Comparison of closing-wedge and opening-wedge high tibial osteotomies for medial compartment osteoarthritis of knee in Asian population: Mid-term follow-up

BackgroundValgus high tibial osteotomy (HTO) is a well-established treatment option for patients with early osteoarthritis of the medial compartment of the knee. It is achievable with either open-wedge or closed-wedge technique. The aim of the study was to compare the radiological and clinical outcomes following HTO done with open- and closed-wedge techniques.Material and methodsTwo groups of patients undergoing HTO and fixation with locking plates were compared. Twenty-five patients were operated using medial open-wedge technique and 23 using closed-wedge technique between January 2000 and June 2014. They were compared on the basis of Hospital for Special Surgery (HSS), knee score, preoperative and postoperative range of motion, femoro-tibial angle and duration required for full-weight bearing. Early and late postoperative complications were noted.ResultsMedian HSS score at 6 months and 1 year post-surgery was better in the open-wedge technique group. The range of motion was also higher at early follow-up in the open-wedge technique group, with shorter duration for full-weight bearing. Delayed union was seen in two patients in the open-wedge technique group and four patients in closed-wedge group. Peroneal nerve palsy was noted in two patients in the closed-wedge group.ConclusionBoth open-wedge and closed-wedge HTO lead to good and comparable results. However, the technique of open-wedge osteotomy provided better outcome in terms of functional scores in early as well as late follow-up with decreased duration required for full-weight bearing.     

Comparison of screw versus locking plate fixation via sinus tarsi approach for displaced intra-articular calcaneal fractures

BackgroundThe optimal treatment of displaced intra-articular calcaneal fractures (DIACF) is controversial. This study compared the fixation stability of screws and locking plates in DIACF treated via the sinus tarsi approach (STA).MethodsWe retrospectively evaluated 118 DIACF cases treated via STA and extracted data that could affect treatment outcomes. Loss of Böhler’s angle after surgery was measured to compare fixation stability.ResultsThe loss of Böhler’s angles was significantly smaller in the locking plate group than in the screw group (2.6 ± 2.7º vs. 5.6 ± 5.3º, P < 0.01). There was no difference in the clinical outcomes between the groups. On multivariate logistic regression analysis, screw fixation was significantly associated with loss of Böhler’s angle by> 10º (odds ratio, 8.63; 95% confidence interval, 1.16–64.4; P < 0.05).ConclusionsLocking plate fixation is more reliable than screw fixation for preventing correction loss in DIACF treated via STA.Level of evidenceIII     

CaP cement is equivalent to iliac bone graft in filling of large metaphyseal defects: 2 year prospective randomised study on distal radius osteotomies

The purpose of this prospective randomised study was to compare the clinical and radiological outcomes of injectable CaP bone cement with corticocancellous bone graft used to fill voids after corrective opening wedge osteotomies in the distal radius. 17 women/3 men, median age 56 (51.3; 61.0), underwent an open-wedge osteotomy of a dorsal malunion in the distal radius randomised to filling the defect either with bone graft (10) or CaP bone cement (10). Dorsal titanium locking plates were used and the wrist was plastered for 8 weeks. Follow-ups for 24 months included X-rays, CT scans, VAS on wrist and iliac crest, grip strength, ROM, Quick-DASH and Gartland & Werley scores. No difference was found between the 2 groups as to clinical outcome or radiological results with no loss of reduction. One bone graft patient developed a pseudarthrosis and one CaP patient suffered a plate fracture 6 months post-operatively. CaP bone cement is a good alternative to bone graft as a void filler in open-wedge osteotomies of the distal radius. The procedure is shorter, easier with the post-operative advantage of no donor site pain.Level of Evidence Randomised controlled trial. Level I evidence.     

Biomechanical evaluation of combined proximal tibial osteotomy for varus knee osteoarthritis implanted novel designed plate system: Finite element analysis

BackgroundCombined proximal tibial osteotomy (CPTO) is an innovative and effective procedure for correcting varus knee osteoarthritis (VKOA) with intra- and extra-articular deformity. Here, we designed a novel internal fixation plate system for CPTO and assessed the biomechanical strength of the bone-implant.MethodsOur newly designed CPTO internal fixation plate system included a specialized plate shape, combination holes, locking screw holes, screw position, and size of fixation. The biomechanical performance of this plate system in CPTO treatment was compared via finite element analysis (FEA) to traditional Tomofix devices implanted in the opening-wedge high tibial osteotomy (OWHTO), tibial condylar valgus osteotomy (TCVO), and CPTO.ResultsThe tibial wedge stiffness and displacement after CPTO implantation of the novel internal plate fixation increased by 9.6%, which was -65% higher than the CPTO with the Tomofix system. The average stress of the bone, plate, and screws in the CPTO implanted the novel designed plate system compared to the Tomofix system decreased by 12.7%, 1.9%, and 20.3 %, respectively. The device maximum stress and wedge stiffness after CPTO with the novel plate system versus traditional OWHTO and TCVO with the Tomofix system were 255.7 MPa, 204 MPa, 130.4 MPa, and 678.9 N/mm, 660.3 N/mm, 1626.0 N/mm, respectively.ConclusionsThe novel internal fixation plate system usage during CPTO exhibited similar bone-implant biomechanical strength, compared to OWHTO, but with enhanced construct stability.     

Comparison of screw fixation versus non-fixation in dorsal opening wedge medial cuneiform osteotomy of adult acquired flatfoot

BackgroundThe aim of this study was to compare the radiographic and functional results between fixation and non-fixation in the Cotton osteotomy for the treatment of adult acquired flatfoot.MethodsA retrospective, case-controlled study of consecutive stage IIB posterior tibial tendon dysfunction (PTTD) patients treated with the same bony reconstructive surgery including cotton osteotomy between 2013 and 2017. Meary’s angle, the medial arch sag angle (MASA), and medial cuneiform cobb angle (MCCA) were evaluated pre-operation, at first weight bearing after surgery, and 12 months post operation.ResultsForty feet were included in the study. The cotton osteotomy utilized screw fixation (n = 20) or non-fixation technique (n = 20). No significant differences between groups were found in pre-operative and follow-up radiographic parameters, union rate, and functional results.ConclusionThe non-fixation with press fit technique is a reliable procedure for Cotton osteotomy and as effective as screw fixation.Level of evidenceLevel III, case control study     

Staples and locking plates provide comparable outcomes for fixation of first metatarsal dorsiflexion osteotomies in pes cavovarus

BackgroundOne commonly encountered deformity within the cavovarus foot is plantarflexion of the first metatarsal which may be a primary or secondary deformity. Correcting the plantarflexion may be achieved through a dorsiflexion osteotomy although the optimal fixation device for this osteotomy has not been determined. This clinical study compared the outcomes using staples and locking plates.MethodsA retrospective evaluation was performed of 52 feet that had undergone dorsiflexion osteotomy of the first metatarsal as part of a cavovarus foot correction with a minimum follow-up of two years. Data was collected on deformity correction, complications and cost-analysis.ResultsAs a cohort, Meary’s angle improved from 13.4° to 7.72° (p < 0.001), Hibbs’ angle improved from 117.1° to 124.2° (p < 0.001) and navicular height dropped from 52.7 mm to 47.7 mm (p < 0.001) while calcaneal inclination changed from 20.9° to 21.2° but this did not reach significance (p = 0.66). These indices and the number of complications were not significantly different between the staple and locking plate group. The overall cost of using staples was less than using locking plates.ConclusionsBoth staples and locking plates are effective devices for fixation of the first metatarsal after a dorsiflexion osteotomy in cavovarus foot surgery. They were both able to provide comparable fixation, although staples were less expensive to use in our study.     

Biomechanical effect of the configuration of screw hole style on locking plate fixation in proximal humerus fracture with a simulated gap: A finite element analysis

BackgroundLocking plate fixation for proximal humeral fractures is a commonly used device. Recently, plate breakages were continuously reported that the implants all have a mixture of holes allowing placement of both locking and non-locking screws (so-called combi plates). In commercialized proximal humeral plates, there still are two screw hole styles included “locking and dynamic holes separated” and “locking hole only” configurations. It is important to understand the biomechanical effect of different screw hole style on the stress distribution in bone plate.MethodsFinite element method was employed to conduct a computational investigation. Three proximal humeral plate models with different screw hole configurations were reconstructed depended upon an identical commercialized implant. A three-dimensional model of a humerus was created using process of thresholding based on the grayscale values of the CT scanning of an intact humerus. A “virtual” subcapital osteotomy was performed. Simulations were performed under an increasing axial load. The von Mises stresses around the screw holes of the plate shaft, the construct stiffness and the directional displacement within the fracture gap were calculated for comparison.ResultsThe mean value of the peak von Mises stresses around the screw holes in the plate shaft was the highest for combi hole design while it was smallest for the locking and dynamic holes separated design. The stiffness of the plate-bone construct was 15% higher in the locking screw only design (132.6 N/mm) compared with the combi design (115.0 N/mm), and it was 4% higher than the combi design for the locking and dynamic holes separated design (119.5 N/mm). The displacement within the fracture gap was greatest in the combi hole design, whereas it was smallest for the locking hole only design.ConclusionsThe computed results provide a possible explanation for the breakages of combi plates revealed in clinical reports. The locking and dynamic holes separated design may be a better configuration to reduce the risk of plate fracture.     

Impact of medial open-wedge high tibial osteotomy for medial compartment osteoarthritis of the knee

BACKGROUNDMost populations worldwide, who are used to squatting and sitting cross-legged for their activities of daily living, largely comprise the lower socioeconomic strata, thus making them candidates for exclusion for total knee arthroplasty. Proximal/high tibial osteotomy (HTO) is a preferred strategy for clinically symptomatic osteoarthritis (OA) with genu varum due to painful medial compartment OA which is not amenable to conservative measures.AIMTo evaluate the outcomes of medial open-wedge HTO along with autologous bone grafting and buttress plate for the treatment of genu varum due to OA of the knee in a rural population of central India.METHODSA total of 65 knees in 56 patients with a mean age of 58.22 ± 5.63 years with genu varum due to intractable painful knee OA were treated with medial open-wedge HTO along with autologous bone grafting and buttress plate osteosynthesis from June 2015 to May 2018. The mean preoperative radiological angle of genu varum was 13.4°. Clinical outcomes were assessed by the range of movement, knee scores, pain scores, and functional scores. Radiographic studies were performed preoperatively and at regular intervals during the follow-up period.RESULTSAll patients reported pain relief immediately after the osteotomy and during the long-term analysis covering between one to three years. The genu varum angle was overcorrected to approximately four degrees in all patients. There was a loss of reduction by approximately three degrees in all patients at around six weeks postoperatively. Preoperative knee movements were restored in all patients. No major perioperative complications were noted during surgery and postoperative follow-up and the clinical scores were significantly improved during the final analysis which revealed good pain relief.CONCLUSIONMedial open-wedge HTO is a reliable, safe, practical, physiological, and feasible treatment for populations who are used to increased activity in their occupation and lifestyle and is associated with excellent short-term and long-term results for OA in genu varum knees.     

Anteromedial plating without filling the gap in open wedge high tibial osteotomy may increase the risk of screw breakage,which can be reduced by medial plating and bone-substitute insertion

BackgroundOpen wedge high tibial osteotomy (OWHTO) brings new complications such as screw breakages with or without correction loss and time-dependent increased posterior tibial slopes (PTS) due to the opening gap. For preventive purposes, we changed our OWHTO procedure from anteromedial plating without filling the gap (non-grafted group, n = 40, 2009–2012) to medial plating with bone-substitute insertion (grafted group, n = 45, 2012–2015). The objectives of this study were to evaluate the complication patterns and the effects of the modifications.MethodsPatients undergoing OWHTO with TomoFix plates were included in this retrospective study. Demographics, clinical outcomes (flexion range and Japanese Orthopaedic Association score) and radiological outcomes (femorotibial angle) were assessed in both groups pre-operatively and 2-years postoperatively. The plate installation angle [PIA] and screw insertion depth [SID] were measured on computed tomographic slices at 6 months. PIA/SID was defined as the angle between the tibial anteroposterior axis and plate–width axis/the distance between the proximal screw tip and the proximal tibiofibular joint. The non-grafted group was further divided into complication and non-complication subgroups. Screw breakages were assessed during plate removal (1.5–2.5 years postoperatively).ResultsThere were no differences in baseline characteristics or radiological/clinical outcomes between the non-grafted and grafted groups. There were 0 and 11 complications in the grafted and non-grafted groups, respectively. Complications included 7 screw breakages, 4 correction losses, and 5 time-dependent increased PTS with some overlaps. PIA and SID were significantly lower (p < 0.001) and higher (p < 0.001), respectively, in the grafted group and significantly lower (p = 0.018) and higher (p = 0.040), respectively, in the non-complication subgroup within the non-grafted group. The cutoff value of PIA for complications was calculated at 48.0°.ConclusionsMedial plating OWHTO (PIA<48°) using bone-substitute with deeper screw insertion reinforces the opening gap for better angular stability compared with anteromedial plating without bone-substitute.     

Locking plate constructs in subtrochanteric fixation: a biomechanical comparison of LCP screws and AO-nuts

ObjectivesVarious studies have reported the use of the 95-degree condylar blade plate in the treatment of a subtrochanteric fracture or non-union. However, the holding power of standard screws in the metaphyseal and diaphyseal area is often diminished due to osteopenia. The alternative in this area is the use of locking plates, Schühlis or AO-nuts. With the latter two, non-locking screws in the blade plate can be converted to a fixed angle fixation. The objective of this study was to compare the stiffness and strength of the AO-nut augmented 95-degree condylar blade plate construct with that of a locking plate construct. In addition, a clinical series of eight patients treated with the AO-nut augmented 95-degree condylar blade plate construct is presented.MethodsSingle screw-plate constructs of a 5.0 mm locking screw/locking compression plate (LCP) and a 4.5 mm non-locking screw/4.5 mm dynamic compression plate (DCP), converted to a fixed-angle screw construct using AO-nuts, were tested by cantilever bending. During loading, force and displacement were recorded, from which the bending stiffness (N/mm) and the yield strength (N) were determined. Secondarily, all patients that underwent surgical treatment for subtrochanteric fracture, malunion or non-union by the senior author using this technique, underwent chart review.ResultsThe stiffness of the locking screws was about four times higher compared to the AO-nut augmented construct. The yield strength was 2.3 times higher for the locking screw construct. In none of the eight patients treated with the fixed-angle blade plate, failure of the AO-nut augmented construct occurred.ConclusionsAlthough the stiffness and strength of the AO-nut augmented construct is less than of the locking screw, excellent clinical outcomes can be achieved utilizing this construct.     

A clinico-radiological study of bicondylar tibial plateau fractures managed with dual locking plates

BackgroundTreatment of bicondylar intra-articular tibial plateau fractures due to high energy trauma is complex and highly prone to complications due to fracture patterns and extensive soft tissue damage.AimThe study's objective was to evaluate the clinical, radiological and functional outcome, including the complications in closed Schatzker type V and VI tibial plateau fractures managed with dual locking plates using less extensile approaches and indirect reduction techniques.Materials and methodsThirty-four patients of closed Schatzker Type V and VI treated with pre-contoured locking plates were evaluated clinically and radiologically. Dual plating was done using a less extensile anterolateral approach for lateral plate and medial/open posteromedial approach for medial plate. Functional results were evaluated using the Knee Society Score (KSS) and radiological results by the Modified Rasmussen score (MRS) for radiological assessment.ResultsThe mean age of patients in our study was 45 years (range = 26–60 years) with a male predominance of 84.4%. The average time difference between trauma and surgery was 7.6 days (range = 5–14 days) with an average length of hospital stay of 8.5 days (range = 7–18 days). Autologous bone grafting from the iliac crest was done in 10 patients (29.4%) with a sizeable metaphyseal void. The study has a mean follow-up period of 22.6 months. The complete union was seen at an average of 17.4 weeks. The average knee ROM at the last follow-up was 110.75°. Three patients had complications, 2 with wound dehiscence and 1 with deep infection.ConclusionInternal fixation with dual locking plates is biomechanically strong and stable and gives excellent to good functional outcomes. However, the timing of internal fixation is essential in such complex injuries to prevent soft tissue complications and failure. The use of rigid fixation by less extensile approaches and indirect reduction techniques helps prevent wound healing problems and allows early knee mobilization.     

Ability of modern distal tibia plates to stabilize comminuted pilon fracture fragments: Is dual plate fixation necessary?

ObjectivesThe purpose of this study was to examine the screw trajectory of ten commercially available distal tibia plates and compare them to common fracture patterns seen in OTA C type pilon fractures to determine their ability to stabilize the three most common fracture fragments while buttressing anterolateral zones of comminution.HypothesisWe hypothesized that a single plate for the distal tibia would fail to adequately stabilize all three main fracture fragments and zones of comminution in complex pilon fractures.MethodsTen synthetic distal tibia sawbones models were used in conjunction with ten different locking distal tibia plate designs from three manufacturers (Depuy Synthes, J&J Co, Paoli, PA; Smith & Nephew, Memphis, TN; and Stryker, Mawa, NJ). Both medial and anterolateral plates from each company were utilized and separately applied to an individual sawbone model. Three implants allowing variable angle screw placement were used. The location of the locking screws and buttress effect 1 cm above the articular surface was noted for each implant using axial computed tomography (CT). The images were then compared to a recently published “pilon fracture map” using an overlay technique to establish the relationship between screw location and known common fracture lines and areas of comminution. Each of the three main fragments was considered “captured” by a screw if it was purchased by at least two screws thereby controlling rotational forces on each fragment.ResultsThree of four anterolateral plates lacked stable fixation in the medial fragment. Of the 4 anterolateral plates used, only the variable angle anterolateral plate by Depuy Synthes captured the medial fragment with two screws. All four anterolateral plates buttressed the area of highest comminution and had an average of 1.25 screws in the medial fragment and an average of 3 screws in the posterolateral fragment. All five direct medial plates had variable fixation within anterolateral and posterolateral fragments with an average of 1.8 screws in the anterolateral fragment and an average of 1.3 screws in the posterolateral fragment. The Depuy Synthes variable angle anterolateral plate allowed for fixation of the medial fragment with two screws while simultaneously buttressing the zone of highest comminution and capturing both the anterolateral and posterolateral fragments with five and three screws respectively. The variable angle anteromedial plate by Depuy Synthes captured all three main fracture fragments but it did not buttress the anterolateral zone of comminution.ConclusionIn OTA 43C type pilon fractures, 8 out of 10 studied commercially available implants precontoured for the distal tibia, do not adequately stabilize the three primary fracture fragments typically seen in these injuries. Anterolateral plates were superior in addressing the coronal primary fracture line across the apex of the plafond, and buttressing the zone of comminution. None of the available plates can substitute for an understanding of the fracture planes and fragments typically seen in complex intra-articular tibia fractures and the addition of a second plate is necessary for adequate stability.Level of evidenceLevel IV.     

How to choose the suitable FNS specification in young patients with femoral neck fracture: A finite element analysis

BackgroundConsensus regarding the optimal approach for the treatment of femoral neck fractures remains lacking. A new internal fixation femoral neck system (FNS) was developed and used in clinical practice. We aimed to investigate the biomechanical outcomes of different types of FNS in the treatment of unstable femoral neck fractures.MethodIn this study, we constructed three different types of unstable femoral neck fractures of Pauwels classification with angles of 50°, 60°, and 70°. We set up four test groups, namely, the one-hole plated FNS group, two-hole plated FNS group, inverted cannulated screw group and triangle cannulated screw group. Under 2100 N axial loads, displacements and the von Mises stress of the femur and internal fixation components were measured for each fracture group.ResultsWhen the Pauwels angle was 50°or 60°, the one-hole locking plated FNS was as superior as the two-hole plated FNS in terms of femur and internal fixation displacement, and the inverted cannulated screw had slightly better stability than the triangular cannulated screw. However, when the angle increases to 70°, the two-hole locking plate has the minimum displacement, followed by the triangular cannulated screw and inverted cannulated screw, which is the worst displacement for the single-hole locking plate. Regardless of the angle, the two sets of FNS have higher internal fixation stress than the two sets of cannulated screws, which is approximately 1.6-3.0 times that of the cannulated screw group.ConclusionFrom the perspective of biomechanics, we suggest that when the angle of the fracture line is less than 60°, both single-hole locking plated or double-hole locking plated FNS can be used to treat unstable femoral neck fractures. However, when the angle of the fracture line is greater than 70°, we recommend using a double-hole locking plated FNS. This result needs further verification in further clinical studies.     

Revisiting the original Akin technique: A comparative analysis of radiographic outcome

BackgroundThe Akin osteotomy is widely used to correct the hallux valgus and different fixation techniques have been proposed. Currently most of these procedures coexist, with disagreement on which offers the best results. The aim of this study is to compare the radiological outcome of the original Akin’s technique with one in which a staple was used to stabilize the osteotomy. We also assessed whether other factors unrelated to the osteosynthesis could influence the radiological outcome.MethodsWe retrospectively reviewed data from 118 patients who underwent a scarf and Akin osteotomy. In 60 patients the Akin osteotomy was fixed with a staple and in 58 cases no staple was used. Hallux valgus angle (HVA), distal articular set angle (DASA), interphalangeal angle (IPA) and tibial sesamoid position were measured. The presence of lateral cortex disruption of the phalanx was also included in the analysis.ResultsSix variables significantly influenced the radiological results of the Akin osteotomy: preoperative HVA, IPA and tibial sesamoid position, laterality, postoperative cortical disruption and use of a staple.ConclusionOurs results suggest that the original Akin’s technique seems to offer equal or better results than a variation in which a staple is added to stabilize the osteotomy.Level of evidenceThis is a level III retrospective case-control study.     

Newer generation of proximal tibia locking plates demonstrate large variability in their ability to capture the posteromedial fragment in bicondylar tibial plateau fractures

IntroductionThe early generations of proximal tibial locking plates demonstrated inferior results when compared to dual plating in bicondylar tibial plateau fractures with posteromedial fragments (PMF). Modern plates have multiple rows of locking screws and variable angle technology —which tote the ability to capture the PMF. The purpose of this study was to determine if the modern plates could capture the PMF in a large series of bicondylar tibial plateau fractures.Materials & methodsAxial computer topography (CT) scans of 114 bicondylar tibial plateau fractures with PMF were analyzed. Five proximal tibia locking plates—in seven total configurations—were applied to radiopaque tibiae models. All possible screws were placed. Templates of screw trajectories were created based on the model CT scans. These were superimposed onto patient CT scan images to assess for screw penetration into the PMF. Number of screws fully within the PMF were recorded. Capture of the PMF was defined as having at least two screws within the fragment.ResultsOn average, all plates were able to capture 81.6% of PMF with an average of 3.77 [95% Confidence Interval (CI): 3.47-4.07] screws. However, their ability to capture all fragments varied greatly, from 55.7%-95.2% in fixed angle constructs. Overall, variable angle constructs had a significantly higher capture rate (98.5% vs. 74.9%; p<0.0001) and more screws in the PMF (5.88 [95% CI: 5.58-6.17] vs 2.93 [95% CI: 2.62-3.24]; p<0.0001) when compared to fixed angle constructs.ConclusionNewer generation locking plates vary greatly in their ability to capture the PMF. Variable angle technology dramatically increases the ability to capture the majority of PMFs. Prior biomechanical and clinical studies may yield substantially different results if repeated with these newer implants. Use of newer generation locked plates should not replace thorough preoperative planning.     

Biomechanical Comparison of Two Pediatric Blade Plate Designs in Proximal Femoral Osteotomies

Background

Blade plates are frequently used for internal fixation following proximal femoral varus rotational osteotomy to treat hip dysplasia in children with cerebral palsy. Recently, cannulated blade plates with the option for a proximal locking screw have demonstrated ease of insertion and low complication rates. Although there are two commonly used blade plates with a proximal screw option, no comparison of their biomechanical profiles has been undertaken.

Questions/Purposes

Our study sought to compare the structural properties under axial loading, as well as the biomechanical contribution of a proximal screw, of two different 90° cannulated blade plates designed for pediatric proximal femurs. Plate A has a hole distal to the blade designed to attach a plate inserter, through which a 3.5-mm non-locking cortical screw could be placed. Plate B has a threaded hole distal to the blade designed to accept a 3.5-mm locking screw.

Methods

Plate A and plate B were inserted into 33 left pediatric synthetic proximal femurs. Axial loading to failure of plate A with and without a proximal screw was compared to that of plate B with and without a proximal screw. An additional 10 samples using plate B, with and without a proximal locking screw, were tested in tension to quantify the effect of the proximal screw on pullout strength.

Results

Plate B failed at a higher axial load than plate A. The addition of a proximal screw did not affect the axial load to failure for either plate. Pullout testing revealed that blade plates fixed with the proximal screw failed in tension at a significantly higher load (856.3?±?120.9 N) than those without proximal fixation (68.1?±?9.3 N, p?<?0.001).

Conclusions

Plate B failed at a higher axial load in biomechanical testing, likely related to differences in its design. The addition of a proximal screw did not increase the axial loading properties of the blade plate construct but did increase the pullout strength by a factor of 12. These results may be used to influence implant selection and post-operative rehabilitation following proximal femoral osteotomies in children.

     

Matched retrospective analysis of three different fixation devices for chevron osteotomy

Chevron osteotomy with consecutive fixation is a commonly performed operative treatment option for hallux valgus deformities. The present retrospective study aims to compare the clinical and radiological outcome of novel bioabsorbable magnesium screw fixation with metal screw and Kirschner wire fixation.Eighteen matched triplets were assembled according to the following criteria: female gender, age difference less than 5 years, date of operation within 4 months, difference in preoperative intermetatarsal angle less than 5°, and equal experience of the first and second surgeon. These patients, between 18 and 85 years of age and with a minimum follow-up period of 12 months, were invited to a follow-up examination, of which only 16 matched triplets of patients entirely kept the appointment. Thus, 48 feet of 44 patients were clinically evaluated using the American Orthopaedic Foot & Ankle Society scale, Foot Function Index, University of California and Los Angeles Activity Score, as well as a visual analogue scale for pain, satisfaction, cosmetic results, and functional impairment. Radiographical assessment included measuring intermetatarsal angle and first metatarsophalangeal angles. All occurring complications and revision surgeries were noted.Significant differences were observed for postoperative intermetatarsal angle between magnesium screw and pin fixation (p = 0.009). Moreover, patients receiving magnesium screw were significantly more prone to undergo the same procedure again (p = 0.03).In conclusion, if the advantages of bioabsorbable magnesium screws outweigh the drawbacks of increased costs and a higher surgical demand, this implant might serve as possible chevron osteotomy fixation method. Compression screws and Kirschner wires also show comparable satisfactory outcomes.Level of evidenceIII retrospective comparative study     

Operative treatment of geriatric ankle fractures with conventional or locking plates. A retrospective case-control study

BackgroundThe incidence of geriatric ankle fractures continues to rise due to demographic changes. While locking plates have become standard implants for injuries of other body regions, clinical studies on their use for geriatric ankle fractures are rare.MethodsTherefore, a retrospective case-control study, including 333 patients with a mean age of 73.5 years was performed. 263 patients underwent operative fixation with one- third tubular plates and 70 were treated with locking plates. Early outcomes and complication rates of locking plates as compared with conventional one- third tubular plates are described.ResultsIn the present study, patients treated with locking plates were older and suffered from more severe fracture patterns. In addition, these patients had more severe comorbidities. Treatment with conventional or locking plate fixation resulted in a comparable complication and revision rate. A matched pair analysis showed significantly more complications and required revision surgeries and a trend towards more implant failures in the group that underwent conventional plating.ConclusionsTherefore, we conclude that precontoured locking plates represent an appropriate treatment option for severe ankle fractures in patients suffering from relevant co-morbidities. Prospective randomized trials are warranted to prove superiority of locking plates for treatment of geriatric ankle fractures.Level 3: Retrospective case- control study.     

Radiological assessments and clinical results of intra-articular osteotomy for traumatic osteoarthritis of the ankle

IntroductionTraumatic osteoarthritis of the ankle joint caused after malleolar fractures of the ankle and tibial plafond fractures are frequently observed in comparatively young and highly active patients. Since the ankle movement in these patients is in general, comparatively favorable, orthopedists may sometimes have difficulty in deciding on a treatment policy. In our department, when treating traumatic osteoarthritis patients having a movable range within their ankle joints, we proactively applied distal tibial oblique osteotomy (DTOO) developed by Dr. Teramoto in 1994 or intra-articular osteotomy developed based on DTOO concepts such as distal tibial intra-articular osteotomy (DTIO) and distal fibular oblique osteotomy (DFOO).The objectives of the current study are to radiologically assess the ankle joint after intra-articular osteotomy for traumatic ankle osteoarthritis and evaluate the change in configuration of the ankle joint. This study summarizes the clinical results of intra-articular osteotomy obtained through the above-mentioned study.Patients and methodsThe subjects of this study were 20 patients diagnosed with traumatic osteoarthritis who were surgically treated for a total of 20 ankles. All patients underwent treatment with intra-articular osteotomy and were evaluated retrospectively for the following parameters: surgical procedure, fixation devices, clinical results based on the Japanese Society for Surgery of the Foot ankle/hindfoot scale (hereafter, JSSF scale) and post-operative adverse events. They were also assessed radiologically with pre- and post-operative anterior-posterior (AP) and lateral weight-bearing ankle radiographs.ResultsThe 20 patients consisted of 12 males and 8 females. The median age at surgery was 49 years old (range 14 - 87 years old) and the average follow-up period was 42 months (range 19 to 121 months). DTOO was applied to 10 cases, DFOO to 2 cases, DTOO and DFOO to 2 cases, medial-distal tibial intra-articular osteotomy (M-DTIO) and DFOO to 1 case, lateral-distal tibial intra-articular osteotomy (L-DTIO) and DFOO to 3 cases, M-DTIO followed by DTOO and DFOO to 1 case, and DTOO followed by low tibial osteotomy (LTO) to 1 case. Fixation devices utilized included circular external fixator for 15 cases, locking compression plate (LCP) to 3 cases, LCP and Kirschner-wire (K-wire) to 1 case, and screw and K-wire to 1 case. Radiological assessment revealed significant changes in the following parameters after surgery: tibial ankle surface angle (TAS, P= 0.0203), tibiotalar surface angle (TTS, P= 0.0021), medial malleolar angle (MMA, P= 0.0217), empirical axis (EA, P= 0.0019), fibular angle (FA, P= 0.0002), talar tilt angle (TTA, P= 0.0374), and tibial lateral surface angle (TLS, P= 0.0279). The JSSF scale also improved significantly after surgery (pre-operative JSSF scale: 51.1±11.0, post-operative JSSF scale: 89.2±8.2), p=0.0001.ConclusionIntra-articular osteotomy may change the radiological configuration of the ankle in a weight-bearing state. The present study showed very good short-term clinical results. Intra-articular osteotomy can prove a viable surgical option applicable for treatment of patients with traumatic ankle osteoarthritis having a reasonable range of motion within their ankle joints.     

Fixed angle plate fixation of comminuted patellar fractures

IntroductionComminuted patella fractures are uncommon and difficult fractures to manage. Multiple treatment modalities have been suggested, with little clinical data to support practice. Recent biomechanical and technical investigations have described successful plate fixation of comminuted patella fractures. The purpose of this study was to evaluate radiographic, clinical and functional outcome of comminuted patella fractures treated with a fixed angle locking plates. We believe stable fixation, which results in successful fracture union and functional recovery, can be achieved with this technique.Materials and methodsA retrospective review was performed at a single regional academic Level 1 trauma hospital. All comminuted patella fractures treated with a fixed angle locking plate (AO/OTA 34C2 and C3) over a six-year period were evaluated. Thirty-six patients were identified. Average length of follow up was 154 weeks (range 12–297 weeks). Twenty patients were available for functional outcome scoring. Primary outcome measures were: Knee Outcome Score (KOS), Lower Extremity Functional Scale (LES) and goniometer measured knee range of motion. Secondary outcomes evaluated the need for additional screw or cerclage fixation, reoperation for any reason, bothersome hardware, infection and nonunion.ResultsAverage KOS = 57.2 (20–74), average LES = 58.9 (15–80). Median extension = 0° (full extension), median flexion = 130°. Supplemental screws were used in 17/36 cases; cerclage used in 2/36 cases. Hardware irritation was noted in 4/20 patients, no patient requested elective hardware removal, one patient had failure of fixation and no nonunions were identified.ConclusionFixed angle plate stabilization of comminuted patella fractures is a viable technique for fracture fixation. Good to excellent return of knee function and low complication rates, including need for hardware removal, can be expected.