Moreover, in unstable basicervical patterns cannulated screws (triangular configuration) demonstrated a lower ultimate load to failure, whereas in subcapital or transervical patterns both the cannulated screws (triangular configuration) and the sliding hip screw demonstrated no compromise in fixation strength. The fracture pattern appears to be the major determinant of the ideal type of implant to be selected. For a successful outcome each patient needs to be considered on an individual basis taking into account all patient and implant related factors.
Andersen, J K; Høgh, A; Gantov, J; Vaesel, M T; Hansen, T Baek
The results in 75 of 105 patients with Older type II/III (AO type A2.2, A3.1, A3.2) Colles' fractures, treated with non-bridging external fixation are presented. The mean age was 67.8 years, and all patients were followed prospectively for 12 months with radiological and functional assessment. No statistically significant loss of radial length, angulation or inclination was seen between the postoperative reduction and the 1-year follow-up examination. The clinical results after 1 year were 66 (88%) excellent/good, nine (12%) fair and 0 (0%) poor according to the modified Gartland and Werley score. Mean visual analogue scale pain score after 1 year was 0.8. In three patients (4%), re-displacement of the fracture occurred and was treated with plating. Non-bridging external fixation offers a reliable method of maintaining radiological reduction of Older type II/III fractures of the distal radius and gives a good functional outcome after 1 year.
Sommerfeldt, Dirk W
Minimally invasive reduction and internal fixation of anterior tibial spine and anterior cruciate ligament (ACL) without harming knee joint cartilage and physis of the proximal tibia. Anterior tibial spine fractures type II-IV according to Meyers/McKeever. ACL tears. Fractures of the tibial plateau. Fractures involving the growth plate (Aitken I-III). 1. Diagnostic arthroscopy and drainage of the knee joint. Search for additional injuries (menisci, knee joint cartilage, collateral ligaments, posterior cruciate ligament). 2. Arthroscopy-assisted reduction of anterior tibial spine fragment. 3. Epiphyseal internal fixation with Kirschner wires or cannulated screws according to fragment size. Full weight bearing as tolerated after wound healing (day 7 after surgery) in 20 degrees of knee flexion (orthesis or ankle-sparing cast tutor). X-rays postoperatively and after 3 and 6 weeks. Passive and active physiotherapy (extension and flexion without weight bearing) 3-4 weeks postoperatively according to patient's age, weight and compliance. Weight bearing in knee flexion (stairs) 6-8 weeks postoperatively. 19 patients were treated from 2001 to 2005 at an age of 7-14 years. All patients achieved free range of motion without pain or growth disturbances. Three patients developed slight joint laxity (anterior drawer test) which did not affect mobility, sports performance, joint surface or menisci on clinical evaluations conducted at least 1 year postoperatively. One patient had bony healing of the tibial spine in slight dislocation without impingement or decrease of range of motion within the knee joint.
Tao, Sheng; Mao, Ke-ya; Liu, Bao-wei; Wang, Yan; Liang, Yu-tian; Tang, Pei-fu; Wang, Hui-xian
To study a new implant material (carbonated hydroxyapatite, CHA) united pedicle screw to cure spine fracture. Thirty-two cases of spine compressed fracture were used with pedicle screw fixator and vertebroplasty. Before operation, patients' vertebral body were compressed (46 + 21)% (20% approximately 70%) on average. In operation, broken vertebral body was reposition through pedicle screw technique, then used self-made syringe to inject CHA into anterior and central column of broken vertebral body through pedicle. And all of patients were not given any bone-graft. In 6 - 26 months followed-up, no immunologic rejection was found about hydroxyapatite, and no any broken of the screws and shafts was found, no loosing and other complications either. All the patients could move in 3 - 5 days after operation. The height of the broken vertebral body were reduced 97% compared with pre-operation. And CHA in vertebral body was degraded gradually, and at the same time it was replace by new bone in vertebral body. After operation, VAS score was 61 +/- 32, and there was significant difference compared with pre-operation. The pedicle screw fixation united vertebroplasty is an efficient way to prevent the failure of the treatment of spine fracture.
Popkov, A. V.; Kononovich, N. A.; Gorbach, E. N.; Tverdokhlebov, S. I.; Irianov, Y. M.; Popkov, D. A.
Purpose. Our research was aimed at studying the radiographic and histological outcomes of using flexible intramedullary nailing (FIN) combined with Ilizarov external fixation (IEF) versus Ilizarov external fixation alone on a canine model of an open tibial shaft fracture. Materials and Methods. Transverse diaphyseal tibial fractures were modelled in twenty dogs. Fractures in the dogs of group 1 (n = 10) were stabilized with the Ilizarov apparatus while it was combined with FIN in group 2 (n = 10). Results. On day 14, a bone tissue envelope started developing round the FIN wires. Histologically, we revealed only endosteal bone union in group 1 while in group 2 the radiographs revealed complete bone union on day 28. At the same time-point, the areas of cancellous and mature lamellar bone tissues were observed in the intermediary area in group 2. The periosteal layers were formed of the trabeculae net of lamellar structure and united the bone fragments. The frame was removed at 30 days after the fracture in group 2 and after 45 days in group 1 according to bone regeneration. Conclusion. The combination of the Ilizarov apparatus and FIN accelerates bone repair and augments stabilization of tibial shaft fractures as compared with the use of the Ilizarov fixation alone. PMID:25379523
Aird, J; Noor, S; Lavy, C; Rollinson, P
There are 33 million people worldwide currently infected with human immunodeficiency virus (HIV). This complex disease affects many of the processes involved in wound and fracture healing, and there is little evidence available to guide the management of open fractures in these patients. Fears of acute and delayed infection often inhibit the use of fixation, which may be the most effective way of achieving union. This study compared fixation of open fractures in HIV-positive and -negative patients in South Africa, a country with very high rates of both HIV and high-energy trauma. A total of 133 patients (33 HIV-positive) with 135 open fractures fulfilled the inclusion criteria. This cohort is three times larger than in any similar previously published study. The results suggest that HIV is not a contraindication to internal or external fixation of open fractures in this population, as HIV is not a significant risk factor for acute wound/implant infection. However, subgroup analysis of grade I open fractures in patients with advanced HIV and a low CD4 count (< 350) showed an increased risk of infection; we suggest that grade I open fractures in patients with advanced HIV should be treated by early debridement followed by fixation at an appropriate time.
De Spirito, Daniele
Closed percutaneous wire fixation of hand fractures frequently requires protection with external splintage. This splintage increases the risk of joint stiffness, prolongs recovery time, and increases therapy input. We have developed a method of linking external Kirschner wires (K-wires), using a metal clamp, after their insertion, so as to increase the security of fixation and facilitate postoperative mobilization. The mechanical properties of this method have been assessed in vitro and compared with conventionally fixed, unlinked, K-wires. We have been able to establish that the linked K-wire system is better able to resist loosening. This work proposes that linkage of K-wires permits omission of all additional external splintage, with no detriment to management. The technique has been applied in clinical cases over the past 8 years and results of treatments were evaluated mainly to detect unexpected complications. We report a low rate of complications and good results in terms of bone healing and recovery of function.
Yadav, Vishal; Sharma, Pulak; Gohiya, Ashish
Background: Displaced intraarticular distal humerus fracture has been conventionally treated operatively with various triceps disrupting approaches. These approaches are associated with several complications, such as triceps weakness, nonunion or delayed union of osteotomy, implant prominence, and delayed mobilization of the elbow. We present the functional outcome of intraarticular distal humerus fracture fixation using a triceps-sparing paratricipital approach which allows early elbow mobilization and preserving triceps strength. Materials and Methods: Twenty five patients with intraarticular distal humerus fracture were operated using triceps-sparing paratricipital approach with orthogonal plate construct. There were 16 male and 9 female patients and average age was 42.16 years (range 23-65 years). The mechanism of injury was fall from height (n = 8), road traffic accident (n = 13) and ground level fall (n = 4). Clinical, radiological, and functional assessment with Mayo Elbow Performance Index (MEPI) were obtained at follow up period. Results: All fractures united primarily. At the mean follow up of 13.58 months (range 6-22 months), mean elbow flexion was 121.08° (range 94°–142°) and mean motion arc was 114.92°(range 65°-140°). The mean MEPI score was 94.40 points (range 70–100) with 17 excellent, five good, and three fair results. The mean flexion deformity or extension loss was 6.16° (range 5°–15°). Conclusion: Open reduction and internal fixation of intraarticular distal humerus fractures with