Reoperation following open reduction and plate fixation of displaced mid-shaft clavicle fractures

BACKGROUND

Operative fixation of displaced, mid-shaft clavicle fractures has become an increasingly common practice. With this emerging trend, data describing patient outcomes with longer follow-up are necessary.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of subjects treated with plate fixation for displaced mid-shaft clavicle fractures from 2003 to 2009 at a Level I trauma hospital. All subjects were greater than 12 months post-index surgery. Treatment involved ORIF with either a low-contact dynamic compression plate (LCDC) or a contoured plate (pre-contoured or pelvic reconstruction plate). Our primary outcome was reoperation for any indication.

RESULTS

143 subjects were included. The mean age was 36 ± 14 years and the mean time to reoperation or chart review was 33 months. Contoured plates were used in 64% of cases and LCDC plates were used in the remaining subjects. Twenty-nine subjects (20%) underwent reoperation: 23.5% of subjects treated with LCDC plates and 18.5% of subjects treated with contoured plates (p=0.52). Indications for reoperation included implant irritation (n=25), implant failure (n=2), and non-union (n=2). There was near statistically significant association with reoperation and female gender (p=0.05) but no association between reoperation and age (p=0.14), fracture class (p=0.53), plate type (p=0.49), or plate location (p=0.93). The mean QuickDASH score for the population surveyed was 8.8 (5.5-12.1; 95% CI) with near statistically significant and clinically relevant difference between those considering reoperation and those not 22.3 (8.6-36.0; 95% CI) versus 6.7 (3.6-9.8; 95% CI).

CONCLUSIONS

This study represents a large series of displaced clavicle fractures treated with open reduction and plate fixation. Reoperation following plate fixation is relatively common, but primarily due to implant irritation. No difference in reoperation rates between plate types or location could be detected in our current sample size. Also, excellent functional outcomes continue to be observed several years after clavicle fracture fixation.

Bicolumnar 90-90 plating of low-energy distal humeral fractures in the elderly patient

Fragility fractures of the distal humerus in elderly patients, especially the low transcondylar fracture pattern, can be difficult to optimally manage. Although the fractures are typically low energy resulting in either extra-articular or simple intra-articular patterns, gaining fixation into the distal fragments can be difficult with open reduction internal fixation (ORIF) using traditional 90-90 or parallel plating techniques. Anatomy preserving reconstruction with ORIF is preferred over total elbow arthroplasty (TEA) if possible. In this study, 15 patients were managed with a bicolumnar 90-90 plating construct as a novel method of enhancing distal fixation in these fractures. Fourteen patients went on to radiographic union at an average of 77 days after surgery with an average arc of motion of 105°. One patient was lost to follow-up. Bicolumnar 90-90 plating of distal humerus fractures in elderly patients may represent a viable alternative to traditional ORIF or TEA.

Low Wound Complication Rates for the Lateral Extensile Approach for Calcaneal ORIF When the Lateral Calcaneal Artery Is Patent

BACKGROUND

Historically, the lateral extensile approach for calcaneal fracture osteosynthesis has had relatively high rates of wound healing problems. The vascular territory (angiosome) of the lateral foot is now known to be dependent upon the lateral calcaneal branch of the peroneal artery (LCBP artery). We postulated that patency of the LCBP artery may have a profound positive impact on incisional wound healing for calcaneal open reduction and internal fixation (ORIF).

METHODS

Ninety consecutive calcaneal fractures that met operative criteria were preoperatively evaluated for the presence of a Doppler signal in the LCBP artery and were followed for the development of wound healing problems.

RESULTS

Among these 90 fractures, 85 had a positive preoperative Doppler signal along the course of the LCBP artery (94%) and 5 had no Doppler signal (6%). All patients underwent ORIF via a lateral extensile approach. Overall, incisional wound healing problems occurred in 6 of 90 calcaneal incisions (6.5%). All 5 feet that exhibited an absent Doppler signal in the LCPB artery developed an incisional wound healing complication (5/6, approximately 83%): 2 large apical wounds and 3 major dehiscence/slough. However, among the 84 feet that possessed a positive preoperative Doppler signal in the LCBP artery, there was only 1 (1/84, approximately 1%) incisional wound healing problem (P < .0001, Fischer's exact test). Smokers with a positive Doppler signal in the LCBP artery did not develop a wound healing complication.

CONCLUSIONS

This study suggests a strong link to low incisional wound healing complications for the lateral extensile approach to the calcaneus when a preoperative Doppler signal is present in the LCBP artery. We believe this simple examination should be routinely performed prior to calcaneal ORIF.

LEVEL OF EVIDENCE

Level III, comparative case series.

Combined medial column primary arthrodesis, middle column open reduction internal fixation, and lateral column pinning for treatment of Lisfranc fracture-dislocation injuries

Lisfranc fracture-dislocation can be a devastating injury with significant long-term sequelae, including degenerative joint disease, progressive arch collapse, and chronic pain that can be potentiated if not effectively treated. We present a case to demonstrate our preferred surgical approach, consisting of combined medial column primary arthrodesis, middle column open reduction internal fixation, and lateral column pinning, with the primary goal of minimizing common long-term complications associated with Lisfranc injuries. We present the case of a typical patient treated according to this combined surgical approach to highlight our patient selection criteria, rationale, surgical technique, and operative pearls. A 36-year-old male who had sustained a homolateral Lisfranc fracture-dislocation injury after falling from a height initially underwent fasciotomy for foot compartment syndrome. The subsequent repair 16 days later involved primary first tarsometatarsal joint fusion, open reduction internal fixation of the second and third tarsometatarsal joints, and temporary pinning of the fourth and fifth tarsometatarsal joints. He progressed well postoperatively, exhibiting an American College of Foot and Ankle Surgeons forefoot score of 90 of 100 at 1 year after surgery with no need for subsequent treatment. Lisfranc fracture-dislocations often exhibit primary dislocation to the medial column and are conducive to arthrodesis to stabilize the tarsometatarsal complex. The middle column frequently involves comminuted intra-articular fractures and will often benefit from less dissection required for open reduction internal fixation instead of primary fusion. We propose that this surgical approach is a viable alternative technique for primary treatment of Lisfranc fracture-dislocation injuries.

Distal volar radial plates: how anatomical are they?

BACKGROUND

Fractures of the distal radius are common, with volar locking plates being increasingly used in their treatment. They aim to provide stable internal fixation and are designed to mirror the natural anatomy. Current volar plate designs incorporate a volar cortical angle (VCA) of 25 degrees.

HYPOTHESIS

The aim of this study is to determine whether the VCA in uninjured distal radii corresponds accurately with modern volar plate designs.

MATERIALS AND METHODS

A retrospective radiological analysis utilizing Computed Tomography scans to assess the VCA of 100 distal radii. Each distal radius was subjected to 3 measurements of the VCA in the sagittal plane.

RESULTS

One hundred patients were identified (67 male, 33 female; mean age 37.4 years). The mean VCA was 32.9 degrees (S.D.±5.14 degrees). The VCA in male patients was significantly greater than in females (33.6 vs 31.5 degrees; P=0.04). There was a statistically significant difference between the lateral VCA and medial VCA (32.2 vs 34.3 degrees, P=0.02).

DISCUSSION

Our study clearly demonstrates that the VCA measured in the distal radius is significantly greater than the volar angulation incorporated within modern plate design. Given that the aim of ORIF is to anatomically reconstruct the distal radius, our study highlights that this may not be possible with current plates.

LEVELS OF EVIDENCE

Level IV Retrospective case series.

A Biomechanical Comparison of Three 1.5-mm Plate and Screw Configurations and a Single 2.0-mm Plate for Internal Fixation of a Mandibular Condylar Fracture

The most stable pattern of internal fixation for mandibular condyle fractures is an area of ongoing discussion. This study investigates the stability of three patterns of plate fixation using readily available, commercially pure titanium implants. Finite element models of a simulated mandibular condyle fracture were constructed. The completed models were heterogeneous in bone material properties, contained approximately 1.2 million elements and incorporated simulated jaw adducting musculature. Models were run assuming linear elasticity and isotropic material properties for bone. No human subjects were involved in this investigation. The stability of the simulated condylar fracture reduced with the different implant configurations, and the von Mises stresses of a 1.5-mm X-shaped plate, a 1.5-mm rectangular plate, and a 1.5-mm square plate (all Synthes (Synthes GmbH, Zuchwil, Switzerland) were compared. The 1.5-mm X plate was the most stable of the three 1.5-mm profile plate configurations examined and had comparable mechanical performance to a single 2.0-mm straight four-hole plate. This study does not support the use of rectangular or square plate patterns in the open reduction and internal fixation of mandibular condyle fractures. It does provide some support for the use of a 1.5-mm X plate to reduce condylar fractures in selected clinical cases.

Treatment of edentulous mandibular fractures with rigid internal fixation: case series and literature review

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.

Risk factors for postoperative wound complications of calcaneal fractures following plate fixation

BACKGROUND

A fairly high prevalence of wound complications after open reduction and internal plate fixation (ORIF) of closed calcaneal fractures via the extensile lateral approach has been reported. The goal of this study was to analyze and identify independent risk factors for wound complications among closed calcaneal fractures undergoing ORIF.

METHODS

The medical records of all closed calcaneal fracture patients who underwent ORIF from July 2005 to July 2012 were reviewed to identify those who developed a wound complication. Then we constructed a univariate and multivariate logistic regression to evaluate the independent associations of potential risk factors for surgical wound complication. Records showed 479 patients who underwent ORIF of a closed calcaneal fracture from July 2005 to July 2012. The patients were followed for 3 to 28 months, with an average follow-up period of 14.2 months. Eleven patients had bilateral fractures, for a total of 490 fractured calcanei.

RESULTS

The overall rate of postoperative wound complications following ORIF of closed calcaneus fractures was 17.8% (87 wound complications in 490 operations). With the regression model, smoking history (odds ratio, 5.79; 95% CI: 1.55 to 21.70; P = .009), diabetes mellitus (odds ratio, 6.23; 95% CI: 1.37 to 28.31; P = .018), Sanders type (odds ratio, 5.44; 95% CI: 2.02 to 14.64; P = .001), number of residents and/or fellows present during the case (odds ratio, 1.63; 95% CI: 1.06 to 2.52; P = .028), duration of surgery (odds ratio, 4.54; 95% CI: 1.46 to 14.12; P < .001), estimated blood loss (odds ratio, 1.02; 95% CI: 1.01 to 1.04%; P < .001), and 10 or more people present in the operating room during the entire case (odds ratio, 2.30; 95% CI: 1.79 to 2.94; P < .001) were risk factors for wound complication. Tourniquet use (odds ratio, 0.02; 95% CI: 0.00 to 0.08; P < .001), which was associated with a decreased risk for the development of a wound complication, was observed as a protective factor. Diabetes mellitus, Sanders type, and smoking were the strongest risk factors for postoperative wound complication after adjusting for all other variables.

CONCLUSIONS

Smoking, diabetes mellitus, Sanders type, number of residents and/or fellows present during the case, duration of surgery, estimated blood loss, and high number of persons present in the operating room during the entire case were related to an increased risk for postoperative wound complication of closed calcaneal fractures following ORIF. Tourniquet use was associated with a decreased risk for the development of a wound complication.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

Inpatient procedures in elderly women: an analysis over time

OBJECTIVES

To describe inpatient surgical and diagnostic/therapeutic procedures in women ≥65 years old and assess procedure trends over time.

STUDY DESIGN

Procedure data for all women ≥65 years was collected using the National Hospital Discharge Survey, a federal dataset drawn from a representative sampling of U.S. inpatient hospitals which includes patient and hospital demographics and ICD-9-CM diagnosis and procedure codes for admissions from 1979 to 2006.

MAIN OUTCOME MEASURES

Age-adjusted rates (AAR) per 1000 women were created using 1990 U.S. Census data to compare trends over time.

RESULTS

Over 96 million procedures were performed in women age≥65 years from 1979 to 2006. Women age≥65 years constituted 17% of women with ≥1 inpatient procedure in 1979, rising to 32% in 2006. The most common surgical procedures were lower extremity joint replacement, open reduction internal fixation, and cholecystectomy. The most common concurrent diagnosis was femoral neck fracture. Women with femoral neck fracture were more likely to undergo open reduction internal fixation compared to joint replacement. AARs for ORIF fell from 4.3 to 3.2 (p=.02) from 1979 to 2006, while AARs for joint replacement increased from 0.2 to 3.4 (p≤.001, 1979-1988; p=.14, 1990-2006).

CONCLUSIONS

The rate of women age≥65 years undergoing inpatient procedures has increased dramatically in the last 30 years. Hip fracture was the most common diagnosis for elderly women, highlighting the impact of osteoporosis and falls and the importance of prevention strategies and optimization of peri-operative care in this population. Further comparative study of hip fracture treatment strategies in this population is needed.

Absorbable fixation in forefoot surgery: a viable alternative to metallic hardware

After 4 to 8 weeks of normal primary bone healing, rigid internal fixation is no longer required. Newer generation absorbable implants have become reliable and cost-effective alternatives to metallic hardware. Modern implants are formulated to have increased strength and smoother resorption over the course of 18 to 24 months, which decreases the possibility of local inflammation. Historically, bioresorbable screws can be time consuming to insert, but newer devices are being developed that help ease their insertion. A case of a bunionectomy is presented with double osteotomy on a 40-year-old nurse fixated with polyglycolic acid and poly-l-lactic acid copolymer screws.

Treatment of radial head and neck fractures: in favor of anatomical reconstruction

Radial head fractures represent the most common elbow fractures. Undisplaced fractures usually occur in isolation and can be treated nonsurgically. Displaced fractures should be treated surgically. Simple two-part fractures can easily be handled by osteosynthesis, but comminuted fractures pose a major problem for reconstruction. As the radial head is an important stabilizer of the elbow joint-especially in the context of concomitant ligamentous injuries-its resection may lead to pain, limited range of motion, and instability. Therefore, radial head resection is not recommended for the acute situation and open reduction internal fixation (ORIF) or prosthetic replacement should be aimed for. Complications such as secondary loss of fixation, radial head necrosis, and nonunion due to insufficient stability of the osteosynthesis have often been described. Therefore, prosthetic replacement is recommended if stable reconstruction is impossible. With the development of new locking plates especially designed for the maintenance of radial head fractures, the indications for osteosynthesis may be extended. As radial head fractures are complicated by a high percentage of ligamentous injuries and concomitant elbow fractures such as the coronoid, capitellum, and proximal ulna, these additional injuries have to be taken into account. The current treatment concepts are discussed within this paper.

Maxillofacial trauma in central karnataka, India: an outcome of 95 cases in a regional trauma care centre

Materials and Methods A 6-year retrospective analysis of 111 patients treated for maxillofacial fractures in Davangere, Karnataka from January 2004 to December 2009 was performed. Variables like age, gender, occupation, type of fracture and mechanism of injury, concomitant injury, mode of treatment, and complications were recorded and assessed. Results Men between 21 and 30 years were mostly affected (male-to-female ratio = 10:1; age range = 17.60 years; mean 31.7 ± 9.8 [standard deviation]). Most fractures were caused by road traffic accidents (RTAs; 74.7%), followed by interpersonal violence (IPV; 15.8%), falls (4.2%), industrial hazards and animal attacks (2.1% each), and self-inflicted injury (1.1%). Forty-two cases were isolated zygomaticomaxillary complex (ZMC) fractures. The total number of facial fractures documented was 316, of which 222 were purely related to the ZMC; however, 11 were confined only to the midface. Fifty-three cases had concomitant lower jaw fractures, totaling 83. Ophthalmic injuries occurred in 30.52% of cases. Ninety-two cases were treated with open reduction and internal fixation (ORIF), and three cases were managed conservatively. The complication rate observed was 25.26%. Conclusion RTA continues to be the chief etiological factor in maxillofacial injury with males being affected predominantly. IPV and falls next contribute significantly to the incidence of such injuries. Concomitant injuries, however, require prompt recognition and appropriate management. ORIF still remains the mainstay of treatment; however, fixation devices are constantly being improved upon in an attempt to reduce immobilization time thereby facilitating early return to function with minimal morbidity. Nevertheless, future advances in maxillofacial trauma diagnosis and management are likely to reduce associated morbidity.

Characteristics of two different locking compression plates in the volar fixation of complex articular distal radius fractures

Objectives

To investigate the differences of open reduction and internal fixation (ORIF) of complex AO Type C distal radius fractures between two different models of a single implant type.

Methods

A total of 136 patients who received either a 2.4 mm (n = 61) or 3.5 mm (n = 75) distal radius locking compression plate (LCP DR) using a volar approach were followed over two years. The main outcome measurements included motion, grip strength, pain, and the scores of Gartland and Werley, the Short-Form 36 (SF-36) and the Disabilities of the Arm, Shoulder, and Hand (DASH). Differences between the treatment groups were evaluated using regression analysis and the likelihood ratio test with significance based on the Bonferroni corrected p-value of < 0.003.

Results

The groups were similar with respect to baseline and injury characteristics as well as general surgical details. The risk of experiencing a complication after ORIF with a LCP DR 2.4 mm was 18% (n = 11) compared with 11% (n = 8) after receiving a LCP DR 3.5 mm (p = 0.45). Wrist function was also similar between the cohorts based on the mean ranges of movement (all p > 0.052) and grip strength measurements relative to the contralateral healthy side (p = 0.583). In addition, DASH and SF-36 component scores as well as pain were not significantly different between the treatment groups throughout the two-year period (all p ≥ 0.005). No patient from either treatment group had a step-off > 2 mm.

Conclusions

Differences in plate design do not influence the overall final outcome of fracture fixation using LCP.