Comparison of single versus double coracoclavicular loop stabilization technique for the management of unstable distal clavicular fractures: a randomized controlled trial

PURPOSE

The coracoclavicular (CC) loop stabilization technique is proposed for unstable distal clavicular fractures. This study aims to compare single and double CC loop stabilizations and evaluate differences in functional and radiographic outcomes between them.

METHODS

We conducted a prospective randomized controlled trial involving 46 patients who sustained unstable distal clavicular fractures between April 2017 and 2019. The participants were randomly assigned to one of two groups: the single CC loop stabilization group (n = 23) or the double CC loop stabilization group (n = 23). We assessed their Constant score, American Shoulder and Elbow Surgeons score (ASES), and pain level. Additionally, we recorded data on time to union, CC distance, and any complications.

RESULTS

The single CC loop group demonstrated a shorter operative time and significantly higher Constant score than the double CC loop group at 1 month (77.32 ± 5.65 vs. 71.91 ± 8.33; p = 0.016) and 3 months (86.17 ± 4.05 vs. 81.13 ± 6.34; p = 0.009) postoperatively. However, there was no differences in the ASES score, time to union or CC distance restoration between two groups. Implant irritation was observed in the double CC loop group (26.1%), but there were no cases requiring revision surgery.

CONCLUSIONS

Both single and double CC loop stabilization demonstrated favorable outcomes, including a high union rate and minimal complications. Single CC loop stabilization showed slightly better early functional outcomes, reduced implant-related irritation, and shorter operative times.

Lateral minimally invasive plate osteosynthesis (MIPO) with long PHILOS for proximal metaphyseal-diaphyseal humeral fracture: surgical techniques and a clinical series

The minimally invasive plate osteosynthesis (MIPO) for proximal metaphyseal-diaphyseal humeral fracture is an effective alternative treatment with satisfactory outcomes. In this study, we described the surgical techniques and clinical results using MIPO via a lateral approach and long PHILOS plate fixation in 23 patients. All fractures were successfully united within a mean union time of 13.5 weeks (range 9-18). There was no iatrogenic radial nerve palsy. The deltoid power was grade 5 in all patients, except for 2 patients who had associated brachial plexus injury and gunshot injury at the deltoid muscle. The mean Constant-Murley score was 85.6 (range 16-98) and DASH score was 12.1 (range 1.7-85). Based on these findings, the lateral MIPO with long PHILOS plate fixation could be an alternative for the proximal metaphyseal-diaphyseal fractures of the humeral shaft.

Efficacy and Safety of Antibiotic Impregnated Microporous Nanohydroxyapatite Beads for Chronic Osteomyelitis Treatment: A Multicenter, Open-Label, Prospective Cohort Study

Chronic osteomyelitis is still a serious health problem that causes disabling conditions and has an impact on the quality of life. The objective of this study was to determine the clinical efficacy and safety of localized antibiotics delivery via impregnated microporous nanohydroxyapatite (nHA-ATB) beads for chronic osteomyelitis treatment. A total of 62 patients were enrolled in this study. After radical surgical debridement, the bone defect was filled with three types of antibiotics (vancomycin or gentamicin or fosfomycin) impregnated HA beads. The follow-up period was 48 weeks. It was found that the success rate was approximately 98% with a re-infection in only one patient. Quality of life of all patients after treatment improved significantly over time. Systemic exposure to vancomycin and gentamicin after beads implantation was limited and high local antibiotics concentrations were found in wound drainage fluid at 24, 48 and 72 h. Blood biochemistry measurements did not show any nephrotoxic or hepatotoxic effects. 20 adverse events were reported, but 90% of the events were resolved without having to remove the beads and the patients recovered. Satisfactory outcomes were observed in terms of success rate, quality of life and adverse effect. nHA-ATB beads impregnated by vancomycin or gentamicin or fosfomycin could potentially be employed as an alternative product of choice for localized antibiotics delivery in chronic osteomyelitis treatment.

Traction-Internal Rotation Radiograph Can Improve Agreement in AO/OTA Classification System for Intertrochanteric Fracture

Purpose

The objective of our study was to evaluate the inter- and intra-observer reliability of the standard anteroposterior of both hips, traction-internal rotation, and the combination of the two radiographs for intertrochanteric fracture.

Methods

In one hundred cases, three sets of radiographs of intertrochanteric fracture were prepared. Two senior and two junior orthopedic trauma surgeons were asked to classify the radiograph according to AO/OTA classification. The standard both hips radiograph, traction-internal rotation radiograph and combination of both techniques were evaluated. All radiographs were evaluated at two different points in time for all observers. The inter- and intra-observer reliability were analyzed with the Kappa agreement index.

Results

Inter-observer agreement for standard radiographs was "substantial" in one while "moderate" in five among observers. After adding the traction radiograph to the standard radiograph, the agreement was improved to "substantial" in 4 while the rest was "moderate."Intra-observer agreement for standard radiographs was "substantial" in two observers and "moderate" in two observers. Adding traction to standard radiographs resulted in "substantial" in three observers and "moderate" in one observer.Overall pattern stability was changed in 19% after adding the traction film. Thirty-four percent of the fracture which initially diagnosed as A2.1 was changed from stable to unstable fracture patterns after adding the traction film.

Conclusions

Adding traction-internal rotation radiograph to the standard radiograph is a useful method for improving agreement to classify intertrochanteric fracture regarding AO/OTA classification. This may be helpful in determining fracture classification.

Minimally invasive plate osteosynthesis via posterior approach for type B and C fractures of distal humeral shaft: surgical tactics and a clinical series

The optimal technique and implant for fixation of multifragmentary fractures of the distal humeral shaft remain inconclusive. We describe the use of minimally invasive plate osteosynthesis (MIPO) via posterior approach and extra-articular distal humerus locking compression plate (LCP-EADH) fixation for 18 such fractures. All fractures were united with a mean union time of 17.6 weeks (range 12-20). Transient radial nerve palsy was demonstrated in 2 patients. Six patients had 5° varus angulation and 1 had 5° valgus angulation. Triceps power was Grade 5 in all patients. The mean arc of elbow motion was 127.5 degrees (range 115-140). Six patients had an excellent MEP score and 12 had a good MEP score. As the results, posterior MIPO and LCP-EADH fixation could be an alternative for multifragmentary fractures of the distal humeral shaft, particularly for fractures with a very short distal fragment.

The radiographic relationship between the cortical overlap view (COV) and the tip of the greater trochanter

For proximal femoral nailing, choosing the proper entry point with the aid of C-arm imaging is crucial. Therefore, obtaining accurate radiological views that facilitate sound identification of the tip of the greater trochanter (GT) is of utmost importance. The aim of this study was to define a radiological view characterised by reproducible radiographic landmarks which will allow the reliable identification of the tip of the GT in the anteroposterior view. Anatomical and radiographic features of 16 cadaveric femurs were analysed. The cortical overlap view (COV), characterised by the radiological overlap of the density line of the piriform fossa and the intertrochanteric crest, was identified. It marks the rotation of the proximal femur at which the GT can be accurately identified and used to determine the desired entry point for a proximal femoral nail. Trainees and fully qualified orthopedic trauma surgeons were asked to identify the correct COV in radiological imaging series. Mean internal rotation of the femur to achieve a COV was 17.5° (range 12.8°–21.8°). In the COV the tip of the GT is the highest visible point and the mean distance from the cortical overlap line to the tip of the GT is 4.45 mm. Intra- and inter-rater reliability was high with ICC(2,k) = 0.932 and ICC(2,k) = 0.987 respectively. Trainees achieved higher rates of correct COV identification than specialists. There was no significant correlation between the internal rotation of the femur to achieve the COV and femoral antetorsion. In conclusion, the COV is a highly reproducible radiological view that is characterised by radiographic landmarks easy to recognise. It allows for accurate identification of the tip of the GT, which can be used by the surgeon as a reference to determine the desired entry point for an intramedullary nail.

The safety and feasibility of minimal invasive plate osteosynthesis (MIPO) of the posterior aspect of the humerus: A cadaveric study

The aim of this study was to determine the feasibility of applying MIPO of the humerus via the posterior approach and to observe the tension of the radial nerve in different elbow positions. Two separate incisions were made on the posterior aspect of the humerus in ten fresh cadavers (20 humeri). The radial nerve was identified at the proximal incision and the distances through which the nerve could be elevated from the bone with the elbow in flexion and extension were measured. A 10-hole extra-articular distal humeral locking compression plate was inserted and fixed through the submuscular tunnel. The tunnel was then explored to identify any entrapment of the radial nerve and to observe the anatomical relationship of the radial nerve to the plate and bone. There was no entrapment of the radial nerve or its branches. The distances through which the radial nerve could be elevated were greater with the elbow in extension than in flexion (P < 0.01). The radial nerve crossed the medial and lateral borders of the posterior surface of the humerus at 80.1-132 mm (average 104.7 mm) and 116.6-175.5 mm (average 142.7 mm) of its total length, respectively. The axillary nerve was located at 38.7-61.7 mm (average 47.9 mm) of total humeral length. MIPO of the humerus using the posterior approach is an alternative option for treating distal humeral shaft fracture. The risk of radial nerve injury can be minimized by careful dissection in the proximal incision. Clin. Anat. 32:176-182, 2019. © 2018 Wiley Periodicals, Inc.

The safety and feasibility of minimally invasive plate osteosynthesis (MIPO) on the medial side of the femur: A cadaveric injection study

INTRODUCTION

Minimally invasive plate osteosynthesis (MIPO) on the medial side of the femur appears to be a dangerous procedure due to possible femoral artery injury.

OBJECTIVE

This study aims to determine the feasibility of applying MIPO of the femur via the medial approach, and to determine the anatomical relationship and structures at risk between the artery and the implant using computed tomography angiography.

MATERIALS AND METHODS

A descriptive study of ten fresh cadavers was done. Two separate incisions were made, creating a submuscular tunnel close to the medial side of the femur. An 11- or 13-hole LCP lateral proximal tibial plate (5.0mm) was inserted through the distal incision into the submuscular tunnel and fixed. A CT angiogram with 3D reconstruction was made to determine the distance from and location of the plate relative to the femoral artery and surgical dissection was done to identify the structures at risk.

RESULTS

No disruptions of superficial or deep femoral arteries were found. The closest distances from the superficial femoral artery and deep femoral artery to the plate were 8.3-27.2mm (average 16.3mm) (99% CI: 12.7-19.9) at the level 3 and 4.5-20.0mm (average 8.6mm) (99% CI: 6.4-10.9) at the level 2 in the proximal part of femur, respectively. The location where the SFA crossed the anterior cortex of the femur in the sagittal plane was 9.7-36.0% of the femoral length (average 20.1%) (99% CI: 15.0-25.3%) and the posterior cortex of the femur was 24.7-55.3% of the femoral length (average 40.8%) (99% CI: 35.0-46.7%). The location where the DFA crossed the anterior cortex of the femur in the sagittal plane was 7.9-25.3% of the femoral length (average 13.4%) (99% CI: 10.6-16.3%) and where it crossed the posterior cortex of the femur was 21.7-39.4% of the femoral length (average 31.2%) (99% CI: 27.1-33.3%).

CONCLUSION

MIPO of the femur via medial approach is a feasible option for treatment of femoral fractures when the lateral approach is contraindicated. The distal 60% of the femoral length is safe for this approach.

Polyester tape scapulopexy for chronic upper extremity brachial plexus injury

PURPOSE

To report the results of scapular stabilization for winging in patients with chronic upper brachial plexus injury.

METHODS

Eight patients, mean age 36 years, who had a winged scapula after successful restoration of major shoulder function by nerve transfer underwent scapular stabilization to the ribcage using polyester tape. The follow-up period ranged from 24 to 40 months (mean, 38 mo). Data collection included radiographic analysis, active range of motion measurement, University of California Los Angeles shoulder score, and visual analog scale pain score.

RESULTS

All patients had clinical improvement with resolution of scapular winging. Five patients had no winging and 3 had mild winging after the surgery. Mean active forward flexion increased from 101° preoperatively to 127° postoperatively. Mean active shoulder abduction increased from 91° preoperatively to 121° postoperatively. Mean University of California Los Angeles shoulder score improved from 17 to 27 and mean visual analog scale pain score improved from 6.1 to 0.7. In addition, mean lateral deviated angle increased from 4° from neutral preoperatively to 9° at the last follow-up. All patients reported satisfaction with postoperative appearance.

CONCLUSIONS

Outcomes of polyester tape scapulopexy in the short to intermediate term were favorable in terms of improved appearance, upper extremity function, and pain reduction in patients with winged scapula resulting from chronic upper brachial plexus injury, and with successful restoration of shoulder motion by previous nerve transfers.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.