Wird das Outcome durch den Einsatz einer minimalinvasiven Operationstechnik mit winkelstabiler Plattenosteosynthese bei proximalen Humerusfrakturen verbessert?

Question

Is it possible to improve the outcome of proximal humeral fractures using minimally invasive fixed-angle plate osteosynthesis with the help of an insertion handle?

Methods

A total of 100 patients treated with fixed-angle plate osteosynthesis after humeral head fractures using an insertion handle and deltoid split approach were examined prospectively over a 3-year period. The results were compared with a group of 100 patients with similar fractures and the same implant but who were treated by osteosynthetic open surgery using a deltoideopectoral access. These data were also collected prospectively over a 3-year period

Results

The use of a minimally invasive surgical technique could significantly shorten surgery time and inpatient stay. Furthermore, a reduction of pain and the rate of complications, as well as an improvement of mobility and functional outcome was found The results could be seen soon after the surgical intervention and remained significant over the first few months and the differences were still detectable later on but no longer in the primary specification.

Conclusions

The use of fixed-angle plates is an effective method for stabilization of proximal humeral fractures. The short-term outcome of proximal humeral head fractures with plate osteosynthesis can be improved by the minimally invasive surgical technique. With this technique there are significant advantages in the perioperative phase as well as in the first few postoperative months; however these benefits can no longer be seen in long-term follow-up.     

Primärer endoprothetischer Ellbogengelenkersatz bei komplexen intraartikulären distalen Humerusfrakturen

Introduction

Open reduction and internal fixation of multifragmentary intra-articular fractures of the distal humerus often do not provide satisfactory results in elderly patients with osteoporosis.

Method

From December 2001 to January 2008 a total elbow arthroplasty (Coonrad-Morrey, Zimmer, USA) was performed on 12 patients (average age 81±9  ears) who presented with a type C distal humeral fracture. The mean time of follow-up with clinical and radiological assessment was 28±17 months.

Results

The Mayo score showed a good functional result with an average of 81±9 out of 100. DASH and SECEC scores showed a fair result with respect to elbow function (43±8 and 68±7 points, respectively). The average range of motion of all patients was 120-33-0°. Heterotopic ossifications were found by X-ray examination in 4 cases and asymptomatic radiolucent lines in 4 cases.

Conclusion

Primary total elbow arthroplasty for complex intra-articular distal humerus fractures in elderly patients has good functional results and is an alternative to osteosynthesis.     

Die kombinierte Humerusschaft- und proximale Gelenkfraktur

Introduction and question

Intramedullary nailing is finding increasing acceptance for humeral shaft fractures. Recently, nailing systems have also been used for proximal metaphyseal humeral fractures. Which possibilities and clinical results are offered by intramedullary nailing of combined proximal and diaphyseal fractures of the humerus with titanium locking nails?

Materials and methods

A prospective study with a standardized protocol was carried out with respect to the “unreamed humeral nail (UHN) with spiral blade” and its possible complications and clinical results between 1^st October 2000 and 31^st December 2005. There were 87 combined shaft and proximal humeral fractures in 28 male and 59 female patients with a median age of 69 years. Results were analyzed 1 year postoperatively in 72 patients according to the Constant-Murley score and x-rays.

Results

Significant complications were bolt or spiral blade perforation of the articular surface (n=3), implant-related pain (n=2), fragment dislocation (n=1), non-union (n=1), humeral head necrosis (n=1) but no wound infection (n=0). The Constant-Murley score showed a median value of 71.2 for the injured side compared to 88.4 for the non-injured side, 1 year after the operation.

Discussion

The combination of diaphyseal and proximal-metaphyseal humeral fractures is a special challenge for the orthopaedic trauma surgeon, as even now the treatment of isolated proximal humeral fractures is not satisfactorily resolved in all cases. Open treatment such as plate osteosynthesis in general needs a long and invasive approach with corresponding biological disadvantages. Low invasive approaches for plates also have high risks on the humerus due to the specific neurovascular topography. In our study closed nailing showed good clinical and radiological results with low invasive approaches and complications mostly occurred in C-type fractures. If the use of additional cerclage wires for the diaphyseal component in nailing is deemed necessary, the biological benefits over plate osteosynthesis become less clear.     

AO extra-articular distal humerus locking plate: extended spectrum of usage in intra-articular distal fractures with metaphyseal extension—our experience with 20 cases

Background

LCP extra-articular plate designed by AO has been used in extra-articular fractures of the distal humerus, mal-unions, and nonunions of the distal humerus. They provide anatomically shaped and angular stable fixation system for extra-articular fractures of the distal humerus. We extended the usage spectrum of this plate to the extra-articular with intra-articular distal humerus fractures and compared it with the standard orthogonal locking plate fixation.

Methods

We included 22 consecutive distal humerus intra-articular fractures with metaphyseal and diaphyseal extension into the study. Each case underwent osteosynthesis with LCP extra-articular plate fixation and augmented the intra-articular fragments with 4.0 mm partially threaded cancellous screws. The cost, surgical time, VAS, Modified Mayo Clinic Performance Index for elbow, and postoperative complications were recorded. The radiological union and postoperative elbow range of motion were assessed at 6 weeks, 6, and 12 months of follow-up. Twenty cases completed the scheduled follow-up. The results were compared with retrospective data of 20 cases from our institute where similar fractures were treated with standard orthogonal LCP distal humerus plate (LCPDHP).

Results

The radiological union rates and the range of motion at 6 weeks, 6, and 12 months in both the groups were comparable and did not vary significantly (p > 0.05). The cost and operative time with the LCP extra-articular plates were significantly less (p < 0.05) when compared to the group LCPDHP.

Conclusion

The usage spectrum of extra-articular distal humerus locking plate can be extended to intra-articular fractures. It provides good results and significantly reduces the cost and operative time.     

Mismatch of AO anatomically shaped distal humeral plate with humeral shaft forward flexion angulation in adult Chinese population

Background

LCP extra-articular distal humerus plate (LCPEA) designed by AO has been introduced as an anatomically shaped plate that improves the results of surgical fixation in extra-articular distal humeral shaft fractures. However, no study analyzed whether LCPEA matches humeral shaft forward flexion angulation (FFA).

Objective

The aims of this study were to evaluate the morphological discrepancies between LCPEA and the humeral shaft FFA in Chinese cadaveric dried adult humeri and to propose a further design of pre-contoured plates to accommodate the FFA.

Materials and methods

Forty-four Chinese cadaveric dried adult humeri were used for this study. An eight-hole LCPEA was applied to the posterior aspect of the distal humerus according to the contour. Mismatches between the bone and the plate were recorded. The distance between the inner surface of the plate and the underlying humeral dorsal cortex was measured at the sites of mismatch. The humeral shaft FFA was measured from the intersection angle between tangent lines placed on the dorsal aspect of the 1/3 distal humeral shaft and the dorsal ridge of the 2/3 proximal humeral shaft. The location of the apex of the FFA was determined by measuring the distance from the most distal point of trochlea of humerus to the point of intersection of the FFA tangent lines. The distance was defined as forward flexion distance (FFD).

Results

Mismatch was found at the level of proximal 3–6 holes of LCPEA with an average distance of 6.9 ± 3.1 mm (range 2.3–14.0 mm) at the tip of the plate. The FFA was present in all specimens. The average FFA was 8.2° ± 2.2° (range 4°–13°), the average FFD was 99.9 ± 9.6 mm (range 79.2–117.9 mm), and the average ratio of FFD to humerus length was 0.33 ± 0.03 (range 0.27–0.39).

Conclusions

A rather consistent pattern of mismatch was found at the proximal part of LCPEA. An attempt to fit the plate to the bone at this level may cause a gap of the fracture at the opposite cortex. The main reason for the mismatch is the existence of the humeral shaft FFA. LCPEA is usually made a bend of about 8° between the fourth and the fifth dynamic-compression portion of the combination hole in the distal-to-proximal direction.     

The olecranon osteotomy provides better outcome than the triceps-lifting approach for the treatment of distal humerus fractures

Introduction

Intra-articular distal humeral fractures can be approached in a variety of ways. The purpose of this study is to evaluate and compare the functional outcomes of two approaches: approach with olecranon osteotomy and triceps-lifting approach for the treatment of intra-articular distal humeral fractures.

Methods

This study shows a consecutive series of 54 intra-articular distal humeral fractures of 54 patients who were treated with open reduction and internal fixation with anatomic plating. Lateral plating was performed in 10 (45.5 %) patients, and medial and lateral parallel plating was performed in 12 (54.5 %) patients in olecranon osteotomy group, while lateral plating was performed in 8 (25 %) patients, and medial and lateral parallel plating was performed in 24 (75 %) patients in triceps-lifting group.

Results

Mean follow-up was 38.3 months for olecranon osteotomy group and 41.4 months for triceps-lifting group. Functional outcomes according to MAYO elbow score and extension-flexion motion arc values were significantly better in olecranon osteotomy group (p < 0.05).

Conclusion

Approach with olecranon osteotomy provided better functional outcomes than triceps-lifting approach. Additionally, intra-articular distal humerus fractures can be safely treated with olecranon osteotomy which provides more control over the elbow joint and better visualisation and allows early postoperative rehabilitation.

Level of evidence

IV.     

Minimally invasive plate osteosynthesis for humeral shaft fracture: a reproducible technique with the assistance of an external fixator

Background

Minimally invasive plate osteosynthesis (MIPO) has become a popular option for treatment of humeral shaft fractures. However, indirect reduction might risk unpromising results, with mal-alignment/mal-union or nonunion. The purpose of this study was to describe a reproducible MIPO technique that used an external fixator during the procedure as a tool for reduction and maintenance, and to assess the outcomes in patients with humeral shaft fracture.

Methods

Of 31 consecutive cases of humeral shaft fracture in 30 patients, 29 were included in this study. There were seven simple (type A) and 22 comminuted (type B or C) fractures. After the insertion of one Schanz pin on each proximal and distal humerus, a provisional reduction was achieved by connecting the pins with a monolateral external fixator. The MIPO procedure was then performed over the anterior aspect of the humerus. To evaluate the efficacy of the provisional reduction by external fixator, coronal and sagittal alignments were assessed. We also assessed bony and functional results, including complications, from this technique.

Results

There was no case of mal-union >10°, and mean angulation was 1.3° (range 0°–9°) in the coronal plane and 1.2° (range 0°–8°) in the sagittal plane. Twenty-eight of 29 fractures were united, including three delayed unions, with a mean union time of 19.1 weeks (range 12.3–38.4 weeks) and a mean follow-up of 20.8 months (range 13.5–31.0 months). There was one hypertrophic nonunion that healed after fixing with two additional screws. Except one patient with associated injury in the elbow, all patients recovered to pre-injury joint motion. There were two cases of postoperative radial nerve palsy that both recovered completely. We attributed them to manipulation, and not to the Schanz pins or plate fixation.

Conclusions

Surgical treatment of humeral shaft fractures with external fixator-assisted reduction and MIPO resulted in excellent reductions and high union rates.

Level of Evidence

IV     

Treatment of three- and four-part proximal humeral fractures with locking proximal humerus plate

Objective

The purpose of this study was to evaluate the effectiveness and complications of the locking proximal humerus plate to treat proximal humerus fractures.

Design

A retrospective clinical trial.

Setting

Department of Orthopaedics, Tianjin Medical University General Hospital.

Patients

Sixty-eight consecutive patients with three- or four-part fractures of the proximal humerus were treated with locking proximal humerus plates.

Intervention

The deltopectoral anterolateral acromial approach was used to the proximal humerus; open reduction and locking proximal humerus plate were applied.

Main outcome measurements

Constant Score was used to measure the shoulder functional recovery, and Visual Analog Scale (VAS) was used to measure subjective evaluation of pain. The radiology was observed.

Results

After average 26.7 months, the average Constant Score was 72.6 ± 13.2 points and the average VAS was 1.2 ± 0.8 points. All the complications such as screw perforation into the glenohumeral joint, screws loosening, soft tissue infections, avascular necrosis and delayed union occurred in eight cases (11.8 %).

Conclusions

The effectiveness of the locking proximal humerus plate was similar to other published literatures on treating fractures of the proximal humerus; however, a lower complications rate in short follow-up time was observed in this study. It may potentially provide a favorable option for treating three- or four-part fractures of the proximal humerus. Dealing with each particular fracture pattern, surgeons should have a decision of appropriate way to internal fixation.     

Surgical result of plate osteosynthesis using a locking plate system through an anterior humeral approach for distal shaft fracture of the humerus that occurred during a throwing motion

Purpose

This paper analyzed outcomes of the osteosynthesis with a locking plate system for the fractures of the humerus in throwers using the anterior humeral approach.

Methods

Retrospective case series including 31 patients. Bone union was assessed through follow-up radiographs. Results of visual analogue scale (VAS) for pain, range of motion in the elbow joint, time of return to work, and the Mayo Elbow Performance Score (MEPS) were evaluated to determine functional outcomes. Direction and length of the fracture, the distal cortical length, the humeral diameter, and the total humeral length were measured as part of fracture configuration analysis.

Results

Mean patient age was 25.8 (range, 18–34) years. The follow-up average was 16.0 months (range, 12–23). Delayed union was observed in one (3.1 %) patient. Mean final VAS was 0.4 (range, 0–2), mean time of return to work was 18.2 weeks (range, 13–36), and mean MEPS was 96.3 (range, 88–100) points. All fractures showed a spiral configuration. Mean fracture length was 79.7 (95 % CI, 72.6-86.7) mm, and mean distal cortical length was 48.3 (95 % CI, 37.8-58.8) mm.

Conclusions

The results of the current study indicates that plate osteosynthesis using a locking plate system combined with interfragmentary lag screws through anterior humeral approach may be a favorable option for the surgical treatment of humeral shaft fractures in throwers.

     

Kirschner-Draht-Osteosynthese von Frakturen des Condylus radialis im Kindes- und Jugendalter

Question

Aim of the study was the evaluation of the results of an operative treatment of dislocated lateral humeral condyle fractures in children and adolescents.

Patients

Over a period of 4 years 58 children with lateral humeral condyle fractures were treated operatively by a Kirschner wire (K-wire) osteosynthesis. The patients were recorded prospectively and clinical follow-up examinations were done.

Results

A total of 36 boys and 22 girls with an average age of 6.4 (range 2–15) years were included in the study with 46 isolated lateral humeral condyle fractures. In 12 cases additional injuries included 4 elbow luxations, 4 fractures of the olecranon, 2 distal forearm fractures and 2 children suffered from multiple injuries. Only closed fractures were identified of which 14 were reduced percutaneously and fixed with two K-wires and in 44 cases an open reduction with K-wire fixation was necessary. All children were provided with casts for a period of 4–6 weeks and the K-wire was removed 10–12 weeks after the operation. The average duration of the hospital stay was 2.9 (range 1–25) days. At the time of metal removal all fractures were completely consolidated. No pseudarthrosis occurred but complications included dislocation of K-wires (n=3) and bursitis (n=5). A fishtail deformity could be shown radiographically in 5 children. Follow-up examinations could be carried out in 53 children for an average time of 13 months (range 4–58). Of the patients 47 showed free functions, in 5 patients there was a lack of extension between 5 and 10° and in 1 patient of 15°. One child had a varus deformity of about 5° and another child of about 10°. Of the parents 49 were very content and 4 parents were content with the course of treatment and the results.

Conclusion

The K-wire osteosynthesis of lateral humeral condyle fractures is an efficient and safe treatment with low complication rates and good results.     

Primäre Alloarthroplastik des frakturierten Ellenbogens beim hochbetagten Patienten

Aim of study

Inadequate treatment of distal intra-articular fractures of the humerus results in painful restriction of movement or malarticulation. Especially in geriatric patients with osteoporosis, stable osteosynthesis can be difficult. Primary total endoprosthetic replacement of the cubital joint could offer an alternative.

Material and methods

In 12 patients with a distal intra-articular fracture of the humerus a cemented semi-constrained Coonrad-Morrey prosthesis was implanted. Patient were followed-up after an average of 13 months and assessed according to the Mayo score.

Results

In 6 patients additional computerized tomography was carried out. Minimally invasive Kirschner wire osteosynthesis resulted in immediate postoperative loss of correction due to osteoporosis. As with the external distraction-compression apparatus the ulnar pinholes can form a predetermined breaking point and fixation in a long-arm cast is recommended. The mean Mayo score was 90.5 points and mean range of motion in extension/flexion was 84.5°.

Conclusion

In elderly patients primary endoprosthetic treatment of a distal intra-articular fracture of the humerus with a semi-constrained cemented prosthesis may offer an alternative to osteosynthesis thus enabling creation of a mobile, painless and stable cubital joint.     

Repeat LISS treatment for femoral shaft fractures due to hardware failure: a retrospective analysis of eleven cases

Objective

To evaluate the effectiveness of a replating technique having a less-invasive stabilization system (LISS) for femoral shaft fractures due to LISS failure in adults.

Patients and methods

There were 11 patients with hardware failure of LISS for femoral shaft fractures, on an average of 50 days after the primary operation. The failed implants were removed, and the fractures were replated with a LISS following the rationale of biological osteosynthesis. Radiological fracture union and incidence of postoperative complications were employed to evaluate the effectiveness of this replating technique for femoral shaft fractures.

Results

Operative duration including removing failed hardware and replating fractures averaged 81.5 min, with an average blood loss of 330 ml. Patients had an average follow-up of 25.7 months. Radiological evaluation indicated that fracture union occurred in an average of 4.4 months in all patients. The length and alignment of the affected limb were satisfactory, and hardware failure did not recur.

Conclusion

The replating technique with LISS for femoral shaft fractures due to hardware failure of LISS can obtain satisfactory results when the appropriate rationale of biological osteosynthesis and functional exercise is followed.     

The amount of humeral head impaction of proximal humeral fractures fixed with the Humerusblock device

Purpose

The Humerusblock is a minimally invasive device allowing fixation of proximal humeral fractures. A drawback of the device is possible K-wire perforation of the head with the need for early removal of the implant. We assessed the amount of humeral head impaction and its role in the postoperative varus/valgus deviation of the humeral head in fractures of the upper humerus treated with Humerusblock.

Methods

Fractures were classified according to the Codman-Lego system. The length of the posteromedial metaphyseal extension and integrity of medial hinge were measured; metaphyseal comminution was assessed. Accuracy of fracture reduction was classified as excellent to poor. An original method of measurement of amount of postoperative impaction of the humeral head was developed. The impaction and varus/valgus inclination of the heads were measured comparing postoperative and three-month follow-up radiographs. Constant score and its relation to sintering was calculated at 12-month follow-up.

Results

Forty-three fractures were available for follow-up. The amount of humeral head impaction was 3.9 mm on average and was directly correlated with patient’s age, sex, Codman-Lego classification, varus inclination and mataphyseal comminution. The postoperative cervico-diaphyseal angle was restored in 35 cases, with 81 % good results. The Humerusblock was removed in 41 % of cases because of K-wire perforation of the humeral head. A negative correlation was found between impaction and Constant score.

Conclusions

The amount of humeral head impaction is related to patients’ age, sex, and fracture patterns, being the most prone to compaction those with metaphyseal comminution. Humeral head impaction negatively affects final Constant score.     

Proximal fractures of the humerus in patients older than 75?years of age: should we consider operative treatment?

Background

Over 75 % of patients presenting with a proximal humerus fracture are 70 years or older. Very little is known about the outcome after operative treatment of these fractures in very old patients. This study was performed to gain more insight in safety and functional outcome of surgical treatment of proximal humerus fractures in the elderly.

Materials and methods

In this observational study, we analyzed all operatively treated patients, aged 75 or older, with a proximal humerus fracture between January 2003 and December 2008 in our center. Patient selection was on clinical grounds, based on physical, mental, and social criteria. Complications were evaluated. We used the DASH Questionnaire to investigate functional outcome, pain, and ADL limitations.

Results

Sixty-four patients were treated surgically for a displaced proximal fracture of the humerus: 15 two-part, 32 three-part, and 17 four-part fractures. Mean DASH scores were 37.5, 36.9, and 48.6, respectively. Regarding the operative methods, overall good results were obtained with the modern locked plate osteosynthesis (mean DASH 34.4). Prosthetic treatment, mostly used in highly comminuted fractures, often resulted in poor function (mean DASH 72.9). Persistent pain and ADL limitations were more present in more comminuted fractures (64 and 50 % in patients with 4-part fractures vs. 14 % in 2-part fractures). There were no postoperative deaths within 3 months of surgery, and fracture-related and non-fracture-related complication rates were low (non-union 3 %; 1 myocardial infarction).

Conclusion

This study shows that it is safe and justifiable to consider surgical treatment of a severely dislocated proximal humerus fracture in selected patients aged 75 and older.

Level of evidence

According to OCEBM Working Group, Level IV.     

Elastic stabilisation of proximal humeral fractures with a new percutaneous angular stable fixation device (ButtonFix®): a preliminary report

Introduction

The ButtonFix^® system represents a new angular stable percutaneous fixation device for stabilisation of fractures of the proximal humerus. The purpose of this study was to present a preliminary report of the radiological and clinical outcome after minimally invasive stabilisation of selected proximal humerus fractures with the ButtonFix^®.

Patients and methods

Seventeen patients with fractures of the proximal humerus were treated in our department with the ButtonFix^® system. The mean final follow-up was performed 19 months postoperatively. Follow-up included assessment of postoperative reposition, range of motion, the DASH score, the Constant–Murley score, and the Short Form 36 (SF36).

Results

Twelve patients showed anatomical head-to-shaft angles, four revealed minor valgus replacement, and one minor varus replacement. In one patient unplanned revision surgery was necessary due to early secondary fracture dislocation requiring ORIF with an angular stable form plate. Implant removal was performed after 6 weeks in all patients. At the final follow-up, mean range of motion was: flexion 135°, extension 45°, abduction 142°, internal rotation 51°, and external rotation 62°. The mean Constant–Murley score was 70. The mean DASH score was 26 points and the average SF36 score was 76 points. One patient showed radiological signs of avascular necrosis.

Conclusion

The ButtonFix^® system represents a valuable tool in the treatment of proximal humeral fractures with results indicating fewer complications compared to prior percutaneous fixation devices. Moreover, the ButtonFix^® seems to be able to maintain reduction even in elderly patients with potentially reduced bone mass.     

Open reduction and bi-columnar internal fixation of intra-articular distal humerus fractures through a combined medial and lateral approach

Purpose

The aim of this retrospective study was to investigate the suitability of bi-columnar internal fixation through a combined medial and lateral approach for the treatment of intra-articular distal humerus fractures.

Methods

Nineteen cases of intra-articular distal humerus fractures were treated with open reduction and bi-columnar internal fixation through a combined medial and lateral approach. The reduction in the articular surface and functional recovery of the affected elbows was assessed at an average follow-up of 15.8 ± 7.9 (7–43) months.

Results

The gap in the main articular fragments was less than 1 mm in 16 cases, while a gap of more than 1 mm and less than 2 mm was identified in 2 cases and of 3.7 mm in one case. All the fractures were united. At the latest follow-up, the mean flexion–extension of the elbows was 113.4° ± 20.7°, while the pronation–supination of the forearms was 158.3° ± 8.5°, and the mean Mayo Elbow Performance Index was 93.7 ± 9.1 points, leading to 13 excellent outcomes, and 6 with good results.

Conclusions

Intra-articular fractures of the distal humerus can be effectively treated by open reduction and internal fixation through a combined medial and lateral approach at the elbow.     

Plate osteosynthesis of fractures of the shaft of the humerus: comparison of limited contact dynamic compression plates and locking compression plates

Background

The aim of this retrospective study was to compare outcomes and complications of displaced fractures of the shaft of the humerus treated with limited-contact dynamic compression plates (LCDCPs) and locking compression plates (LCPs).

Materials and methods

Two hundred and twelve patients with displaced fractures of the shaft of the humerus, treated with plate osteosynthesis from January 2005 to December 2009 were reviewed. One hundred and two patients (group A) were treated with LCDCP osteosynthesis and 110 patients (group B) were treated with LCP osteosynthesis. Clinical and radiological assessments were made at monthly intervals for the first 6 months and then at 2-month intervals for the next 6 months. Primary outcome measures like operative time, duration of hospital stay, time to fracture union, union rate and secondary outcome measures (functional outcome and complications such as infection, malunion, delayed union, nonunion, implant failure and iatrogenic radial nerve palsy) were compared between both groups. The ULCA scoring system and Mayo elbow performance index (MEPI) were used to assess shoulder and elbow functions, respectively. Rodriguez-Merchan criteria were used to assess the functional outcomes of the fracture fixation.

Results

There was no significant difference found between the two groups in terms of primary outcome measures. According to Rodriguez-Merchan criteria, comparison of functional outcomes of both groups showed insignificant difference (p = 0.48). There was no significant difference found between the two groups regarding mean ULCA score (p = 0.34) and mean MEPI sore (p = 0.54). In terms of complications, no significant difference was found between the two groups.

Conclusion

This study concludes that the principle of fracture fixation was more important than plate selection in fractures of the shaft of the humerus.

Level of evidence

Level 3.     

3D-navigierte Fersenbeinosteosynthese

Background

It is hypothesized that misplacement of sustentacular screws during osteosynthesis of intraarticular calcaneal fractures can be reduced with the help of navigation. A method for three-dimensional (3D) navigated placement of sustentacular screws for treating intraarticular calcaneal fractures is presented and evaluated.

Material and Methods

11 consecutive patients with 15 intraarticular calcaneal fractures were treated using 3D navigation. In 12 cases osteosynthesis was done through an extended lateral approach; in three cases, it was achieved through a minimally invasive percutaneous approach. For verification and documentation of the placed screws, a second 3D scan was performed.

Results

A total of 20 screws were placed using 3D navigation. None of the navigated screws was misplaced. Extra operating time due to navigation averaged 11.9 minutes (±2.2 min).

Conclusion

Through a combination of intraoperative 3D imaging and navigation, placement of sustentacular screws is possible and can yield precise and reliable results. Especially in minimally invasive treatment, a high quality of osteosynthesis can be achieved.     

Posterior bridging osteosynthesis for traumatic sacroiliac joint dislocation: a report of seven cases

Objective

To evaluate the long-term clinical and radiographic results in patients treated for 61C3-2 (OTA class) pelvic ring disruption with a posterior bridging sacroiliac fixation.

Design

Retrospective clinical and radiological study.

Setting

University Hospital.

Patients/participants

Between May 2002 and March 2003, seven patients with sacroiliac dislocation were treated with a technique developed for the treatment of pelvic injuries with vertical and horizontal instability.

Intervention

We applied spino-pelvic fixation techniques, using spine instrumentation, to stabilize an SI dislocation. This technique consists of two 5 mm diameter screws inserted into the S1 pedicle and S2 ala. A 5.5 mm rod joins the 2 sacral screws to two 7 mm screws placed into the posterior iliac crest and secured into the cancellous mass of the posterior ilium . The described technique stabilizes the SI-joint by performing a bridging osteosynthesis instead of the commonly performed iliosacral screw osteosynthesis passing the SI-joint. Symphyseal platting is performed to reduce and stabilize the anterior ring if necessary.

Main outcome measurements

Data were analyzed as follows: pelvic fracture classification; functional outcome; radiographic outcome; Leg length discrapency; and CT scan aspect of the sacroiliac joint.

Results

Associated pelvic injuries were present in all the patients and include symphysis rupture and acetabular fractures. Four of the seven patients had fractures of the lower extremities. Follow-up was available for all patients at an average of 27 months (range, 32–24 months). Neither septic nor cutaneous complications were reported. No loss of post-op reduction and no fixation failure were observed. The functional results noted at the last examination were satisfactory with a mean Majeed score of 93.

Conclusion

In our opinion, this surgical technique may be indicated in Tile type C1.2 (61C3-2 OTA class) pelvic ring disruption. It obviously reaches its limits in sacral fractures. The technique described provides effective control of vertical displacement while providing a certain degree of horizontal mobility to facilitate reduction and osteosynthesis of anterior lesions. The quality of the fixation allowed early weight bearing.