Cement-augmented locked plate fixation proximal humerus fractures in elderly patient: a systematic review and meta-analysis

BACKGROUND

This systemic review and meta-analysis aimed to evaluate the clinical outcomes of proximal humeral fracture in elderly patient fixation using locked plate with or without cement augmentation.

METHODS

The databases of PubMed, Embase, and Cochrane Library were searched in August 2023 for literature comparing the clinical outcomes of patients with PHFs treated with locked plate alone and locked plate augmented with cement. Data describing study design; level of evidence; inclusion criteria; demographic information; final follow-up; revision rate; implant failure rate; avascular necrosis rate; total complication rate; constant score; and disability of arm, shoulder, and hand (DASH) score were collected.

RESULTS

Eight studies (one randomized-controlled trial and seven observational studies), involving 664 patients, were identified. Compared with locked plates alone, using cement-augmented locked plates reduced the implant failure rate (odds ratio (OR) = 0.19; 95% confidence interval (CI) 0.10-0.39; P < 0.0001) and total complication rate (OR = 0.45; 95% CI 0.29-0.69; P = 0.0002) and improved DASH scores (mean difference (MD) = 2.99; 95% CI 1.00-4.98; P = 0.003). However, there was no significant difference in clinical outcomes, including revision rate, avascular necrosis rate, and constant score.

CONCLUSION

In this review and meta-analysis, fixation of the PHFs in elderly patients using locked plates with or without cement augmentation has no significant difference in revision rate, but the implant failure and total complication rates may be lesser on using the cement-augmented locked plate for fixation than on using a locked plate alone. Good results are expected for most patients treated with this technique.

TRIAL REGISTRATION

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)21 guidelines were followed to conduct this systematic review and meta-analysis and was registered as a protocol in PROSPERO (CRD42022318798).

Biomechanical analysis of plate versus K-wire fixation for metacarpal shaft fractures with wedge-shaped bone defects

BACKGROUND

Metacarpal shaft fracture is a common type of hand fracture. Numerous studies have explored fixing transverse fractures in the midshaft of the metacarpal bone. However, this section of the metacarpal bone is often susceptible to high-energy injury, resulting in comminuted fracture or bone loss. In such cases, wedge-shaped bone defects can develop in the metacarpal shaft, increasing the difficulty of performing fracture fixation. Notably, the research on this type of fracture fixation is limited. This study compared the abilities of four fixation methods to fix metacarpal shaft fractures with wedge-shaped bone defects.

METHODS

In total, 28 artificial metacarpal bones were used. To create wedge-shaped bone defects, an electric saw was used to create metacarpal shaft fractures at the midshaft of each bone. The artificial metacarpal bones were then divided into four groups for fixation. The bones in the first group were fixed with a dorsal locked plate (DP group), those in the second group were fixed with a volar locked plate (VP group), and those in the third group were fixed by combining dorsal and volar locked plates (DP + VP group), and those in the fourth group were fixed with two K-wires (2 K group). Cantilever bending tests were conducted using a material testing machine to measure yielding force and stiffness. The four groups' fixation capabilities were then assessed through analysis of variance and Tukey's test.

RESULTS

The DP + VP group (164.1±44.0 N) achieved a significantly higher yielding force relative to the 2 K group (50.7 ± 8.9 N); the DP group (13.6 ± 3.0 N) and VP group (12.3 ± 1.0 N) did not differ significantly in terms of yielding force, with both achieving lower yielding forces relative to the DP + VP group and 2 K group. The DP + VP group (19.8±6.3 N/mm) achieved the highest level of stiffness, and the other three groups did not differ significantly in terms of stiffness (2 K group, 5.4 ± 1.1 N/mm; DP group, 4.0 ± 0.9 N/mm; VP group, 3.9 ± 1.9 N/mm).

CONCLUSIONS

The fixation method involving the combined use of dorsal and volar locked plates (DP + VP group) resulted in optimal outcomes with respect to fixing metacarpal shaft fractures with volar wedge bone defects.

Management of periprosthetic femoral fractures following total knee arthroplasties using locking plates or intramedullary nailing. Comparative study of 567 cases

INTRODUCTION

Proximal femur fractures in elderly patients pose a common problem that requires surgical management. The main objective of this study was to compare the results of treatment by locked plate (LP) and by anterograde (AIN) or retrograde (RIN) intramedullary nailing. The secondary objective was to analyze the complications related to each group. The hypothesis of this study was that the radiological and clinical results of each group were comparable.

MATERIALS AND METHODS

The data of 438 patients from 8 centers were studied retrospectively with 365 LP and 69 cases of intramedullary nailing (49 AIN and 20 RIN). The groups were comparable in terms of mean age (75±2years), mean preoperative Parker score (5.3±0.5) and mean KOOS score (74±2). Most patients lived at home before their fracture [n=375 (86%)]. At follow-up, the joint range of motion, the KOOS and Parker scores, living premises, the time required to regain full weight-bearing, the time required for consolidation as well as the reduction alignment: frontal, sagittal, horizontal.

RESULTS

The average follow-up was: 79±2weeks (65 to 82). The functional and radiological results were comparable, although nailing allowed a faster return to weight-bearing (1±2weeks for nailing versus 7±2weeks for LP, p=0.048) and a better postoperative Parker score (5.5±0.5 for nailing versus 4.7±0.2 for LP, p=0.045). Rotational malalignment in femoral nailing was often in the direction of internal rotation, compared to the LP (p=0.045). Complications were comparable with the exception of mortality, which was more frequent for LP [22.5% in the LP group versus 13% in the nailing group (p=0.045)]. Complications were categorized as: mechanical complications 6.8% of LP, 5.7% of nailing (p>0.05), infections [11% of LP, 5.8% of nailing (p>0.05)], surgical revisions [2% of LP, 10% of nailing (p>0.05)].

DISCUSSION AND CONCLUSION

The hypothesis was refuted. These results show that nailing conferred a faster recovery of weight-bearing, a better Parker score, and is associated with a lower mortality rate. The morbidity rate is comparable between the two techniques. Indeed, when the indication for osteosynthesis by LP or by nailing is made, and both choices are technically justifiable, it would be prudent to favor the technique, which carries the least risk, which in this case is nailing. This conclusion must, however, be taken in to consideration with regard to the reduced number of nailing. A larger series of nailing, particularly retrograde, would be necessary to be able to confirm this last difference between the 2 groups.

LEVEL OF EVIDENCE

IV; comparative retrospective study.

Comparative study of patients with midshaft clavicle fracture fixed with a locked plate via an open versus percutaneous approach

OBJECTIVE

To compare the results of surgical treatment of midshaft clavicle fractures, treated with the technique of minimally invasive plate osteosynthesis (MIPO) with locking compression plate versus open reduction and internal fixation (ORIF) with locked plate.

METHODS

Quasi-randomized comparative study, evaluating displaced midshaft clavicle fractures treated with MIPO versus ORIF, with procedures performed by a single surgeon. We evaluated patients at 12 months using the University of California at Los Angeles (UCLA) scale and radiographically at 8, 12, 26 and 52 weeks, in addition to describing complications.

RESULTS

We evaluated 44 patients; 22 submitted to MIPO and 22 to ORIF. The median UCLA scores at 12 months were 35 in the ORIF group and 35 in the MIPO group (p = 0.712). All patients had fracture healing at 3 months (p > 0.999). The mean surgery time was 87.5 min in the ORIF group and 47.5 in the MIPO (p < 0.001) group. As complications, 1 suture dehiscence (4.5%), 2 protruding plates (9.1%) and 1 change in sensitivity around the surgical wound (4.5%) were observed in the MIPO group, while in the ORIF group, 15 changes in sensitivity (68.2%) and 3 hypertrophic scars (13.6%) were observed. The only complication that showed a difference between the groups was the change in sensitivity (p < 0.001). No cases of pseudarthrosis or failure of osteosynthesis were identified in either technique.

CONCLUSION

This study demonstrated that the two treatments, ORIF and MIPO, are equally effective in the treatment of displaced middle third clavicle fractures. However, MIPO is superior to ORIF in regard to reduced surgical time and preservation of supraclavicular nerve sensitivity.

Treatment of supracondylar periprosthetic femoral fractures with retrograde intramedullary nailing versus distal femoral plating: A systematic review and meta-analysis of current evidence

BACKGROUND

Supracondylar periprosthetic fractures, when amenable to fixation, can be treated by either retrograde intramedullary nailing (RIMN) or plating. There is paucity of evidence regarding the superiority of one fixation method over the other. This review aims to determine which fixation method leads to better functional outcomes and perioperative complications.

HYPOTHESIS

Superiority of intramedullary nailing in terms of fracture healing and surgical complications when compared to distal femoral plating.

MATERIALS AND METHODS

Using PRISMA guidelines, a systematic search was performed. Studies which reported comparative outcome data following the two interventions were included. Qualitative data analysis and narrative synthesis were reported. Pooled comparisons were conducted when similar quantifiable outcomes were reported in a minimum of three studies.

RESULTS

A total of 151 records were generated by the search. Eight studies met the eligibility criteria so were included in the final analysis. The studies comprised a total of 407 cases, with a follow up period ranging from 1 to 15 years. 252 cases were treated with plate fixation and 155 with RIMN. All studies were mitigated by heterogeneity and methodological limitations. The review showed marked variation in descriptive fracture classifications. Narrative data synthesis was conducted. Although guarded by the methodological limitations of individual studies, outcomes showed that mean time to union was equivalent; 5.88 months for RIMN compared to 6.75 months in plating, standardised mean difference=0.28 (95% CI -0.02-0.58). Similarly, no statistically significant differences were reported between RIMN and plating for deep infection (OR:1.41 95%CI 0.40-5.00) and revision surgery (OR: 0.74, 95%CI 0.39-1.41).

DISCUSSION

Clinical outcomes showed a tendency that favours intramedullary nailing; however, generalisation of results was not possible. Future priority must be awarded to higher quality research in the form of a collaborative multicentre observational studies to delineate appropriate major diagnostic categories, ultimately informing a large comparative trial using condition specific validated outcome measures.

LEVEL OF EVIDENCE

III, meta-analysis.

Early peri-implant fractures after distal femur fracture locked plating?

PURPOSE

To report the peri-implant fracture rates after locked plating of distal femur fractures and examine risk factors.

METHODS

Over a 7 year period, 89 AO/OTA 33A/C distal femur fractures were identified and reviewed. After excluding treatment with intramedullary nails, age under 50, those with the proximal femur protected, or those without 6 months of follow-up, 42 distal femur fractures in 41 patients, mean age 72.3 were studied. All were treated with lateral locked plating of distal femur fractures. The details of the constructs were recorded. Mean follow-up was 562 days (18.7 months).

RESULTS

3/42 were open injuries, 9/42 were type C, 16/42 were type A, and 17 were periprosthetic above a knee arthroplasty. Two patients were treated with a dynamic plating construct using all far-cortical locking (FCL) screws in the diaphysis. 40 patients were treated with a variety of non-dynamic diaphyseal constructs including locking, non-locking, and four with 1-2 FCL screws distally. There was one asymptomatic nonunion. 2/2 patients in the dynamically plated group experienced a peri-implant fracture versus 1/40 in the non-dynamically plated group (p = 0.001). 3/9 with an all-locked construct versus 0/25 patients with a most proximal non-locking screw experienced a fracture.

CONCLUSIONS

The overall peri-implant fracture risk was 7.1% (3/42), 3/17 patients with a locking screw most proximal experienced a peri-implant fracture, 3/9 with an all-locking construct, and 2/2 patients with a dynamic construct experienced a fracture. These findings merit additional clinical and biomechanical study.

Excellent outcomes after double-locked plating in very low periprosthetic distal femoral fractures

INTRODUCTION

Very low periprosthetic distal femur fractures (PPDFFs) are rare injuries and often have a relatively high failure rate after single lateral locked plating. The double plating technique yields good outcomes in osteoporotic fractures of the distal femur. To date, there is limited information on double-locked plate fixation of very low PPDFFs. This study aimed to evaluate the outcomes and complications of surgically treated very low PPDFFs using double-locked plate fixation.

MATERIALS AND METHODS

Between January 2013 and December 2018, sixty-one consecutive patients with PPDFFs have been conducted. Only Su type III PPDFFs with double-locked plate fixation through a lateral minimally invasive approach and a medial subvastus approach to the distal femur were analyzed. Patients were encouraged to perform straight leg raising exercises and active knee motion on the second postoperative day. Assisted weight bearing from the early postoperative days was supported, and full weight-bearing was allowed after healing the fracture site. All patients were evaluated according to the time to union, limb alignment, range of knee motion, Knee Society Score, and presence of complications.

RESULTS

Twenty one patients (17 females and 4 males, mean age 76 years, range 56-90) were included in the study. There were 10 of 33-A1, 6 of 33-A2 and 5 of 33 A3 fractures, according to the AO classification. Of 21 patients, 20 achieved union at an average of 14 weeks postoperatively. Postoperative limb alignment was satisfactory in all cases, with an average mechanical distal lateral femur angle of 89° and average mechanical posterior distal femur angle of 86°. All patients recovered the knee joint motion similar to that of the contralateral side, and daily life pre-injury. The average knee and function scores were 94 and 89, respectively. There were one case of non-union and three cases of superficial wound infection, which resolved after intravenous antibiotic therapy.

CONCLUSIONS

Double locked plating showed excellent radiographic and functional outcomes with few complications in patients with very low PPDFFs. Based on these promising results, we propose the consideration of double-locked plate fixation in the treatment of very low PPDFFs.

Treatment of distal femur fractures with VA-LCP condylar plate: A single trauma centre experience

INTRODUCTION

Given the recent criticisms in the literature regarding Synthes Variable Angle Locking Compression Condylar Plate (VA-LCP), the purpose of this study was to evaluate functional outcome, fracture healing, and complications of distal femoral intra-articular fractures using this device.

METHODS

Patients with distal femoral fractures treated with 4.5 mm VA-LCP Curved Condylar Plate were included in this retrospective study. Follow-ups were at 4 weeks, 3 months, 6 months and 1 year. For the clinical and functional assessment of the knee, WOMAC, Koos Knee Survey, the Knee Score Society and the SF-12 questionnaire were used. Radiographically we assessed the fracture healing and the angles of the operated limb compared to the healthy contralateral limb. Complications have also been described.

RESULTS

Forty-two patients with distal femoral fractures were included in the study. The mean follow-up was 8 months. Most cases (57%) reported a type 33-A fracture. Radiological healing was achieved in 33 cases; the mean time required to heal was 13 weeks. Three patients had an early postoperative complication and four cases had a late complication. Five cases required additional surgical procedures. Most patients (47.2%) achieved a complete flexion of 130° or more. WOMAC mean value 27.4%, KSS mean value 77.6 for the clinical part and 60 for the functional part, KOOS mean score 60.1, SF-12 mean score 46.1 for MCS and 35.5 for PCS.

DISCUSSION

The results of this retrospective study suggest that VA-LCP Curved Condylar Plates have a good functional outcome and fracture healing similar to other standard distal femoral locking plates. VA technology allows greater versatility in fractures internal fixation regardless of the plate design. Fixation devices or Prosthesis implants previously placed may be avoided, as in periprosthetic fractures. Moreover, we have not recorded any early mechanical damage.

CONCLUSIONS

Osteosynthesis with Synthes 4.5 mm VA-LCP Curved Condylar Plate demonstrated to have no early mechanical failure rate with good clinical and radiological results.

An evaluation of the results of locked plate osteosynthesis applied without the use of bone graft in Sanders type III and IV intra-articular calcaneus fractures

PURPOSE

The clinical and radiological results of locked plate osteosynthesis with an extensive lateral approach without bone graft in Sanders type III and IV intra-articular calcaneus fractures and the factors affecting these results were evaluated retrospectively.

METHODS

A total of 61 patients with Sanders type 3 and 4 calcaneus fractures who underwent a lateral approach with locked plate osteosynthesis were included in the study. The mean follow-up was 44.8 months.

RESULTS

The mean pre- and post-operative Gissane and Bohler's angles were 113.5° ± 13.9° and 106.7° ± 13.6° (p = 0.006) and 2.8° ± 14.1° and 19.6° ± 13.1° (p < 0.001), respectively. The mean post-operative AOFAS scores, SF-36, and Maryland were 80.5 ± 13.6 in type IIIAB, 89.4 ± 6.3 in IIIAC, and 82.4 ± 12.5 in IV; 58.6 ± 14.5 in type IIIAB, 60.3 ± 11.7 in IIIAC, and 58.0 ± 15.6 in IV; and 63.8 ± 7.2 in type IIIAB, 64.3 ± 7.1 in IIIAC, and 62.8 ± 11.7 in IV (p = 0.173, p = 0.932, p = 0.824, respectively). Wound problems were observed in 15 (28.6%) patients. Deep infection was not observed in any patient.

CONCLUSION

The clinical results were similar in type III and IV intra-articular calcaneus fractures applied with locked plate osteosynthesis in an extensive lateral approach and without the use of bone graft. Intra-articular calcaneus fracture fixation with a lateral locked plate is an effective treatment method.

Non-union in lateral locked plating for distal femoral fractures: A systematic review

INTRODUCTION

This study aims to identify patient and intra-operative factors that contribute to non-union in locked lateral plating for distal femoral fractures.

METHODS

Systematic searches of English-language articles in Ovid Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews were undertaken in February 2018 according to the PRISMA guidelines. The search terms were (fracture or fracture*) AND (distal femur or distal femoral) AND (malunion or non-union). Eligible studies published at any time reported non-union rates and compared patient and intraoperative factors in patients who underwent locked lateral plating for traumatic distal femoral fractures. The quality of included papers was assessed using The Journal of Bone and Joint Surgery levels of evidence (Wright et al., 2003), and further appraised using the Downs and Black score (Downs and Black, 1998).

RESULTS

Eight studies investigating 1380 distal femoral fractures were found to satisfy the inclusion and exclusion criteria. These studies analysed a variety of patient and intra-operative factors that may contribute to non-union. These include high BMI, open fracture, comminution, fracture infection, stainless steel plate material, shorter working length, open reduction and internal fixation when compared with minimally invasive plate osteosynthesis, high construct rigidity scores and purely locking screw constructs.

CONCLUSION

This review has identified multiple factors which potentially contribute to non-union including stainless steel plate material, high construct rigidity scores and purely locking screw constructs. These findings may reflect that overly rigid plating constructs can contribute to non-union. However, they should be taken in the context of heterogeneity amongst included studies, with further research necessary to support these findings.

Locking plate fixation versus antegrade intramedullary nailing for the treatment of extra-articular distal femoral fractures

INTRODUCTION

The current study aimed to retrospectively analyze locked plating (LP) and antegrade intramedullary nailing (AIN) for the treatment of extra-articular distal femoral fractures.

PATIENTS AND METHODS

Between January 2000 and March 2015, 97 patients (49 male, 48 female) underwent surgery for extra-articular distal femoral fractures in our clinic. Patients were grouped based on their method of treatment (69 (71.1%) with locked plate (LP group) and 28 (28.9%) with antegrade intramedullary nailing (AIN group)), and the groups were analyzed with regards to fracture types, associated trauma, hospital stay, Injury Severity Score (ISS), nonunion, reoperation rate and Lysholm Functional Knee Score.

RESULTS

The LP and AIN groups had no significant differences with regards to age and gender. Sixteen patients (16.4%) experienced nonunion; all of these (5 (5.1%) in the AIN group and 11 (11.3%) in the LP group) required a secondary procedure (p = 0.773). ISS was significantly higher in the AIN group (p = 0.033). There were no significant differences between the two groups with regards to hardware failure, postoperative malreduction, reoperation rate, deep infection, and nonunion. However, the AIN group (mean 88) had a significantly higher Lysholm Functional Knee Score than the LP group (mean 75.9) (p = 0.019).

CONCLUSION

In our study we encountered less nonunion in AIN group. Both fixation methods offer good results; however, functional outcomes in the AIN group were significantly better than those in the LP group.

Locked Plating and Advanced Augmentation Techniques in Osteoporotic Fractures

"The incidence of osteoporotic fracture is increasing with the aging US population. Because osteoporosis leads to a decrease in bone mineral density with a decrease in both trabecular and cortical bones, osteoporotic fracture presents fixation challenges with standard plate and screw constructs. Locked plating has been developed to create a fixed-angle plate-screw construct that is more resistant to failure in osteoporotic bone. Endosteal replacement, additional plates, and cement augmentation have all been demonstrated to further supplement osteoporotic fracture fixation. Technologies on the horizon to treat osteoporotic fracture include SMV screws, hydroxyapatite-coated implants, and far cortical locking screws."

Outcomes of distal femur fractures treated with the Synthes 4.5 mm VA-LCP Curved Condylar Plate

PURPOSE

Given the recent controversy in the literature and the alarming reports of early mechanical failure associated with the use of the Synthes 4.5 mm VA-LCP Curved Condylar Plate in acute distal femur fractures, the goal of our study was to examine the outcomes and mechanical failure rates of this implant in a larger patient population.

METHODS

Patients 18 years of age and older who underwent plate fixation of their acute distal femoral fracture using the Synthes 4.5 mm VA-LCP Curved Condylar Plate were included in this retrospective study. The study data was collected through a retrospective chart review and review of the existing radiographic studies. Primary outcome measure was mechanical hardware failure while secondary outcome measures included nonunion, malunion, and medical and surgical complications.

RESULTS

A total of 74 patients (77 fractures) were included in this study. The fractures were classified according to the OTA/AO classification as 33-A2 (n = 6), 33-A3 (n = 19), 33-C1 (n = 5), 33-C2 (n = 25), and 33-C3 (n = 22). Thirty-two out of 77 fractures presented as open fractures (41.6%). A mechanical failure was observed in 7 patients (9.1%). Twenty additional patients needed a re-operation of the surgical site including two nonunion repairs, one malunion repair, 15 staged treatments of traumatic segmental bone defects, and two soft tissue debridements.

CONCLUSIONS

In our experience, the Synthes 4.5 mm VA-LCP Curved Condylar Plate is a safe and effective implant with a relatively low mechanical failure rate.

Equivalent mortality and complication rates following periprosthetic distal femur fractures managed with either lateral locked plating or a distal femoral replacement

INTRODUCTION

Management of distal femur fractures above total knee arthroplasty (TKA) remains challenging. Two common surgical options are locked lateral plating (LLP) and distal femoral arthroplasty (DFR). Unfortunately, approximately 30-50% of patients may die within one year of injury, require further surgery, or not regain prior mobility performance. We compared 87 LLP to 53 DFR patients - to our knowledge the largest comparative study - focusing on 90- and 365-day mortality, mobility maintenance, and further surgery.

METHODS

We performed a retrospective review of patients at least 55 years old who sustained femur fractures near a primary TKA (essentially OTA-33 or Su types 1, 2, or 3) from 2000 to 2015 assigning cohort based on treatment: LLP or DFR. We excluded patients having prior care for the injury, whose surgery was not for fracture (e.g. loosening), or having other surgical intervention (e.g. intramedullary nail).

RESULTS

Results Cohorts were similar based on body mass index and age adjusted Charlson Comorbidity Index (aaCCI). LLP was more common than DFR for fractures above and at the level of the implant, but similar for fractures within the implant for patients with aaCCI ≥ 5. LLP and DFR had similar mortality at 90 days (9% vs 4%) and 365 days (22% vs 10%), need for additional surgery (9% vs 3%), and survivors maintaining ambulation (77% vs 81%). Patients whose surgery occurred 3 or more days after presentation had similar mortality risk to those whose surgery was before 3days. The mean age of one year survivors was 77 whereas for patients who died it was 85. Neither surgical choice nor aaCCI was associated with increased risk in time to surgery.

CONCLUSIONS

Fracture location, remaining bone stock, and patient's prior mobility and current comorbidities must guide treatment. Our study suggests that 90- and 365-day mortality, final mobility, and re-operation rate are not statistically different with LLP vs DFR management.

The outcome of super-cutaneous locked plate fixation with percutaneous reduction of displaced intra-articular calcaneal fractures

INTRODUCTION

Supercutaneous (external) fixation with locking plate is utilized for fixation of long bone fractures. One retrospective study for open reduction and supercutaneous fixation of the calcaneus is reported. We prospectively evaluated the use of this method of fixation combined with percutaneous reduction.

MATERIALS AND METHODS

Between January 2014 and June 2015, 32 displaced calcaneus fractures in 30 patients were stabilized with percutaneous reduction and super-cutaneous fixation. They were 24 males and six females. The mean age was 37.9±5.7 years (21-55). All cases were closed. The time to surgery, complications, radiographic alignment, and time to radiographic union were recorded. Clinical results at the final follow-up were assessed by evaluating Bohler's angles for the radiographic alignment, and the system of the American Orthopedic Foot and Ankle Society (AOFAS) for the functional outcome.

RESULTS

According to the Sanders' classification, two cases were type II, 17 cases were type III and 13 cases were type IV. The preoperative average Bohler's angle was 10.57°±4.8. The postoperative X-ray films demonstrated that the average Bohler's angle improved to 29.07°±5.9 (p<0.001). At the time of radiologic healing (about 3 months), the plates and screws were removed under general anesthesia. The average follow-up was 13.2 months (11-18). Four cases (type IV) showed mal-union and heel pain. According to (AOFAS) rating, the fine score was 87.1±17.1 points.

CONCLUSION

Super-cutaneous fixation with percutaneous reduction of calcaneal fracture is an effective method in type II and III and can be effective with type IV but with less favorable results.

Complications during removal of conventional versus locked compression plates: is there a difference?

BACKGROUND

Osteosynthesis plate removal is one of the most commonly performed procedures in orthopaedic surgery. Due to technological advances and the quality of increasing osteosynthesis material, more and more locked plates have been implanted over the last 20 years. The aim of this study was to determine whether the complication rate during plate removal differs between conventional and locked plates.

MATERIAL AND METHODS

In this retrospective cohort study, 620 patients were included and divided into two groups based on the type of plate (locked and conventional). Technical complications during implant removal included screw breakage, destroyed screw head, implant breakage, remaining implant material, refracture, bony or soft tissue overgrowth. The following plate-associated complications were identified: osteosynthesis plate not detachable, plate bent or broken, necessity of special tools or plate loosened. Three types of screw-related complications were observed: screw not detachable, screw broken or screw dislocated.

RESULTS

Overall, complications related to the plate or screws were documented in 110 of the 620 cases. These complications occurred in 48 of the 382 cases involving conventional osteosynthesis (7.7% of all removals, 12.6% of all conventional removals) and in 62 of the 238 cases involving locked plate osteosynthesis (10.0% of all removals, 26.1% of all locked plate removals). The statistical analysis showed a significantly higher implant-related complication rate with locked plates compared to the conventional plates (p < 0.01).

CONCLUSIONS

Hardware removal can be a complication-afflicted operation, especially cases involving locked-plate removal should only be performed if a strong indication is evident. Possible benefits of the procedure should be considered carefully, taking the cost-benefit ratio into account.

A biomechanical comparison study of a modern fibular nail and distal fibular locking plate in AO/OTA 44C2 ankle fractures

Background

A lateral approach with open reduction and internal fixation with a plate is a very effective technique for the majority of distal fibular fractures. However, this open approach for ankle fixation may be complicated by wound dehiscence and infection, especially in high-risk patients. An alternative to plating is an intramedullary implant, which allows maintenance of length, alignment, and rotation and which allows for decreased soft tissue dissection. While there has been clinical data suggesting favorable short-term outcomes with these implants, there is no current biomechanical literature investigating this technology in this particular fracture pattern. This study sought to biomechanically compare an emerging technology with an established method of fixation for distal fibular fractures that traditionally require an extensive exposure.

Methods

Ten matched cadaveric pairs from the proximal tibia to the foot were prepared to simulate an Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) 44C2 ankle fracture and randomized to fixation with a distal fibular locking plate or intramedullary fibular rod. A constant 700-N axial load was applied, and all specimens underwent testing for external rotation stiffness, external rotation cyclic loading, and torque to failure. The syndesmotic diastasis, stiffness, torque to failure, angle at failure, and mode of failure were obtained from each specimen.

Results

There was no significant difference in syndesmotic diastasis during cyclic loading or at maximal external rotation between the rod and plate groups. Post-cycle external rotation stiffness across the syndesmosis was significantly higher for the locking plate than the fibular rod. There was no significant difference between the rod and plate in torque at failure or external rotation angle. The majority of specimens had failure at the syndesmotic screw.

Conclusions

In the present cadaveric study of an AO/OTA 44C2 ankle fracture, a modern fibular rod demonstrated less external rotation stiffness while maintaining the syndesmotic diastasis to within acceptable tolerances and having similar failure characteristics.

The bicipital groove as a landmark for reconstruction of complex proximal humeral fractures with hybrid double plate osteosynthesis

Background

Complex proximal humerus fractures with metaphyseal comminution remain challenging regarding reduction and stability. In most fracture patterns the hard bone of the bicipital groove remains intact. In this case series, we describe a novel technique of hybrid double plate osteosynthesis of complex proximal humerus fractures with metaphyseal comminution.

Methods

In randomly chosen shoulder specimens and synthetic bones, pilot studies for evaluation of the feasibility of the technique were performed. Between 4/2010 and 1/2012 10 patients underwent hybrid double plate osteosynthesis. Seven patients (4 male, 3 female, mean age was 50 years (range 27–73)) were available for retrospective analysis. Based on plain radiographs (anterior-posterior and axial view), the fractures were classified according to the Orthopaedic Trauma Association classification (OTA) and by descriptive means (head-split variant (HS), diaphyseal extension or comminution (DE)).

Results

Follow-up radiographs demonstrated complete fracture healing in six patients and one incomplete avascular necrosis. None of the patients sustained loss of reduction. Three patients where reoperated. The medium, not adapted, Constant score was 80 Points (58–94). Patients subjective satisfaction was graded mean 3 (range: 0–6) in the visual analog scoring system (VAS).

Conclusion

The technique of hybrid double plate osteosynthesis using the bicipital groove as anatomic landmark may re-establish shoulder function after complex proximal humerus fractures in two dimensions. Firstly the anatomy is restored due to a proper reduction based on intraoperative landmarks. Secondly additional support by the second plate may provide a higher stability in complex fractures with metaphyseal comminution.

Locked plate versus retrograde intramedullary nail for periprosthetic femur fractures above total knee arthroplasty: a meta-analysis

PURPOSE

Locked plate (LP) and retrograde intramedullary nail (RIN) are the most commonly used treatment options for periprosthetic femur fracture above total knee arthroplasty (TKA). Controversy still exists regarding which is better. Therefore we performed a meta-analysis to compare their clinical results.

METHODS

A comprehensive search was conducted through PubMed, EMBase and the Cochrane Collaboration Library. Six comparative studies (265 patients) were included for the meta-analysis.

RESULTS

No statistically significant differences were found between the LP group and RIN group in terms of six month union rate (OR, 1.19; 95 % CI, 0.52-2.69; P = 0.68), union time (WMD, 0.22; 95 % CI, -0.41 to 0.84; P = 0.50), operation time (WMD, 0.54; 95 % CI, -13.09 to 14.17; P = 0.94) or complication rate (OR, 0.79; 95 % CI, 0.22-2.91; P = 0.73). The LP fixation may have a relatively higher re-operation rate (OR, 5.17; 95 % CI, 1.02-26.27; P = 0.05) compared with RIN. The mean union time was 4.0 months in the LP group and 3.7 months in the RIN group.

CONCLUSION

This meta-analysis found no statistically significant difference in six month union rate, union time, operation time and complication rate between the LP group and RIN group. The RIN fixation may have a potential of lower re-operation rate compared with LP. The mean union time was 4.0 months in the LP group and 3.7 months in the RIN group.

The oblique fracture of the manubrium sterni caused by a seatbelt--a rare injury? Treatment options based on the experiences gained in a level I trauma centre

INTRODUCTION

Sternal fractures are rare with 3-8 % out of the total number of trauma cases mostly caused by direct impact to the anterior chest wall. Most cases described are due to motor vehicle crash either caused by direct impact to the steering wheel or by the seat belt. Fractures mainly occur to the sternal body. Only rarely are cases of manubrium fractures described in literature, for example, in relationship with a direct impact to the shoulder which caused an oblique fracture near to the sternoclavicular joint. Three patients with profoundly dislocated oblique manubrium fracture were admitted to our Level I Trauma Center in 2012 and 2013. Those patients suffered from instability of the upper sternum and the shoulder girdle.

MATERIAL AND METHODS

Between January 2012 and October 2013, a total of 538 trauma patients were admitted to the emergency room and received whole body CT-scan. They were analysed retrospectively for sternal fractures. In cases of instability and dislocation, fracture stabilisation was performed by anterior plating through a medial approach using low profile titanium plates (MatrixRib®).

RESULTS

Seventy-nine (14.7 %) patients showed sternal fracture, out of which 13 (2.4 %) patients showed a fracture of manubrium, ten caused by seatbelt. In three cases stabilization was performed. Follow up showed sufficient consolidation without complications.

DISCUSSION

A total of 16.5 % of sternal fractures were localized at the manubrium, mostly caused by seat belt. Fractures without significant dislocation seemed to be stable and healed well under conservative treatment. Dislocation in this region leads to unstable shoulder girdle. Anterior plating provides sufficient stabilisation and allowed consolidation.

A comprehensive update on current fixation options for two-part proximal humerus fractures: a biomechanical investigation

BACKGROUND

Recent advancements in implant technology offer updated options for surgical management that have been rapidly adopted into clinical practice. The objective of this study is to biomechanically test and compare the current fixation options available for surgical fixation of two-part proximal humerus fractures and establish load to failure and stiffness values.

METHODS

Sixteen match-paired (32 total) fresh-frozen, cadaveric specimens were randomized to receive 1 of 4 fixation constructs following creation of an AO/OTA Type 11A3 (two-part) proximal humerus fractures. Fixation constructs tested consisted of 3.5 mm fixed angle plate (3.5-FAP), 4.5 mm fixed angle plate (4.5-FAP), humeral intramedullary nail (IMN), and a humeral intramedullary nail with a fixed angle blade (IMN-FAB). Specimen bone density was measured to ensure no adequate, non-osteoporotic bone. Constructs were tested for stiffness and ultimate load to failure and compared via one-way ANOVA analysis with subsequent post hoc Tukey HSD multiple group comparison statistical analysis.

RESULTS

The IMN-FAB construct was significantly stiffer than the 3.5-FAP construct (123.8 vs. 23.9, p<0.0001), the 4.5-FAP construct (123.8 vs. 33.3, p<0.0001) and the IMN construct (123.8 vs. 60.1, p=0.005). The IMN-FAB construct reported a significantly higher load to failure than the 3.5-FAB construct (4667.3 N vs. 1756.9 N, p<0.0001), and the 4.5-FAP construct (4667.3 N vs. 2829.4 N, p=0.019, Table 2). The IMN construct had a significantly higher load to failure than the 3.5-FAP construct (3946.8 vs. 1756.9, p=0.001, Table 2).

CONCLUSION

Biomechanical testing of modern fixation options for two-part proximal humerus fracture exhibited that the stiffest and highest load to failure construct was the IMN-FAB followed by the IMN, 3.5-FAP and then the 4.5-FAP constructs. However, prospective clinical trials with longer-term follow-up are required for definitive assessment of the ideal fixation construct for surgical management of two-part proximal humerus fractures.

Treatment of unstable distal third clavicular fracture with locked distal radius plate

BACKGROUND

The ideal surgical fixation for displaced distal clavicle fractures should not involve restrictions of the movements of nearby joints.

AIM OF THE WORK

To evaluate the results of internal fixation of unstable displaced distal third clavicle fractures using locked distal radius plates.

PATIENTS AND METHODS

Fifteen patients with Type II distal clavicle fractures were treated with open reduction and internal fixation using locked distal radius plates.

RESULTS

Thirteen patients achieved full range of motion of the shoulder while two patients had minor limitations. The mean modified shoulder score was 18.3 at the final follow-up. None of the patients developed implant failure, loss of reduction, wound breakdown, or deep infection.

CONCLUSION

Good clinical results can be achieved with locked distal radius plate fixation in Type II fractures of the distal clavicle. With this technique, range of shoulder movement could be restored early without the needs for implant removal.

Polyaxial Locked Implants in the Treatment of Type Vancouver B1 Periprosthetic Fractures of the Femur: Retrospective Clinical Examination in 58 Cases with Review of the Literature

We concluded a retrospective study of the outcomes of a consecutive series of Vancouver B1 and C femoral injuries using two specific locked implants. The study center is a dedicated trauma hospital with a large catchment area. Over a five-year period we treated 58 patients with a periprosthetic fracture of the femur with an angular stable plate, defined as the index procedure. The mean age at the index procedure was 72.4 years; 40 patients were female (69%). In 32 cases (55.2%) we saw a hip endoprosthesis, in 21 cases (36.2%) a knee endoprosthesis, and in five cases both (8.6%). Outcome measures were intra- and postoperative complications, bony union, degree of mobility and social status with comparison to the preoperative status, Barthel index, and timed ''up and go'' test. Union occurred in 56 cases (96.5%) after the index procedure. Three patients were bedridden before the injury; the remainder regained full weight-bearing status. The mean duration until full weight-bearing status in these patients was 8.6 weeks (4-13). Early implant failure with proximal dislocation of the screws occurred in two cases (3.5% revision rate). At follow up, 78% had maintained the same social status as before the injury. Fifty-two patients (89%) had regained their previous level of mobility. The mean Barthel index was 85 points (70-100) out of a possible 100, and improved from a mean of 35 points at the start of rehabilitation. It decreased on average by ten points compared to the preoperative status. The mean ''up and go'' time was measured as 21.4 s. In conclusion, polyaxial plates can achieve excellent surgical results. On the other hand, patients with this type of injury exhibit a clear deterioration in their social status, especially regarding lower limb motor function and self-independence.

Is the Wave Plate Still a Salvage Procedure for Femoral Non-union? Results of 75 Cases Treated with a Locked Wave Plate

OBJECTIVE

To analyse the results of the treatment of aseptic femoral non-unions using a singular locked implant.

DESIGN

Consecutive case series.

SETTING

A level-1 trauma center with a high number of specialist referrals.

PATIENTS

The study is based on a consecutive series of patients with prospective data evaluation. From 1993 to 2003, 75 patients were treated with a wave plate. All patients had persistent non-union of the femoral shaft without clinical or laboratory signs of infection and previous unsuccessful attempts to treat the non-union.

INTERVENTION

The method of treatment was standardized and included a lateral approach, cancellous bone hip grafting, osteosynthesis with a wave-shaped plate (PPF) and polyaxial locking screws as well as the application of a gentamicin-PMMA chain.

MAIN OUTCOME MEASUREMENTS

Time to achieve union, rate of implant failure and number of remaining nonunions after treatment. A total of 75 patients had full follow-up and were included in the study.

RESULTS

The union of the fracture was found in 64 patients after the initial procedure. In eight cases a second procedure was performed to achieve union in the form of a second bone graft because of a delay in callus formation. The mean time to union was 7.3 months with a range from 3 to 19 months. The implant failed in three cases accounting for 4% of the total.

CONCLUSION

The locked wave plate offers a further reliable treatment for complex aseptic femoral non-unions.