Anti-sliding plate technique for coronal shear fractures of the distal humerus

The 3D-Printed Custom Elbow Prosthesis for Salvage Treatment of Complex Intra-Articular Distal Humerus Fracture Malunion

Intra-articular fractures of the distal humerus are complex injuries that often require surgery with the goal of restoring elbow range-of-motion and function. Open reduction and internal fixation has been the preferred surgical modality; however, restoration of the medial and/or lateral columns can be complicated in fractures involving a major loss of the articular surface and bony structure. Over the past decade, 3-dimensional (3D) printing has made significant advances in the field of orthopedic surgery, specifically in guiding surgeon preoperative planning. Recently, the incorporation of 3D-printing has proven to provide a safe and reliable construct for the restoration of anatomy in complex trauma cases. We present a 47-year-old woman who sustained a complex, intra-articular distal humerus fracture with associated shearing of the capitellum that went onto malunion. Patient was treated with a patient-specific 3D-printed custom elbow prosthesis with excellent outcomes. Our goal was to shed light on the use of 3D-printing technology as a viable salvage option in treating complex, intra-articular distal humeral fractures associated with lateral condylar damage that subsequently went onto malunion.

The Role of Platelet Rich Plasma in Vertebrogenic and Discogenic Pain: A Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

The present investigation evaluates clinical uses and roles of platelet rich plasma in the management of vetrebrogenic and discogenic mediated pain states.

RECENT FINDINGS

Back pain is a common and significant condition that affects millions of people around the world. The cause of back pain is often complex and multifactorial, with discogenic and vertebrogenic pain being two subtypes of back pain. Currently, there are numerous methods and modalities in which back pain is managed and treated such as physical therapy, electrical nerve stimulation, pharmacotherapies, and platelet-rich plasma. To conduct this systematic review, the authors used the keywords "platelet-rich plasma", "vertebrogenic pain", and "discogenic pain", on PubMed, EuroPMC, Who ICTRP, and clinicaltrials.gov to better elucidate the role of this treatment method for combating vertebrogenic and discogenic back pain. In recent decades, there has been a rise in popularity of the use of platelet-rich plasma for the treatment of numerous musculoskeletal conditions. Related to high concentration of platelets, growth factors, cytokines, and chemokines, platelet-rich plasma is effective in reducing pain related symptoms and in the treatment of back pain. Platelet-rich plasma use has evolved and gained popularity for pain related conditions, including vertebrogenic and discogenic back pain. Additional well-designed studies are warranted in the future to better determine best practice strategies to provide future clinicians with a solid foundation of evidence to make advancements with regenerative medical therapies such as platelet-rich plasma.

Clinical outcomes of capitellar fractures with posterior comminution treated with Herbert screws combined with metacarpal locking plates

BACKGROUND

The treatment of Dubberley type B capitellar fractures, which are frequently complicated, is widely debated. This study aimed to investigate the prognostic factors and clinical outcomes of Dubberley type B capitellar fractures treated with Herbert screws combined with posterior buttress plates.

METHODS

Seven men and nine women (aged 30-68 years) with Dubberley type B capitellar fractures were operated on with Herbert screws combined with posterior buttress plates. The patients were classified into Dubberley types IB (seven), IIB (four), and IIIB (five). Complications and bone union were observed, and functional outcomes were evaluated by the Mayo Elbow Performance Index (MEPI).

RESULTS

All patients were followed up for a mean period of 23.5 months (12-30 months). All fractures healed in 8-14 weeks (mean, 10.5 weeks). No cases of non-union, elbow instability, or avascular necrosis occurred. Degenerative arthritis occurred in 7 (44%) and heterotopic ossification in 11 (69%) patients. The median MEPI score was 92.5 (interquartile range, 85-100) points, with 11 reporting excellent, 3 good, and 2 fair outcomes. The MEPI scores of type IIIB fractures were significantly lower than those of types IB and IIB fractures, while the MEPI scores of type IB and IIB fractures did not differ significantly.

CONCLUSIONS

Dubberley type IIIB capitellar fractures with multiple articular fragments have a poorer prognosis than type IB and IIB fractures. However, Herbert screw fixation combined with posterior metacarpal locking plates is feasible, providing satisfactory recovery of elbow joint function.

Coronal Plane Articular Shear Fractures of the Distal Humerus

Coronal plane articular shear fractures of the distal humerus are a rare injury, comprising 6% of distal humerus fractures. The fracture can be easily missed on initial radiographs; therefore, a high index of suspicion is warranted. Radiographically obvious fractures are often more complex than initially appreciated, with plain radiographs often underestimating the extent of posterior comminution and trochlear involvement. Associated bony and ligamentous injuries are common. Anatomic reduction and internal fixation of displaced fractures is the standard of care because poor results have been described with nonsurgical treatment. However, the regional anatomy and the often-limited bone stock can make open reduction and internal fixation challenging. The lateral approach, with headless compression screws placed from anterior to posterior, is commonly used for simpler fracture patterns, but exposure and fixation of trochlea extension can be difficult. In the absence of posterior comminution, the anterolateral approach can enhance trochlea exposure and allow for a better trajectory for screw placement. Posterior comminution often requires locking plate fixation. Better results and lower complication rates have been reported for fractures with less fragmentation of the articular surface and those without posterior comminution. Contracture and symptomatic implants are the most common reasons for revision surgery.

Three-dimensional printing designed customized plate in the treatment of coronal fracture of distal humerus in teenager: A case report

RATIONALE

Because of the complicated anatomy and considerable change in size and morphology with age in teenagers, the appropriate internal fixator of coronal shear fracture of distal humerus is difficult to choose, and therefore, the fixation of this kind of fracture is difficult and controversial. Furthermore, distal humeral fractures in teenagers often involve the epiphysis, the rigid fixation of fracture and the simultaneous minimally invasive and protection of the epiphysis are contradictory. Coronal shear fractures of the distal humerus in teenagers are great challenge for orthopedic surgeons. Three-dimensional (3D) printing designed customized plate in the treatment of coronal fracture of distal humerus in teenager is a potential satisfactory choice in the treatment of the complex fractures.

PATIENT CONCERNS

A teenager suffered from an elbow joint injury due to a fall while running, resulting in pain, swelling and limited movement of the elbow joint. The epiphyseal has not closed in this patient, conventional surgical procedures have great traumatic and invasive, and to some extent affect bone growth in children.

DIAGNOSES

Coronal shear fracture of right distal humerus according to computed tomography scan.

INTERVENTIONS

We used 3D printing technology to design an internal fixation device for this patient, which was to treat the distal humeral coronal shear fracture in a teenager via an anterior approach to the elbow joint, and finally the child was instructed to perform immediate postoperative functional exercises and rehabilitation.

OUTCOMES

Radiographic reexamination performed 1 day and 2 month after the operation showed that the internal fixation was in good position, no fracture displacement. the patient was instructed to perform active flexion and extension internal and external rotation of the right elbow 6 weeks postoperatively. The Mayo elbow function score was excellent 5 months postoperatively. The range of motion of the elbow was (15°-130°).

LESSONS

The treatment of coronal shear fractures of the distal humerus in teenager is controversial at present. This report 3D printing technology designed customized plate in treatment of such fractures showed satisfactory results, which provides a feasible method for the treatment of fractures without suitable internal fixation devices in the future.

Coronal Shear Fractures of the Distal Humerus

Coronal shear fractures of the distal humerus are rare, frequently comminuted, and are without consensus for treatment. The aim of this paper is to review the current concepts on the diagnosis, classification, treatment options, surgical approaches, and complications of capitellar and trochlear fractures. Computed Tomography (CT) scans, along with the Dubberley classification, are extremely helpful in the decision-making process. Most of the fractures necessitate open reduction and internal fixation, although elbow arthroplasty is an option for comminuted fractures in the elderly low-demand patient. Stiffness is the most common complication after fixation, although reoperation is infrequent.

Biomechanical stability of complex coronal plane fracture fixation of the capitellum

INTRODUCTION

Coronal plane fractures of the distal humerus are relatively rare and can be challenging to treat due to their complexity and intra-articular nature. There is no gold standard for surgical management of these complex fractures. The purpose of this study was to compare the biomechanical stability and strength of two different internal fixation techniques for complex coronal plane fractures of the capitellum with posterior comminution.

MATERIALS AND METHODS

Fourteen fresh frozen, age- and gender-matched cadaveric elbows were 3D-navigated osteotomized simulating a Dubberley type IIB fracture. Specimens were randomized into one of two treatment groups and stabilized with an anterior antiglide plate with additional anteroposterior cannulated headless compression screws (group antiGP + HCS) or a posterolateral distal humerus locking plate with lateral extension (group PLP). Cyclic testing was performed with 75 N over 2000 cycles and ultimately until construct failure. Data were analyzed for displacement, construct stiffness, and ultimate load to failure.

RESULTS

There was no significant difference in displacement during 2000 cycles (p = 0.291), stiffness (310 vs. 347 N/mm; p = 0.612) or ultimate load to failure (649 ± 351 vs. 887 ± 187 N; p = 0.140) between the two groups.

CONCLUSIONS

Posterolateral distal humerus locking plate achieves equal biomechanical fixation strength as an anterior antiglide plate with additional anteroposterior cannulated headless compression screws for fracture fixation of complex coronal plane fractures of the capitellum. These results support the use of a posterolateral distal humerus locking plate considering the clinical advantages of less invasive surgery and extraarticular metalware.

LEVEL OF EVIDENCE

Biomechanical study.

Biomechanical stability of simple coronal shear fracture fixation of the capitellum

BACKGROUND

Coronal shear fractures of the capitellum are rare, and their surgical management is challenging, without a defined gold standard. The purpose of this study was to compare the biomechanical stability of 3 different internal fixation techniques for simple coronal shear fractures of the capitellum without posterior comminution.

METHODS

Dubberley type IA fractures of the capitellum were created in 18 cadaveric elbows, which were age and sex matched to the following 3 internal fixation groups: (1) two anteroposterior cannulated headless compression screws (HCSs), (2) two anteroposterior HCSs with an additional anterior antiglide plate (antiGP), and (3) a posterolateral distal humeral locking plate (LP). All fixation techniques were cyclically loaded with 75 N over 2000 cycles and ultimately until construct failure. Data were analyzed for displacement, construct stiffness, and ultimate load to failure.

RESULTS

Fragment displacement under cyclic loading with 2000 cycles did not show a significant difference (P = .886) between the 3 groups. The HCS group showed the highest stiffness compared with the HCS-antiGP and LP groups (602 N/mm vs. 540 N/mm vs. 462 N/mm, P = .417), without reaching a statistically significant difference. Ultimate load to failure was also not significantly different on comparison of all 3 groups (P = .297).

CONCLUSIONS

Simple coronal shear fractures of the capitellum are biomechanically equally stabilized by HCSs compared with HCSs with an additional antiGP or a posterolateral distal humeral LP. In view of the advantages of less (invasive) metalware, the clinical use of 2 isolated anteroposterior HCSs appears reasonable.

Complications of articular distal humeral fracture fixation: a systematic review and meta-analysis

BACKGROUND

Distal humeral fractures are relatively rare injuries in adults. Fractures that involve the articular surface can be particularly challenging to treat. Open reduction-internal fixation (ORIF) remains the preferred treatment for most intra-articular distal humeral fractures, depending on the degree of comminution and functional demands of the patient. Many surgical approaches, fixation techniques, and potential complications have been described in the literature; however, the relative incidence and associated characteristics of these complications have not been studied. The purpose of this study was to identify the prevalence of complications and reoperations after ORIF for intra-articular distal humeral fractures. We sought to provide practical guidance to surgeons and offer insights on the avoidance and prognosis of complications through a systematic review of the published literature over the past 20 years.

METHODS

We performed a systematic review and meta-analysis of studies reporting complications and reoperation rates after ORIF for intra-articular distal humeral fractures. Subgroup analysis was conducted for complication rates between type 13B and 13C fractures, olecranon osteotomy and non-osteotomy approaches, and parallel and perpendicular plating.

RESULTS

Eighty-three studies met the inclusion criteria (2362 elbows; 5 level II, 2 level III, and 76 level IV studies). The mean clinical follow-up period was 2.6 years. The majority of fractures were type C (83%), the remainder were type B (17%). Of the fractures, 71% were closed whereas 9% were open; this was not reported for 20%. The mean postoperative flexion arc was 110°. The overall complication rate was 53%, and the overall reoperation rate was 21%. Although a parallel plating approach resulted in a lower rate of fixation failure requiring revision (1% vs. 6%, P < .001), a perpendicular plating approach showed a significantly lower rate of overall complications (45% vs. 54%, P = .006). This was primarily driven by lower rates of wound dehiscence (0.1% vs. 5%, P < .001), neuropathy (9% vs. 13%, P = .03), and implant prominence (3% vs. 7%, P = .01).

CONCLUSIONS

This systematic review is the largest report of complications and reoperations of intra-articular distal humeral fractures after ORIF in the current literature. These results suggest that complications may be more frequent than previously understood. In contrast to prior small comparative studies, our study observed a significantly higher overall complication rate with parallel plating than with perpendicular plating. Perpendicular plating for intra-articular distal humeral fractures may be considered if adequate fixation and biomechanical stability can be achieved.