Bone graft from greater trochanter in posterior wall fractures with impacted fragments

Background

Posterior wall fracture is the most common acetabular fracture. Comminuted fractures with an impacted segment represent a subtype of this injury. The subchondral bone of the articular zone is compressed and causes a bone defect. The impacted fragment should be isolated, mobilized, and then reduced. A bone graft should be used to fill the gap. The other fragments are fixed following the reduction of the impacted segment.

Materials and methods

Ten patients with comminuted fractures and impacted segments with bone defects were enrolled in our study, from January 2010 to July 2012. Autogenous bone grafts from the greater trochanter were used to fill the gap in all patients. The reduction was achieved through the insertion of the graft above the impacted fracture, and plate fixation was performed subsequently. Merle d’Aubigne and Postel scoring, modified by Matta, was applied to evaluate the patients during follow-up. The mean follow-up was 12 months.

Results

The clinical results included one “excellent”, four “very good”, four “good” and one “poor”. Pain in the zone of graft harvesting was not detected in any patient. Femoral head necrosis was observed in one case. No other severe complications were detected.

Conclusions

Using an autogenous bone graft to fill the bone defect supplies excellent mechanical stability without any severe complications at the donor site. This surgical technique seems to be effective and safe in treating a comminuted fracture of the posterior wall in association with an impacted segment.

Level of evidence

Level IV.     

The use of external fixation combined with vacuum sealing drainage to treat open comminuted fractures of tibia in the Wenchuan earthquake

Purpose

The purpose of this study was to review the results of external fixation combined with vacuum sealing drainage (VSD) to treat patients who sustained tibial and fibular fractures in the Wenchuan earthquake.

Methods

We retrospectively analysed 179 cases (of which 85 were classified as Gustilo grade III) of open comminuted fracture of the tibia and fibula caused by the Wenchuan earthquake. The patients were followed up for an average of 15 months; detailed records were kept on their function and recovery.

Results

After caring for the life-threatening injuries; fractures were treated by external fixation, with VSD used on the surface or in the cavity of the wound after debridement. Antibiotics were administered on the basis of drug sensitivity test results. After the infection had been controlled and healthy granulation tissue had developed, the patients underwent secondary suture, free skin grafting, or skin flap transfer.

Conclusion

Good results can be achieved when external fixation combined with vacuum sealing drainage were used to treat open comminuted fractures of tibia and fibula in the Wenchuan earthquake.     

Percutaneous Distraction Pinning for Metacarpophalangeal Joint Stabilization After Blast or Crush Injuries of the Hand

Background

Unstable, severely comminuted fractures of the metacarpophalangeal (MCP) joint are difficult to treat. Closed treatment and casting of these fractures often fail to maintain proper alignment and impede wound care where concomitant open injuries such as gunshot wounds are present. Conventional pinning or plating techniques are not feasible if extensive bone loss and comminution are present. A distraction pinning technique represents a potential alternative, but results with this approach, to our knowledge, have not been reported.

Questions/purposes

The purposes of this study were (1) to evaluate the effectiveness (defined as osseous union and joint stability) of distraction pinning for comminuted fractures involving MCP joints after gunshot or crush injuries; (2) to report the short-term results in terms of pain and function in a small group of patients who underwent MCP distraction pinning; and (3) to evaluate complications and return to work status of these patients in the short term.

Methods

We reviewed 10 patients with comminuted pilon-type fractures of the base of the proximal phalanx or metacarpal head treated with wire distraction fixation from 2005 and 2014. During that period, we used this technique to treat all patients whose fractures were deemed too comminuted for plating or pinning, and during that period, no other techniques (such as simple external fixation) were used for patients meeting those indications. The minimum followup was 6 months; eight of the 10 patients were accounted at a median of 10 months (range, 6–89 months). The median age was 47 years (range, 28–57 years), and seven of the eight were male. Kirschner wire fixation frames were removed 3.5 to 6 weeks after the index surgery when fracture consolidation was confirmed on radiography by the treating surgeon. Stability and range of motion of the MCP joint were assessed using physical examination, radiographs, and goniometer by the treating surgeon. Patients completed the Quick Disabilities of the Arm, Shoulder and Hand score at latest followup or by telephone, and complications were assessed by chart review.

Results

All fractures were healed with stable MCP joints. Eight patients reported having no pain or minimal pain of their injuries to the hand. The median finger and thumb MCP arc of motion were 80° (range, 70°–105°) and 30° (range, 0°–60°), respectively. The median Quick Disabilities of the Arm, Shoulder and Hand score was 3 (range, 0–41). One patient underwent a second surgical procedure for bone grafting and soft tissue coverage. Three patients developed pin site irritations and were treated with oral antibiotics. Six patients returned to their original job.

Conclusions

The distraction pinning technique provides reliable osseous union and joint stability of comminuted pilon-type fractures of the base of the proximal phalanx or metacarpal head, even with associated open wounds. Future studies will need to evaluate these patients at longer term followup and compare this approach with other available techniques, because arthrosis, stiffness, and progressive loss of function seem likely to occur given the severity of these injuries.

Level of Evidence

Level IV, therapeutic study.     

Management of fractures of the distal third tibia by minimally invasive plate osteosynthesis – A prospective series of 50 patients

Background

Minimally invasive plate osteosynthesis (MIPO) is an established technique for fixation of fractures of the distal third tibia. Our study aimed to manage intra articular and extraarticular fractures of the distal third tibia by the minimally invasive plate osteosynthesis technique and follow them prospectively. Clinical and radiological outcomes were studied and clinical indications & efficacy of the procedure reviewed. Though many studies on the subject have been done previously, these have been retrospective reviews or small series.

Methods

From May 2010 to May 2013, 50 patients of closed distal tibial fractures were operated by MIPO technique with a distal tibial anatomical locking plate having 4.5/5 proximal and 3.5/4 distal screw holes. The follow up duration was for 3 years.

Results

The mean fracture healing time was 21.4 weeks (range 16–32 weeks) and average AOFAS score 95.06 was out of a total possible 100 points. At last follow up, superficial infection occurred in 5 patients (10%); deep infection, implant failure and malunion in 1-patient each (2%).

Conclusion

MIPO technique provides good, though slightly delayed bone healing and decreases incidence of nonunion and need for bone grafting. This technique should be used in distal tibia fractures where locked nailing cannot be done like fractures with small distal metaphyseal fragments, vertical splits, markedly comminuted fractures and in fractures with intra-articular extension.     

A biomechanical study of conventional acetabular internal fracture fixation versus locking plate fixation

Background

Conventional internal fixation entails the use of an interfragmentary lag screw along with a plate. Not all acetabular fractures are amenable to the placement of an interfragmentary lag screw, and the fracture may be displaced during tightening of the interfragmentary lag screw. Locking plates are a possible solution. We sought to determine whether a locking plate construct can provide stability equivalent to that provided with a conventional construct for transverse acetabular fractures.

Methods

We used 5 paired fresh-frozen cadaveric acetabula. We fixed one side with the conventional technique and the other side with a locking plate. We subjected each fixation to a cyclic compressive force up to 500 cycles, followed by compressive force until failure. We monitored 3-dimensional motion of the fracture.

Results

The average fracture gap at 50 N compressive force after 500 loading cycles was 0.41 (standard deviation [SD] 0.49) mm for the conventional plate and lag screw construct compared with 0.76 (SD 0.62) mm for the locked plate construct (p = 0.46). The force to failure, as defined by 2 mm of fracture gap, was 848 (SD 805) N for the conventional plate and lag screw construct compared with 506 (SD 277) N for the locked plate fixation (p = 0.34).

Conclusion

The locking plate construct is as strong as the conventional plate plus interfragmentary lag screw construct for fixing transverse acetabular fractures. Locking plates may improve management of acetabular fractures by eliminating the need for placement of an interfragmentary lag screw. Furthermore, they may be helpful in revision hip arthroplasty in patients with pelvic discontinuity.     

The use of a single volar locking plate for AO C3-type distal radius fractures

Background

A single volar locking plate (VLP) is now frequently used for open reduction and internal fixation (ORIF) of many types of distal radius fractures. Comminuted intra-articular distal radius fractures (AO C3-type) are typically the most challenging to surgically treat. No studies directly address the adequacy of a VLP alone for maintaining reduction of AO C-type fractures. We hypothesized that a single VLP provides an effective method for maintaining reduction for these fractures.

Methods

We retrospectively evaluated radiographs of a series of AO C-type fractures. Seventy-seven patients with 77 AO C3-type fractures were identified from billing records and were eligible for the study. All patients were treated by fellowship-trained hand surgeons. Radiographs at the time of union were compared to those from immediately postoperatively.

Results

Sixty-nine of 77 (89.6 %) fractures treated with VLP fixation alone for AO C3-type distal radius fractures united without loss of reduction. Eight of 77 (10.4 %) patients treated with VLP for AO C3 fractures lost reduction. The most common fracture fragment to lose reduction was the lunate fossa (5 of 8); loss of reduction of the scaphoid fossa die-punch fragment (2 of 8) and the radial styloid (1 of 8) were also seen.

Conclusions

The majority (89.6 %) of AO C3-type fractures treated with a single volar locking plate come to union without loss of reduction.Level of evidence: Level IV.     

Locked plate fixation of the comminuted distal fibula: a biomechanical study

Background

The purpose of this study was to compare the biomechanical properties of locked versus nonlocked lateral fibular bridge plating of comminuted, unstable ankle fractures in a mode of catastrophic failure.

Methods

We created comminuted Weber C fractures in 8 paired limbs from fresh cadavers. Fractures were plated with either standard or locked one-third tubular bridge plating techniques. Specimens were biomechanically evaluated by external rotation to failure while subjected to a compressive load approximating body weight. We measured the angle to failure, torque to failure, energy to failure and construct stiffness.

Results

There was no significant difference in construct stiffness or other biomechanical properties between locked and standard one-third tubular plating techniques.

Conclusion

We found no difference in biomechanical properties between locked and standard bridge plating of a comminuted Weber C fibular fracture in a model of catastrophic failure. It is likely that augmentation of fixation with K-wires or trans-tibial screws provides a construct superior to locked bridge plating alone. Further biomechanical and clinical analysis is required to improve understanding of the role of locked plating in ankle fractures and in osteoporotic bone.     

Intramedullary fixation of distal fibular fractures: a systematic review of clinical and functional outcomes

Background

Ankle fractures are extremely common and represent nearly one quarter of all lower-limb fractures. In the majority of patients, fractures involve the distal fibula. The current standard in treating unstable fractures is through open reduction and internal fixation (ORIF) with plates and screws. Due to concerns with potentially devastating wound complications, minimally invasive strategies such as intramedullary fixation have been introduced. This systematic review was performed to evaluate the clinical and functional outcomes of intramedullary fixation of distal fibular fractures using either compression screws or nails.

Materials and methods

Numerous databases (MEDLINE, PubMed, Embase, Google Scholar) were searched, 17 studies consisting of 1,008 patients with distal fibular fractures treated with intramedullary fixation were found.

Results

Mean rate of union was 98.5 %, with functional outcome reported as being good or excellent in up to 91.3 % of patients. Regarding unlocked intramedullary nailing, the mean rate of union was 100 %, with up to 92 % of patients reporting good or excellent functional outcomes. Considering locked intramedullary nailing, the mean rate of union was 98 %, with the majority of patients reporting good or excellent functional outcomes. The mean complication rate across studies was 10.3 %, with issues such as implant-related problems requiring metalwork removal, fibular shortening and metalwork failure predominating.

Conclusion

Overall, intramedullary fixation of unstable distal fibular fractures can give excellent results that are comparable with modern plating techniques. However, as yet, there is unconvincing evidence that it is superior to standard techniques with regards to clinical and functional outcome.

Level of evidence

Level IV evidence.     

Triangular Fixation Technique for Bicolumn Restoration in Treatment of Distal Humerus Intercondylar Fracture

Background

Distal humerus intercondylar fractures are intra-articular and comminuted fractures involving soft tissue injury. As distal humerus is triangle-shaped, parallel plating coupled with articular fixation would be suitable for bicolumn restoration in treatment of distal humerus intercondylar fracture.

Methods

This study included 38 patients (15 males and 23 females) who underwent olecranon osteotomy, open reduction and internal fixation with the triangle-shaped cannulated screw and parallel locking plates (triangular fixation technique). Functional results were assessed with the visual analog scale (VAS) scores, Mayo elbow performance (MEP) scores and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires. Anteroposterior and lateral elbow radiographs were assessed for reduction, alignment, fracture union, posttraumatic arthrosis, and heterotopic ossification, and computed tomography (CT) scans were used to obtain more accurate measurements of articular discrepancy.

Results

All fractures healed primarily with no loss of reduction. The mean VAS, MEP, and DASH scores of the affected elbow were not significantly different from those of the unaffected elbow (p = 0.140, p = 0.090, and p = 0.262, respectively). The mean degree of flexion was significantly lower in the affected elbow than in the unaffected elbow, but was still considered as functional (p = 0.001, > 100° in 33 of 38 patients). Two cases of articular step-offs (> 2 mm) were seen on follow-up CT scans, but not significantly higher in the affected elbow than in the unaffected elbow (p = 0.657). Binary logistic regression analysis revealed that only Association for Osteosynthesis (AO) type C3 fractures correlated with good/excellent functional outcome (p = 0.012). Complications occurred in 12 of the 38 patients, and the overall reoperation rate for complications was 10.5% (4 of 38 patients).

Conclusions

Triangular fixation technique for bicolumn restoration was an effective and reliable method in treatment of distal humerus intercondylar fracture. This technique maintained articular congruency and restored both medial and lateral columns, resulting in good elbow function.     

Efficacy of different fixation devices in maintaining an initial reduction for surgically managed distal radius fractures

Background

Fracture of the distal radius is a common injury. Many treatment options exist for the surgical management of extra-articular and intra-articular distal radius fractures. The best method of treatment for these fractures remains controversial. We sought to examine radiographic outcomes of patients treated with non-spanning external fixator (NSEF), open reduction and internal fixation (ORIF) with locking plates and screws or closed reduction and percutaneous pinning (CRPP) and compare their ability to maintain radiographic parameters over the initial 6-week postoperative period.

Methods

We performed a retrospective review of radiographs showing 211 distal radius fractures treated with NSEF, ORIF or CRPP. We examined the images for a variety of radiological parameters. Measurements were taken immediately postoperatively and at 6-week follow-up to determine whether there was any loss of reduction.

Results

Of the 211 fractures, 104 (49.3%) were type-A fractures, 12 (5.7%) were type-B fractures and 95 (45.0%) were type-C fractures. The 3 treatments maintained the reduction obtained at surgery until healing. The CRPP and ORIF treatments failed to maintain correction in ulnar variance for the 6-week period; however, only ORIF actually changed the ulnar variance from presurgical values.

Conclusion

Treatment with ORIF for comminuted, intra-articular distal radius fractures produces good radiographic results with maintenance of surgical radiographic parameters, whereas NSEFand CRPP of less complex fractures also provide good results. This suggests that fracture-specific fixation with CRPP or NSEF are sufficient for certain distal radius fractures.     

Mortality and Revision Surgery Are Increased in Patients With Parkinson’s Disease and Fractures of the Femoral Neck

Background

Patients with Parkinson’s disease are at increased risk for falls and associated hip fractures as a result of tremor, bradykinesia, rigidity, and postural instability. The available literature is limited and conflicting regarding the optimal surgical treatment and risk for postoperative complications and mortality in this unique patient population.

Questions/purposes

We asked: (1) Is there a difference in mortality after surgical treatment of hip fractures in patients with Parkinson’s disease compared with similar patients with hip fractures without Parkinson’s disease? (2) Does Parkinson’s disease lead to a higher rate of reoperation after operative treatment of femoral neck fractures? (3) Does Parkinson’s disease lead to a higher rate of dislocation after hemiarthroplasty for displaced femoral neck fractures, and (4) does the operative approach affect dislocation rates?

Methods

In this case-controlled study, we retrospectively reviewed 141 patients with a diagnosis of Parkinson’s disease and a fracture of the femoral neck. Each patient with Parkinson’s disease was matched with two control patients (n = 282) without Parkinson’s disease stratified by age, sex, American Society of Anesthesiologists classification, and fracture type (nondisplaced/displaced). Clinical outcomes included mortality after surgical intervention, rate of reoperation, dislocation events after hemiarthroplasty, and the rate of failure after internal fixation for nondisplaced fractures.

Results

The median survival time of the patients with Parkinson’s disease after fracture was 31 months (95% CI, 25–37 months) compared with 45 months (95% CI, 39–50 months) in our control group (p = 0.007). The rate of reoperation for displaced and nondisplaced fractures was higher in the Parkinson’s disease group compared with the control group (11% versus 4%; p = 0.005). Failure of fixation for patients treated with internal fixation of nondisplaced femoral neck fractures was significantly higher in the Parkinson’s disease group compared with our control group (22% versus 5%; p = 0.01). Dislocation rates after hemiarthroplasty were significantly higher in the Parkinson’s disease group compared with the control group (8% versus 1%; p = 0.003). Patients treated with a hemiarthroplasty through an anterolateral approach had a significantly lower dislocation rate compared with those treated with a posterior approach (2% versus 15%; p = 0.002).

Conclusions

Parkinson’s disease is an independent predictor of mortality after femoral neck fracture and is associated with an increased rate of dislocation, revision surgery, and failure of internal fixation. Although patients with Parkinson’s disease with a nondisplaced or valgus impacted femoral neck fracture may be treated with internal fixation, they are at significantly higher risk of failure of fixation compared with patients without Parkinson’s disease. Use of a hemiarthroplasty through an anterolateral approach may reduce the likelihood of requiring a revision operation.

Level of Evidence

Level III, therapeutic study.     

Role of suture anchors in management of fractures of inferior pole of patella

Background:

The traditional recommendation for displaced comminuted inferior pole fractures is excision of the comminuted pole followed by reattachment of the patellar tendon with transosseous suture. To the best of our knowledge there has been no previous published study mentioning the use of suture anchors for fracture inferior pole of patella. We present a retrospective analysis of five cases of patients doing well at final follow-up of two years.

Materials and Methods:

Five patients treated at our institute using suture anchors for repair of comminuted inferior pole fractures of patella between January 2007 to March 2007. (range 28 years-55 years). There were three males and two females.

Results:

The average follow-up was 25 months (range 24 months-26 months). The patients were evaluated for range of motion, strength, patellofemoral scores and any alteration of patellar height. The outcome of the procedure was assessed with use of the patellofemoral scoring system of Noyes et al,⁵ as adapted by Saltzman et al.⁶ The final patellofemoral score (maximum 100 points) was 94.6 (range 93-96).

Conclusion:

We believe it is a novel extended indication of the use of suture anchors and should be in the armament of every trauma surgeon.     

Static monolateral external fixation for the Rolando fracture: a simple solution for a complex fracture

INTRODUCTION

Rolando fractures are often difficult to manage because of their inherent instability. We describe a simple technique for the treatment of this fracture using the principle of ligamentotaxis, with a static, two-pin external fixator spanning the trapeziometacarpal joint, and present the results of a single-surgeon case series.

METHODS

Eight consecutive patients (mean age: 32.8 years) with Rolando fractures were treated using a Hoffmann II® Micro small bone external fixator using blunt ended 2.0mm half pins, inserted into the trapezium and diaphysis of the first metacarpal. Functional outcome was assessed with the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score at a mean time of 2.7 years following the fracture (range: 4 months – 6.0 years). The mean time to frame removal was 28 days.

RESULTS

There were three cases of superficial pin site infection. Follow-up x-rays at four months did not demonstrate significant joint incongruity or malunion in any case. The mean QuickDASH score was 7.95 and all patients returned to their previous levels of activity.

CONCLUSIONS

Although external fixation risks pin site infection, the results of this study support the use of spanning trapeziometacarpal external fixation for Rolando fractures as it reliably gives excellent functional outcomes.