Transverse patella fracture fixation: A cadaveric biomechanical comparison of cannulated screws and anterior tension band versus low-profile, multiplanar mesh plating

INTRODUCTION

Multiplanar mesh plating of patella fractures has become more popular in recent years. It was the goal of this study to compare the biomechanical stability of cannulated screw with anterior tension band to multiplanar mesh plating for fixation of transverse patella fractures in cadaver specimens.

MATERIALS AND METHODS

Eight matched pairs of fresh frozen cadaveric knees were obtained and soft tissues dissected leaving the extensor mechanism, joint capsule, and retinaculum intact. Transverse fractures were created at the mid-portion of the patella. For each pair, one specimen was repaired using cannulated screws with anterior tension band, and the second was repaired using multiplanar mesh plating. Each specimen underwent cyclic extension loading with loads increasing by 1.1 kg after every 50 cycles. Interfragmentary displacement was measured at the end of each interval at both 5° and 45° of knee flexion angle, with fixation failure defined by >2 mm displacement.

RESULTS

The specimens fixed with multiplanar mesh plating survived more cycles and higher loads than the specimens fixed with cannulated screws with anterior tension band (p = 0.011 comparing survival plots). After 150 cycles of extension loading, 3 of 8 of the specimens fixed with screws/tension band had failed, whereas none of the mesh plated specimens had failed. After 400 cycles, 7 of 8 of the screws/tension band had failed, whereas half of the mesh plated specimens had failed.

CONCLUSIONS

While a more technically challenging and expensive technique, mesh plating for patella fractures appears to offer greater durability than traditional cannulated screw with tension banding.

Treating Inferior Pole Fracture of Patella with Hand Plating System: First Clinical Results

OBJECTIVE

Inferior pole fractures of patella are notorious fractures where it is difficult to obtain rigid internal fixation by conventional methods. The objective of the study was to introduce the Hand Plating System (HPS), which was a novel surgical technique for inferior pole fractures of patella, and to report the radiological and clinical outcomes following the application of the surgical technique.

METHODS

The study was designed as a retrospective cohort study. Between July 2017 and December 2018, 30 patients who were diagnosed with inferior pole fracture of the patella without additional orthopaedic injuries were enrolled in this case series. After X-ray and 3D-CT examinations, all patients underwent open reduction and internal fixation by HPS with or without supplementary cannulated screw and lag screw stabilization. The bony union time, final range of motion (ROM), Bostman score, visual analog scale (VAS), and complications were measured as the clinical outcomes under a minimum of 12 months of follow-up.

RESULTS

All of the operations went well with the mean operative time of 76.2 ± 15.3 min. Bony union achieved in all the cases at an average of 9.5 ± 1.4 weeks after surgery. There was no loss of reduction, fixative failure, or surgical implant removal during follow-up. The average range of motion 1 year postoperatively was 0°-123.3°. The mean Bostman Score at the last follow-up was 26.8 ± 2.1 with the satisfactory rate of 100%. The pain feeling during walking as measured by VAS averaged at 0.9 ± 1.3. No complications developed except for one case of poor incision healing, which healed eventually after surgical debridement.

CONCLUSIONS

HPS was demonstrated as a secure fixation and as a kind of tension band for inferior pole fractures of the patella. Satisfactory recovery of knee function and low complication rate, including no need for hardware removal, could be expected.

A cortical screw based tension band construct for transverse patella fractures: An evolving strategy for addressing common modes of failure

INTRODUCTION

Displaced patella fractures represent a clinical challenge. We evaluate the effectiveness of an alternative fixation construct to address common modes of fixation failure.

METHODS

A retrospective review of 49 patients who underwent fixation via the specific construct at a single institution between 2013 and 2019.

RESULTS

Median follow-up was 52.7 weeks (Mean: 75.4 weeks; SD: 54.9; range: 27-267.7 weeks). Construct failure rate was 6.1% (3/49). This included two mechanical hardware failures, one the result of trauma and the other due to noncompliance.

CONCLUSIONS

The modified construct represents a safe and effective means of treating transverse patella fractures.

LEVEL OF EVIDENCE

Level 4.

A case report of patellar fracture treated by percutaneous strong suture technique

Tension-band wiring with metal such as Kirshner wire or soft steel wire is commonly used for the treatment of patellar fractures. In recent years, metal-free surgery using a strong suture with high breaking strength has been reported to have excellent outcomes. We report a case of patellar fracture treated with a minimally invasive percutaneous strong suture. The patient is a 57-year-old salesman who fell at work, hit his knee, and came to our hospital complaining of pain. His range of motion was −15° in extension and 60° in flexion. His X-ray results showed a transverse fracture of the right patella with a 3-mm displacement, and surgery was performed 7 days post-injury. A small incision of 1 cm was made distally and proximally on the patella. Two 2.0-mm perforated K-wires were inserted from distal to proximal sides, and the wire was pulled out proximally with FiberWire® No. 2. The distal end of the FiberWire was pulled through the proximal incision via the anterior surface of the patella and finally fastened. The procedure was completed in 21 min. The patient did not use a brace since the operation day and was not restricted in terms of load or range of motion. He was able to walk without any assistance after 10 days and returned to driving and office work 14 days postoperatively. At the final follow-up, no symptoms of skin irritation were detected, and the patient did not require suture removal.

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Patella fractures are operated with strong sutures such as fiberwire.

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Strong suture technique has the same or higher strength as soft steel wire tension band.

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Less complications such as subcutaneous pain due to the non-metal method.

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Strong suture technique can be performed percutaneously.

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Strong suture technique is minimally invasive surgery for patellar fractures.

Treatment of olecranon fractures using an intramedullary cancellous screw and suture tension band: minimum 2-year follow-up

Background

Tension band wiring and plates are the most widely used treatments for transverse displaced fractures of olecranon despite high rates of hardware complications, subsequent implant removal, and associated costs. The purpose of this study was to report the outcomes of displaced transverse olecranon fractures treated with intramedullary screw and suture tension band.

Methods

We performed an observational, retrospective, consecutive, monocentric, continuous multioperator study. We reviewed 31 Mayo type IIA displaced olecranon fractures treated in our institution with intramedullary 6.5 mm AO cancellous screw and high-strength suture tension band (No. 2 FiberWire®) from 2016 to 2018. Inclusion was limited to functionally independent patients with Mayo type IIA fractures and minimum 24-month follow-up for implant removal. We assessed clinical outcomes including range of motion; QuickDASH score; and Mayo Elbow Performance Score. Categorical data were analyzed with Fisher's exact test when appropriate. Continuous data were analyzed with the Student t-test or Mann-Whitney U test after assessment for normality. Statistical analysis was performed with STATA 16 software.

Results

Twenty-seven patients with a mean follow-up period of 38.4 ± 6.2 months (range, 24.1-50 months) were included in the study. The average flexion was 134.5° ± 14.8° (range, 70°-140°) and the mean extension was -5.9° ± 7.0° (range, -20°-0°). Mean pronation and supination were 85.8° ± 11.9° (range, 45°-90°) and 86.9° ± 14.3° (range, 20°-90°), respectively. The mean Mayo Elbow Performance Score was 90.8 ± 9.6 (range, 70-100) with 92.3% good and excellent results. The mean QuickDASH score was 17.1 ± 16 (range, 0-54.5). There were 3 hardware-related removals (11.1%). The overall removal rate was 18.5%. Univariate analysis of the factors associated with implant removal were pain in relation to the implant (60% vs. 11%, P = 0.0482), proximal screw migration (3.7 mm vs. 1.7 mm, P = 0.05), articular angle (22.5° vs. 27.7°, P = 0.0353), and olecranon width (22.2 mm vs. 24.4 mm, P = 0.0166). In total, 26.1% of the cases presented some degree of proximal migration of the implant (2.7 ± 1.8 mm of migration; range, 1.5-6.2 mm). Univariate analysis of the factors associated with implant proximal migration were proximal ulnar dorsal angulation (1.7° vs. 6.4°, P = 0.0179), anteroposterior endomedullary canal (7.3 mm vs. 6.0 mm, P = 0.0369), and lateral endomedullary canal (7.2 mm vs. 5.0 mm, P = 0.0219).

Conclusion

The functional outcomes of simple transverse olecranon fractures treated with an intramedullary cancellous screw and a suture tension band are excellent, associated with a low rate of complications and material removal.

A retrospective cohort study on prevalence of postoperative complications in comminuted patellar fractures: comparisons among stabilized with Cannulated-Screw, Kirschner-Wire, or Ring-Pin Tension Bands

Background

Displaced patellar fractures are commonly treated with open reduction and fixation with several different types of tension-band (TB) constructs. The main objective of this study was to compare the prevalence of postoperative complications after surgical stabilization of comminuted patellar fractures with either a modified Kirschner-wire tension band (MKTB), a cannulated-screw tension band (CSTB), or a ring-pin tension band (RPTB).

Methods

We conducted a retrospective and consecutive cohort study of comminuted patellar fractures (n = 334) stabilized using a TB construct. Postoperative premature loss of reduction, infection, and skin breakdown were compared according to the type of TB constructs received (MKTB, CSTB, or RPTB). The rate of implant removal due to symptomatic hardware was also evaluated.

Results

Fixation failure rate was significantly different among the groups (P = 0.013), with failure rates of 4.7% observed in the MKTB group,14.5% in the CSTB group, and 4.9% in the RPTB group. Skin breakdown and infection were not significantly different among the groups (Ps > 0.05). Due to symptomatic hardware, 40.5% of the patients in the MKTB group, 22.9% in the CSTB group, and 24.3% in the RPTB group underwent implant removal (P = 0.004). After adjusting for age, gender, comorbidities, number of supplementary screws/K-wires, and use of cerclage cables, multivariate regression analysis revealed that CSTB contributed to a 2.08-times greater risk of fixation failure compared to RPTB, while MKTB and RPTB were similar in risk of failure. In addition, it was found that patients who underwent MKTB fixation were more than twice as likely to undergo implant removal for symptomatic hardware compared with RPTB (odds ratio = 2.11, 95% CI = 1.20 to 3.72; P = 0.010).

Conclusions

RPTB have advantage over MKTB and CSTB fixation in terms of symptomatic hardware and premature failure, respectively.

Level of evidence

Therapeutic Level III

A Novel Technique for Supplementing Transosseous Suture Repair of Inferior Pole Patella Fractures with a Tension Band

INTRODUCTION

The transosseous suture fixation is a recognised surgical technique for inferior pole patella fractures. However, post-operative range of motion (ROM) is typically restricted to reduce complications of fracture displacement. We present a novel modified surgical technique using a supplemental Ethibond figure-of-eight stitch to reinforce the transosseous suture repair and studied its outcomes. We performed a retrospective study looking at outcomes of patients with displaced inferior pole patella fractures who underwent modified suture fixation from 2010 to 2018.

OPERATIVE TECHNIQUE

In the modified suture fixation technique, after the standard transosseous repair was performed, the remnant Ethibond suture was placed in a figure-of-eight tension band fashion anteriorly across the patella. Immediate post-operative ROM was allowed if the fixation was stable. The patients were assessed up to 6 months post-surgery to monitor for fracture displacement/gap and for bony union.

CASE SERIES

We analysed the results of 14 patients who underwent modified suture repair. All patients were allowed immediate post-operative ROM. Only 1 fixation failure (7%) was noted at 6 months.

CONCLUSION

Complication rates were low with the modified technique even when patients were allowed immediate post-operative mobilisation. This shows greater confidence in the stability of the fixation and represents a viable technique for early mobilisation post-fixation of inferior pole patella fractures.

Olecranon mayo IIA fractures treated with transosseous high strength suture: A series of 29 cases

BACKGROUND

The aim of this study is to assess the causes and rates of re-operation in olecranon fractures in adults treated with transosseous suture.

METHODS

We prospectively recruited 29 patients who were treated with this technique between 2010 and 2018. The type of suture used, tourniquet time and surgical time were analyzed for each one. X-rays were taken after 2 weeks, 6 weeks and 6 months, recording complications, causes, rates of re-operation and the final clinical condition.

RESULTS

Median time for ischemia and surgery were 51 (95% CI:48;62) and 45 (95% CI:42;55) minutes respectively. The radiologic studies showed diastasis of the posterior cortex in the X-rays taken after 2 weeks and after 6 weeks in 7 (24,1%) cases. Of these cases, two (6,8%) were no longer followed-up after 6 months. There was only one case of aseptic non-union. Among these cases, two patients (6.8%) required surgical debridement due to acute soft tissue infection. No complication had any clinical impact, maintaining all patients full range of motion and no pain. Osteosynthesis removal was not necessary in any case.

CONCLUSION

Transosseous suture with high strength thread is a valid alternative for treating Mayo IIA olecranon fractures in adult patients, decreasing re-operation rates for implant removal. There may be, in a moderate percentage of cases, radiologic diastasis of the posterior cortex at the fracture site, without causing pain nor limiting mobility LEVEL OF EVIDENCE: III.

Patella fractures treated with cannulated lag screws and fiberwire® have a high union rate and low rate of implant removal

OBJECTIVES

The purpose of this study is to report the results of open reduction internal fixation of patella fractures (OTA 34 A-C) using cannulated lag screws and FiberWire® (Arthrex, Naples, FL, USA) with regard to union and symptomatic implant removal.

DESIGN

Retrospective review of prospectively collected database.

SETTING

Urban Level 1 trauma center and Level 2 trauma center METHODS: All displaced intra-articular patella fractures (OTA 34 A-C) treated with ORIF by cannulated lag screws and FiberWire® tension band/cerclage between January 1, 2009 and August 1, 2018. Three hundred and eighty seven consecutive patients were identified. Fifty fractures were included in the final analysis.

MAIN OUTCOME MEASUREMENT

All patients were followed to clinical and radiographic union. Nonunion was defined as lack of clinical and radiographic union, fracture displacement, and/or return to OR for revision surgery. Rate of symptomatic implant removal was recorded.

RESULTS

Average age was 57.7 years (range 21-86). Average follow up was 20.6 months (range 6-98 months). Average time to clinical and radiographic union was 3.1 months (range 3-7 months). Four fractures were open. There was a 96% (48/50) rate of primary union, with one patients requiring revision surgery to achieve union, and one developing an asymptomatic radiographic nonunion. The rate of symptomatic implant removal was 8% (4/50). Only 1 of the 4 was operated for a prominent suture knot, and the remaining 3 were for prominent screw removal. Knee range of motion averaged 0.37° extension to 119° flexion (range, 0-150°).

CONCLUSION

Patella fractures can be treated with cannulated lag screws and FiberWire® with a high rate of primary union (96%) and a low rate of symptomatic implant removal (8%). The implant removal rate compares favorably with alternative constructs, with an equivalent rate of fracture union.

Comparison of a modified technique with conventional tension-band using Cable Grip System for comminuted patella fractures

INTRODUCTION

Treatment of comminuted patella fractures with tension band has resulted in impaired functional outcomes because the relationship between tension band and the tendons is always underestimated. We developed a modified enlacement (ME) technique to better place the tension-band under the quadriceps and patellar tendons and close to the patella. The study aimed to compare the ME with conventional enlacement (CE) technique regarding recovery of knee function.

PATIENTS AND METHODS

51 patients with comminuted patella fractures operated between January 2012 and December 2016 were reviewed retrospectively. 22 patients in the ME group (9 males and 13 females) with a mean age of 51.3 years, 29 patients in the CE group (16 males and 13 females) with a mean age of 47.1 years. ROM was measured at postoperative intervals of 1, 2, 4, 12, and 48 weeks; Knee function was evaluated using the Rasmussen scores at 4, 12, and 48 weeks postoperative.

RESULTS

There was no difference (P = 0.082) regarding the fracture healing time between the two groups. Patients with the ME technique had clinically and statistically significantly higher ROM recovery throughout the study period (P < 0.001) with an earlier recovery. The Rasmussen scores also demonstrated significant improvements in patients with ME technique than CE group at all time-points (P < 0.05). Three patients in the CE group had migration of K-wires, with no migration observed in the ME group.

CONCLUSION

The ME technique enables improved clinical outcomes and functional performance for the treatment of comminuted patella fractures.

Comparison of a Novel Tension Band and Patellotibial Tubercle Cerclage in the Treatment of Comminuted Fractures of Inferior Pole of the Patella

Objective

To assess the therapeutic effect of a novel tension band using 3.0 mm cannulated screw combined with a titanium cable and specific shims comparatively with patellotibial tubercle cerclage in comminuted fractures of the inferior pole of the patella.

Methods

The retrospective study from March 2012 to July 2017 was conducted in Peking University Third Hospital and comprised 63 patients with comminuted fractures of the inferior pole of the patella: 41 treated with new tension band using 3.0 mm cannulated screw combined with a titanium cable and specific shims (new tension band group) and 22 with patellotibial tubercle cerclage (tubercle cerclage group). Gender, age, AO/OTA fracture type, injury mechanism, inter‐fragmentary gap, and follow‐up time of patients were recorded. Two groups were compared regarding: operation time, blood loss, partial weight‐bearing time, fracture‐healed time, Bostman score and knee mobility at 12‐month follow‐up, and postoperative complications. Continuous and categorical parameters were analyzed by Mann‐Whitney U test and the chi‐squared test, respectively. Fisher's exact test was used for small data subsets.

Results

Between the two groups, no statistically significant difference was found in mean age, gender, AO/OTA fracture type, injury mechanism, mean inter‐fragmentary gap, or mean follow‐up time (P > 0.05). The mean operation time of new tension band group was significantly longer than that of tubercle cerclage group (76.4 min vs 64.2 min, P = 0.006), while there was no significant difference in blood loss. After surgery, new tension band group had a significantly earlier mean partial weight‐bearing time (5.2 weeks vs 7.4 weeks, P < 0.001) and fracture‐healed time (9.6 weeks vs 11.6 weeks, P < 0.001). At 12‐month follow‐up, patients of new tension band group had a significantly higher mean Bostman score (28.5 vs 25.8, P < 0.001) and knee mobility (126.7 vs 117.3, P < 0.001). Ten complications related with internal fixation were found in tubercle cerclage group including two cases of loose internal fixation, two cases of cerclage breakage, and six cases of low patella position who undertook secondary operation. No complications were found in new tension band group (0 in 41 vs 10 in 22, P < 0.001).

Conclusion

Patients with comminuted fractures of the inferior pole of the patella treated with a novel tension band experienced a longer operation time, but earlier partial‐weight‐bearing and fracture‐healed time, better clinical outcomes at 12‐month follow‐up, and less complications. It should be considered an alternative therapy for the treatment of distal pole patellar fractures.

Temporary epiphysiodesis using the FlexTack™ implant (tension band) featuring a modified explantation technique

OBJECTIVE

Presenting the implantation of the PediatrOS™ FlexTack™ (Merete, Berlin, Germany) for growth guidance and a modified explantation procedure to facilitate explantation and prevent bone and soft tissue damage.

INDICATIONS

Implantation: Genua vara and valga, coxa vara, varus and valgus deviation of the ankle joint, the elbow joint and the wrist Modified Explantation: Removal of the implant after successful limb correction or dislocation of the implant.

CONTRAINDICATIONS

Implantation: Closed growth plates, insufficient remaining growth potential, acute or chronic infection, insufficient osseous structures, severe muscular, nervous or vessel diseases endangering the respective limb Explantation: General inoperability of the patient.

SURGICAL TECHNIQUE

Implantation: Localization of the growth plate. Insertion of K‑wire parallel to joint line on the joint side. Setting of the implant. Insertion of second K‑wire and insertion with the implantation instrument and hammer. Modified Explantation: Cutting of the implant bridging part. Both ends of the bridging part are bent vertically to prevent soft tissue damage. Dissection of both implant arms from the bone with the chisel. Extraction in 360° motion using tooth extraction pliers.

POSTOPERATIVE MANAGEMENT

Implantation: Full weight bearing. X‑ray controls every 3 months to control growth correction. Explantation: Full weight bearing.

RESULTS

Complications such as breaking of the k‑wires, breaking of the chisel or extraction of adhering bone tissue occurred in 14 of the 64 (21.9%) explanted FlexTack implants. Complication-free removal using the original instruments provided by the manufacturer was possible for five implants. The modified explantation procedure as described above was applied in 45 explanted implants (70.3%) with complete removal of the implant without further complications within the follow up period.

Comparison of outcomes of osteosynthesis in type II accessory navicular by variable fixation methods

BACKGROUND

To compare the outcomes of fixation methods for osteosynthesis of a type II symptomatic accessory navicular between screw and tension band wiring.

METHODS

Forty-four patients (mean age, 29.2 years; range, 13-54 years; 21 males and 23 females) who had undergone operative treatment after failed conservative treatment were chosen for the study between 2007 and 2014. The patients were divided into two groups by the method of osteosynthesis: group 1 (screw) and group 2 (tension band wiring). Pre and postoperative evaluations were performed, using the midfoot scale from the American Orthopaedic Foot and Ankle Society (AOFAS), a visual analog scale, time to return to social activities, and plain radiography.

RESULTS

The AOFAS midfoot and visual analog scale scores of both groups were improved at the last postoperative follow-up. The time to return to social activities was 12.3 weeks in the screw group and 11.9 weeks in the tension band wiring group (p=0.394). A broken screw was observed in one case in the screw group and a broken k-wire was detected in two cases in the tension band wiring group. Nonunion was observed in two cases in each group.

CONCLUSION

The tension band wiring technique could be another treatment choice of osteosynthesis for fixation of the accessory navicular bone.

LEVEL OF EVIDENCE

Level III, Retrospective Case Control Study.

Tension band or pre-formed plate? Analysis and results

OBJECTIVE

The objective of this study was to compare the clinical outcomes of surgical treatment using tension band with needles and preformed plates in type ii olecranon fractures according to the Mayo classification in patients older than 65 years.

MATERIAL AND METHOD

A descriptive, retrospective study of 49 patients with a mean age of 75.1 years who underwent surgery olecranon fracture using 2 different fixing systems. The Mayo classification was used to define them, excluding type i and iii, and the VAS to assess postoperative pain. Patients were assessed functionally by the questionnaire Quick DASH. All measurement was performed with goniometer and joint balance serial radiographs at one month, 3, 6 and 12 months. Minimum follow-up was one year.

RESULTS

In 26 patients the tension band was used and the preformed plates in 23. There were no statistically significant differences in functional outcomes, joint balance or postoperative VAS between the 2 groups. There were a greater proportion of patients who had to be operated because of problems related to osteosynthesis material in those in which preformed plates were used.

CONCLUSIONS

Treatment of olecranon fractures with tension band with needles and cerclage remains the surgery of choice in patients older than 65 years.

Tension band wiring for simple olecranon fractures: evaluation of surgical technique

Background

In some settings, specific techniques for open reduction and internal fixation are preferred based on the eminence of a surgeon or professional organization. An emphasis on technical aspects of surgery that are not proved superior and vary substantially from surgeon to surgeon can be confusing for trainees. This study applied a numerical grading of the technical aspects of tension band wire (TBW) fixation for olecranon fracture; assessed the interobserver agreement of each criterion; and measured the correlation of the technical grading and objective and subjective long-term outcomes.

Materials and methods

Forty observers were invited to rate the technical aspects of TBW fixation of the olecranon on 26 post-operative radiographs. The interobserver reliability of the rating was measured using the intra-class correlation coefficient. The correlation between the rating and motion, Mayo elbow performance index, and disabilities of the arm, shoulder and hand score was tested with the Spearman’s rank correlation test.

Results

None of the figure-of-eight TBW constructs were considered perfect according to the numerical grading: the majority of observers found three deviations per fixation. The interobserver agreement was only fair for the total number of deviations and no correlation between the number of deviations and long-term objective and subjective outcome was found.

Conclusions

A rating of the technical aspects of TBW for olecranon fractures was unreliable and did not correlate with subjective and objective outcomes. Emphasis on specific technical aspects of fixation might be confusing for trainees and could distract them from the principles of effective treatment.

Level of evidence

Level IV diagnostic study.

Os acromiale fixation: a biomechanical comparison of polyethylene suture versus stainless steel wire tension band

BACKGROUND

Symptomatic hardware is a commonly reported complication after surgical fixation of an unstable meso-type os acromiale. This study compared the biomechanical properties of a cannulated screw tension band construct using a metal wire tension band vs. a suture tension band, considering that the suture construct could allow for decreased hardware burden in the clinical setting.

METHODS

A meso-type os acromiale was created in 16 cadaveric shoulders. Two cannulated 4-mm screws were placed in each specimen. Tension band augmentation was accomplished with a 1-mm stainless steel wire (wire group) or a #5 braided polyethylene suture (suture group), with 8 specimens in each group. An inferiorly directed force was applied to the anterior acromion at 1 mm/s on a materials testing machine. Stiffness and ultimate failure load were recorded and analyzed.

RESULTS

No significant difference (P = .22) was observed in the ultimate failure load between the wire (228  ± 85 N; range, 114-397 N) and the suture (275 ± 139 N; range, 112-530 N). No significant difference (P = .17) was observed in the stiffness between the wire (28  ± 12 N/mm; range, 18-53 N/mm) and the suture (38  ± 25 N/mm; range, 10-83 N/mm).

CONCLUSIONS

Stainless steel wire and polyethylene suture have similar biomechanical strength in the cannulated screw tension band fixation of meso-type os acromiale at time zero.

Non-metallic implant for patellar fracture fixation: A systematic review

INTRODUCTION

Despite good clinical outcome proposals, there has been relatively little published regarding the use of non-metallic implant for patellar fracture fixation. The purpose of the study was to perform a systematic literature review to summarize and evaluate the clinical studies that described techniques for treating patella fractures using non-metallic implants.

METHODS

A comprehensive literature search was systematically performed to evaluate all studies included in the literature until November 2015. The following search terms were used: patellar fracture, patella suture, patella absorbable, patella screw, patella cerclage. Two investigators independently reviewed all abstracts and the selection of these abstracts was then performed based on inclusion and/or exclusion criteria.

RESULTS

A total of 9 studies involving 123 patients were included. Patients had a mean age of 33.7 years and were followed up for a mean of 18.9 months. The most common method for fracture fixations included the use of suture material. Good clinical outcomes were reported among all studies. Thirteen patients (10.5%) presented complications, while 4 patients (3.2%) required additional surgery for implant removal.

CONCLUSION

There is a paucity of literature focused on the use of non-metallic implant for patellar fracture fixation. However, this systematic review showed that non-metallic implants are able to deliver good clinical outcomes reducing the rate of surgical complications and re-operation. These results may assist surgeons in choosing to use alternative material such as sutures to incorporate into their routine practice or to consider it, in order to reduce the rate of re-operation.

A comparative study in fixation methods of medial malleolus fractures between tension bands wiring and screw fixation

OBJECTIVES

The aim of this study is to compare two methods of internal fixations of fractured medial malleolus which are simple screw fixation and tension band wiring.

PATIENTS AND METHODS

Over 5 years we grouped 20 patients with fractured medial malleolus into two groups of operative treatments, group1 treated by malleolar screw fixation and group2 by tension band wiring. The patients were with same age group, gender, fracture type, and etiology. We use statistical analysis for make a comparative study between the two ways of surgical treatment.

RESULTS

The mean time for radiologic bone union was 11.8 weeks in group1 patients and 9.4 weeks in group2 patients (P = 0.03). No patients had any sign of fixation failure or Kirschner wires migration. According to the modified ankle scoring system of Olerud and Molander, excellent and good results were achieved in 80 % in group1 patients and 90 % in group2 patients (P = 0.049).

CONCLUSIONS

Tension-band wiring may be better treatment option for internal fixation of medial malleolar fractures than screw fixation.

RECOMMENDATIONS

From these findings we recommend a further randomized clinical trial of larger number of cases and longer follow-up duration in order to regard tension-band wiring a better operative option for fixation of medial malleolar fractures.

Surgical Management of Patellar Fractures

The patella plays a crucial role in the extensor mechanism to increase the mechanical advantage of the quadriceps. Fractures can be classified based on displacement, comminution, and fracture pattern, which often guide treatment. Modern treatment options include internal fixation using tension bands with Kirschner wires or cannulated screws, lag screw fixation, partial patellectomy, and rarely total patellectomy. Nondisplaced, closed patellar fractures or fractures with less than 2-mm articular steps can be successfully treated conservatively. Open fractures, articular step of 2 mm or greater, and loss of knee extension are indications for surgical intervention.

Olecranon Fractures

Olecranon fractures are common upper extremity injuries, with all but nondisplaced fractures treated surgically. There has been a recent shift in the surgical management of these fractures from tension band wiring to locking plate fixation and intramedullary nailing; however, this comes with increased implant cost. Although most patients can expect good outcomes after these various techniques, there is little information to guide a surgeon's treatment plan. This article reviews the epidemiology, classification, treatment, and outcomes of olecranon fractures.

A novel technique of patella fracture fixation facilitating early mobilization and reducing re-operation rates

OBJECTIVE

Fractures of patella constitute 1% of all fractures. Various techniques have been described for internal fixation of patella fractures. Superiority of one technique over the other has long been debated. We reviewed a series of fifty-one patients with transverse or comminuted fractures of patella treated with a novel technique to assess if it had any advantages over the existing methods of fixation.

DESIGN

Retrospective.

SETTING

A tertiary care centre.

PATIENTS & METHODS

Fifty-one patients with patella fracture OTA 34C, with a mean age of 39 years (range 18-61) were treated with technique of cerclage and two tension bands at our institute. Forty-eight patients completed the study.

MAIN OUTCOME MEASUREMENTS

Range of Motion and evidence of radiological union were assessed at regular follow-ups.

RESULTS

Forty-four out of forty-eight patients had gained up-to 90 degrees of active flexion at the end of 1 week. Two patients (4.2%) developed superficial infection. All fractures had united at the end of 12 weeks. Five patients (10.3%) underwent a second surgery; four (8.3%) due to implant related complications. Malunion or non-union was not noted in any of the cases.

CONCLUSION

The advantages of the described method are early mobilization, elimination of k-wire related complications, and ease of use in comminuted fracture pattern as well and a lower reoperation rates as compared to the available literature. We strongly recommend its use in cases of displaced comminuted/transverse fractures of patella as an alternate method of treatment.

LEVEL OF EVIDENCE

Level III.

FiberWire tension band for patellar fractures

BACKGROUND

Symptomatic hardware represents the most frequent complication reported following surgical treatment of patellar fracture. For this reason, some authors suggested using nonabsorbable sutures to fix the fracture with various techniques. The aim of this study was to evaluate clinical and radiological results of patients treated following a modified Pyriford technique using a FiberWire suture (Arthrex, Naples, FL, USA).

MATERIALS AND METHODS

We retrospectively evaluated a case series of seventeen patients with displaced patellar fractures treated by open reduction and internal fixation with a modified tension band using FiberWire sutures. Clinical and radiological outcome were evaluated. Union time, complications, and reoperation rate were observed and recorded.

RESULTS

All fractures healed (time to union 9.2 ± 2 weeks), and no fixation failure was observed. Slight losses of reduction (<4 mm) were noted in two patients at 4 weeks postoperatively. The average Lysholm and Bostman scores at the final follow-up were 91 ± 5.7 (range 83-100) and 28.3 ± 1.6 (range 26-30), respectively.

CONCLUSION

Modified tension band using FiberWire sutures showed satisfactory clinical results, with a low incidence of complications and reoperations. FiberWire tension bands could be used in place of metal-wire tension bands to treat patellar fracture, reducing the rate of symptomatic hardware.

LEVEL OF EVIDENCE

4.

Biomechanical evaluation of internal fixation techniques for unstable meso-type os acromiale

BACKGROUND

Several internal fixation surgical techniques have been described for the treatment of symptomatic os acromiale. The purpose of this study was to compare the biomechanical characteristics of different internal fixation techniques for the operative treatment of unstable meso-type os acromiale in a cadaveric model.

METHODS

Testing was performed on 12 matched pairs of cadaveric acromia with simulated meso-type os acromiale. Twelve specimens were prepared with 2 cannulated 4.0-mm screws only (SO group), inserted in the anterior-posterior direction. Contralateral specimens were repaired with screws and a tension band (TB group). An inferiorly directed load to the anterior acromion was applied at a rate of 60 mm/min until failure. Ultimate failure load, stiffness, and fracture pattern were recorded and analyzed.

RESULTS

Ultimate failure load was significantly higher for the TB group (mean, 336 N ± 126 N; range, 166-623 N; P = .01) than for the SO group (mean, 242 N ± 57 N; range, 186-365 N). In contrast, no significant difference in stiffness was found between the SO group (mean, 22.1 N/mm ± 4.7 N/mm; range, 13.0-33.3 N/mm; P = .94)) and the TB group (mean, 22.2 N/mm ± 2.9 N/mm; range, 18.2-26.6 N/mm).

CONCLUSION

Surgical repair of simulated unstable meso-type os acromiale by a combination of cannulated screws with a tension band leads to significantly higher repair strength at time zero in a cadaveric model compared with cannulated screws alone.

Decompression and paraspinous tension band: a novel treatment method for patients with lumbar spinal stenosis and degenerative spondylolisthesis

BACKGROUND CONTEXT

Prior studies have demonstrated the superiority of decompression and fusion over decompression alone for the treatment of lumbar degenerative spondylolisthesis with spinal stenosis. More recent studies have investigated whether nonfusion stabilization could provide durable clinical improvement after decompression and fusion.

PURPOSE

To examine the clinical safety and effectiveness of decompression and implantation of a novel flexion restricting paraspinous tension band (PTB) for patients with degenerative spondylolisthesis.

STUDY DESIGN

A prospective clinical study.

PATIENT SAMPLE

Forty-one patients (7 men and 34 women) aged 45 to 83 years (68.2 ± 9.0) were recruited with symptomatic spinal stenosis and Meyerding Grade 1 or 2 degenerative spondylolisthesis at L3-L4 (8) or L4-L5 (33).

OUTCOME MEASURES

Self-reported measures included visual analog scale (VAS) for leg, back, and hip pain and the Oswestry Disability Index (ODI). Physiologic measures included quantitative and qualitative radiographic analysis performed by an independent core laboratory.

METHODS

Patients with lumbar degenerative spondylolisthesis and stenosis were prospectively enrolled at four European spine centers with independent monitoring of data. Clinical and radiographic outcome data collected preoperatively were compared with data collected at 3, 6, 12, and 24 months after surgery. This study was sponsored by the PTB manufacturer (Simpirica Spine, Inc., San Carlos, CA, USA), including institutional research support grants to the participating centers totaling approximately US $172,000.

RESULTS

Statistically significant improvements and clinically important effect sizes were seen for all pain and disability measurements. At 24 months follow-up, ODI scores were reduced by an average of 25.4 points (59%) and maximum leg pain on VAS by 48.1 mm (65%). Back pain VAS scores improved from 54.1 by an average of 28.5 points (53%). There was one postoperative wound infection (2.4%) and an overall reoperation rate of 12%. Eighty-two percent patients available for 24 months follow-up with a PTB in situ had a reduction in ODI of greater than 15 points and 74% had a reduction in maximum leg pain VAS of greater than 20 mm. According to Odom criteria, most of these patients (82%) had an excellent or good outcome with all except one patient satisfied with surgery. As measured by the independent core laboratory, there was no significant increase in spondylolisthesis, segmental flexion-extension range of motion, or translation and no loss of lordosis in the patients with PTB at the 2 years follow-up.

CONCLUSIONS

Patients with degenerative spondylolisthesis and spinal stenosis treated with decompression and PTB demonstrated no progressive instability at 2 years follow-up. Excellent/good outcomes and significant improvements in patient-reported pain and disability scores were still observed at 2 years, with no evidence of implant failure or migration. Further study of this treatment method is warranted to validate these findings.

Titanium mesh as a low-profile alternative for tension-band augmentation in patella fracture fixation: A biomechanical study

OBJECTIVES

We performed a simple biomechanical study to compare the fixation strength of titanium mesh with traditional tension-band augmentation, which is a standard treatment for transverse patella fractures. We hypothesised that titanium mesh augmentation is not inferior in fixation strength to the standard treatment.

METHODS

Twenty-four synthetic patellae were tested. Twelve were fixed with stainless steel wire and parallel cannulated screws. Twelve were fixed with parallel cannulated screws, augmented with anterior titanium mesh and four screws. A custom test fixture was developed to simulate a knee flexed to 90°. A uniaxial force was applied to the simulated extensor mechanism at this angle. A non-inferiority study design was used to evaluate ultimate force required for failure of each construct as a measure of fixation strength. Stiffness of the bone/implant construct, fracture gap immediately prior to failure, and modes of failure are also reported.

RESULTS

The mean difference in force at failure was -23.0 N (95% CI: -123.6 to 77.6N) between mesh and wire constructs, well within the pre-defined non-inferiority margin of -260 N. Mean stiffness of the mesh and wire constructs were 19.42 N/mm (95% CI: 18.57-20.27 N/mm) and 19.49 N/mm (95% CI: 18.64-20.35 N/mm), respectively. Mean gap distance for the mesh constructs immediately prior to failure was 2.11 mm (95% CI: 1.35-2.88 mm) and 3.87 mm (95% CI: 2.60-5.13 mm) for wire constructs.

CONCLUSIONS

Titanium mesh augmentation is not inferior to tension-band wire augmentation when comparing ultimate force required for failure in this simplified biomechanical model. Results also indicate that stiffness of the two constructs is similar but that the mesh maintains a smaller fracture gap prior to failure. The results of this study indicate that the use of titanium mesh plating augmentation as a low-profile alternative to tension-band wiring for fixation of transverse patella fractures warrants further investigation.

Transosseous braided-tape and double-row fixations are better than tension band for avulsion-type greater tuberosity fractures

INTRODUCTION

The optimal treatment for avulsion-type greater tuberosity fractures is yet to be determined. Three fixation methods are tested: tension band with #2 wire suture (TB), double-row suture bridge with anchors (DR), and simple transosseous fixation with braided tape (BT).

MATERIALS AND METHODS

Twenty-four porcine proximal humeri were randomised into three groups: TB, DR and BT. A standardised greater tuberosity (GT) osteotomy was performed at 90° to the humeral diaphysis axis. A mechanical testing machine was used to simulate supraspinatus contraction. The force required to produce 3mm and 5mm displacement, as well as complete failure was measured with an axial load cell. Also, three cycles of shoulder flexion/extension with 25 N of supraspinatus contraction were performed. Maximum GT fragment translation and rotation amplitude during one cycle were measured.

RESULTS

During supraspinatus contraction, DR and BT groups (p < 0.05) were superior to TB group for both displacements. The BT technique had the strongest maximal load to failure (BT = 466 N; DR = 386 N; TB = 320 N). For the flexion/extension, DR and BT groups had less displacement and rotation than TB group (anterio-posterior displacement: BT = 2.0mm, DR = 1.9 mm, TB = 5.8 mm; anterio-posterior angular displacement: BT = 1.4°, DR = 1.0°, TB = 4.8°). No significant difference was observed between DR and BT groups, except for the medio-lateral rotation favouring the DR group.

CONCLUSION

In conclusion, BT and DR are good fixation methods to treat displaced avulsion-type greater tuberosity fractures. They have similar mechanical properties, and are stronger and more stable that the TB construct. Potential advantages of the BT over the DR may be a lower cost and easier surgery.

LEVEL OF EVIDENCE

Basic science study (LEVEL II).

Vertical open patella fracture, treatment, rehabilitation and the moment to fixation

Patella fracture is relatively uncommon and the vertical trace fracture represents almost 12-17%. The open patella fracture expresses 6-30%. The association of these two uncommon conditions was the aim of this case report even as the treatment and the moment of fixation (definitive surgical treatment). A 27-year-old man after a motorcycle accident showed an open patella fracture classified as a Gustilo and Anderson type IIIA lesion. The patient was immediately treated with precocious surgery fixation with a modified tension band which consists of two parallel K-wires positioned orthogonal to the fracture line and a cerclage wire shaped anteriorly at patella as an eight. The premature fixation benefited the infection prevention and provided earlier joint motion, which increased the nutrition of articular cartilage. Six months postoperatively, the patient had a satisfactory joint motion with full extension and 116° of joint flexion and returned to his daily life activities without restriction. Twelve months postoperatively, the patient had full extension and 120° of knee flexion without pain, joint effusion and instability. Muscle strength force was considered normal at grade V. In conclusion, early chirurgic treatment and precocious articular mobilization improve prognosis, suggesting that the employment of these practices should be adopted whenever possible in most of the open fractures.

Tension band wiring for treatment of extra articular fracture of the base of first metacarpal

Eleven patients with unstable extra-articular fractures of the base of the first metacarpal with angulations more than 30° uncorrected by closed reduction were treated by open reduction and tension band fixation. Ten men and one woman with a mean age of 36.18 years. Fall on a stretched hand was the cause in eight while a punch in two and trauma from a basket ball in one. The mean follow up period was 12.45 months. All fractures united within a mean of 4.36 weeks. Patients were evaluated by subjective and objective criteria: the mean of pain was 0.5, quick-DASH was 10.48 and Kapandji score was 9.8. While the mean of the grip strength was 94 % and the pinch strength was 99 % of the contra lateral hand. There were no complications except local irritation of the k-wires in two patients that had to be removed at 4 months. Tension band technique proved to be a valuable technique which is easy to apply and gives rigid fixation with early mobilization.

Locking plate fixation provides superior fixation of humerus split type greater tuberosity fractures than tension bands and double row suture bridges

BACKGROUND

This paper aims to determine the strongest fixation method for split type greater tuberosity fractures of the proximal humerus by testing and comparing three fixation methods: a tension band with No. 2 wire suture, a double-row suture bridge with suture anchors, and a manually contoured calcaneal locking plate.

METHODS

Each method was tested on eight porcine humeri. A osteotomy of the greater tuberosity was performed 50° to the humeral shaft and then fixed according to one of three methods. The humeri were then placed in a testing apparatus and tension was applied along the supraspinatus tendon using a thermoelectric cooling clamp. The load required to produce 3mm and 5mm of displacement, as well as complete failure, was recorded using an axial load cell.

FINDINGS

The average load required to produce 3mm and 5mm of displacement was 658N and 1112N for the locking plate, 199N and 247N for the double row, and 75N and 105N for the tension band. The difference between the three groups was significant (P<0.01). The average load to failure of the locking plate (810N) was significantly stronger than double row (456N) and tension band (279N) (P<0.05). The stiffness of the locking plate (404N/mm) was significantly greater than double row (71N/mm) and tension band (33N/mm) (P<0.01).

INTERPRETATION

Locking plate fixation provides the strongest and stiffest biomechanical fixation for split type greater tuberosity fractures.

Use of miniplates in parasymphysis fractures : a survey conducted among oral and maxillofacial surgeons of India

Aim of the study was to find out the number of miniplates used by Indian Oral and Maxillofacial Surgeons for parasymphysis fractures. A survey was done among Oral and Maxillofacial Surgeons of India at the 34th annual meeting of Association of Oral and Maxillofacial Surgeons of India. Four questions were given to each individual to find out their opinion regarding use of miniplates in parasymphysis fractures. Eighty-eight per cent of Indian surgeons were in favour of using intra-operative or post-operative intermaxillary fixation. Thirty-eight per cent responded in favour of using single miniplate for parasymphysis fracture instead of using two miniplates. Fifty-four per cent maxillofacial surgeons use various modifications depending on different conditions. Forty-two per cent of maxillofacial surgeons accepted that lower arch bar can be used as a tension band. Use of miniplates for the treatment of parasymphysis fracture varies from centre to centre and from surgeon to surgeon. Though miniplates are best used following Champy's principle, still many surgeons use single miniplate. Arch bars placed for intermaxillary fixation can be used as a tension band, again eliminating the need for upper plate.