A Simple Percutaneous Technique to Reduce Valgus-Impacted Femoral Neck Fractures

The mainstream surgery for valgus-impacted femoral neck fractures (FNFs) is closed reduction and internal fixation under fluoroscopy. However, femoral neck shortening and anterior femoroacetabular impingement are common complications in healed valgus-impacted FNFs after in situ fixation. Some methods have been reported to prevent complications, but these techniques require the use of a transfixing guide wire that passes through the femoral head, which may cause articular cartilage damage. We introduce a simple reduction technique using one Steinmann pin (S-pin) for valgus-impacted FNFs without any interference of the femur head. A S-pin was placed percutaneously at the inferomedial margin of the fracture, and reduction was achieved by applying manual valgus force along the fracture line. By restoring the anatomical alignment, we confirmed the maximum contact area of the fracture and connection of the medial cortical buttress, so the risk of nonunion was also minimized.

Is Full-Length Intramedullary Nail Necessary for Atypical Subtrochanteric Femoral Fracture Associated with Bisphosphonate?

Background

American Society for Bone and Mineral Research recommend the use of intramedullary reconstruction of full length-nail for atypical subtrochanteric femoral fracture (ASFF). However, there is no study on the incidence of the ipsilateral femoral fracture after index operation of ASFF, and full-length nail has disadvantage as iatrogenic fracture and leg length discrepancy (LLD). The aim of this study was to investigate the incidence of ipsilateral secondary fracture after using partial-length nail, and to compare the outcomes on surgery of ASFF between partial length-nails and full length-nails.

Methods

Forty-five consecutive fractures with ASFFs which had undergone intramedullary fixation using cephalomedullary nail between 2011 and 2018 were enrolled. The 45 cases were grouped based on nail length into the partial-length nail group (n=26) and the full-length nail group (n=19). Ipsilateral secondary fracture, time to union, intra-operative iatrogenic fracture, metal failure, LLD, operative duration, and post-operative 24-hr blood loss were investigated.

Results

There was no ipsilateral secondary fracture after index operation. There were no statistically significant differences between the partial-length nail and full-length nail groups in the time to union, LLD, and post-operative 24-hr blood loss (P=0.427, 0.478, and 0.228, respectively). Operative duration showed statistically significant difference between 2 groups (P=0.034). Metal failure were occurred in 1 (3%) case of the partial-length nail group and 2 (10%) cases of the full-length nail group. Iatrogenic fractures during nail insertion occurred in 2 (7%) cases of the partial-length-nail group and 3 cases (15%) of the full-length nail group.

Conclusions

Although large scale studies are required, our study indicate that full-length nails are not usually required for the treatment of ASFF.

Comparison of open reduction and internal fixation with total elbow arthroplasty for intra-articular distal humeral fractures in older age: a retrospective study

Background

Intra-articular distal humeral fractures can be surgically challenging. It remains under discussion whether open reduction and internal fixation (ORIF) or total elbow arthroplasty (TEA) is more beneficial for treatment of the elderly. This study aimed to compare the clinical and functional outcomes of ORIF and TEA for managing intra-articular distal humerus fractures in patients aged 65 years or older.

Methods

Patients who underwent ORIF (n=28) or TEA (n=43) for in intra-articular distal humerus fracture between May 2008 and December 2018 were reviewed. Range of motion, Mayo Elbow Performance Score (MEPS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, radiologic outcomes, and surgical complications were evaluated at the final follow-up visit.

Results

The ORIF and TEA groups showed a mean arc of flexion–extension of 97°±21° and 101°±12°, respectively. The mean MEPS and DASH scores were 94±15 and 27±12 points, respectively, in the ORIF group and 81±27 and 47±28 points in the TEA group. This difference was statistically significant. The incidence of total complications was similar between the groups.

Conclusions

In patients older than 65 years with intra-articular distal humerus fracture, ORIF had better outcomes than TEA.

[Injuries in children and adolescents with inflammatory rheumatic diseases : Special risks and techniques for fracture treatment of the growing skeleton]

BACKGROUND

Inflammatory rheumatic diseases in childhood and adolescence are a special challenge in the treatment of acute trauma. The pharmaceutical treatment strategies for children and adolescents have been modified.

OBJECTIVE

Which special aspects must be considered in young patients suffering from rheumatism when a trauma necessitates an operative procedure?

MATERIAL AND METHOD

A literature search was carried out to elaborate recommendations for the practice.

RESULTS

The joint-related alterations in young patients suffering from rheumatism differ with respect to the differently altered inflammatory rheumatic destruction. The extent of these inflammatory destructive alterations dictates the operative approach. Consequences arise in paying attention to the concurrent medication with respect to avoidance of events triggering an exacerbation and tissue infections. The bone strength necessitates an individualized selection of implants and sometimes influences the duration of follow-up treatment. In the early stages of the inflammatory process the approach in cases of trauma is no different to that for healthy patients but in later stages (Larsen stage III) it does differ.

CONCLUSION

An interdisciplinary concept can help to avoid disadvantages in the treatment of the underlying disease. Due to the special dysplastic anatomy and tissue alterations, trauma in these patients is a particular challenge.

Which Headless Compression Screw Produces the Highest Interfragmentary Compression Force in Scaphoid Fracture?

BACKGROUND

Interfragmentary compression at the fracture site facilitates healing. Headless compression screws used to treat scaphoid fractures can be grouped as shank screws, conical tapered screws and double component screws. There has been no meta-analysis of biomechanical studies to compare interfragmentary compression produced by the above screws.

METHODS

A computerised search of Pubmed, Embase and OVID database was undertaken to identify the studies. We estimated the weighted mean difference of interfragmentary compression (in Newton) with 95% confidence intervals. Random effects model was selected for meta-analysis.

RESULTS

The pooled estimate of nine studies demonstrated that conical tapered screw produced significantly higher interfragmentary compression force compared to the shank screw (WMD 19.96, 95% CI 11.2-28.8, p < 0.0001, I ² = 99%). The pooled estimate of four studies demonstrated that dual component screw produced significantly higher interfragmentary compression force compared to the shank screw (WMD 16.93, 95% CI 12.3-21.6, p < 0.0001, I ² = 97.7%). The pooled estimate of four studies showed that there was no significant difference in the interfragmentary compression force generated by either conical tapered screw or dual component screw (WMD 3.93, 95% CI - 8.3 to 16.2, p = 0.53, I ² = 99.7%). There was evidence of minimal publication bias.

CONCLUSION

Conical tapered screws and dual component screws produced statistically significant higher interfragmentary compression force at the scaphoid fracture site compared to shank screws. There was no difference in the compression force generated by either conical tapered screw or dual component screw.

Comparative analysis of clinical outcomes of fixed-angle versus variable-angle locking compression plate for the treatment of Lisfranc injuries

BACKGROUND

Fixed-angle locking compression plate (LCP) and variable-angle LCP are utilized for internal fixation of Lisfranc injuries. However, studies regarding the difference of clinical outcomes of these two plates are limited. The purpose of present study was to compare postoperative outcomes between these two plate types in Lisfranc injuries.

METHODS

A total of 45 consecutive patients (22 patients with fixed-angle LCP and 23 patients with variable-angle LCP) who underwent surgical treatment for Lisfranc injury were reviewed for this retrospective study. The Foot Function Index (FFI), numerical rating scale (NRS) for pain, development of complications, operative time, and patient satisfaction for current activity were compared.

RESULTS

There were no significant differences in FFI and NRS for pain at three months and 12 months following surgery. Postoperative complication rate was similar between two groups. Patients with variable-angle LCP had an 18 min shorter mean length of operation (p = 0.040). Patient satisfaction for current activity was not differ between two groups.

CONCLUSIONS

The use of variable-angle LCP for treatment of Lisfranc injuries did not show superiority in functional outcomes, pain, complication rates, or patient satisfaction to fixed-angle LCP, but operative time was shorter with variable-angle LCP.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

[Distal radius T-plate for 18 patients with vertical shear medial malleolus fractures]

OBJECTIVE

To explore clinical effects of distal radius T-plates in treating vertical shear medial malleolus fractures.

METHODS

From March 2014 and March 2016, clinical data of 18 patients with vertical shear medial malleolus fractures were retrospectively analyzed, including 12 males and 6 females aged from 22 to 63 years old with an average of (41.3±5.2) years old; 6 patients were on the left side and 12 patients were on the right side; 5 patients combined with external malleolus fractures and 13 patients combined with external malleolus and posterior malleolus fractures. All patients were treated with distal radius T-plate fixation. Fracture healing time, loss of reduction, stability of internal fixation, occurrence of osteoarthritis were observed, postoperative AOFAS score at 12 months was used to evaluate clinical effects.

RESULTS

All patients were followed up from 18 to 36 months with an average of (22.5±4.3) months. All incisions healed well at stageⅠ. Review of X-ray showed that ankle joints were got anatomically reset. All fractures healed well ranged from 12 to 18 weeks with an average of (13.4±2.4) weeks. After surgery, patients resumed normal walking from 12 to 17 weeks with an average of (14.5±1.3) weeks. No complications such as loss of reduction, loosening or rupture of internal fixation, nonunion of fracture, radiographic appearance of osteoarthritis occurred during following up. AOFAS scores was 92.4 ±6.7 at 12 months after operation, and 15 patients got excellent result, 3 moderate.

CONCLUSION

Distal radius T-plates for treatment of vertical shear medial malleolus fractures have advantages of firm fixation, conforming to biomechanical requirements, better matching with plate anatomy, and less soft tissue stimulation. It could achieve early function exercise, obtain good recovery of function, and it is an ideal choice for the treatment of vertical shear medial malleolus fractures.

[Effect of changes of inflammatory factors on prognosis of tibia plateau Schatzker Ⅲ fractures treated under arthroscopic or open reduction and internal fixation]

OBJECTIVE

To explore changes of inflammatory factors on prognosis of tibia plateau Schatzker Ⅲ fractures treated under arthroscopic or open reduction and internal fixation.

METHODS

From November 2013 to November 2016, clinical data of 30 patients with tibia plateau Schatzker Ⅲ fractures were retrospectively analyzed, and divided into minimally invasive group and control group according to different surgical methods 15 patients in each group. Minimally invasive group were treated by arthroscopic internal fixation, including 8 males and 7 females, aged from 20 to 50 years old with an average of (35.0± 14.6) years old, the time from injury to operation ranged from 7 to 15 days with an average of (11.0±4.1) days. Control group were treated by open reduction and internal fixation, including 7 males and 8 females, aged from 18 to 48 years old with an average of (33.0±13.6) years old, the time from injury to operation ranged from 6 to 14 days with an average of (10.0±3.4) days.Operation time, length of incision, blood loss, postoperative loading time and fracture healing time, complications were compared between two groups. Level of IL-1β, IL-6, TNF-α were detected at 3 days, 6 months and 12 months after operation, Lysholm knee function score at 6 and 12 months were compared between two groups.

RESULTS

Allpatients were followed up, but there was no significant difference in following up between two groups. Operation time, length of incision, blood loss, postoperative loading time, fracture healing time and cases of complications in minimally invasive group were (80.3±9.7) min ,(4.2± 1.0) cm ,(102.2±26.4) ml ,(30.0±10.0) d ,(70.0±5.0) d and 0 case respectively; while in control group were (90.3±9.1) min, (10.5±1.1) cm ,(221.1±46.8) ml ,(50.0±15.0) d ,(90.0±6.0) d and 2 cases respectively; there were significant difference between two groups. Lysholm score in minimally invasive group 89.2±5.1 was higher than that of control group 80.1±3.1; and score of swelling, squat and pain in minimally invasive group was higher than that of control group at 6 months after opertaion. While there were no significant difference in each items and total score of Lysholm score between two groups at 12 months after operation. Level of IL-1β, IL-6, and TNF-α in minimally invasive group at 3 days and 6 months were [(52.1±20.1) pg/L, (0.9±0.1) pg/L ],[(56.1±20.1) pg/L ,(1.1±1.3) pg/L ] and [(28.3±2.5) pg/L ,(8.4±1.5) pg/L ] respectively; while in control group were [(64.8±9.1) pg/L ,(8.1±2.1) pg/L ],[(65.8±12.3) pg/L ,(9.1±5.3) pg/L ] and [(38.5±2.3) pg/L ,(26.5± 1.4) pg/L ] respectively; there were statistically difference in level IL-1β, IL-6 and TNF-α between two groups at 3 days and 6 months after operation; while there was no difference at 12 months after operation (P>0.05) . Inflammatory cytokines level at 3 days after operation IL-1β [OR=1.279, 95%CI (1.047, 1.512), P<0.05 ], IL-6 [OR=1.687, 95%CI (1.478, 1.888), P<0.05 ], TFN-α [ OR=2.096, 95%CI (1.863, 2.316), P<0.05 ] was an independent risk factor for Lysholm knee function score at 6 months after operation.

CONCLUSION

Arthroscopic surgery and open surgery also could obtain good clinical effects in treating tibia plateau Schatzker Ⅲ fractures. Arthroscopic internal fixation could shorten operation time, lessen the mount of blooding with minimally invasive, lower occurrence of postoperative complications, faster recovery of knee function.

Wrist deformity, bother and function following wrist fracture in the elderly

Objective

Wrist deformity in older people is common following treatment for a wrist fracture, particularly after non-surgical treatment. A cohort of older wrist fracture patients were surveyed by telephone regarding perceived deformity, bother with deformity and patient-reported wrist function. The objectives were to: (1) determine whether older patients with wrist fractures perceived a deformity of their wrist and if they were bothered by it; (2) test if there were associations between deformity and treatment-type and between deformity and function; (3) test for associations between bother and treatment-type and between bother and function; (4) measure the test–retest reliability of the ‘bother’ question.

Results

Of 98 eligible patients who were invited to participate, 41 responded. Out of 41, 14 (34%) believed they had a deformity and 4 (10%) reported that they were bothered by the appearance of their wrist. Deformity was associated with non-surgical treatment (RR = 3.85, p = 0.006) but was not significantly associated with functional outcomes (p = 0.15). All those who were bothered belonged to the non-surgical treatment group. Bother was significantly associated with poorer functional outcomes (p = 0.006) and this association was clinically significant (MD = 35 points). The deformity and bother questions were found to have excellent test–retest reliability; κ = 1.00 and κ = 0.92, respectively.

The high sub-mandibular approach: Our experience about 496 procedures

INTRODUCTION

The potential drawbacks of surgical approaches to neck and base fractures of the mandibular condyle (visible scare, facial nerve injury) are still considered by many surgeons as a brake for open reduction and internal fixation. The aim of our study was to analyze the results in terms of access, scare quality and complications that could be noticed in a 12 years period of time with the use of the high sub-mandibular approach (HSMA) we first described in 2006 for the surgical treatment of neck and base fractures.

MATERIAL AND METHOD

All the files of patients operated on for condylar neck and base fractures approached by mean of a HSMA between January 2006 and December 2018 in our department and containing information concerning age, sex, type of fracture, kind of osteosynthesis material, operating time, name of the surgeon, postoperative complication linked to the approach, scare quality at 6 months follow-up at least were included. The skin incision and the dissection planes followed the original publication of Meyer et al. in 2006.

RESULTS

434 patients (sex ratio: 2.06, mean age: 32, 496 approaches) met the inclusion criteria. Following the AO classification, 21.2% of the fractures were classified as neck fractures and 78.8% as base fractures. 97.6% of all fractures were stabilized by mean of a 3D plate (TCP® plate, Medartis, Basel-CH), the remaining ones by mean of a combination of 1.2, 1.5 and 2.0 straight plates. Mean operating time was 40minutes per side. Patients were operated on by senior surgeons in 71.7% of the cases and by trainees under supervision for the others. Concerning the complications linked to the approach, we noticed 11 (2.2%) temporary (0 definitive) paresis of the facial nerve, 1 (0.2%) hematoma and 1 (0.2%) abscess that both needed revision. Scare was hypertrophic or considered as unaesthetic by the patient in 5 cases (1%).

DISCUSSION

The HSMA, if performed as initially described, is a safe and quick procedure compared to other cutaneous approaches. It gives access to all base fractures and to most of neck fractures. The very low rate of facial nerve complications is mainly explained by the plane by plane dissection making it very easy to avoid the facial nerve branches or to check them when encountered. The HSMA is particularly suited to the use of TCP plates as the upper holes of these plates, placed horizontally, are easy to reach from below. The HSMA is therefore still our preferred cutaneous approach to the condylar process.

[Supracondylar humeral fractures in childhood]

The classification of supracondylar humeral fractures in German-speaking areas is carried out according to von Laer, which has been appropriated from the AO system and has the advantage that it can be used to derive the treatment. When indicated immediate surgery is given preference over a delayed treatment. The result is controlled by functional tests directly during the operation. Instability of the fracture and correct placement of the Kirschner (K) wires are challenging. Alternatives are an external fixator and elastically stable intramedullary nailing (ESIN). Concomitant injuries initially affect the median nerve and the brachial artery and secondarily the radial nerve. Lesions of the ulnar nerve are mostly a postoperative complication. The bony consolidation is achieved after 3-4 weeks and afterwards implant removal can be safely carried out. Embedded K‑wires and ESIN are removed after 3-6 months, depending on the surgical capacity and complaints of the patient.

Axillary nerve elongation in humeral fracture plating: A cadaveric study for comparison between straight and helical Philos plates

Helical plating is a known concept in humeral fracture treatment. Attention should be paid to the axillary nerve when inserting a plate underneath the deltoid muscle. The purpose of this cadaveric study was to estimate axillary nerve stretching when introducing the plate.

METHODS

On 42 fresh frozen human humeri, an 8-, 10- and 12-hole Philos plate in a straight and a helical shape were compared measuring the maximum plate-bone-distance.

RESULTS

For all three plate lengths, the helical plates had a significantly lower plate-bone-distance.

CONCLUSION

Indirectly, this suggests a lower axillary nerve elongation and hence less chance of nerve damage.

Finite element analysis of bone and implant stresses for customized 3D-printed orthopaedic implants in fracture fixation

3D printing allows product customisation to be cost efficient. This presents opportunity for innovation. This study investigated the effects of two modifications to the locking compression plate (LCP), an established orthopaedic implant used for fracture fixation. The first was to fill unused screw holes over the fracture site. The second was to reduce the Young's modulus by changing the microarchitecture of the LCP. Both are easily customisable with 3D printing. Finite element (FE) models of a fractured human tibia fixed with 4.5/5.0 mm LCPs were created. FE simulations were conducted to examine stress distribution within the LCPs. Next, a material sweep was performed to examine the effects of lowering the Young's modulus of the LCPs. Results showed at a knee joint loading of 3× body weight, peak stress was lowered in the modified broad LCP at 390.0 MPa compared to 565.1 MPa in the original LCP. It also showed that the Young's modulus of material could be lowered to 50 GPa before the minimum principal stresses increased exponentially. These findings suggested the modifications could lead to improved performances of fracture fixation, and therefore likely that other orthopaedic implants survivorship could also be enhanced by customisation via 3D printing. Graphical abstract.

The role of a trauma review system and development of intra-operative checklists in improving the quality of fracture fixations in a high volume tertiary centre

INTRODUCTION

In high volume centres, audits are essential to ensure good surgical techniques and fracture fixations to avoid complications, revision surgeries and poor outcomes. A method to assess fixations for fractures of different regions employing different implants and surgical demands is a challenge. We present here a simple method of review and follow-up work flow of more than 6000 fixations every year that helped in improving outcomes and also provide training for residents and junior staff.

MATERIALS AND METHODS

The results of 6348 fracture fixations in 2014, led to a trauma review system in January 2015 to classify all fracture fixations by senior consultants into three categories: category A (good fixations); category B (acceptable fixations; need further follow-up); category C (poor/unacceptable fixations needing revision) combined with a teaching program. A strategy was evolved that included the following practices: (1) identifying 'red flag' fractures that led to frequent failures, (2) routine senior surgeons' involvement in such fractures, (3) evolving 'intra-operative checklists', (4) requirement of senior surgeons' intervention if there was a 'fiddle time' of more than 20 min, and (5) approval of post-fixation c-arm image by a senior person before closure. The impact of these rules on the fixations for 2015, 2016 and 2017 were prospectively analysed.

RESULTS

In the years 2015, 2016 and 2017 the number of fracture fixations performed were 6579, 6978 and 7012, respectively. There was a significant increase (p < 0.001) in the number of category A fixations (87.7%, 94.6% and 96.3% in 2015, 2016 and 2017, respectively) and also a decrease in the number of category C fixations (2.23%, 0.7% and 0.2% in 2015, 2016 and 2017, respectively). The quality of fixations of the 'red flag' fractures also improved.

CONCLUSION

We present here a very effective, tested, simple and easily reproducible method of audit and follow-up work flow that can be used in all high turnover trauma centres to improve outcomes and can also serve as a teaching resource for junior staff.

STUDY DESIGN

Prospective study.

LEVEL OF EVIDENCE

Level II.

Computer-assisted preoperative planning improves the learning curve of PFNA-II in the treatment of intertrochanteric femoral fractures

Background

Intertrochanteric femoral fractures are prevalent among the elderly, and usually demands surgical treatments. Proximal femoral nail antirotation Asian version (PFNA-II) is widely used for intertrochanteric fracture treatment. The computer-assisted preoperative planning (CAPP) system has the potential to reduce the difficulty of PFNA-II in the treatment of intertrochanteric fractures. The aim of the study was to investigate and compare the learning curves of PFNA-II treatment with CAPP and conventional preoperational planning methods for intertrochanteric femoral fractures.

Methods

A total of 125 patients with intertrochanteric fracture who were treated with PFNA-II between March 2012 and June 2015 were retrospectively analyzed. Patients who underwent surgery with CAPP procedure by a junior surgeon were regarded as group A (n = 53); patients who underwent the conventional surgery by another junior surgeon were regarded as group B (n = 72). Each group was divided into three subgroups (case 1–20, case 21–40, case 41–53 or case 41–72).

Results

The average operation time of group A was 45.00(42.00, 50.00) minutes, and in group B was 55.00 (50.00, 60.00) minutes (P < 0.01). Average radiation frequency and blood loss were 13.02 ± 2.32, 160.00 (140.00, 170.00) ml and 20.92 ± 3.27, 250.00 (195.00, 279.50) ml, respectively, with significant differences (P < 0.01). The learning curve of the surgical procedure in group A was steeper than that in group B. There were no significant differences in patient reported outcomes, hospital stay and complication rate between the two groups. Significant differences were observed between group A and B in Harris score at last follow-up in the AO/OTA type 31-A2 intertrochanteric fracture (P < 0.05).

Conclusion

Compared with conventional preoperative planning methods, CAPP system significantly reduced operation time, radiation frequency and blood loss, thus reshaped the learning curve of PFNA-II treatment with lower learning difficulty.

Trial registration

researchregistry4770. Registered 25 March 2019.

Does Combined Anterior-Posterior Approach Improve Outcomes Compared with Posterioronly Approach in Traumatic Thoracolumbar Burst Fractures?: A Systematic Review

The aim of this systematic review was to evaluate the surgical, radiological, and functional outcomes of posterior-only versus combined anterior-posterior approaches in patients with traumatic thoracolumbar burst fractures. The ideal approach (anterior-only, posterior-only, or combined anterior-posterior) for the surgical management of thoracolumbar burst fracture remains controversial, with each approach having its advantages and disadvantages. A systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed (registration no., CRD42018115120). The authors reviewed comparative studies evaluating posterior-only approach compared with combined anterior-posterior approaches with respect to clinical, surgical, radiographic, and functional outcome measures. Five retrospective cohort studies were included. Postoperative neurological deterioration was not reported in either group. Operative time, estimated blood loss, and postoperative length of stay were increased among patients in the combined anterior-posterior group in one study and equivalent between groups in another study. No significant difference was observed between the two approaches with regards to long-term postoperative Cobb angle (mean difference, -0.2; 95% confidence interval, -5.2 to 4.8; p =0.936). Moreover, no significant difference in functional patient outcomes was observed in the 36item Short-Form Health Survey, Visual Analog Scale, and return-to-work rates between the two groups. The available evidence does not indicate improved clinical, radiologic (including kyphotic deformity), and functional outcomes in the combined anterior-posterior and posterior-only approaches in the management of traumatic thoracolumbar burst fractures. Further studies are required to ascertain if a subset of patients will benefit from a combined anterior-posterior approach.

Comparison of Functional and Radiological Outcomes of Olecranon Fractures Treated with Tension Band Wiring with Kirschner Wires to Transcortical Screw Fixation-A Randomised Controlled Study

Aim

To compare the clinical and radiological outcomes of fixation of olecranon fractures by a transcortical screw with conventional tension band wiring (TBW) using a Kirschner wire (K-wire).

Materials and methods

This is a non-blinded randomised controlled trial comprising two groups (n = 30 each) with Mayo type A olecranon fractures fixed with either TBW or transcortical cancellous screws (CCS). Outcomes included the Mayo elbow performance index (MEPI), time to union, range of motion (ROM), and rates of complication among these two groups.

Results

Most of the patients showed excellent scoring as per MEPI in both the groups at 6 weeks (90% in TBW group and 76.7% in CCS group) and were not significant (p = 0.719). Signs of the radiological union were noted in 80% of the cases at 6 weeks and complete at 6 months. Hardware-related complications (8.3% symptomatic hardware and 6.7% implant back-out), infection, and mean ROM were similar between the two groups (elbow flexion was 142.33 ± 24.67° in TBW group and 143.1 ± 10.19° in transcortical screw group, p = 0.246) at the end of the study.

Conclusion

There were no statistically significant differences in the clinical–radiological outcomes and complications fixing the non-comminuted olecranon fractures with either transcortical screw or TBW.

Clinical significance

Transcortical screw fixation is an acceptable alternative to TBW for non-comminuted olecranon fractures in terms of union and functional outcome.

How to cite this article

Sinha S, Maharjan R, Khanal GP, et al. Comparison of Functional and Radiological Outcomes of Olecranon Fractures Treated with Tension Band Wiring with Kirschner Wires to Transcortical Screw Fixation—A Randomised Controlled Study. Strategies Trauma Limb Reconstr 2020;15(3):131–137.

Open reduction and compression with double Kirschner wires for the treatment of old bony mallet finger

Background

The management of old bony mallet fingers is complicated. The aim of the study is to present a new method of open reduction and compression with double Kirschner wires (K-wires) in treating old bony mallet fingers.

Methods

This was a retrospective analysis of patients with old closed bony mallet fingers treated between June 2013 and December 2016. Complications were observed. The range of motion (ROM) of the DIP joints was measured using a protractor. At the last follow-up, anteroposterior and lateral X-ray of the affected finger was performed, the flatness of the articular surface was scored, and the results were graded using Crawford’s criteria.

Results

Seventeen patients were followed up for 8 (6–19) months. The width of the avulsion fracture block accounted for 25–62% of the articular surface of the distal phalanx. Twelve (70.6%) patients had anterior dislocation of the interphalangeal joint. All patients reported healing at the fracture sites. Healing time was 7.6 ± 2.1(5–13) weeks. All patients had incision healing of I/Class A. Lateral X-ray showed 13 and four patients had excellent and good articular surface flatness, respectively. At the last follow-up, no traumatic arthritis was present. Only one patient developed mild pain after surgery (VAS score of 3). Postoperative ROM was 76.5 ± 10.6° (P = 0.0625 vs. healthy side). At the last follow-up, the angle of loss of dorsiflexion was 0–10° (P < 0.0001 vs. baseline). The flexion angle was 50–90° (P = 0.0625 vs. healthy side).

Conclusions

Open reduction and compression with double K-wires is feasible in treating old bony mallet finger.

Finite element analysis of two cephalomedullary nails in treatment of elderly reverse obliquity intertrochanteric fractures: zimmer natural nail and proximal femoral nail antirotation-ΙΙ

Background

More elderly patients are suffering from intertrochanteric fractures. However, the choice of internal fixation is still controversial, especially in the treatment of unstable intertrochanteric fracture; thus, previous implants continue to be improved, and new ones are being developed. The purpose of our study was to compare the biomechanical advantages between the zimmer natural nail (ZNN) and proximal femoral nail antirotation-II (PFNA-II) in the treatment of elderly reverse obliquity intertrochanteric fractures.

Methods

A three-dimensional finite element was applied for reverse obliquity intertrochanteric fracture models (AO31-A3.1) fixed with the ZNN or PFNA-II. The distribution, peak value and position of the von Mises stress and the displacement were the criteria for comparison between the two groups.

Results

The stresses of the internal fixation and femur in the ZNN model were smaller than those in the PFNA-II model, and the peak values of the two groups were 364.8 MPa and 171.8 MPa (ZNN) and 832.3 MPa and 1795.0 MPa (PFNA-II). The maximum amount of displacement of the two groups was similar, and their locations were the same, i.e., in the femoral head vertex (3.768 mm in the ZNN model and 3.713 mm in the PFNA-II model).

Conclusions

The displacement in the two models was similar, but the stresses in the implant and bone were reduced with the ZNN. Therefore, the ZNN implant may provide biomechanical advantages over PFNA-II in reverse obliquity intertrochanteric fractures, as shown through the finite element analysis. These findings from our study may provide a reference for the perioperative selection of internal fixations.

Implications of the Ankle Injury Management (AIM) trial: close contact casting or surgery for older adults with an unstable ankle fracture?

The Ankle Injury Management (AIM) trial was a pragmatic equivalence randomized controlled trial conducted at 24 hospitals in the United Kingdom that recruited 620 patients aged more than 60 years with an unstable ankle fracture. The trial compared the usual care pathway of early management with open reduction and internal fixation with initially attempting non-surgical management using close contact casting (CCC). CCC is a minimally padded cast applied by an orthopaedic surgeon after closed reduction in the operating theatre. The intervention groups had equivalent functional outcomes at six months and longer-term follow-up. However, potential barriers to using CCC as an initial form of treatment for these patients have been identified. In this report, the results of the AIM trial are summarized and the key issues are discussed in order to further the debate about the role of CCC. Evidence from the AIM trial supports surgeons considering conservative management by CCC as a treatment option for these patients. The longer-term follow-up emphasized that patients treated with CCC need careful monitoring in the weeks after its application to monitor maintenance of reduction. Cite this article: Bone Joint J 2019;101-B:1472-1475.

Treatment of comminutive fractures by firearm projectiles with adapted wrist external fixator

INTRODUCTION

Facial and mandibular aggression with gunshot wound (GSW) is highly complex and represents a challenge for the assistant surgical team because in addition to the inherent lethal potential, they have the capacity for destruction and mutilation caused by the high kinetic energy conferred to the firearm projectile. Among these lesions, comminutive mandibular fractures are difficult to treat because the anatomical planes are distorted, soft tissues are in severe disarrangement, and bone fragments are without periosteum, which, if opted for an open treatment, with internal fixation, favor the development of soft tissue infections, osteomyelitis, and suture dehiscence. The treatment of comminuted mandibular fractures with external fixator, widely used during the Second World War, represents a modality of treatment that minimizes the risks of failure, since it allows stabilization of the fractured mandible with minimal aggression to the soft tissues.

OBJECTIVES

The objective of this study is to report three cases where surgical procedures were performed to treat comminuted mandible fractures with the adaptation of specific external orthopedic fixator for wrist.

A practical guide for the use of contour locking plates for the repair of humeral diaphyseal fractures with proximal extension

INTRODUCTION

The emergence of minimally invasive techniques has expanded the use of plates and improved their safety for the repair of humeral diaphyseal fractures with proximal extension. In this study, we aimed to determine the best contouring method for long locking plates in the repair of humeral fractures using this approach.

PATIENTS AND METHODS

Comparative observations were performed between helical and spiral modelling in plastic models to identify which shape best fits the contours of the humerus. To determine the best shape, we attempted to assess the torsion required for the plate to settle laterally in the greater tuberosity and anteriorly in the diaphyseal region of the humerus. After establishing the best approach, we transferred the method to two anatomical specimens and confirmed the viability of the method and pathways. Additionally, to confirm the clinical applicability of the method, we applied the method in ten patients.

RESULTS

After placing the plates in the bone models, it was found that the helical plate was more distant from the bone. On the other hand, the spiral plate achieved better accommodation along the contours of the humerus. The amount of twist was tested at 50°, 70° and 90°. When the plate was twisted at 70°, it maintained contact with the greater tuberosity proximally and the anterior cortical diaphyseal region. Eight patients completed the follow-up. Radiographic consolidation and good functional outcomes were achieved in all patients.

CONCLUSIONS

Spiral modelling at 70° allows anatomical accommodation at the greater tuberosity proximally and in the diaphyseal region.

Study protocol: design and rationale for an exploratory phase II randomized controlled trial to determine optimal vitamin D3 supplementation strategies for acute fracture healing

Background

Observational studies have found that 75% of healthy adult fracture patients (ages 18-50) have serum 25-hydroxyvitamin D (25(OH)D) levels < 30 ng/mL. Although lower serum 25(OH)D levels have yet to be correlated to fracture healing complications or poor fracture outcomes, many orthopedic surgeons are routinely prescribing vitamin D supplements to improve fracture healing in healthy non-osteoporotic patients. To address this gap in the literature, we propose a phase II exploratory randomized controlled trial comparing three vitamin D₃ dosing regimens for early surrogate treatment response.

Methods

We will conduct a 4-arm blinded exploratory phase II trial in 96 adults aged 18-50 years with a closed or low-grade open (Gustilo type I or II) tibial or femoral shaft fracture. Eligible patients will be randomized in equal allocation ratio of 1:1:1:1 to one of the treatment groups: (1) 150,000 IU loading dose vitamin D₃ plus daily dose placebo; (2) loading dose placebo plus 4000 IU vitamin D₃ per day, (3) loading dose placebo plus 600 IU vitamin D₃ per day, or (4) loading dose placebo plus daily dose placebo. The primary outcome is fracture healing, assessed as follows: (1) clinical fracture healing measured using the Function IndeX for Trauma, (2) radiographic fracture healing measured using the Radiographic Union Score for Tibial fractures, and (3) biological fracture healing measured using serum levels of cross-linked C-terminal telopeptides of type I collagen and amino-terminal procollagen propeptides of collagen type I. The main secondary outcome will be assessed by measuring serum 25(OH)D levels. All outcome analyses will be exploratory and adhere to the intention-to-treat principle. Per-protocol sensitivity analyses will also be conducted.

Discussion

Study results will be disseminated through a publication in an academic journal and presentations at orthopedic conferences. Study results will inform dose selection for a large definitive randomized controlled trial and provide preliminary clinical data on which dose may improve acute fracture healing outcomes in healthy adult patients (18-50 years) at 3 months.

Trial registration

Vita-Shock (A Blinded Exploratory Randomized Controlled Trial to Determine Optimal Vitamin D₃ Supplementation Strategies for Acute Fracture Healing) was registered at ClinicalTrials.gov (identifier NCT02786498) prior to enrollment of participants.

Biomechanical properties of off-axis screw in Pauwels III femoral neck fracture fixation: Bicortical screw construct is superior to unicortical screw construct

OBJECTIVES

The purpose of this study is to determine the biomechanical properties of the bicortical off-axis screw fixation for stabilizing of Pauwels III femoral neck fractures compared with other fixation methods.

METHODS

Eighteen synthetic femurs (Sawbones Pacific Research Laboratories, Vashon, WA) were divided into three groups. The osteotomy was made vertically to mimic the Pauwels type III femoral neck fracture. Group A (n = 6) was fixed with traditional inverted triangle cannulated screws. Group B (n = 6) was fixed with a unicortical off-axis screw and two parallel cannulated screws. Group C (n = 6) was fixed with a bicortical off-axis screw and two parallel cannulated screws. Each group was tested with a nondestructive axial compression test at a 7° of valgus followed with 1000 cycles of cyclic loading test from 100 N to 1000 N. Finally, a destructive axial compression test was applied until catastrophic failure.

RESULTS

The average axial stiffness from group A to group C was 856.5, 934, and 1340 N/mm, respectively. The average ultimate failure load from group A to group C was 2612.7, 2508.8, and 3706 N, respectively. Group C exhibited significantly greater axial stiffness and a higher ultimate failure load than the other two groups (P < 0.05). Regarding the interfragmental displacement, the values from group A to group C were 0.41, 0.83, 0.36, respectively, and group B exhibited significantly larger fracture gap formation after the cyclic loading test.

CONCLUSIONS

The results of this biomechanical study show statistically significant increases in axial stiffness and ultimate failure load for the off-axis screw placed in bicortical fashion. Once the off-axis screw was positioned unicortically, the largest fracture diastasis was observed as compared to the other two methods.

A high-strength biodegradable thermoset polymer for internal fixation bone screws: Preparation, in vitro and in vivo evaluation

Thermoset polymers synthesized from the polycondensation of glycerol with biocompatible diacids represent a promising class of absorbable materials for biomedical applications. However, the utility of these polymers for bone fixation devices is hampered due to the lack of mechanical strength. Herein we synthesized a high-strength thermoset polymer, poly(glycerol-succinate) (PGS), via a catalyst-free and solvent-free reaction. The bending strength of PGS reaches 122.01 ± 8.82 MPa, signifying its great potential for fixation devices. The degradation property of the polymer can be tuned by adjusting the monomer ratio and reaction time. Bone screws based on the PGS polymer were successfully manufactured using a lathe. In vitro evaluation showed the PGS polymer was able to well support cell adhesion and proliferation. In vivo evaluation using a rat subcutaneous implantation model showed that the inflammatory response to the polymer was mild. After the PGS screws were implanted in the rabbit femoral condyle for 12 weeks, micro-computed tomography (micro-CT) and histological analysis revealed that the screws achieved good osseointegration. Consequently, the polymer developed in current study can serve as internal fixation devices due to the proper mechanical strength, excellent biocompatibility, and feasibility of manufacturing screws.