Intramedullary nailing of proximal tibia fractures—An anatomical study comparing three lateral starting points for nail insertion

Introduction

Intramedullary nailing is challenging in proximal tibia fractures, associated with high rates of malalignment. To date, no studies report the potential of lateral tibia nail insertion to correct primary valgus malalignment, commonly seen in proximal quarter fractures.

Materials and methods

18 fresh-frozen cadaver lower extremities were used to simulate an AO/OTA 41-A3 fracture. Six nails (Expert Tibial Nailing System, Synthes, Salzburg, Austria) were inserted at the lateral third, six nails at the middle third and six nails at the medial third of the lateral tibia plateau. After nail insertion, alignment in the coronal plane was recorded.

Results

Mean varus malalignment was dependent on the entry point at the lateral tibia plateau. Mean varus malalignment was 16° if nails were inserted at the lateral third, 10° at the middle third and 4° after nail insertion at the medial third. If nails were inserted from the medial third, valgus malalignment was recorded in two specimens.

Discussion

The effect of correction of coronal malalignment in proximal tibia fractures is dependent on the point of nail entry at the lateral plateau. Primary valgus deformation up to 20° can be corrected by inserting tibia nails at the lateral third of the lateral tibia plateau. Surgeons should be aware of possible varus deformity and valgus malalignment despite lateral nail insertion.     

Fat extravasation due to unreamed and experimentally reamed intramedullary nailing of the sheep femur

Aim

To compare systemic fat extravasation in unreamed and experimentally reamed nailing.

Methods

An osteotomy was created in the proximal third of the femoral shaft in 16 sheep, and intramedullary pressure increase and fat extravasation were monitored for the two nailing techniques.

Results

The highest intramedullary pressures, median 2700 mmHg, and highest percentages of fat extravasation, peaking at almost 90% of fat, were found for the unreamed nailing technique. The values for the reamed group were significantly lower.

Conclusions

The extravasation of intramedullary fat can be attributed to the great increase in intramedullary pressure that occurs during unreamed nailing. Correctly performed intramedullary reaming with the new reaming system produces lower pressures and much less systemic fat extravasation, reducing the risk for fat embolism.     

Proximal femoral fractures in the elderly: how are we measuring outcome?

Introduction

Patients with proximal femoral fractures present a difficult problem to health care systems in view of their complex presentations and co-morbidities. Traditionally, the focus of outcome measurement for this patient group has been on mortality and surgical implant success. Increasing recognition of the need to diversify outcome measurements has led to the creation and use of a number of outcome scales. We sought to examine how these scales are being used in the current literature.

Methods

Abstracts to over 4000 papers related to proximal femoral fracture research were screened to identify commonly used scales in the five main categories of general quality of life measures (QoL), Activities of Daily Living scales (ADL), mobility and physical performance scales, disease-specific scales and hip-specific scales. The 14 identified scales were then searched for directly, and papers analysed for scale usage, timing and interpretation.

Results

ADL scales were the most commonly used group, followed by QoL measures, which are validated for elderly patients. Scale timing and use varied widely between studies. A large number of scales were found in addition to the 14 identified scales. None of the 14 identified scales were validated for the proximal femoral fracture population.

Discussion

A good scale must be appropriate in content, method and clinical utility. Its method of application must be reliable, responsive, and validated for the population in question. Outcome scale usage was difficult to assess in proximal femoral fracture research due to difficulties in isolating the relevant research, and in differences in scale timing and interpretation. Scale prevalence was skewed by use by specific research groups.

Conclusion

There is no single unifying scale in widespread use for proximal femoral fracture patients. We would recommend the validation of commonly used scales for this population, and would advise the use of scales from more than one category to assess outcome.     

Quality of life after a subtrochanteric fracture: A prospective cohort study on 87 elderly patients

Background

The subtrochanteric fracture constitutes approximately 5-10% of all hip fractures. This particular fracture type, owing to its configuration and instability, poses significant challenges to the fixation method, especially in elderly patients with varying degrees of osteoporosis. There has been a gradual change in the operative techniques used to stabilise these fractures leading to the current widespread use of cephalomedullary nails. In contrast to the field of research on patients with the more common femoral neck and trochanteric fractures, few studies have evaluated the health-related quality of life (HRQoL) in patients with subtrochanteric fractures.

Objective

To report the long-term outcome for patients with subtrochanteric fractures treated with a cephalomedullary nail with special regard to the HRQoL.

Setting

Four university hospitals.

Design

A prospective cohort study with a 2-year follow-up.

Patients and methods

Eighty-seven consecutive elderly patients with a subtrochanteric fracture treated with a cephalomedullary nail. Main outcome measurements were mortality rate, reoperation rate, pain at the hip, walking ability, activities of daily living (ADL) function and HRQoL assessed with the EQ-5D (EQ-5D_index score).

Results

The EQ-5D_index score decreased from 0.73 before fracture to 0.53 at 4 and 12 months and to 0.52 at 24 months. At the final follow-up 80% of the patients reported no or only limited pain at the hip, 46% had regained their prefracture walking ability, 48% their prefracture level of ADL function and 71% had living conditions similar to those before the fracture. The reoperation rate was 8%. The mortality rate was 8% at 4 months, 14% at 12 months and 25% at 24 months.

Conclusions

A subtrochanteric fracture in elderly patients had a substantial negative effect on both their short and long-term HRQoL. Although pain at the hip was not a major problem there was an obvious deterioration in walking ability and ADL function. However, the rate of revision surgery was comparatively low which confirms that the cephalomedullary nail constitutes a safe treatment for elderly patients with a subtrochanteric fracture. The data on HRQoL obtained in this study can be used in future healthcare evaluations and to calculate quality-adjusted life-years (QALYs).     

A comparative biomechanical study of proximal femoral nail (InterTAN) and proximal femoral nail antirotation for intertrochanteric fractures

Purpose

The purpose of this study was to compare the biomechanical strength of the cephalomedullary nail InterTAN in cases of intertrochanteric fractures with the commonly used PFNA.

Methods

Sixteen fresh specimens of the proximal femur were used as intertrochanteric fracture models and were fixed using two fixation devices: the new proximal femoral nail (InterTAN) and proximal femoral nail antirotation (PFNA). An intertrochanteric fracture was created in composite bone models. Each specimen was loaded to simulate single leg stance while stiffness, migration (cut out), compressive force across the fracture site, and distal fragment rotation were monitored. The different internal fixation methods were tested by an experimental press analysis.

Results

Results of tests for femoral strength, stiffness, stability, and bearing capacity demonstrated that the biomechanical function of InterTAN was better than that of PFNA (P < 0.05). Compared with the PFNA nail, InterTAN showed increased strength, stiffness, and resistance torque of 30 %, 15 %, and 27 %, respectively.

Conclusion

Comparison of the treatment of intertrochanteric fractures with InterTAN and PFNA internal fixation showed that the InterTAN yielded improvement relative to the PFNA. InterTAN has a firmer and biomechanically superior performance and is therefore an ideal internal fixation method for treating intertrochanteric fractures. Additional research in osteopenic bone is necessary to comprehensively characterize the effects of the design enhancements of these two implants.     

Lower limb malrotation following MIPO technique of distal femoral and proximal tibial fractures

Objective

To determine the incidence of rotational malalignment in distal femoral and proximal tibial fractures using computed tomography (CT) scanograms following indirect reduction and internal fixation with the minimally invasive percutaneous osteosynthesis (MIPO) technique.

Design

Prospective Cohort.

Setting

Level I Trauma Centre.

Patients/Participants

A total of 27 consecutive subjects, and 14 proximal tibia and distal femur fractures.

Intervention

All patients underwent indirect reduction and internal fixation with a MIPO plating system. A CT scanogram to measure rotational malalignment between the injured and non-injured extremity was then undertaken.

Main outcome measure(s)

Femoral anteversion angles and tibial rotation angles between the injured and non-injured extremities were compared. Malrotation was defined as a side-to-side difference of >10°.

Results

A total of 14 postoperative tibias and 13 femurs underwent CT scanograms. Three females and 11 males with an average age of 38.1 years sustained proximal tibia fractures and six females and seven males with an average age of 55.8 years sustained distal femur fractures. The difference between tibial rotation in the injured and the non-injured limbs ranged from 2.7 to 40.0° with a mean difference of 16.2° (p = 0.656, paired T-test). Fifty percent of the tibias fixed with MIPO plates were malrotated >10° from the uninjured limbs. The difference between femoral anteversion in the injured and non-injured limbs ranged from 2.0 to 31.3° with a mean difference of 11.5° (p = 0.005, paired T-test). A total of 38.5% of the distal femurs fixed with MIPO plates were malrotated >10° from the uninjured limb.

Conclusions

Following fixation of distal femoral and proximal tibial fractures, the incidence of malrotation was 38.5% and 50%, respectively. The difference of the mean measures was significant for femoral malrotation; however, statistical significance could not be demonstrated for tibial malrotation. The incidence of malrotation following MIPO plating in this study is much higher than that quoted in previous studies.     

Treatment for ipsilateral fractures of femoral neck and shaft

Background

Concomitant ipsilateral femoral shaft and neck fractures present a challenge to the orthopaedic surgeon, and no consensus has yet emerged on the optimal treatment method. We report the results of a retrospective study of 43 patients with these complex fractures who were treated at a single Level 1 trauma centre.

Patients and methods

The study participants consisted of 28 males and 15 females with a mean age of 43 years. The mean follow-up period was 48 months. Four different treatment methods were used: (1) antegrade reamed intramedullary nailing of the shaft with cancellous screw fixation of the neck, (2) dynamic hip screw (DHS) fixation of the neck and low-contact dynamic compression plate (LCDCP) fixation of the shaft, (3) cancellous screw fixation of the neck and LCDCP fixation of the shaft, and (4) reconstruction nailing of both shaft and neck.

Results

No statistically significant differences in amount of blood loss, duration of surgery, total complication rate, nor clinical results were found among the four treatment methods. For femoral neck fracture, however, the complication rate of cannulated screw with antegrade intramedullary nailing fixation was 11 times that of DHS with LCDCP fixation.

Conclusions

Antegrade nail with screw fixation is not a recommended treatment method in patients with ipsilateral femoral shaft and neck fractures.     

Subtrochanteric hip fractures treated with cerclage cables and long cephalomedullary nails: a review of 17 consecutive cases over 2 years

Background

The conflict between the anatomist and biologist surgeons is exemplified by the debate about subtrochanteric hip fractures. Closed intramedullary nailing is biologically friendly but may result in prolonged procedures and malunion. By contrast, accurate anatomical open reduction may disturb the biological composition of the fracture environment.

Methods

There were 17 patients at our institution over a 2-year period whose long oblique subtrochanteric fractures would not reduce perfectly in an anatomical fashion using closed methods. All these patients had their fractures treated identically using a new policy at our unit. This strategy involved reduction of the fracture through an open approach, and then employing cerclage cables to stabilise the fracture in an anatomical position before finally inserting a cephalomedullary nail. These patients were retrospectively reviewed at an average of 18 months postoperatively, to assess their progressive functional and radiological outcome up to that point.

Results

One patient had nonunion and required a secondary procedure. One patient died 8 days postoperatively from a medical complication. The remaining 15 healed within 6 months and all returned to independent living.

Conclusions

The results demonstrate that judicious use of cerclage cables to augment fixation of subtrochanteric femur fractures does not have a deleterious effect on healing. One should endeavour, however, to minimise the number of cables used. The basic science literature underpinning our approach to these unstable fractures is also discussed.     

The incidence of non-union following unreamed intramedullary nailing of femoral shaft fractures

Introduction

Stabilisation of fractures with an intramedullary nail is a widespread technique in the treatment of femoral shaft fractures in adults. To ream or not to ream is still debated. The primary objective of this study was to determine the incidence of non-union following unreamed intramedullary stabilisation of femoral fractures. Secondary objectives were intra- and postoperative complications and implant failure.

Methods

Between March 1995 and June 2005, 125 patients with 129 traumatic femoral shaft fractures were treated with as unreamed femoral nail. From this retrospective single centre study, 18 patients were excluded due to insufficient follow up data, including 1 patient who died within 2 days after severe head injury. Sixty-six patients had suffered multiple injuries. 21 fractures were open. According to the AO classification, there were 54 type A, 42 type B, and 14 type C fractures. Dynamic proximal locking was performed in 44 cases (36 type A and 8 type B fractures).

Results

Non-union occurred in two patients (1.9%; one type B and one type C fractures). Intra-operative complications were seen in three patients (2.8%). Postoperative in-hospital complications occurred in 29 patients (27%). Local superficial infection occurred in two patients (1.9%), there were no cases of deep infection. Implant failure occurred in three patients (2.8%): nail breakage was seen in two patients.

Conclusion

In this study, the incidence of non-union following unreamed intramedullary nailing is low (1.9%) and comparable with the best results of reamed nailing in the literature.     

Correcting rotational deformity following femoral nailing

Introduction

The incidence of rotational malalignment after femoral nailing has been reported to be at least 20%. If the deformity is recognised early, it can be corrected by changing the distal locking screw and rotating the bone prior to fracture union. It is common practice to use the same distal locking screw of the nail if this surgery is performed, however, there is a risk of the new drill hole “cutting out” into the old screw hole. The degree of rotational deformity that needs to be corrected to use the same distal locking hole without cut out of the screw has not been defined.

Method

Ten femora, five from cadavera and five synthetic (“Synbone”), were stabilised in a vice and then fitted with one distal transverse screw. The screw was then removed and a second distal transverse screw was inserted at the same level after variable amounts of rotation. The bone bridge between the drill holes was then measured and any cut out was noted.

Results

Both of the femora cut out when rotated 10°, and one when rotated 15°. The size of the bone bridge between drill holes in femora rotated by 20° was 3 mm. This bone bridge was increased to 4 mm when the femora were rotated by 25°, and 8 and 9 mm when rotated by 30°.

Conclusion

The amount of rotational deformity that needs to be corrected in order to use the same distal locking hole in a femoral nail is significant. In our study, this equates to a correction of at least 25°, but this is not a definitive value in practice. Particular attention must be paid to the location and size of the distal locking screw when correcting malrotation after femoral nailing, to ensure an adequate bone bridge between the two holes.     

A biomechanical comparison of the Surgical Implant Generation Network (SIGN) tibial nail with the standard hollow nail

Objective

In developing countries, tibial shaft fractures are frequently stabilised using Surgical Implant Generation Network (SIGN) nails. Despite widespread use throughout the world, little is known regarding their biomechanical properties. This study aimed to compare the mechanical stiffness of the SIGN tibial nail with a standard hollow tibial nail.

Methods

A fracture gap model was created to simulate a comminuted mid-shaft tibia fracture (AO/OTA42-C3) using synthetic composite bones. The constructs were stabilised with either a 9 mm solid SIGN nail or a 10 mm hollow Russell-Taylor nail. Both nail systems were interlocked proximally and distally. Following fixation, the specimens were loaded in axial, torsional, and cyclical axial modes to calculate construct stiffness and irreversible (plastic) deformation.

Results

The mean axial stiffness for the SIGN nail constructs was 47% higher than mean stiffness for the RT nail constructs (p < 0.001). The difference in torsional stiffness was not statistically significant. However, the SIGN group demonstrated 159% more irreversible deformation than the Russell-Taylor group (p = 0.006) for the loading parameters studied.

Conclusion

The SIGN tibial nail, despite its slightly smaller diameter, can provide similar construct stiffness and stability, when compared to a larger hollow nail for stabilisation of tibial shaft fractures.     

Risk factor analysis of proximal junctional kyphosis after posterior fusion in patients with idiopathic scoliosis

Study design

A retrospective analysis of 150 adolescents who underwent spinal fusion for idiopathic scoliosis.

Objective

To analyse the incidence of the postoperative proximal junctional kyphosis after posterior fusion to the upper thoracic vertebra in adolescents with idiopathic scoliosis and to explore its risk factors.

Summary of background data

The reported incidence of the proximal junctional kyphosis after the posterior fusion in patients with idiopathic scoliosis varies depending on surgical methods and strategies adopted by the institution.

Methods

The changes in the Cobb angle of the proximal junctional kyphosis on the lateral spine X-ray were measured and the presence of PJK was recorded. The risk factors were screened using statistical analysis.

Results

PJK occurred in 35 out of 123 patients with an overall incidence of 28%. Among them, 28 patients (80%) experienced PJK within 1.5 years after surgery. The PJK-inducing factors included greater than 10° intraoperative decrease in thoracic kyphosis, thoracoplasty, the use of a pedicle screw at the top vertebra, autogenous bone graft and fusion to the lower lumbar vertebra (below L2).

Conclusions

There is a high incidence of postoperative proximal junctional kyphosis after posterior fusion to the upper thoracic vertebra within 1.5 years after surgery in adolescents with idiopathic scoliosis. In order to reduce its incidence, the risk factors for PJK should be carefully evaluated before surgery.     

Predicting failure after surgical fixation of proximal humerus fractures

Background

Several studies reported high failures rates after internal fixation of proximal humerus fractures. Loss of reduction and screw cut-out are the most common reasons for revision surgery. Several risk factors for failure have been described in the literature. The aim of the present study was to assess risk factors for failure after surgical fixation of unstable proximal humerus fractures in a multivariate setup.

Methods

Two different surgical techniques (PHILOS locking plate and Humerusblock) were used. In the PHILOS group, every kind of postoperative relative movement between the implant and the humeral head or shaft was defined as failure. In the Humerusblock group, postoperative movement between the humeral head and the shaft in terms of angulation or translational displacement was defined as failure. The following parameters were assessed: age, gender, cancellous bone mineral density (BMD) of the humeral head, fracture type, medial metaphyseal comminution, medial metaphyseal head extension, initial angulation of the humeral head in the frontal plane, initial anteversion of the humeral head, medial hinge displacement, maximum displacement of the tuberosities with respect to the head, surgical technique, anatomic reconstruction and restoration of the medial cortical support.

Results

The following parameters were found to have a significant influence on the failure rate: age, local BMD, anatomic reduction, and restoration of the medial cortical support. The failure rate significantly increased with the number of risk factors.

Conclusion

Preoperative assessment of the local BMD and the patients’ biological age as well as intraoperative anatomic reduction and restoration of the medial cortical support are the essentials for successful surgical fixation of proximal humerus fractures. Multifragmentary fracture patterns in old patients with low local BMD are prone for fixation failure. If the surgeon is not able to achieve anatomic reduction and restoration of the medial cortical support intraoperatively in this situation, adjustments such as augmentation or primary arthroplasty should be considered.     

Effects of orthotopic liver transplantation in inbred rats on bone biomechanical properties

Aim

To determine the effects of orthotopic liver transplantation in inbred rats on the mechanical properties of bones at different anatomic sites.

Methods

The 24 rats that survived liver transplantation were paired with sham-operated rats of similar body weight. Six months after surgery, the lumbar vertebra, the proximal femur, and the middle femoral shaft were measured for their biomechanical properties and bone mineral density.

Results

The ultimate force, the ultimate stress, the Young modulus and the bone mineral density of both the proximal femur and the middle femur shaft of the rats were significantly reduced in the liver transplant group. However, no significant change was observed in the various parameters that indicate the biomechanical properties and the bone mineral density of the lumbar vertebra.

Conclusions

Orthotopic liver transplantation impairs the biomechanical properties of the proximal femur and the middle femoral shaft. Orthotopic liver transplantation itself is one of the risk factors for posttransplant fracture.     

Mid-term outcomes after intramedullary fixation of peritrochanteric femoral fractures using the new proximal femoral nail antirotation (PFNA)

Background

Controversy persists concerning the preferred treatment of peritrochanteric femoral fractures. The purpose of the present study was to evaluate the mid-term outcomes of the newly developed implants - proximal femoral nail antirotation (PFNA) for the stabilisation of this type of fracture.

Methods

Between April 2006 and March 2008, 169 patients with peritrochanteric femoral fractures were treated with PFNA. As many as 26 patients were excluded from the study. According to the Orthopaedic Trauma Association (OTA) classification system, the remaining 143 fractures were classified as 19 cases of AO/OTA 31A1 fractures, 83 cases of 31A2 fractures, 28 cases of 31A3 fractures and 13 cases of 31A combined with proximal 32 fracture or separate proximal 32 fracture. The mean age of these patients was 67 years (range, 20-93 years). The operative time, the overall fluoroscopy time, the duration of hospitalisation and the surgical complications were noted. Patients were followed up for a mean of 21 months (range, 12-36 months). Functional outcomes were assessed according to the Harris hip scoring system.

Results

Fifteen patients (10%) required open reduction. The mean duration of surgery (from the beginning of close reduction to wound closure) was 72 min with a range between 45 and 170 min. The mean fluoroscopy time was 164 s with a range between 92 and 396 s. The mean time of hospital stay was 15 days. Postoperative X-rays showed a good or acceptable reduction in 134 cases (94%), and an ideal implant position in 131 cases (92%). There were 12 (8%) postoperative complications. All patients except one healed their fractures without any implant-specific complication (bending, breaking of the implant, cut out of the PFNA blade, femoral head penetration of the blade or ipsilateral fractures of the femoral shaft at the tip of the implant). The average time to bone healing was 16 weeks (range, 12-25 weeks). At the time of the latest follow-up, 106 patients (74%) were restored to their preoperative mobility. The mean Harris hip score was 84 points (range, 46-100 points). A total of 106 patients (74%) had an excellent or good outcome. According to the patients and/or their caregivers, outcome was described as satisfactory in 120(84%) of the 143 patients, and 36(90%) of the 40 patients, who were more than 80 years old.

Conclusion

The results suggest that PFNA is a very effective and safe method in the treatment of different patterns of peritrochanteric femoral fractures. The fixation is adequate to maintain reduction over time even in osteoporotic bones.     

Femoral nailing during serum bicarbonate-defined hypo-perfusion predicts pulmonary organ dysfunction in multi-system trauma patients

Objective

To assess the value of venous serum bicarbonate as an endpoint of resuscitation and guide to timing of femoral nailing in multi-system trauma patients.

Design

Retrospective cohort study.

Setting

Academic Level 1 Trauma Centre.

Patients

Seventy-two consecutive adult multi-system trauma patients (Injury Severity Score ≥ 15) with femoral shaft fracture (Orthopaedic Trauma Association Class 32-A to 32-C) treated with reamed medullary nail fixation.

Intervention

Femoral nailing in the setting of hypo-perfusion defined by venous serum bicarbonate (SB). Threshold values of SB were determined first by correlating SB and simultaneously drawn arterial base deficit (BD). Then, corresponding values of SB to previously defined thresholds of hypo-perfusion based on BD were identified using regression analysis.

Main outcome measurement

Pulmonary organ dysfunction (POD) component of the Denver Multiple Organ Failure scoring system.

Results

Simultaneous admission SB and BD values were correlated (r = −0.43, p = 0.001). Adjusting for age, ISS and baseline POD, patients with SB < 24.7 mequiv./L within 6 h of treatment had a 12-fold increase in POD (OR 12.2, 95% CI 1.5-98.6, p = 0.019). This association was diminished, but still significant with hypo-perfusion present within 12 h prior to treatment (OR 5.6, 95% CI 1.0-29.1, p = 0.042) and 24 h prior to treatment (OR 5.9, 95% CI 1.1-30.7, p = 0.037).

Conclusions

Medullary fixation of femoral shaft fracture in the setting of serum bicarbonate-defined hypo-perfusion is associated with increased morbidity. Appropriate damage-control measures and aggressive resuscitation prior to definitive fracture care are advised and physiologic markers such as serum bicarbonate should guide clinical decision making rather than temporal distinctions.     

Male cryptoglandular fistula surgery outcomes: a retrospective analysis

Purpose

The purpose of this study was to evaluate cryptoglandular fistula surgery outcomes in men with common types of fistulae.

Method

A database review identified study patients. Exclusion criteria included history of previous fistula, previous anorectal surgery, inflammatory bowel disease, pelvic radiation, complex fistula, age <21 years, and absence of follow-up.

Results

Four hundred twenty-five patients met criteria for review. Mean follow-up was 5.8 years. Concurrent abscess at presentation was strongly associated with poorer outcomes. New-onset seepage is more common with seton treatment (P = 0.01), but seepage resolution occurred less commonly with fistulotomy (P <0.01).

Conclusions

Although both treatments are highly successful, men treated with primary fistulotomy are more likely to heal than seton patients. Fistulotomy patients have less early postoperative seepage than seton patients, but when this is present it is less likely to resolve. Presentation with concurrent abscess is strongly associated with poorer outcomes.     

Health and cost consequences of surgical versus conservative treatment for a comminuted proximal humeral fracture in elderly patients

Objective

This study aims to evaluate the costs and health outcome for surgical and conservative treatment of displaced proximal humeral fractures.

Design

This study is a randomised controlled trial.

Participants

This study included 50 patients aged 60 or older admitted to hospital with a severely displaced three- or four-part fracture.

Interventions

The patients were treated surgically with an angular stable interlocking implant (25 patients) or conservative treatment (25 patients).

Main outcome measure

The outcomes measured included quality-adjusted life years (QALYs) and societal costs.

Results

At 12 months’ follow-up, the mean difference in the number of QALYs was 0.027 (95% confidence interval (CI) = −0.025, 0.078) while the mean difference in total health-care costs was €597 in favour of surgery (95% CI = −5291, 3777).

Conclusion

There was no significant difference in QALYs or costs between surgical and conservative treatment of severe displaced proximal humeral fractures.     

Phalangeal neck fractures of the proximal phalanx of the fingers in adults

Introduction

The outcome of adult phalangeal neck fractures of the proximal phalanx of the fingers has not been previously investigated.Purpose To report the outcome of adult phalangeal neck fractures of the proximal phalanx of the fingers following a specific management protocol.

Methods

A total of 10 phalangeal neck fractures of the proximal phalanx of the fingers in nine adult male patients are presented. Three patients presented with type I (undisplaced) fractures and these were treated with splinting for 3 weeks. There were a total of five type II (displaced but with bone-to-bone contact) fractures: two were stable after closed reduction and were treated with splinting alone and the other three were unstable requiring Kirschner (K)-wire fixation. The last patient had a type III (displaced with no bone-to-bone contact) fracture, which was treated with open reduction and K-wire fixation. We emphasised that K-wires should not immobilise any of the finger joints to allow immediate active motion after surgery.

Results

All fractures healed clinically and radiologically without complications. The outcome in our series, following our management protocol, was excellent in one patient and good in the remaining eight patients.

Conclusion

Phalangeal neck fractures of the proximal phalanx in adults are rare and there are not many available options for fixing unstable type II/III fractures. Our protocol of management and the technique of K-wire fixation (leaving both the proximal interphalangeal and metacarpophalangeal joints free) followed by early active mobilisation gives consistent satisfactory results.     

Surgical treatment of two-part fractures of the proximal humerus: Comparison of fixed-angle plate osteosynthesis and Zifko nails

Introduction

Closed reduction and percutaneous pinning using Zifko nails offer the advantage of a minimal soft-tissue dissection but have been criticised for limited stability and secondary fracture dislocation. Angular stable plate osteosynthesis enables anatomic reduction, but carries the risk of soft-tissue traumatisation and consecutive humeral head necrosis. The present study compares the clinical and radiological outcome of patients with dislocated two-part fractures of the proximal humerus, who were treated with either Zifko nails or angular stable plate fixation.

Material and methods

A matched-pair analysis was performed and patient groups were matched according to age (±3 years), sex and fracture type. As many as 11 pairs of patients with a minimum follow-up of 3 years were formed and investigated radiographically and clinically using the Constant score (CS) and the visual analogue scale (VAS) for the patients’ satisfaction.

Results

At the time of follow-up, the absolute CS was 83 points in the PHP group and 78 points in the Zifko group (n.s.). Neither in the age and gender-corrected CS was found a significant difference between the study groups (PHP 104 ± 29, Zifko 95 ± 17, n.s.) nor in terms of subjective patient satisfaction (PHP 6.54; Zifko 7.8, n.s.). The complication rate was also comparable in both groups.

Conclusion

In conclusion, Zifko nailing represents a cost-effective minimally invasive surgical method with a complication rate and clinical outcome comparable to that after angular stable osteosynthesis by angular stable plate fixation in the treatment of two-part fractures of the proximal humerus.