Tibia vara: results of hemiepiphyseodesis

Tibia vara is a condition characterized by progressive deformity of the proximal tibia resulting in varus malalignment of the lower extremity. An alternative treatment strategy involving lateral hemiepiphyseodesis of the proximal tibia in the skeletally immature has been utilized at our institution for the last 10 years. The study group consisted of 23 patients (16 male, seven female) with 33 involved extremities. The median age at surgery was 11.8 years (range, 7.0-17.3). The median follow-up was 3.1 years (range, 0.8-6.2). Of the patients, 82.6% had a weight greater than the 95th percentile. The preoperative mechanical axis had a median value of 18.0 degrees (range, 5.0-31.0) and at the most recent follow up, a median value of 7.0 degrees (range, -12.0 to 46.0). In 18 (54.5%) extremities, the mechanical axis improved by more than 5 degrees . There was no progression of the overall deformity in 11 (33.3%) extremities. Four (12.1%) extremities had worsening of the deformity. At the time of latest follow up, nine (27.2%) extremities had required corrective osteotomy. Twenty-four (72.7%) were skeletally mature and had not required any further treatment. Goals of hemiepiphyseodesis in adolescent tibia vara or late sequelae of infantile tibia vara include (1) correction of deformity to avoid need for osteotomy, and (2) prevention of progression of the deformity to facilitate subsequent surgery. In this series of patients, 87.8% had either improvement or stabilization of the degree of their deformity.

Hemiepiphyseal stapling for knee deformities in children younger than 10 years: a preliminary report

Epiphyseal stapling, which is the only reversible method of growth alteration, has traditionally been reserved for teenagers. We are reporting the application of hemiepiphyseal stapling in a series of 25 children younger than 10 years. With a variety of underlying diagnoses, three children had genu varum and 22 had genu valgum. The technique involved fluoroscopic localization of all growth plates and careful preservation of the periosteum while inserting (and subsequently removing) one or two staples per physis. The mean age at stapling was 6 years + 4 months. Follow-up averaged 3 years + 3 months. The anatomic (tibiofemoral) angle and mechanical axis improved in all patients. One staple broke on removal; there were no other hardware failures. We conclude that hemiepiphyseal stapling is a safe and effective treatment for children younger than 10 years who have angular deformities of the knee. No growth-plate arrests have occurred. In the event of recurrent deformity, stapling may be repeated.

Increasing Use of Reverse Total Shoulder Arthroplasty for Proximal Humerus Fractures in Elderly Patients

This study described surgical treatment patterns for proximal humerus fractures among elderly patients, focusing on reverse total shoulder arthroplasty (TSA), and evaluated how the type of fixation affects inpatient factors (cost, length of stay), transfusion rates, and patient disposition (home vs skilled nursing facility). With Nationwide Inpatient Sample data from 2011 to 2013, the authors identified patients 65 years and older who had proximal humerus fractures and divided them into 3 groups: (1) open reduction and internal fixation (ORIF); (2) hemiarthroplasty; and (3) reverse TSA. From 2011 to 2013, 38,729 surgically treated proximal humerus fractures were identified. The rate of reverse TSA increased 1.8-fold during this time, from 13% of operative cases in 2011 to 24% of operative cases in 2013 (P<.001). At the same time, the rates of hemiarthroplasty and ORIF decreased (hemiarthroplasty, from 28% to 21%; ORIF, from 59% to 55%). Although reverse TSA accounted for 32.2% of arthroplasty procedures for proximal humerus fractures in 2011, this value was 53.3% in 2013 (P<.001). In 2013, mean total hospital cost for reverse TSA was $24,154, which was significantly higher than that for ORIF ($16,269) or hemiarthroplasty ($19,175) (P<.001). In a multivariable model, patients undergoing reverse TSA were less likely than those undergoing hemiarthroplasty to be discharged to a skilled nursing facility (odds ratio, 0.75; P=.027). The national rate of reverse TSA nearly doubled from 2011 to 2013. As of 2013, reverse TSA replaced hemiarthroplasty as the most commonly performed arthroplasty procedure for proximal humerus fractures for patients 65 years and older. Patients undergoing reverse TSA were more likely than those undergoing hemiarthroplasty to be discharged home. [Orthopedics. 2017; 40(6):e982-e989.].

Hemi-epiphysiodesis for unclassified congenital scoliosis: immediate results and mid-term follow-up

Complex spinal anomalies involved in congenital scoliosis consist of a jumble of vertebral defects. Progressive scoliotic curves are frequently encountered in these patients. We evaluated the results of hemi-epiphysiodesis for this patient population. A series of ten patients with unclassified scoliosis, involving multiple hemivertebrae and/or bars, was reviewed retrospectively. Hemi-epiphysiodesis was the primary treatment in all patients. Mortality, complications and wound healing problems did not occur. The average Cobb angle for all patients changed from 54 degrees (range: 40 degrees -74 degrees), preoperatively, to 58 degrees (range: 30 degrees -104 degrees), postoperatively. Applying the criterion of a minimum change of 20 degrees, to take into account measurement variability, an epiphysiodesis effect was achieved in two procedures, progression was arrested in six procedures and failure occurred in two procedures. The mean rate of Cobb angle change per annum decreased from 2.9 degrees (range: -35 degrees to 14 degrees), preoperatively, to 2.4 degrees (range: -4 degrees to 13 degrees), following surgery. Repeat surgery was necessitated by coexisting progressive kyphosis and pseudoarthrosis in one patient, and involved extension of primary epiphysiodesis in two patients. A mean intervention-free period of 58 months was established. These results suggest that hemi-epiphysiodesis stabilized the unclassified congenital scoliosis. Being under 5 years of age, having a thoracolumbar curve location, and the absence of coexisting kyphosis were found to be associated with a more favorable outcome.

Open reduction or epiphysiodesis for slipped upper femoral epiphysis. A comparison of Dunn's operation and the Heyman-Herndon procedure

Forty-eight consecutive patients (53 hips) were treated for moderate or severe slips of the upper femoral epiphysis between 1974 and 1984; 46 patients (96%) returned for clinical and radiological assessment at a mean of five years after operation. Twenty-three patients (23 hips) underwent a Dunn's open reduction and 25 patients (30 hips) were treated by epiphysiodesis and surgical osteoplasty as advocated by Heyman and Herndon. The results of the two methods of treatment are compared. Analysis revealed that 11 hips with moderate slip (30 degrees to 50 degrees) treated by the Heyman-Herndon procedure did significantly better than the 18 hips with severe slip (greater than 50 degrees) treated by the same method. Furthermore, when these hips with severe slip were compared to the hips treated by Dunn's open reduction, all of which were displaced greater than 50 degrees, the latter fared significantly better. The authors conclude that the Heyman-Herndon procedure gave consistently good results for moderate slips, but Dunn's open reduction gave better results for hips with severe slips.

Epiphyseal fractures of the proximal tibia

During a 12-year period there were 15 patients with proximal tibial epithyseal fractures. Eleven were examined at follow-up with a mean observation time of 7 years (range 3.5-12.5). Five patients with type IV or type V lesions had concomitant avulsion fractures of the tibial insertion of the anterior cruciate ligament, two being displaced. Eight out of twelve patients had concomitant ligamentous injuries. At follow-up two patients complained of instability, confirmed by clinical examination. Another two patients had symptom-free anterior laxity. Serious angular deformity was found in two patients, while important leg length discrepancy was observed in one. Degenerative changes of the knee joint were found in three patients. An active reconstructive approach is recommended, and attention is drawn to concomitant ligamentous injuries which, it seems, in the past have tended to be underestimated.

[Leg length inequality. Indications for treatment and importance of shortening procedures]

Real leg length discrepancies may be cosmetically disturbing and lead to gait abnormalities, pelvic obliquity with subsequent lumbar scoliosis as well as functional disturbances of hip, knee and ankle joint. During the growth period even discrepancies of more than 1 cm should be treated by simple conservative means in order to prevent a compensatory lumbar scoliosis. In adults, inequalities up to 2 cm are tolerable. As an alternative to cosmetically often unaccepted shoe lifts for discrepancies of 2 to 6 cm, lengthening and shortening procedures should be considered. The latter involve lower costs and fewer complications. However, reduced final height may be an issue. In cases of an open physis, shortening can be achieved by Blount stapling or percutaneous epiphysiodesis. Considering the minimal number of incisions, simple technique and a low complication rate percutaneous epiphysiodesis is the first choice. The key problem, though, is the correct timing of the procedure. Age, anticipated leg length discrepancy at skeletal maturity, calculated loss of length of the longer leg and growth potential of the shorter leg have to be considered. More complex problems require repeated assessment and documentation of the lengths of both legs in order to find out the individual developmental pattern of the leg length discrepancy, which is primarily associated with the underlying pathology. After skeletal maturity, precise shortening may be achieved by osteotomies with resection of up to 6 cm of bone of the femur and up to 3 cm of the tibia. More shortening is limited by muscle insufficiency, as well as relative increase of soft tissues and risk of compartment syndrome in the lower leg.

Perthes' disease in the adolescent

We studied the natural history of Perthes' disease in 62 children in whom the onset of symptoms was in adolescence. Three patterns of disease were noted, namely, late-onset pattern, segmental collapse, or destructive with failure of revascularisation. In the late-onset pattern, the disease followed the sequence of healing seen in younger children, but adequate epiphyseal remodelling did not occur. Consequently, the femoral head was never spherical after revascularisation. With segmental collapse, early and irreversible collapse of part of the epiphysis occurred with gross deformation of the femoral head. The destructive pattern was characterised by a failure of revascularisation and repair of the avascular epiphysis. The radiological outcome was poor in all three patterns. The poorest clinical results were found in the destructive type which was frequently associated with incapacitating pain requiring arthrodesis or excision arthroplasty within three years of onset of the disease.

Dysplasia epiphysealis hemimelica: radiographic and magnetic resonance imaging features and clinical outcome of complete and incomplete resection

OBJECTIVES

The objectives of this communication were to discuss radiographic and magnetic resonance (MR) imaging manifestations and clinical outcome after complete and incomplete resection of the mass of dysplasia epiphysealis hemimelica (DEH).

MATERIALS AND METHODS

Clinical records, radiographs, and MR images of eight patients with DEH were retrospectively examined. Six patients were treated by complete excision of the lesional mass, and two patients were treated by incomplete resection at our University Hospitals during the period from 1980 to 2006.

RESULTS

We found that, unlike in osteochondroma, DEH was radiographically not clearly separable from the underlying or host bone with preserved cortical bone and marrow continuity. The finding in the talus distinguished DEH from (osteochondroma-like) parosteal osteosarcoma, in which a radiolucent demarcation line clearly separated the tumor from the host bone. The DEH mass had a well-defined low to intermediate signal intensity on T1-weighted images and an intermediate to high signal intensity on T2-weighted images, with irregularity of the articular surface. Simple excision was performed in all patients. The excision was complete in six patients and incomplete in two patients whose lesions was juxta-articular in the ankle and articular in the knee, respectively. The residual mass slowly absorbed and vanished, resulting in mild flaring of the affected portion of the epiphysis. No local recurrence or complication was seen in any of the eight patients.

CONCLUSIONS

Although the radiographic signs of DEH are characteristic, (osteochondroma-like) parosteal osteosarcoma should be differentiated from DEH when there is a radiolucent separation line between the mass and host bone in the talus. Simple excision was effective in the management of DEH if the deformity was not complicated. Incompletely excised masses resolved and vanished with time.

Femoral remodeling may influence patient outcomes in slipped capital femoral epiphysis

Clinical studies of patients treated for slipped capital femoral epiphysis have found limited functional impairment and femoral neck deformity causing eventual coxarthrosis. Since patient-focused assessments minimize bias and reflect health-related quality of life status, we coupled their use to a clinical examination to obtain a more patient-centered picture of slipped capital femoral epiphyseal outcomes. The impact of residual deformity on outcomes also was examined. Of 78 patients treated for slipped capital femoral epiphyses between 1972 and 1998, 29 (38 hips) were evaluated at a mean followup of 7.6 years (range, 1.4-26 years). The average patient age was 21.8 years (range, 14.6-39 years), 55% were female, and the average body mass index was 28.7 (range, 16.1-50.2). Most slips were stable (92%, 35 of 38) and mild or moderate in severity (98%, 36 of 37). Followup examinations revealed slight deficits in range of motion, strength, and limb length. Radiographs showed slight improvements in head-shaft angle and reduced but persistent femoral neck deformity. Osteoarthritic changes were absent or negligible in 84% (32 of 38) of the hips. The average Iowa hip score was 90.5 (range, 51-100). Patient outcome scores for the AAOS Hip/Knee Questionnaire fell slightly below 50th percentile norms. Neither slip stability, severity, nor body mass index impacted outcome. Femoral neck deformity correlated with function, pain, and Boyer grade. Overall, patients had minor functional deficits and pain that may have been related to femoral neck deformity, but longer followup is warranted.

Treatment of nonunion of fractures in the epiphyseal-metaphyseal region of long bones

Twenty-four consecutive patients with fracture nonunion in the metaphyseal-epiphyseal areas of long bones were surgically treated. Average time from injury to treatment of the nonunion was 10 months, and average follow-up time after surgical treatment was 29 months. Eight patients with infected nonunions had initial debridement procedures; three of these patients then had placement of external fixators and bone grafting. The remaining five patients and 13 others were then treated by open reduction and internal fixation alone or with the addition of autogenous cancellous bone grafting. Single or double plates and screws were used. Arthrolysis, joint manipulation, and intensive postsurgical exercises were considered necessary to regain joint function. One patient underwent a hemiarthroplasty, and two others underwent arthrodesis as the initial nonunion treatment. Twenty of the 21 patients not treated by arthrodesis or arthroplasty healed their fractures in an average time of 7 months. Fifty-two percent of the patients achieved good or excellent range of motion (ROM) of the contiguous joint, with 70% of the patients reporting no pain in this joint. These fractures have excellent intrinsic healing capability because they occur in anatomical regions with a normally abundant circulation. We recommend stable fixation, with the need for bone grafting only in defect nonunions, together with intra- and postoperative joint mobilization to obtain a satisfactory functional end result.

What Injury Mechanism and Patterns of Ligament Status Are Associated With Isolated Coronoid, Isolated Radial Head, and Combined Fractures?

BACKGROUND

Isolated coronoid, isolated radial head, and combined coronoid and radial head fractures are common elbow fractures, and specific ligamentous injury of each fracture configuration has been reported. However, the osseous injury mechanism related to ligament status remains unclear.

QUESTIONS/PURPOSES

The objectives of this study were: (1) to determine what ligamentous injury patterns (medial or lateral collateral) and bone contusion patterns (medial or lateral) are associated with isolated coronoid, isolated radial head, and combined coronoid and radial head fractures; (2) to correlate the osseous injury mechanism based on these findings with isolated coronoid, isolated radial head, and combined coronoid and radial head fractures; and (3) to determine whether isolated and combined coronoid fractures have different fracture lines through the coronoid (tip or anteromedial facet), speculated to be caused by different injury mechanisms.

METHODS

Between June 2007 and June 2012, 100 patients with elbow fractures were included in the cohort, with 46 of these patients being excluded owing to incongruity for our surgical indication. Finally, 54 patients with surgically treated elbow fractures who had MRI preoperatively were assessed retrospectively. There were 17 elbows with isolated coronoid fractures, 22 with isolated radial head fractures, and 15 with combined coronoid and radial head fractures. Collateral ligament injury pattern and existence of distal humerus bone contusion were reviewed on MR images.

RESULTS

Patients with isolated radial head fractures were at greater risk of medial collateral ligament rupture compared with patients with isolated coronoid fractures (radial head only: 15 of 22 [68%]; coronoid only: three of 17 [18%]; odds ratio [OR], 10.0; 95% CI, 2.2-46.5; p = 0.002). Patients with isolated coronoid fractures had greater risk of lateral ulnar collateral ligament ruptures (coronoid: 16 of 17 [94%]; radial head: seven of 22 [32%]; OR, 3.5; 95% CI, 3.8-333.3; p < 0.001). The presence of radial head fractures was associated with the risk of lateral bone bruising (isolated radial head fracture: 32 of 37 [86%], isolated coronoid fracture: four of 17 [24%]; OR, 29.6; 95% CI, 5.2-168.9; p < 0.001). Medial bone bruising was only detected in isolated coronoid fractures (isolated coronoid fracture: 12 of 17 [71%], others: zero of 37 [0%]). All isolated coronoid fractures involved the anteromedial facet of the coronoid (17 of 17; 100%). However, combined coronoid and radial head fractures often involved the tip (13 of 15; 87%).

CONCLUSIONS

Isolated coronoid fractures mostly involved the anteromedial facet of the coronoid process associated with lateral ulnar collateral ligament rupture and medial bone bruising. However, isolated radial head fractures were associated with medial collateral ligament rupture and lateral bone bruising. Combined coronoid and radial head fractures mostly involved a tip fracture of the coronoid with lateral ulnar collateral ligament rupture and lateral bone bruising. Thus surgeons may predict which ligament they should be aware of in the surgical field.

LEVEL OF EVIDENCE

Level III, prognostic study.

Clinical outcome after transfixation of the epiphysis with Kirschner wires in unstable slipped capital femoral epiphysis

Treatment of slipped capital femoral epiphysis (SCFE) is still controversial. Agreement has not yet been reached on the appropriate time to perform surgery, the necessity of repositioning manoeuvres, the type of implants for stabilisation, or the need for prophylactic treatment of the contralateral side. In this retrospective study, we present 29 patients with unstable (acute and acute-on-chronic) SCFE treated by internal fixation of the epiphysis with three or four Kirschner wires both therapeutically on the affected side and prophylactically on the not (yet) affected side. After hardware removal and mean follow-up of 3.5 years, radiological and clinical examination of hip function was carried out. X-ray in two planes showed no incidence of any slip progression. Applying the score used by Heyman and Herndon, 18 results (62.1%) were classified as excellent, nine (31.1%) as good, one (3.4%) as fair, and one (3.4%) as poor. The rate of severe complications such as chondrolysis and avascular necrosis of the femoral head was low in our series (0% and 6.8%, respectively). This form of therapeutic management shows good clinical results with low complication rates. The slip can be efficiently stabilised, progression is reliably prevented, and remodelling of the joint gives the patient good overall hip function. We see no indication for emergency surgery.

Effect of proximal phalangeal epiphysiodesis in the treatment of macrodactyly

The recommended treatment for macrodactyly of the foot will often include epiphysiodesis of the proximal phalanx in an attempt to halt further longitudinal growth of the toe. Nine patients who underwent open epiphysiodesis and debulking of the excess soft tissues involving 11 toes were reviewed to evaluate the effectiveness of this procedure. In 9 of 11 toes, overall length of the proximal phalanx did not change after surgery. Two toes demonstrated continued growth; one of these toes underwent a repeat epiphysiodesis of the phalanx, and the other foot underwent epiphysiodesis of the affected metatarsal. Overall, this surgical approach led to radiographic results that satisfied the surgical goals.

Treatment of Posterior Epiphyseal Disruption of the Medial Clavicle with a Modified Balser Plate

BACKGROUND

Acute posterior dislocation of the sternoclavicular joint is a rare but dangerous injury that is often difficult to diagnose. Because of late closure of the medial clavicular epiphysis, epiphyseal disruption must be taken into consideration in patients up to 25 years of age with an apparent diagnosis of posterior sternoclavicular dislocation. We developed a novel method of treating epiphyseal disruptions with a modified Balser plate.

METHODS

This method was used in a 19-year-old patient with a posterior epiphyseal disruption of the left medial clavicle. After molding of the plate, the hook was introduced into the manubrium sterni and the plate was fixed on the clavicle with screws.

RESULTS

The new method could be applied safely and achieved a good functional result without any external immobilization. The postoperative course was uneventful.

CONCLUSION

Fixation of the posterior epiphyseal disruption of the medial clavicle with a modified Balser plate is feasible and may be an alternative to traditional methods.

Arthroscopic management of elbow trauma

The arthroscope can assist in effectively treating traumatic injuries about the elbow, including some intra-articular fractures. Proper selection of patients is important to ensure effective treatment, but when used judiciously, arthroscopic-assisted debridement and fracture fixation is effective. The arthroscope is a valuable tool in the diagnosis and management of acute intra-articular fractures and in dealing with the sequelae that sometimes cause problems after healing has occurred. It allows for effective fracture treatment without the extensive soft tissue disruption that would be otherwise necessary for exposure. The authors certainly cannot advocate arthroscopic treatment of all intra-articular elbow fractures, but in specific circumstances, the arthroscope cannot only assist but also improve treatment of these sometimes difficult and often challenging injuries. The arthroscope is also useful in the identification of varus, valgus, and posterolateral rotatory instability, particularly when these instabilities are less obvious on clinical examination.

Metatarsal epiphyseal bracket: treatment by central physiolysis

Longitudinal epiphyseal bracket (LEB) is a rare ossification anomaly in which an epiphysis brackets the diaphysis of a phalanx, metacarpal, or metatarsal. This abnormal epiphysis tethers longitudinal growth, resulting in a shortened and oval-shaped bone. Four patients with five LEBs were treated by central physiolysis and followed for a mean of 6 years. The patients had significant hallux varus deformity. Three patients had duplicated great toes, and two had tibia hemimelia significant enough to require epiphysiodesis as they neared adolescence. Resection of the LEB allowed the proximal and distal epiphysis to resume untethered growth. Silastic or methyl methacrylate was placed over the resected physis to prevent bony rebridging. The associated hallux varus deformity was corrected by capsulorrhaphy and K-wire fixation. In all patients, the metatarsal resumed longitudinal growth and correction of the hallux varus was maintained.

Equalization of lower limbs by epiphysiodesis: results of treatment

Equalization of lower limb length was achieved by epiphysiodesis in 20 children. During the period under review the Phemister procedure was replaced by percutaneous epiphysiodesis, and orthoroentgenogram was superseded by computed tomography (CT) scanning. In five children with anisomelia, whose expected discrepancy was 4.5 cm, the results at maturity showed an average discrepancy of 0.7 cm. In 10 girls with limb-length discrepancy (LLD) caused by ischemic necrosis with congenital dislocation of the hip, the average LLD at maturity was 0.6, whereas the expected LLD was 4 cm. In five children with LLD caused by infection, the average discrepancy was 3.8 cm at the time of epiphysiodesis, whereas at maturity it was 0.5 cm. A good result was achieved in 90% of the patients. We recommend the Moseley straight-line graph, CT scanography, and percutaneous epiphysiodesis.

Use of bone allograft in tibial plateau fractures

To determine the behaviour of bone allografts in the treatment of tibial plateau fractures, 20 recipients of frozen bone allograft for a depressed tibial plateau fracture were studied. Incorporation of grafts took place in all cases, and no complication secondary to the allograft use has been detected. To avoid donor site morbidity associated with harvesting iliac crest, the use of frozen bone allograft is a good alternative in the treatment of depressed tibial plateau fractures.

Transpedicular hemiepiphysiodesis and posterior instrumentation as a treatment for congenital scoliosis

Anterior and posterior hemiepiphysiodesis using a transpedicular approach is an effective alternative treatment when compared with the traditional convex hemiepiphysiodesis or hemivertebrae excision. No study has reported the results of instrumentation with transpedicular hemiepiphysiodesis. Our study was a retrospective radiographic evaluation to assess the efficacy of transpedicular convex hemiepiphysiodesis with short segment instrumented posterior spinal fusion for congenital scoliosis. Ten hemivertebrae in 9 patients were evaluated. The average patient age was 10.5 years (range, 2.9-14.5 years). The average follow-up was 29.7 months. Cobb angles were recorded for the instrumented segment (segmental main curve) and the global or entire curve (total main curve). These values were compared preoperatively, postoperatively, and at 2-year follow-up. The average total main curve improved in 6 of 10 curves, from 35.0 to 29.6 degrees (15.4%). The average segmental main curve improved in 8 of 10 curves, from 30.0 to 21.5 degrees (28.3%). Seven of 10 curves demonstrated either no progression or improvement at the average 2-year follow-up. Two curves in older patients (greater than 9 years, 10 months) progressed until a comprehensive posterior spinal fusion was required. Multiple surgical techniques have been developed to provide treatment for progressive congenital scoliosis. Transpedicular hemiepiphysiodesis with a short segment instrumented posterior spinal fusion is a safe and effective treatment method to halt the progression of congenital scoliosis due to a hemivertebra in patients who are skeletally immature.

Ankle joint biomechanics following transepiphyseal screw fixation of the distal tibia

Transepiphyseal screws have traditionally been removed after fixation of pediatric ankle fractures due to concerns about increased forces and contact pressures within the tibiotalar joint secondary to the implant. No study has assessed pressure across the ankle joint after such fixation. Seven adult and two pediatric cadaveric ankles underwent axial loading in a uniaxial material test machine. Each was tested before fixation (control), after fixation (screw in place), and after removal (after screw removal). Three sequential test runs at three loading conditions (approximate body weight, twice body weight, and five times body weight) were performed to simulate forces of standing and ambulation. Total force, peak contact pressure, and contact area were measured with an intra-articular sensor. After screw placement, all loads caused a significant increase in total force versus control. Peak contact pressures after placement also increased significantly. Screw removal subsequently led to a net decrease in force and peak pressure values. Total contact area was unchanged. Concerns regarding subchondral screws in the distal tibia appear warranted. Findings in this study support implant removal following union of such fractures.

Supracondylar fractures of the elbow: open reduction, internal fixation

This principle-based approach for fixing distal humerus fractures has many advantages. Complex fractures are able to be fixed with sufficient stability to permit immediate intensive rehabilitation. Some fractures believed to be unfixable have been fixed satisfactorily by applying the principles outlined in this article. More straightforward fractures are fixed easily using the same techniques. In the author's experience, the stability achieved with this approach is so much greater than that with traditional methods of fixing distal humerus fractures that bone graft has been required only rarely, despite the severity of injuries so typical of the tertiary referral nature of the author's practice. The key points are that the plates should be placed in parallel configuration medially and laterally and that the screws passing through these plates in the distal fragments should interdigitate and lock together.