Minimally invasive plate osteosynthesis (MIPO) for scapular fractures

OBJECTIVE

Presentation of a minimally invasive surgical approach for the treatment of scapular fractures and the clinical outcome using this technique.

INDICATIONS

Displaced extra-articular fractures of the scapula body and glenoid neck (AO 14B and 14F) and simple intra-articular fractures of the glenoid.

CONTRAINDICATIONS

Complex intra-articular fractures and isolated fractures of the coracoid base.

SURGICAL TECHNIQUE

Make a straight or slightly curved incision along the lateral margin of the scapula leaving the deltoid fascia intact. Identify the interval between the teres minor muscle and infraspinatus to visualize the lateral column, whilst retracting the deltoid to visualize the glenoid neck. Reduce and align the fracture using direct and indirect reduction tools. A second window on the medial border of the scapula can be made to aid reduction and/or to augment stability. Small (2.0-2.7 mm) plates in a 90° configuration on the lateral border and, if required, on the medial border are used. Intra-operative imaging confirms adequate reduction and extra-articular screw placement.

POSTOPERATIVE MANAGEMENT

Direct postoperative free functional nonweight-bearing rehabilitation limited to 90° abduction for the first 6 weeks. Sling for comfort. Free range of motion and permissive weight-bearing after 6 weeks.

RESULTS

We collected data from 35 patients treated with minimally invasive plate osteosynthesis (MIPO) between 2011 and 2021. Average age was 53 ± 15.1 years (range 21-71 years); 17 had a type B and 18 a type F fracture according the AO classification. All patients suffered concomitant injuries of which thoracic (n = 33) and upper extremity (n = 25) injuries were most common. Double plating of the lateral border (n = 30) was most commonly performed as described in the surgical technique section. One patient underwent an additional osteosynthesis 3 months after initial surgery due to pain and lack of radiological signs of healing of a fracture extension into the spine of the scapula. In the same patient, the plate on the spine of scapula was later removed due to plate irritation. In 2 patients postoperative images showed a screw protruding into the glenohumeral joint requiring revision surgery. After standardisation of intra-operative imaging following these two cases, intra-articular screw placement did not occur anymore. No patient suffered from iatrogenic nerve injury and none developed a wound infection.

Percutaneous sacroiliac screw fixation in fragility fractures of the pelvis: Comparison of two different augmentation techniques

OBJECTIVE

Fragility fractures of the pelvis (FFP) are becoming increasingly common. Percutaneous sacroiliac screw fixation is an accepted and safe treatment method for FFP. Augmentation is an option to optimize fixation strength of the screws. This study aims to compare patient mobility and the occurrence of complications after operative treatment of FFP utilizing two different augmentation techniques.

METHODS

All patients who received augmented sacroiliac screws for the treatment of FFPs between 01.01.2017 and 31.12.2018 at one of the two participating hospitals were included. The operative techniques only differed with regards to the augmentation method used. At the one hospital cannulated screws were used. Definitive screw placement followed augmentation. At the other hospital cannulated and fenestrated screws were used, permitting definitive screw placement prior to augmentation.

RESULTS

In total, 59 patients were included. The NRS score for pain was significantly lower after surgery. Preoperative mobility levels could be maintained or improved in 2/3 of the patients. There were no fatal complications. Two revision surgeries were performed because of screw misplacement. There were no significant differences between the two augmentation techniques in terms of complications.

CONCLUSION

Both augmentation techniques have a low complication rate and are safe methods to maintain patients' mobility level. The authors advocate early consideration of surgical treatment for patients with FFP. Augmentation can be considered a safe addition when performing percutaneous sacroiliac screw fixation.

Anatomical analysis of different helical plate designs for proximal humeral shaft fracture fixation

Objective

Helical plates are preferably used for proximal humeral shaft fracture fixation with metaphyseal extension into the humeral head and potentially avoid radial nerve irritation as compared to straight plates. The aims of this study were: (1) to investigate the safety of applying different long plate designs (straight, 45°-, 90°-helical and ALPS) in MIPO-technique to the humerus and (2) to assess and compare their distances to adjacent anatomical structures at risk.

Methods

MIPO was performed in 16 human cadaveric humeri using either a straight plate (group1), a 45°-helical (group2), a 90°-helical (group3) or an ALPS (group4). Using CT-angiography, distances between brachial arteries and plates were evaluated. Following, all specimens were dissected, and distances to the axillary, radial and musculocutaneous nerve were evaluated.

Results

None of the specimens demonstrated injuries of the anatomical structures at risk after MIPO with all investigated plate designs. Closest overall distance (mm(range)) between each plate and the radial nerve was 1(1–3) in group1, 7(2–11) in group2, 14(7–25) in group3 and 6(3–8) in group4. It was significantly longer in group3 and significantly shorter in group1 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the musculocutaneous nerve was 16(8–28) in group1, 11(7–18) in group2, 3(2–4) in group3 and 6(3–8) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.001. Closest overall distance (mm(range)) between each plate and the brachial artery was 21(18–23) in group1, 7(6–7) in group2, 4(3–5) in group3 and 7(6–7) in group4. It was significantly longer in group1 and significantly shorter in group3 as compared to all other groups, p<0.021.

Conclusion

MIPO with 45°- and 90°-helical plates as well as ALPS is safely feasible and showed a significant greater distance to the radial nerve compared to straight plates. However, distances remain low, and attention must be paid to the musculocutaneous nerve and the brachial artery when MIPO is used with ALPS, 45°- and 90°-helical implants. Moreover, the anterior part of the deltoid insertion will be detached when using 90°-helical and ALPS implants in MIPO-technique.

Surgical and non-operative management of displaced scapular fractures and long-term outcomes

Objective

To compare the long-term functional outcome of surgically and non-operatively managed patients with displaced intra- and extra-articular scapular fractures.

Methods

This study included patients with intra- and extra-articular scapula fractures, treated between 2010 and 2020 in a Swiss level 1 trauma centre. The decision to operate was based on standardized criteria for fracture displacement. Patients with isolated Bankart lesions (Ideberg 1) and process fractures (AO type 14-A) were excluded. Primary outcomes were functional patient reported measures (DASH score) and quality of life (EQ5D score). Secondary outcomes were complications, radiological union, satisfaction with treatment, pain and range of motion.

Results

Out of 486 cases, 74 patients had displaced scapula fractures. Forty patients were treated surgically and 34 were treated conservatively. Significantly more patients with intra-articular fractures and high-energy trauma were treated surgically. Fifty percent returned the questionnaires after a mean follow-up of 47 months (± SD 36). The mean DASH score of this group was 12 (SD 15.6), with a mean of 14.7 (SD 15.9) in the surgery group and 9.8 (SD 14.6) in the non-operative group (p = 0.7). Multivariate analysis did not show statistically significant correlating factors. No significant differences in quality of life were observed. Patients rated their treatment with a mean of 8.6/10 (SD 1.8). Among surgically treated patients, 19 underwent a deltoid sparing procedure with significant shorter time to union than those that underwent deltoid release (23 vs. 49 weeks, p<0.01). Complications occurred in 3/28 surgically treated patients and all three required a reoperation.

Conclusion

Functional results after conservative and surgical treatment were similar, despite more complex fractures and more intra-articular fractures being treated surgically. Osteosynthesis of both intra- and extra-articular scapula fractures is safe and leads to good functional results, furthermore, new minimal invasive techniques may lead to faster bone healing and return to work and sports.

Anatomical analysis of different helical plate designs for distal femoral fracture fixation

Objective

Helical plates potentially avoid the medial neurovascular structures of the thigh. Recently, two plate designs (90°- and 180°-helix) proved similar biomechanically behavior compared to straight plates. The aims of this study were: (1) feasibility of applying 90°- and 180°-helical plates in MIPO-technique to the femur, (2) Assess the distances to adjacent anatomical structures which are at risk, (3) Compare these distances with medial straight plates, and (4) Correlate measurements performed during anatomical dissection with CT-angiography.

Methods

MIPO was performed in ten cadaveric femoral pairs using either a 90°-helical 14-hole-LCP (group1) or a 180°-helical 15-hole-LCP-DF (group2). Using CT-angiography, distances between femoral arteries and plates as well as distances between plates and perforators were evaluated. Following, specimens were dissected, and distances determined again. All plates were removed, and all measurements were repeated with straight medial plates (group3).

Results

Closest overall distances between plates and femoral arteries were 15 mm(11–19 mm) in group1, 22 mm(15–24 mm) in group2 and 6 mm(1–8 mm) in group3 with a significant difference between group1 and group3(p<0.001). Distances to the nearest perforators were 24 mm(15–32 mm) in group1 and 2 mm(1–4 mm) in group2. Measurement techniques (visual after surgery and CT-angiography) showed a strong correlation of 0.972(p<0.01).

Conclusion

MIPO with 90°- and 180°-helical plates is feasible and safe. Attention must be paid to the medial neurovascular structures with 90°-helical implants and to the proximal perforators with 180°-helical implants. Helical implants can avoid medial neurovascular structures compared to straight plates although care must be taken during their distally insertion. Measurements during anatomical dissection correlate with CT-angiography.

Long-term follow-up of patients with displaced scapular fractures managed surgically and non-operatively

INTRODUCTION

Controversy remains on which patients with displaced scapula fractures benefit from surgery. This retrospective cohort study aims to compare and describe long-term patient-reported outcomes of patients with displaced scapula fractures treated both surgically and conservatively.

METHODS

This study included patients with intra- and extra-articular scapula fractures, treated between 2010 and 2020 in a Swiss level 1 trauma centre. The decision to operate was based on standardized criteria for fracture displacement. Patients with isolated Bankart lesions (Ideberg 1) and process fractures (AO type 14-A) were excluded. Primary outcomes were functional patient reported measures (DASH score) and quality of life (EQ5D score). Secondary outcomes were complications, radiological union, satisfaction with treatment, pain and range of motion.

RESULTS

Out of 486 cases, 74 patients had displaced scapula fractures. Forty patients were treated surgically and 34 were treated conservatively. Significantly more patients with intra-articular fractures and high-energy trauma were treated surgically. Fifty percent returned the questionnaires after a mean follow-up of 47 months (± SD 36). The mean DASH score of this group was 12 (SD 15.6), with a mean of 14.7 (SD 15.9) in the surgery group and 9.8 (SD 14.6) in the non-operative group (p = 0.7). Multivariate analysis did not show statistically significant correlating factors. No significant differences in quality of life were observed. Patients rated their treatment with a mean of 8.6/10 (SD 1.8). Among surgically treated patients, 19 underwent a deltoid sparing procedure with significant shorter time to union than those that underwent deltoid release (23 vs. 49 weeks, p<0.01). Complications occurred in 3/28 surgically treated patients and all three required a reoperation.

CONCLUSION

In this cohort, functional results after conservative and surgical treatment were similar, despite more complex fractures and more intra-articular fractures being treated surgically. Osteosynthesis of both intra- and extra-articular scapula fractures is safe and leads to good functional results, furthermore, new minimal invasive techniques may lead to faster bone healing and return to work and sports.

Conservative treatment versus reversed shoulder prothesis for proximal humerus fractures in the elderly: A meta-analysis of observational studies and randomised clinical trials

Objective

The treatment of complex proximal humerus fractures in elderly patients is not yet fully eluci-dated. Of all treatment options reverse shoulder arthroplasty (RSA) and non operative treat-ment (NOT) appear to provide the best results. Evidence to guide the choice between the two is sparse. Therefore, this review provides an overview of the available evidence on RSA versus non-operative treatment.

Methods

Studies comparing RSA and NOT were included for direct comparison by systematic re-view and pooled analysis for patient rated outcome and range of motion. Additionally, indirect comparison of case-series and non-comparative studies on either treatment modalities was performed separately.

Results

Comparative: Reverse shoulder arthroplasty resulted in better patient rated outcome scores and better range of motion. Pain and treatment satisfaction scores were better after RSA. Non comparative studies reported similar patient rated and range of motion scores for both RSA and after NOT.

Conclusion

The functional and range of motion outcomes after RSA seem satisfactory and potentially superior to NOT in elderly patients. The complication rate is acceptably low and an overall revision rate of 5% was found. These results should however be viewed in light of distinct differences in patient characteristics between treatment groups.

Low-profile dual mini-fragment plating of diaphyseal clavicle fractures. A biomechanical comparative analysis

Objective

Implant removal rates after clavicle plating are high. Recently, low-profile dual mini-fragment plate constructs have proven safe for the fixation of diaphyseal clavicle fractures. Therefore, the aims of this study was to investigate: (1) the biomechanical competence of different dual plate designs in terms of stiffness and cycles to failure, and (2) to compare them against 3.5 mm single superoanterior plating.

Methods

12 artificial clavicles were assigned to 2 groups and instrumented with titanium matrix mandible plates as follows: group 1 (2.5 mm anterior+2.0 mm superior) and group 2 (2.0 mm anterior+2.0 mm superior). An unstable clavicle shaft fracture (AO/OTA15.2C) was simulated. Specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with torsion around the shaft axis and compared to previous published data of 6 locked superoanterior plates tested under the same conditions (group 3)

Results

Displacement (mm) after 5000 cycles was highest in group 3 (10.7±0.8) followed by group 2 (8.5±1.0) and group 1 (7.5±1.0), respectively. Both outcomes were significantly higher in group 3 as compared to both groups 1 and 2 (p≤0.027). Cycles to failure were highest in group 3 (19536±3586) followed by group 1 (15834±3492) and group 2 (11104±3177), being significantly higher in group 3 as compared to group 2 (p=0.004).

Conclusion

Low-profile 2.0/2.0 dual plates demonstrated similar initial stiffness compared to 3.5 mm single plates, however, they revealed significantly lower endurance to failure. Moreover, low-profile 2.5/2.0 dual plates showed significant higher initial stiffness and similar resistance to failure compared to 3.5 mm single locked plates and can therefore be considered as a useful alternative for diaphyseal clavicle fracture fixation. These results complement the promising results of several clinical studies.

Superior versus anterior plate fixation for midshaft clavicular fractures – a multicentre analysis

Objective

To date it remains unclear whether superior or anterior plating is the best option for treating midshaft clavicular fractures. The aim of this study was to compare both techniques with regard to the need of implant removal due to hardware irritation or uncomforting during daily activities, to healing and to complications.

Methods

This was a retrospective study on all midshaft clavicular fractures treated operatively between 2017 and 2019 in two hospitals different in respect to anterior versus superior plating for midshaft clavicular fractures in Switzerland. The primary outcome was the number of implant removal due to hardware irritation, uncomforting, weather sensitivity or the patients wish for removal, whereas the specific reason was not evaluated. Secondary outcomes were time to union, complications, re-interventions and range-of-motion during the follow-up period of at least 6-months.

Results

In total 171 patients were included in the study of which 89 (52%) received anterior plating and 82 (48%) superior plating. The overall mean age was 45 years (SD 16). There was no significant difference between anterior and superior plating in the number of implant removals (39.3% versus 45.1%), infection rate (1.1% versus 1.2%), implant failure (1.1% versus 0%), non-union (1.1% and 0%) and time to union (mean 40 weeks versus 51 weeks).

Ninty-four patients had a documented range of motion after a follow up from 6 up to 12 months with no significant difference in anteflexion (mean 170 degree anterior versus 178 degree superior) and abduction (mean 166 degree versus 176 degree).

Conclusion

There is no significant difference between anterior and superior plating for midshaft clavicular fractures with regard to implant removal, healing, complications and shoulder function. As both treatment opinions are viable, the decision may depend on surgeons experience.

Treatment and outcome in combined scapula and rib fractures

Objective

The primary aim was to describe the population characteristics of patients with combined scapula and rib fractures and outcomes associated with different treatment strategies. Secondarily, a systematic literature review was conducted to provide an overview of the available literature on this population.

Methods

All adult (≥18 years) patients with concurrent ipsilateral scapula and rib fractures admitted to the study hospital between 1st January 2010 and 31st June 2021 were retrospectively reviewed. Secondarily, the Pubmed, EMBASE and CENRTAL databases were searched to identify studies reporting on this patient population.

Results

A total of 243 patients were admitted with concurrent ipsilateral rib and scapula fractures. 160 patients (72%) were treated conservatively, 63 patients (28%) operatively. Among operatively treated patients, 32 (51%) underwent rib fixation (RF) only, 24 (38%) underwent scapula fixation (SF) only and 7 patients (11%) underwent combined fixation of scapula and ribs (SRF). In general, more severely injured patients were treated with more extensive surgery. RF patients had a median hospital length of stay of 16 days, the SF patients 11 days and SRF patients 18 days. There were no significant differences in complications (pneumonia, recurrent pneumothorax, and revision surgery) between groups. The systematic review included 9 studies of which none reported on outcomes or treatment strategy for this combined injury.

Conclusion

Injury severity resulted in different treatment modalities. As a result different patient characteristics between treatment groups were observed, which makes direct comparison between treatment modalities impossible. All treatment modalities seem feasible, however the additional value of both rib and scapula fixation has yet to be proven in large multicentre studies.

Primary or secondary wound healing of the pin sites after removal of the external fixator: A monocenter prospective randomized controlled trial

Objective

The aim of this monocentre randomized controlled trial was to compare primary wound closure using a single button suture to secondary wound healing of pin sites after removal of the external fixator.

Methods

This non-inferiority trial included all patients who were treated with an external fixator. The primary outcome was infection. Secondary outcomes included all other complications, time to wound healing (in weeks), patients most satisfactory pin site, Visual Analogue Scale (VAS) for pain and the Vancouver Scar Scale (VSS) measured at every 2, 6, 12, 24 and 52 weeks. The most proximal pin site was randomly allocated (1:1) to either primary closure or secondary wound healing, while the following pin sites were treated alternately. Physicians at follow-up were blinded to the closure technique.

Results

A total of 70 patient, providing 241 pin sites were included between 1st January 2019 and 1st March 2020. One-hundred-twenty-three pin sites were treated with primary closure and 118 with secondary wound healing. Median age was 55 (46–67), 44% was male and median duration of the external fixator was 6 days (4–8).There was no significant difference in pin site infections (2% in the primary closure group versus 0% in the secondary healing group). Wound healing was significantly faster in the primary closure group (median 2 vs. 6 weeks, p=0.013). Although not statistically significant, patients seemed more satisfied with the primary closed pin sites (55%). The Vancouver Scar scale showed no differences between groups.

Conclusion

Primary closure of external pin sites does not result in higher infection rate than secondary wound healing and pin sites healed significantly faster after primary closure. Primary closure, therefore, should be the preferred method.

MIPO vs. nail for extra-articular distal tibia fractures and the effect of intra-operative alignment control

Objective

Definitive treatment of distal extra-articular fractures of the tibia is challenging and both minimal invasive plate osteosynthesis (MIPO) and intramedullary nailing (IMN) are considered feasible surgical modalities with their own implant-specific merits and demerits. This retrospective study was designed to compare MIPO versus IMN in terms of fracture healing, complications, functional and radiological outcomes and to assess the efficacy of intra-operative alignment control in order to reduce the rate of malalignment after definitive fixation of distal extra-articular fractures of the tibia.

Methods

All consecutive adult patients with extra-articular distal meta- or diaphyseal tibia fractures that were treated in a level 1 trauma center in Switzerland between January 2012 and September 2019 either with plating or IMN were included. Outcome measures included fracture healing, complications (infection, malalignment, subsequent sur-geries), functional and radiological outcomes. Intra-operative alignment control encompassed bilateral draping of the lower extremities.

Results

A total of 135 patients were included out of which seventy-two patients (53%) were treated with MIPO and 63 patients (47%) underwent IMN. There was a significantly higher incidence of non-union for fractures treated with an IMN (13 (22%) vs. 4 (6%), p = 0.037). There was no significant difference between both groups in terms of rotational malalignment (4% vs. 9%) and angular malalignment (4% vs. 5%). The incidence of malalignment in both groups was lower than reported in literature. A significantly higher rate of infection was found after MIPO (13% vs. 6%, p = 0.028). No differences were found in subsequent surgeries or functional outcomes.

Conclusion

Both MIPO and IMN are reliable surgical techniques. IMN is associated with higher rates of non-union whereas MIPO results in a higher risk for infection. The incidence of malalignment was surprisingly low endorsing the utility of the intra-operative alignment control.

ORIF versus nailing for humeral shaft fractures: A meta-analysis and systematic review of randomised clinical trials and observational studies

Objective

This meta-analysis aims to compare open reduction and internal fixation with a plate (ORIF) versus nailing for humeral shaft fractures in terms of healing, complications, general quality of life and shoulder/elbow function.

Methods

PubMed/Medline/Embase/CENTRAL/CINAHL was searched for both randomised clinical trials (RCT) and observational studies comparing ORIF with nailing for humeral shaft fractures. Effect estimates were pooled across studies using random effects models and presented as weighted odds ratio (OR) or risk difference (RD) with corresponding 95% confidence interval (95%CI). Subgroup analysis was performed stratified by study design (RCTs and observational studies).

Results

A total of ten RCT's (525 patients) and eighteen observational studies (4906 patients) were included. The effect estimates obtained from observational studies and RCT's were similar in direction and magnitude. More patients treated with nailing required re-intervention (RD: 2%; OR 2.0, 95%CI 1.0 – 3.8) with shoulder impingement being the most predominant indication (17%). Temporary radial nerve palsy secondary to operation occurred less frequently in the nailing group (RD: 2%; OR 0.4, 95% CI 0.3 – 0.6). Notably, all but one of the radial nerve palsies resolved sponta-neously in each groups. Nailing leads to a faster time to union (mean difference: -1.9 weeks, 95%CI -2.9 – -0.9), lower infection rate (RD: 2%; OR: 0.5, 95%CI 0.3 – 0.7) and shorter operation duration (mean difference: -26 minutes, 95%CI -37 – -14). No differences were found regarding non-union, general quality of life, functional shoulder scores, and total upper extremity scores.

Conclusion

Nailing carries a lower risk of infection, postoperative radial nerve palsy, shorter operation duration, and time to union. Absolute differences, however, are small and almost all patients with radial nerve palsy recovered spontaneously. Satisfactory results can be achieved with both treatment modalities and both techniques have their inherent pros and cons.

The spanning plate as an internal fixator in complex distal radius fractures – a prospective cohort study

Objective

Minimal invasive temporary spanning plate (SP) fixation of the wrist has been described as an alternative treatment method in complex distal radius fractures (DRFs). The purpose of this study is to conduct an outcome analysis of all consecutive DRFs treated by SP fixation representing the so far largest published patient cohort outside the United States.

Methods

Indication for SP fixation included DRFs with severe metaphyseal comminution, radiocarpal luxation fractures with concomitant ligamentous injuries and very distal intra-articular fractures lacking the possibility of adequate plate anchoring. All consecutive patients undergoing SP fixation of DRFs were prospectively included in a single level I trauma centre between 01/01/2018 and 31/12/2020. Post-operative assessments included radiological, functional and patient-rated outcomes at a minimum of 12 months follow-up.

Results

In the mentioned timeframe, a total of 508 DRFs were treated operatively of which 28 underwent SP fixation. Average age was 58.1 years (range 22-95 years). The fracture type ranged from AO/OTA type B1.1 to C3.3 and included 8 fracture dislocations. SP removal was performed on average 3.7 months after the initial operation (range 1.4-6.5 months). The mean follow-up time was 14.5 months (range 12-24 months). Radiological evidence of fracture healing appeared on average 9.9 weeks (range 5-28 weeks) after the initial operation. One patient experienced oligosymptomatic non-union. Complications included 2 patients with tendon rupture and one patient with extensor tendon adhesions needing tenolysis at the time of plate removal leaving an overall complication rate of 12%. There was no implant failure and no infection. Mean satisfaction score was 8 (range 0-10) and mean visual analogue scale for resting pain was 0.9 (range 0-9). The mean PRWE score was 17.9 (range 0-59.5) and the mean DASH score was 16.6 (range 0-60.8). Grip strength averaged 23kg (range 4-74kg) amounting to 68% of the opposite side. Mean radial inclination, volar tilt and ulnar variance at 1 year were all within the acceptable limit predictive of symptomatic malunion.

Conclusion

The radiological, functional and patient-rated outcomes in this study are remarkably good considering the complexity of the included fractures. Therefore, this method represents a valuable alternative for the treatment of complex DRFs in selected patients.

Cement augmentation for trochanteric femur fractures: A meta-analysis and systematic review of randomized clinical trials and observational studies

Objective

To date, it is unclear what the clinical benefit of cement augmentation in fixation for trochanteric fractures is. The aim of this meta-analysis is to compare cement augmentation to no augmentation in fixation of trochanteric femur fractures in the elderly patients (&gt;65 years) following low energy trauma.

Methods

PubMed/Medline/Embase/CENTRAL/CINAHL were searched for both randomized clinical trials (RCT) and observational studies comparing both treatments. Effect estimates were pooled across studies using random effects models. Subgroup analysis was performed stratified by study design (RCTs and observational studies). The primary outcome is overall complication rate. Secondary outcomes include re-operation rate, mortality, operation duration, hospital stay, general quality of life, radiologic measures and functional hip scores.

Results

A total of four RCT's (437 patients) and three observational studies (293 patients) were included. The effect estimates of RCTs were equal to those obtained from observational studies. Cement augmentation has a significantly lower overall complication rate (28.3% versus 47.2%) with an odds ratio (OR) of 0.3 (95%CI 0.1-0.7). The occurrence of device/fracture related complications was the largest contributing factor to this higher overall complication rate in the non-augmented group (19.9% versus 6.0%, OR 0.2, 95%CI 0.1-0.6). Cement augmentation also carries a lower risk for re-interventions (OR 0.2, 95%CI 0.1- 0.7) and shortens the hospital stay with 2 days (95%CI -2.2 to -0.5 days). The mean operation time was 7 minutes longer in the augmented group (95%CI 1.3-12.9). Radiological scores (lag screw/blade sliding mean difference -3.1mm, 95%CI -4.6 to -1.7, varus deviation mean difference -6.15°, 95%CI; -7.4 to -4.9) and functional scores (standardized mean difference 0.31, 95%CI 0.0-0.6) were in favor of cement augmentation. Mortality was equal in both groups (OR 0.7, 95%CI 0.4-1.3) and cement related complications were rare.

Conclusion

Cement augmentation in fixation of trochanteric femoral fractures leads to fewer complications, re-operations and shorter hospital stay at the expense of a slightly longer operation duration. Cementation related complications occur rarely and mortality is equal between treatment groups. Based on these results, cement augmentation should be considered for trochanteric fractures in elderly patients.

Comparison of two whole-body computer tomography protocols for polytrauma patients

Objective

The use of whole-body computed tomography (CT) is an established standard primary diagnostic method in the work up of polytrauma patients. The protocols used for such CTs however vary between trauma centers. In our Level 1 trauma Centre the protocol was changed from a three phase to a two phase protocol with different positioning of the patient. The primary aim of this study was to compare the estimated radiation dose and scan duration of the two protocols. The secondary aim was to evaluate whether the revision of the CT protocol led to a reduction of required additional imaging of the upper extremities.

Methods

For this retrospective, cross-sectional study two groups of consecutive trauma patients, which were treated in a level 1 trauma center in Switzerland and received a whole-body CT were analyzed. Group A consisted of patients, who presented between January and August 2016. These patients received a three-phased CT in which a repositioning of the arms from the side of the torso to above the head between phases two and three was needed. Group B consisted of those, who presented between January and July 2017. These patients received a CT according to a revised protocol, which was performed in two phases with the arms positioned ventral on a pillow to the torso throughout the entire CT. Scan duration, estimated radiation dose, number of upper extremity injuries, number of addition imaging (xray and CT) of the upper extremities within 24 hours of initial CT.

Results

A total of 182 patients were included in group A and 218 in group B. Baseline characteristics didn't differ, except for there being more males in group B (p 0.006). The estimated radiation dose was lower (15.0 mSv vs 22.9 mSv, p &lt; 0.001) and the scan duration shorter (4 vs 7 minutes, p &lt; 0.001) in group B. No difference could be shown in the number of upper extremity injuries detected. Further, the number of additional images of the upper extremities needed within 24 hours of the initial CT did not differ between the groups.

Conclusion

Both the estimated radiation dose and the scan duration of a whole-body CT scan in trauma patients can be reduced when a two phase protocol in which the arms are positioned on a pillow ventral to the torso is used instead of a three phase protocol with repositioning of the arms. The amount of additional imaging of the upper limb could not be reduced by having the arms visible on the scan.

Plate vs. nail for extra-articular distal tibia fractures: How should we personalize surgical treatment? A meta-analysis of 1332 patients

BACKGROUND

Treatment for distal diaphyseal or metaphyseal tibia fractures is challenging and the optimal surgical strategy remains a matter of debate. The purpose of this study was to compare plate fixation with nailing in terms of operation time, non-union, time-to-union, mal-union, infection, subsequent re-interventions and functional outcomes (quality of life scores, knee- and ankle scores).

METHODS

A search was performed in PubMed/Embase/CINAHL/CENTRAL for all study designs comparing plate fixation with intramedullary nailing (IMN). Data were pooled using RevMan and presented as odds ratios (OR), risk difference (RD), weighted mean difference (WMD) or weighted standardized mean difference (WSMD) with a 95% confidence interval (95%CI). All analyzes were stratified for study design.

RESULTS

A total of 15 studies with 1332 patients were analyzed, including ten RCTs (n = 873) and five observational studies (n = 459). IMN leads to a shorter time-to-union (WMD: 0.4 months, 95%CI 0.1 - 0.7), shorter time-to-full-weightbearing (WMD: 0.6 months, 95%CI 0.4 - 0.8) and shorter operation duration (WMD: 15.5 min, 95%CI 9.3 - 21.7). Plating leads to a lower risk for mal-union (RD: -10%, OR: 0.4, 95%CI 0.3 - 0.6), but higher risk for infection (RD: 8%, OR: 2.4, 95%CI 1.5 - 3.8). No differences were detected with regard to non-union (RD: 1%, OR: 0.7, 95%CI 0.3 - 1.7), subsequent re-interventions (RD: 4%, OR: 1.3, 95%CI 0.8 - 1.9) and functional outcomes (WSMD: -0.4, 95%CI -0.9 - 0.1). The effect estimates of RCTs and observational studies were equal for all outcomes except for time to union and mal-union.

CONCLUSION

Satisfactory results can be obtained with both plate fixation and nailing for distal extra-articular tibia fractures. However, nailing is associated with higher rates of mal-union and anterior knee pain while plate fixation results in an increased risk of infection. This study provides a guideline towards a personalized approach and facilitates shared decision-making in surgical treatment of distal extra-articular tibia fractures. The definitive treatment should be case-based and aligned to patient-specific needs in order to minimize the risk of complications.

Simple Wound Irrigation in the Postoperative Treatment for Surgically Drained Spontaneous Soft Tissue Abscesses: A Prospective, Randomized Controlled Trial

BACKGROUND

Soft tissue abscesses are among the most frequently encountered medical problems treated by different surgeons. Standard therapy remains incision and drainage with sterile saline irrigation during postoperative wound healing period. Aim of this prospective randomized controlled trial was to compare sterile irrigation versus nonsterile irrigation.

STUDY DESIGN

A single center randomized controlled trial was performed to investigate postoperative wound irrigation. The control group used sterile irrigation, and the intervention group used nonsterile irrigation. Primary endpoints were reinfection and reintervention rates, assessed during follow-up controls for up to 2 years. Secondary endpoints were the duration of wound healing, inability to work, pain and quality of life.

RESULTS

Between 04/2016 and 05/2017, 118 patients were randomized into two groups, with 61 allocated to the control- and 57 to the intervention group. Reinfection occurred in a total of 4 cases (6.6%) in the sterile protocol and 4 (7%) in the nonsterile protocol. Quality of life and pain values were comparable during the wound healing period, and patients treated according to the nonsterile irrigation protocol used significantly fewer wound care service teams. Despite equal wound persistence rates, a substantially shorter amount of time off from work was reported in the nonsterile protocol group (p value 0.086).

CONCLUSION

This prospective, randomized trial indicates that a nonsterile irrigation protocol for patients operated on for soft tissue abscesses is not inferior to the standard sterile protocol. Moreover, a nonsterile irrigation protocol leads to a shorter period of inability to work with comparable pain and quality of life scores during the wound healing period.

Absolute or relative stability in plate fixation for simple humeral shaft fractures

INTRODUCTION

Minimal invasive plating (MIPO) techniques for humeral shaft fractures appear to have fewer complications and higher union rates compared to open reduction and internal fixation (ORIF). It is questionable if this also applies to simple humeral shaft fractures, as simple fractures are generally treated with absolute stability which cannot be obtained with MIPO. This raises the question whether biology or biomechanics is more important in fracture healing. This study was developed to investigate the biomechanical part of this equation. The aim of the study was to compare relative stability to absolute stability in simple humeral shaft fractures with regard to fracture healing METHODS: This was a retrospective study of all patients treated with plate fixation for AO/OTA type A1-B3 humeral shaft fractures. Patients were categorized into two groups: absolute stability and relative stability. Both groups were compared with regard to time to radiological union and full weight bearing RESULTS: Thirty patients were included in the relative-stability-group with either an AO/OTA type A (n = 18) or type B (n = 12) humeral shaft fracture and a mean age of 55 (SD 21) years. A total of 46 patients were included in the absolute-stability-group: 27 patients had a type A and 19 type B fracture. The mean age in this group was 45 (SD 19) years. Median follow-up was 12 months (IQR 8-13). Minimally invasive approach was used in 15 (50%) patients in the relative stability group. Time to radiological union was significantly shorter in the absolute-stability-group with a median of 14 (IQR 12-22) versus 25 (IQR17-36) weeks and HR 2.60 (CI 1.54-4.41)(p < 0.001). This difference remained significant after correction for type of approach (adjusted HR 3.53 CI 1.72-7.21) (p 0.001). There was no significant difference in time to full weight bearing. The addition of lag screws in the absolute stability group did not influence time to radiological healing or full weight bearing.

CONCLUSION

Absolute stability for simple humeral shaft fractures leads to a significantly shorter time to radiological union compared to relative stability. The addition of lag screws to gain interfragmentary compression does not reduce fracture healing time.

[Definitions and explanations on the topic of fracture reduction]

The process of reduction is a key step for successful fracture treatment. The goal of fracture reduction is the realignment of the displaced fractured fragments caused by muscle tension or impaction back into the original anatomic relationship. The reduction process includes not only the application of force at or remote from the fracture site to reverse the deforming forces but also the preoperative planning where to apply these forces and by what means. Furthermore, consideration should be preoperatively given on how to position the patient and the C‑arm and how to temporarily maintain reduction for intraoperative x‑ray control of the axis, rotation and lengths before definitive fixation.

Plate fixation of the proximal humerus: an international multicentre comparative study of postoperative complications

OBJECTIVE

The primary aim was to evaluate the number of complications following locking plate fixation of proximal humeral fractures in country X and in country Y. The secondary aim was to identify risk factors for complications.

METHODS

Multicentre retrospective case series of 282 consecutive patients with proximal humeral fractures, treated with a locking plate between 2010 and 2014.

SETTING

two level 1 trauma centres in country X and one in country Y. Data pertaining to demographics, postoperative complications and re-operations were collected. Fractures were classified according to the AO and Hertel classifications and experienced surgeons assessed the quality of reduction and plate fixation on the postoperative X-rays. Outcomes of the two different countries were compared and logistic regression analysis was performed to analyse the relationship between risk factors and complications.

RESULTS

During a median follow-up of 370 days, 196 complications were encountered in 127 patients (45%). The most frequent complications were: screw perforation in the glenohumeral joint (23%), persistent shoulder complaints (16%), avascular necrosis of the humeral head (10%) and secondary fracture displacement (5%). In 80 patients (28%), 132 re-operations were performed. The patients operated in country X had significantly more complications compared with the patients operated in country Y. For implant-related complications, advanced age, non-anatomic reduction of the greater tuberosity, and country of operation were risk factors.

CONCLUSION

The use of locking plates for proximal humeral fractures was associated with a high number of complications in both countries; the patients operated in country Y, however, had better results compared with the patients operated in country X.

LEVEL OF EVIDENCE

IV.

Absolute or relative stability in minimal invasive plate osteosynthesis of simple distal meta or diaphyseal tibia fractures?

INTRODUCTION

Minimal invasive plate osteosynthesis in simple distal meta or diaphyseal tibia fractures can be applied using absolute (lag screw and neutralisation plate; LSN) or relative stability (bridge plate; BP). The primary aim of the study was to compare time to radiological union and time to full weight bearing in the two groups (LSN vs. BP). Reduction was performed either percutaneously or by a minimally open approach (mini open). Secondary aim was to analyse the number of complications between both groups.

METHODS

Retrospective single centre review of patients with a simple distal meta or diaphyseal tibia fracture operated with a Locking Compression Plate (LCP) between 2009 and 2015 in a Level one Trauma Centre. Postoperative radiographs were assessed in a standardised manner. Time to radiological fracture union and time to full weight bearing were observed. Callus index and postoperative complications were analysed.

RESULTS

Fifty-seven patients with a minimum follow-up of 6 months were analysed. Forty-eight patients had a shaft (AO/OTA Type 42) and nine a distal tibia fracture (AO/OTA Type 43). Forty patients were treated with using the LSN concept and 17 patients with the BP concept. Median time to radiological fracture union was statistically significant shorter (p=0.04) in the LSN group with 19 weeks compared to 27 weeks in the BP-group. Time to full weight bearing was 10 weeks in both groups. A total (including implant removal) of 35 reoperations were performed in the LSN-group and 18 in the BP-group. Wound healing disorders (deep surgical site infections) were seen less the LSN group in 3/40 (7.5%) compared to the BP-group with 3/17 (17.6%). In the LSN group, there was no statistical difference in time to union or weight bearing between a percutaneous or mini open approach.

CONCLUSION

Stable osteosynthesis of simple distal meta or diaphyseal tibia fractures leads to faster radiologic fracture healing without an increase in complications or number of revisions compared to bridge plating. If a percutaneous reduction is not feasible for the insertion of a lag screw, a mini-open approach does not lead to a delay in fracture healing.

Evaluation of radiographic fracture position 1 year after variable angle locking volar distal radius plating: a prospective multicentre case series

Treatment with a variable angle locking plate can, in theory, maintain near anatomic reduction of intra-articular distal radius fractures, but it is unknown to what extent reduction is maintained as measured by computed tomography. We assessed changes in radiographic fracture position 1 year post-operatively. We included 73 patients of whom 66 patients (90%) had radiographs available for review at 1 year post-operatively. We found a small (less than 2 mm or 2°) but statistically significant change in several measures. Accounting for inter-observer variability, this is probably within measurement error. We found no difference in change in fracture position or range of motion, grip strength or patient-reported outcome between the use of one or two distal rows of screws. Our results show that minimal changes in reduction can be expected after volar plate fixation in most patients. We recommend using only one screw row routinely, limiting costs, surgical time and the risk of misplacement of screws.

LEVEL OF EVIDENCE

IV.

[Distal humerus fracture-extensile approaches]

The majority of dislocated, intra-articular fractures are treated with an open reduction and internal fixation. In this paper we describe a variety of dorsal approaches to the distal humerus. Beside the dorsal approach through an olecranon osteotomy we also discuss the alternative dorsal approaches without osteotomy and their advantages and drawbacks. Moreover we discuss the preoperative planning and operative procedure. Early functional rehabilitation, without weight bearing, is important to achieve an optimal outcome. Finally we present the results of the last 6 years of patients treated operatively in our clinic with distal humeral fractures.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation

PURPOSE

Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth.

METHODS

A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure.

RESULTS

The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups.

CONCLUSIONS

When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable.

TYPE OF STUDY/LEVEL OF EVIDENCE

Diagnostic III.

[Minimally invasive plating osteosynthesis of proximal humeral shaft fractures with long PHILOS plates]

OBJECTIVE

Closed reduction and minimally invasive stabilization of proximal humeral shaft fractures with long PHILOS plates. The presented technique enables stable extramedullary fixation of the fractures without affecting surrounding nerves.

INDICATIONS

Proximal humeral shaft fractures that may not be fixed by intramedullary nailing because of a narrow, deformed or occupied intramedullary canal or because of open growth plates.

CONTRAINDICATIONS

Fractures that may not be reduced adequately by traction or with percutaneous techniques. Furthermore, fractures with delayed or nonunion and pseudarthrosis should not be treated with this technique.

SURGICAL TECHNIQUE

An anterolateral delta split approach is used to create an epiperiosteal tunnel along the humeral shaft from proximally to distally. A second incision is made distally at the lateral border of the biceps muscle. The brachialis muscle is dissected longitudinally. The PHILOS plate is twisted so that the proximal part of the plate can be placed laterally and the distal part anterolaterally at the humeral shaft. The plate is inserted into the epiperiostal tunnel and fixed with percutaneous screws.

POSTOPERATIVE MANAGEMENT

The arm is immobilized in a Gilchrest bandage until wounds are healed. Active-assisted physiotherapeutic mobilization without loading starts on the first postoperative day. Active mobilization starts 8-12 weeks postoperatively. In cases of soft tissue irritation the PHILOS plate may be removed after 1 year.

RESULTS

Between 2005 and 2011 a total of 16 patients (8 women and 8 men) were treated with the presented technique. The patients mean age was 61 years. According to the AO classification, five fractures were classified as type A, eight as type B and three fractures as type C. All patients had clinical and radiological follow-up examinations after a mean of 24 months (12-38 months). All fractures showed complete bony consolidation at the final follow-up. The mean Constant-Murley score was 81 points representing 84% of the Constant-Murley score of the healthy contralateral shoulder. The average DASH score was 33 points and the mean SF36 was 85 points.

Current concepts in fractures of the distal femur

This paper describes current treatment strategies of distal femoral fractures as well as their evidence based rationale. The treatment of distal femoral fractures has improved with the evolution of plating and nailing technologies. The commonly selected surgical approaches are outlined and surgical treatment techniques including both internal and external fixation are discussed.

Outcomes following operative and non-operative management of humeral midshaft fractures: a prospective, observational cohort study of 47 patients

Background

Although the non-operative management of closed humeral midshaft fractures has been advocated for years, the increasing popularity of operative intervention has left the optimal treatment choice unclear.

Objective

To compare the outcomes of operative and non-operative treatment of traumatic closed humeral midshaft fractures in adult patients.

Methods

A multicentre prospective comparative cohort study across 20 centres was conducted. Patients with AO type 12 A2, A3 and B2 fractures were treated with a functional brace or a retrograde-inserted unreamed humeral nail. Follow-up measurements were taken at 6, 12 and 52 weeks after the injury. The primary outcome was fracture healing after 1 year. Secondary outcomes included sub-items of the Constant score, general patient satisfaction, complications and cost-effectiveness parameters. Functions of the uninjured extremity were used as reference parameters. Intention-to-treat analysis was applied with the use of t-tests, Fisher’s exact tests, Mann–Whitney U-tests and adjusted analysis of variance (ANOVA).

Results

Forty-seven patients were included. The patient sample consisted of 23 women and 24 men, with a mean age of 52.7 years (range 17–86 years). Of the 47 cases, 14 were treated non-operatively and 33 operatively. The follow-up rate at 1 year was 81%. After 1 year, 11 fractures (100%) healed in the non-operative group and at least 24 fractures (≥89%) healed in the operative group [1 non-union patient (4%) and no data for 2 patients (7%)]. There were no significant differences in pain, range of motion (ROM) of the shoulder and elbow, and return to work after 6 weeks, 12 weeks and 1 year. Although operatively treated patients showed significantly greater shoulder abduction strength (p = 0.036), elbow flexion strength (p = 0.021), functional hand positioning (p = 0.008) and return to recreational activities (p = 0.043) after 6 weeks, no statistically significant differences existed in any outcome measure at the 1-year follow-up.

Conclusions

Our findings indicate that the non-operative management of humeral midshaft fractures can be expected to have similar functional outcomes and patient satisfaction at 1 year, despite an early benefit to operative treatment. If no radiological evidence of fracture healing exists in non-operatively treated patients during early follow-up, a switch to surgical treatment results in good functional outcomes and patient satisfaction.

The impact of stereo-visualisation of three-dimensional CT datasets on the inter- and intraobserver reliability of the AO/OTA and Neer classifications in the assessment of fractures of the proximal humerus

We evaluated the impact of stereo-visualisation of three-dimensional volume-rendering CT datasets on the inter- and intraobserver reliability assessed by kappa values on the AO/OTA and Neer classifications in the assessment of proximal humeral fractures. Four independent observers classified 40 fractures according to the AO/OTA and Neer classifications using plain radiographs, two-dimensional CT scans and with stereo-visualised three-dimensional volume-rendering reconstructions. Both classification systems showed moderate interobserver reliability with plain radiographs and two-dimensional CT scans. Three-dimensional volume-rendered CT scans improved the interobserver reliability of both systems to good. Intraobserver reliability was moderate for both classifications when assessed by plain radiographs. Stereo visualisation of three-dimensional volume rendering improved intraobserver reliability to good for the AO/OTA method and to excellent for the Neer classification. These data support our opinion that stereo visualisation of three-dimensional volume-rendering datasets is of value when analysing and classifying complex fractures of the proximal humerus.

[Distal radius fractures: new concepts as basis for surgical treatment]

New advances in the biomechanics and pathomechanics of distal radius fractures as well as new generations of plates and improved surgical approaches now make possible the stable management and early functional rehabilitation not only of simple but also of complicated distal radius fractures according to the principles for articular and juxta-articular fractures. Especially for complex articular fractures, the fracture patterns are so heterogeneous that an individual surgical treatment strategy must be developed for each case. The preoperative clarification of articular fractures with computed tomography is particularly useful for planning surgery. Mental exposition with the three-column model and pathomechanics is an important prerequisite for understanding this type of injury and the appropriate choice of operative technique. A decisive factor for success is the subtle surgical procedure in approaching and handling the fine plates.

[Impact and risks of cost cutting programs on the quality of hospital care in Switzerland]

Cost-minimization programs in Switzerland either in the public or the private sector have impact on quality and accessibility of the health care system. Rationalization may induce in fact hidden rationing of care and increases the workload of the health care workers involved. The relation of hospital staffing to inpatient quality of care are important issues. The reduction of funds may place patients at risk, due to lower staffing levels. Patient to nurses ratio have a substantial effect on inpatient mortality and nurse burnout. Research in Switzerland is needed to define the measurement of the nursing case mix on the basis of discharge data and to elucidate the factors influencing the staffing levels of nurses and the mix of nursing personnel in hospitals. Due to reduced funding the ability of hospitals to handle emergency cases may be compromised. The impact on quality and risks of unreflected cost minimization programs in hospitals but also the whole health care system are important and worth of public notice. Possible solutions for a health care reform in Switzerland are outlined and discussed.

Locking compression plate loosening and plate breakage: a report of four cases

The Locking Compression Plate (LCP) system offers a number of advantages in fracture fixation combining angular stability through the use of locking screws with traditional fixation techniques. This makes the implant particularly suitable for use in poor bone stock and complex joint fractures, especially in the epimetaphyseal area. However, the system is complex, requiring careful attention to biomechanical principles, and a number of potential pitfalls need to be considered. These pitfalls are illustrated in the 4 cases described herein, in which treatment was unsuccessful due to implant breakage or loosening. In each case, treatment failure could be attributed to the choice of an inappropriate plate and/or fixation technique, rather than to the features of the Locking Compression Plate system itself. Such experiences highlight the importance of detailed understanding of the biomechanical principles of plate fixation as well as careful preoperative planning for the successful use of the Locking Compression Plate system.

[Management of complex distal radius fractures]

Complex injuries of the distal radius can be associated with articular comminution, severe soft tissue injury, large metaphyseal and/or diaphyseal bone defects, carpal ligament tears or its combinations. We recommend a standardized three step approach for the management of these severe injuries: external fixation as an emergency procedure; treatment of soft tissue damage and further diagnostics as needed; definitive adapted operative therapy after thorough analysis of the specific injury.

[Dorsal double plating for fractures of the distal radius--a biomechanical concept and clinical experience]

This article describes the anatomical and biomechanical rationale for stable internal fixation of distal radius fractures using a dorsal approach. The three column biomechanical model is illustrated. Advances in the understanding of the anatomy, the biomechanical model of the three columns and our clinical experience with dorsal double plating have lead to the development of a new set of precontoured 2.4 mm Titanium plates with the option for head locking screws.

[Osteosynthesis of combined radius head and capitulum humeri fractures with mini-implants]

INTRODUCTION

Combined injuries of the capitellum humeri and the radial head are rare. Most of them show combined osteocartilaginous lesions and collateral ligament lesions. Recommendations for treatment of these fatal injuries of the elbow are missing.

TYPE OF STUDY

Five cases were investigated in an retrospective analysis. The same approach was used for the osteocartilaginous lesion of the capitellum as well as the injury of the radial head. Internal fixation was done with mini-titanimplants, three of them combined with resorbable pins.

PATIENTS AND METHODS

Between 1996-1999 five patients (four men, one woman) with combined injury of the radial head and the capitellum were stabilized. The average age was 34 years (31-40 years). All fractures were stabilized by a direct radial approach with 1.5 mm or 2.0 mm lag screws partly with resorbable pins. All patients were evaluated radiologically and clinically according to the Mayo-elbow-performance score.

RESULTS

All patients were personally examined after an average period of 12.8 month (8-24 month) by an independent investigator. 4/5 patients were assessed for their satisfaction. No radiological signs of avascular necrosis of the capitellum or arthrosis were found. Three patients showed periarticular calcifications. The range of motion was averagely 124 degrees (extension 5-30 degrees, flexion 110-145 degrees), in three of five cases a secondary intervention for improvement of joint mobility was necessary. The Mayo-elbow-performance score rated for 85 points in average (range 70-100 points).

CONCLUSION

Direct screw fixation with mini-implants, eventually combined with resorbable pins allows to use the same approach for anatomic reconstruction and fixation of the capitellum humeri and radial head. Transarticular fragment fixation of the capitellum allows for safe compression. Therefore early functional rehabilitation is possible postoperatively. Secondary interventions for improve joint motion were necessary in three of five cases.

Neue Prinzipien der operativen Behandlung von distalen Radiusfrakturen – winkelstabile Implantate

Das Ziel der Behandlung von distalen Radiusfrakturen ist die vollständige Wiederherstellung der Funktion des Handgelenks. Voraussetzungen dazu sind die Wiederherstellung der Anatomie und die frühfunktionelle Nachbehandlung entsprechend den Behandlungsgrundsätzen anderer artikulärer und juxtaartikulärer Frakturen. Ein besseres Verständnis der anatomischen Gegebenheiten und neue biomechanische Modelle haben zur Entwicklung neuer Implantate und Operationstechniken geführt. Das LCP-Konzept mit winkelstabil verankerten Plattenschrauben hat auch in der osteosynthetischen Versorgung der distalen Radiusfraktur wesentliche Fortschritte gebracht.

Neue minimalinvasive Verfahren zur Stabilisierung distaler Femurfrakturen

Neue minimalinvasive Verfahren bieten gegenüber der herkömmlichen Plattenosteosynthese am distalen Femur den Vorteil einer zuverlässigen Knochenheilung auch ohne Spongiosaplastiken und eines besseren Haltes auch im osteoporotischen Knochen. Zudem weisen sie niedrigere Infektraten bei vergleichbaren Fehlstellungsraten auf.

Neue Stabilisierungskonzepte bei proximalen Humerusfrakturen

Bessere Bildgebung, neuere Erkenntnisse über die Perfusionsverhältnisse am proximalen Humerus und entsprechend adaptierte Osteosynthesetechnik sowie Implantate mit sicherer Verankerung auch im osteoporotischen Knochen bedeuten einen Fortschritt bei der Behandlung proximaler Humerusfrakturen. Die Probleme der Kopfnekrose, des Implantatversagens im osteoporotischen Knochen und die mäßigen funktionellen Resultate sollten dadurch günstig beeinflusst werden. Adäquate Bildgebung, gelegentlich ergänzt durch Schnittbildverfahren, sind Voraussetzung für die Wahl eines dem Patienten und dem Frakturmuster adaptierten Verfahrens. Sie erlaubt eine zuverlässige präoperative Planung. Das angewandte Stabilisierungsprinzip ist Ausdruck chirurgischer Präferenz. Es erfordert aber unterschiedliche Nachbehandlungsmodalitäten. Letztere sollten in Zusammenarbeit mit dem Operateur anhand klinischer und standardisierter radiologischer Kontrollen nach drei respektive sechs und zwölf Wochen dem Heilungsverlauf entsprechend adaptiert werden.

[LISS tractor. Combination of the "less invasive stabilization system" (LISS) with the AO distractor for distal femur and proximal tibial fractures]

Minimally invasive plate osteosynthesis (MIPO) in conjunction with the less invasive stabilization system (LISS) first requires reduction and retention of the fracture using such aids as external fixation, distractors, and percutaneous reduction clamps before the plate can be applied. Based on the open indirect "biological" technique of osteosynthesis, the LISS was combined with an AO distractor (LISS tractor) integrated into the LISS plate. This made reduction possible against the plate before final fixation of the LISS plate. The LISS tractor concept was validated in three patients and we present the technique here. No malalignments > 5 degrees occurred. Fluoroscopy lasted 3.0 min (range: 2.1-4.5) and the operation 125 min (range: 90-150). Modification of the well-known LISS technique by integrating the distractor into the LISS plate to simplify reduction and to provide temporary retention of the fracture has the potential to reduce the fluoroscopy time, the operation time, the rate of malalignments, and the learning curve for this MIPO technique.

["Bone tumor" diagnostic error in stress fracture of the medial tibial plateau]

Stress fractures occur in 13.2-37.0% in running athletes. There is a decreasing incidence of these fractures in the tibia (33%), navicular (20%), metatarsus (20%), femur (11%), fibula (7%) and pelvis (7%). Clinically stress fractures present themselves with uncharacteristic local pain under weightbearing conditions. In 75% the medial tibial crest is involved. Usually the pain disappears when the patient is non-weightbearing. As causal factors wrong training methods, oligomenorrhoe (6x incidence), low nutrition input (8x incidence) and a genu recurvatum-morphotype can be found. Misinterpretation can result from a similar clinical and radiological (conventional x-ray, scintigraphy, MRI) early course in stress fractures and bone tumors. We present a patient with a clinical diagnosis of a meniscus lesion. The following MRI was suspect for a malignant lymphoma or histiocytoma. Biopsy was performed and showed the final diagnosis of a stress fracture.

Intralipid-based short-term total parenteral nutrition does not impair small intestinal mucosa-related cellular immune reactivity in the healthy rat

BACKGROUND

The lipid component of total parenteral nutrition (TPN) has reportedly been associated with trophic effects on the intestinal mucosa and suppressive effects on the immune system.

METHODS

We have challenged these hypotheses using a 7-day TPN rodent model comparing the effects of isocaloric, isonitrogenous lipid-based (TPN-lipid, 50% of calories as long-chain triacylglycerol) and carbohydrate-based TPN (TPN-CH, 100% of calories as carbohydrates) on mucosal morphology and immune function. Enterally fed animals were included to establish a baseline for immunologic read-outs. The study was performed in healthy, metabolically stable animals to avoid interference by septic or trauma-related stress factors.

RESULTS

Both TPN regimens resulted in a significantly smaller weight gain (TPN-lipid, 29.8 +/- 4.0 g; TPN-CH, 30.3 +/- 4.4 g) compared with enterally fed reference animals (49.2 +/- 3.2 g; p = .007), with no difference in nitrogen balance between the TPN groups. Mucosal sucrase activity was significantly lower in both TPN groups (TPN-lipid, 8.8 +/- 1.0 x 10(-7) katal per gram (kat/g) of protein; CH: 11.9 +/- 1.6 x 10(-7) kat/g of protein) compared with enteral feeding (17.4 +/- 0.9 x 10(-7) kat/g of protein; ANOVA: p = .0007). Morphometric analysis of the small intestine revealed no differences between the two TPN groups although a significantly depressed villus height in the TPN-lipid group could be observed in comparison to enterally fed reference rats (TPN-lipid, 0.47 +/- 0.02; TPN-CH, 0.50 +/- 0.01; enteral, 0.56 +/- 0.02 mm; ANOVA: p = .0298). Light and electron microscopy revealed a normal surface architecture in all three groups of rats. Cellular immune reactivity was evaluated using a novel specific immunization protocol: animals were immunized against OVA 4 weeks before TPN. OVA-induced lymphoproliferative responses and phenotypic data from draining popliteal and mesenteric lymph nodes were evaluated after the different regimens. Results did not differ among the three groups.

CONCLUSIONS

In healthy rodents, short-term lipid-based and carbohydrate-based TPN regimens lead to limited mucosal atrophy with preserved surface architecture compared with enteral feeding. However, peripheral and mesenteric cellular immune responsiveness after both TPN regimens remained comparable to enterally fed reference animals. Therefore, mesenteric and systemic cellular immune reactivity does not appear to be impaired by lipid-based or carbohydrate-based TPN.

Avascular necrosis of the femoral head after open reduction and internal fixation of femoral neck fractures: an inevitable complication?

Between 1980 and 1989 71 patients with a femoral neck fracture were treated at the University Hospital of Basel by a Dynamic Hip Screw (n = 54) or by three compression screws (n = 17). Fifty out of 71 patients (70%) were reviewed clinically and radiologically after an average of 116 months. 32/50 fractures (64%) had united. In 18/50 (36%) either avascular necrosis (12) or secondary fracture dislocation (6) had resulted in failure after an average of 29 months following injury. Despite these results, the patients assessment had been very good or good in 44 patients (88%) and fair only in six patients (12%). The cause of secondary dislocation proved to be mainly due to a technical failure at surgery. The incidence of avascular necrosis was significantly higher in displaced fractures compared to non-displaced fractures (p < 0.05), regardless of the quality of the reduction achieved (varus or valgus) or the time delay between accident and operation. However it was interesting to note, that more than one third of all avascular necrosis became apparent more than 3 years (4-10 years) after the accident.

Trauma decreases leucine enkephalin hydrolysis in human plasma

Plasma hydrolysis of leucine enkephalin was evaluated, together with several cellular immune parameters, in a homogeneous group of human subjects who had undergone severe trauma (proximal femur fracture); data obtained were compared with those obtained in an age-matched control group. In the experimental group, immediately after hospitalization, substrate hydrolysis was reduced with respect both to the control subjects and the same patients 4 weeks after the trauma. Chromatographic separation of the enzymes active on leu-enkephalin showed that the reduction of substrate hydrolysis is mainly attributable to the decrease in the activity of enkephalin-degrading enzymes, principally of aminopeptidases, per se, whereas the role of the low-molecular-weight plasma inhibitors is only minor. In the same subjects, several of the immunological parameters measured underwent modifications that may be considered stress related. However, the absence of a quantitative relationship between reduction in hydrolysis and modifications of immune parameters does not support the hypothesis of a direct relationship between these two sets of data.

Clinical results using the trochanter stabilizing plate (TSP): the modular extension of the dynamic hip screw (DHS) for internal fixation of selected unstable intertrochanteric fractures

OBJECTIVE

To evaluate whether the implantation of the modular trochanter stabilizing plate (TSP) in addition to the dynamic hip screw (DHS) prevents excessive telescoping and limb shortening in four-part and selected three-part trochanteric fractures.

DESIGN

Prospective clinical study.

SETTING

The study was conducted at the trauma unit of the Surgical Department of the University of Basel, Switzerland.

PATIENTS

Forty-six consecutive patients with unstable intertrochanteric fractures were treated with an additional TSP super-imposed on the regular DHS at our institution between July 1991 and July 1993. Five patients died before the first follow-up, one patient was lost to follow-up, and another patient refused follow-up. Thus, thirty-nine patients were followed for at least twelve months (mean 14 months, range 12 to 20 months).

INTERVENTION

The fractures treated were classified according to the OTA classification, which is based on the AO classification. Seventeen were 31-A2.2, seven were 31-A2.3, and fourteen were 31-A3.3 fractures.

RESULTS

Lateralization of the greater trochanter was successfully prevented in all fractures. Limited fracture impaction was found in 90 percent (n = 35) of the patients with telescoping of 9.5 millimeters (range 0 to 30 millimeters), resulting in mean limb shortening of 5.37 millimeters (range 0 to 14.9 millimeters). Four patients suffered limb shortening exceeding fifteen millimeters (range 15.6 to 21.3 millimeters). Functional results were excellent and good in 87 percent of patients and fair in 13 percent according to the Salvati-Wilson score. All fractures had healed six months after the operation. Three complications required a secondary procedure: one from not inserting a second screw parallel to the gliding hip screw to prevent rotation of the head-neck fragment ("antirotation screw"), one because of deep infection, and one because of a refracture after premature implant removal.

CONCLUSION

In unstable pertrochanteric fractures with small or missing lateral cortical buttress, the addition of a TSP to the DHS effectively supports the unstable greater trochanter fragment and can prevent rotation of the head-neck fragment. Excessive fracture impaction and consecutive limb shortening was prevented by this additional implant in 90 percent of these patients.

Age-induced increase of leucine enkephalin enzyme degradation in human plasma

Possible age-induced variations of the hydrolysis of leucine enkephalin in the presence of plasma enzymes were studied by kinetic and chromatographic techniques in a group of elderly individuals. Results obtained indicate that in elderly individuals the activity of enkephalin-degrading plasma enzymes is greater than in the controls; ANOVA analysis of these data indicates that the dependency of the variation of hydrolysis upon the two age groups is statistically significant. Increased substrate hydrolysis, and a modified hydrolysis pattern, appear to be associated with increased activity of the enzymes involved, and with different distribution of the individual enzymes within each class, as well as with severely reduced activity of the low molecular weight plasma inhibitors. The combination of these factors defines a characteristic hydrolysis pattern for the elderly individuals, different from that found in the controls.