Treatment of posttraumatic sternal non-union with a locked sternum-osteosynthesis plate (TiFix)

Only a minority of sternal fractures require osteosynthesis. Unstable non-union of the sternum is a very disabling condition which often requires treatment. The method most often used is tension-wiring. Due to loosening of the tensile strength or wire cut-out, this method often fails. We report the results of locked plate osteosynthesis of sternal non-union and displaced fractures.Over a five-year period, 12 patients have been treated using this method in a multicentre trial. Mean age at trauma was 32.8 years, the implant used in all cases was an 8-hole titanium plate, the fixation of the screws is based on the principles of angular stable fixation.In all cases the index procedure was possible, in all cases there was bony healing at follow-up examination.Multidirectional locked plating offers a reliable method for the successful treatment of sternal non-union and displaced fractures.     

胸骨直型重建钢板内固定治疗Ⅴ型肩胛盂骨折

目的探讨胸骨直型重建钢板内固定治疗Ⅴ型肩胛盂骨折的疗效。方法采用胸骨直型重建钢板内固定治疗28例Ⅴ型肩胛盂骨折患者。末次随访时根据Neer评分标准评定肩关节功能。结果患者均获得随访,时间6~12个月。骨折均愈合,时间6~10个月。无畸形愈合,无创伤性关节炎、肩峰撞击征、冻结肩等并发症发生。末次随访时肩关节功能按Neer评分标准评定:优11例,良10例,可7例。结论采用胸骨直型重建钢板内固定治疗Ⅴ型肩胛盂骨折,术中塑形方便,可进行环形内固定,使固定更牢靠。     

Operative fixation of chest wall fractures: an underused procedure?

Chest wall fractures, including injuries to the ribs and sternum, usually heal spontaneously without specific treatment. However, a small subset of patients have fractures that produce overlying bone fragments that may produce severe pain, respiratory compromise, and, if untreated mechanically, result in nonunion. We performed open reduction and internal fixation on seven patients with multiple rib fractures-five in the initial hospitalization and two delayed--as well as 35 sternal fractures (19 immediate fixation and 16 delayed). Operative fixation was accomplished using titanium plates and screws in both groups of patients. All patients with rib fractures did well; there were no major complications or infections, and no plates required removal. Clinical results were excellent. There was one death in the sternal fracture group in a patient who was ventilator-dependent preoperatively and extubated himself in the early postoperative period. Otherwise, the results were excellent, with no complications occurring in this group. Three patients had their plates removed after boney union was achieved. No evidence of infection or nonunion occurred. The excellent results achieved in the subset of patients with severe chest wall deformities treated initially at our institution and those referred from outside suggest that operative fixation is a useful modality that is likely underused.     

Transverse plate fixation of sternum: a new sternal-sparing technique

We report 2 cases of vacuum-assisted closure therapy and thoracic reconstruction using new sternum titatium plates in patients with deep sternal wound infection after median sternotomy. The specific advantage of this new approach is anatomical reduction of the sternum that prevents paradoxical movement and severe anterior chest instability, and improves postoperative outcome.     

Unstable trochanteric femoral fractures: extramedullary or intramedullary fixation. Review of literature

For operative treatment of unstable trochanteric fractures two options exist: extramedullary or intramedullary stabilisation. A review of 18 international papers that compared two different treatment methods for trochanteric fractures, in prospective randomised clinical trials, is presented. In view of the overall results, routine use of intramedullary fixation devices is not to be recommended for stable trochanteric fractures. For these fractures one of the sliding hip screw systems provides a safe and simple alternative. For unstable fractures intramedullary implants are (biomechanically) superior. The review shows that clinical advantages of both treatment methods are suggested and advocated, but still remain to be demonstrated on evidence base.     

Osteosynthesis of sternal fractures with double locking compression plate fixation: a retrospective cohort study

Purpose

Sternal fractures are rare injuries and mostly treated non-operatively. In selected cases, internal fixation becomes necessary. No standard operative approach has been determined yet among experts. The aim of this study is to describe our treatment algorithm and results after operative stabilisation of sternal fractures with locking compression plates (LCP), mainly focusing on the functional outcome.

Methods

A retrospective cohort study was conducted. We included all patients after operative stabilisation of a sternal fracture between 2008 and 2016. Endpoints were the functional outcome using the Activities of Daily Living (ADL) score, pain analysed by the numeric rating scale (NRS), breathing ability, complications and implant removal.

Results

Eighteen out of 153 (12%) patients with a sternal fracture underwent operation. Three patients were lost to follow-up. Eleven out of 15 (73%) patients were treated with double straight LCP 3.5 mm implants and 4 (27%) patients with pre-countered LCP 3.5 mm implants. Mean follow-up was 57 months. The median ADL score was 1 (1–4), the median NRS was 0 (0–9), and respiratory complaints scored a median of 1 (1–4). No non-union, hardware failure or implant-related complication occurred. Post-operative complications were pneumonia (20%) and respiratory insufficiency (20%). Implants were removed in 4/15 (27%) patients; three times due to implant-related irritation, once on patient’s request.

Conclusion

Operative stabilisation of sternal fractures with double LCP 3.5 mm provides excellent long-term functional results and seems to be an appropriate option for internal fixation. The rate of post-operative complications is low; however, 27% had a second operation for implant removal.

     

Repair of right ventricular free wall defect with a de-epithelized pedicled myocutaneous latissimus dorsi muscle flap

Rupture of the right ventricle may occur because of sternal dehiscence or mediastinitis after cardiac surgery. Direct suture, polytetrafluoroethylene patch, fasciae, and muscle flaps have been used to close a right ventricular rupture. A unique occurrence of repair of a full-thickness right ventricle defect with a de-epithelized myocutaneous flap is presented. Our patient experienced a rupture of the right ventricle complicating sternal wound infection. The rupture was reconstructed with a polytetrafluoroethylene patch, but the patch needed to be removed because of infection. The defect was reconstructed with a de-epithelized myocutaneous latissimus dorsi flap. The patient indicated no signs of complication during follow-up.     

Patellar Fractures: Contemporary Approach to Treatment

Patellar fractures are a diverse group of injuries with a variety of fracture patterns. The surgical goals are anatomic reconstruction of the articular surface and stable fixation to allow early motion. Contemporary methods of treatment include screws, the modified tension band, and a combination of the two. Screws and wires have demonstrated specific failure patterns in experimental models, and biomechanical studies suggest that the combination of screws and wires provides more secure fixation. Partial patellectomy is the procedure of choice in comminuted fractures that cannot be anatomically reduced. Optimal treatment of patellar fractures requires individualization of surgical technique. The postoperative rehabilitation program should be based on the intraoperative findings and the stability of fixation.     

Elastic stable intramedullary nailing of midclavicular fractures with a titanium nail

This study presents the results of a minimally invasive operative treatment for markedly displaced midclavicular fractures. In all patients a flexible titanium nail was inserted in an unreamed technique from the sternal end of the clavicle. The result of surgery was determined with clinical and radiographic controls. The clinical outcome was evaluated 12 months after hardware removal using the scoring system of Constant and Murley. Fifty-eight fractures in 55 patients were treated with intramedullary fixation. Postoperatively on Day 3, the mean subjective pain was significantly lower and range of motion was improved compared with the day before surgery. One nonunion occurred. There was no infection and no implant displacement or refracture. Intramedullary nailing of midclavicular fractures with a flexible titanium nail is a safe minimally invasive surgical technique with excellent functional and cosmetic results compared with plate fixation or conservative treatment. Marked pain reduction along with early restoration of shoulder function and early mobilization are advantageous for patients. This technique can be used as an alternative treatment to conservative procedures or plate fixation in patients with markedly displaced midclavicular fractures, multiple trauma, fractures of the lower extremities, or associated shoulder girdle injuries.     

胸椎胸骨复合型骨折的疗效分析

目的评价胸椎胸骨复合型骨折的不同方式的治疗效果。方法对31例胸椎胸骨复合型骨折病例的治疗进行回顾性分析。31例患者均合并有多处创伤．其中胸椎压缩性骨折15例,骨折脱位11例,爆裂型骨折5例;完全性神经损伤5例,不完全神经损伤16例,无神经损伤10例。手术治疗20例（单纯胸骨手术4例,胸椎手术12例,胸椎胸骨联合手术5例）,非手术治疗11人。结果随访时间0．5～5年,平均2．4年。患者均有不同程度的恢复。术后3例完全性神经损伤患者神经功能无明显改善;2例出现迟发型神经功能损害。余27例病情无加重：16例不完全神经损伤患者中3例恢复正常,9例有改善,4例无改善。结论胸骨胸椎复合型骨折多伴有神经损伤及其他多处创伤,病情复杂多变,应根据患者情况制定个体化治疗方案;早期固定胸骨有助于维持脊柱的稳定性,有效预防或延缓脊柱侧弯等疾患的发生进展。     

冠心病搭桥术后胸骨裂开的防治(附5例报道)

目的 探讨冠心病搭桥术后胸骨裂开及其合并感染的诊断、治疗和预防。方法 未感染者及时再手术重新固定,合并感染者及时彻底清创、有效引流、牢固固定。结果 本组治愈率100％,伤口愈合时间平均10天(7～14天),1例除外。二次术后平均拔除引流管时间7.4天(2～20天)。结论 伤口局部的症状、体征、全身表现和X线胸片对诊断和治疗有重要意义。早发现、早诊断,及时重新固定,合并感染者及时彻底清创、有效引流、牢固固定是治疗成功的关键,可以有效缩短住院时间。重视胸骨裂开的预防,可减少其发生率。     

Primary sternal plating in high-risk patients prevents mediastinitis.

OBJECTIVE: Sternal wound infection leading to post-operative mediastinitis is a devastating complication of cardiac surgery carrying nearly a 15% mortality rate despite current treatment methods. Instability of bone fragments pre-disposes a patient to have non-union, mal-union and can subsequently lead to deep sternal wound infections progressing to mediastinitis. Rigid plate fixation has been utilized for acquired and surgically created fractures of virtually every bone in the body to prevent instability. However, the current standard for sternotomy closure remains the method of wire-circlage. Application of rigid plate fixation for sternal osteotomies affords greater stability of the sternum. We report on our preliminary experience with this technique in high-risk patients. METHODS: From July of 2000 to December 2001, rigid plate fixation was applied to 45 patients designated as having high risk for sternal dehiscence and subsequent mediastinitis. High risk was defined as patients having 3 or more established historical risk factors, including: COPD, Re-Operative Surgery, Renal Failure, Diabetes, Chronic Steroid Use, Morbid Obesity, Concurrent Infection and Acquired or Iatrogenic Immunosuppression. Intra-operative risk factors included off-midline sternotomy, osteoporosis, long cardio-pulmonary bypass runs (>2 h), transverse fractures of the sternum. Rigid plate fixation was performed using a combination of plates secured by bi-cortical screws, after the cardiac surgical procedure was complete and hemostasis was secured. RESULTS: Rigid plate fixation was performed on 26 males and 19 females. The average age of patients was 63 (43-88) years. The average follow-up was 15 weeks (range 8-41 weeks). While there were 4 peri-operative deaths unrelated to sternal closure: one from aspiration pneumonia (post-operative day 9), one from a pulmonary embolus (post-operative day 29), one from overwhelming sepsis from pre-existing endocarditis (post-operative day 15), and one for primary respiratory failure (post-operative day 12). All others healed successfully. One patient who had a sterile dehiscence subsequently underwent successful re-operative rigid fixation. Comparing the cohort of patients who received rigid plate fixation to a matched population of high-risk patients during a similar time period who received wire closure, revealed a significant difference in the incidence of post-operative mediastinitis. The wire closed group (n = 207) had 18 deaths unrelated to sternal closure and had 28 patients who developed mediastinitis (14.8%). The rigid plate fixation group had no mediastinitis (Fisher's exact test, P = 0.006). The total incidence of post-operative mediastinitis during the designated study period was 4.2%. CONCLUSION: Patients who benefited from sternal closure with rigid plate fixation showed a significant decrease in the incidence of post-operative mediastinitis when compared to similar population of patients whose sterna were closed with wire.     

Surgical fixation of sternal fractures: locked plate fixation by low-profile titanium plates—surgical safety through depth limited drilling

Purpose

Operative treatment of sternal fractures has become a matter of increasing interest. Anterior plating seems to be the most appropriate method for fixing sternal fractures. However, there are several concerns in relation to the operative procedure such as severe injuries to mediastinal organs, patient comfort and proper stabilisation, for example. This paper describes a safe method of anterior sternal plating using locked plate fixation with limited depth drilling.

Methods

Ten patients with sternal fractures were included in this cohort study and were treated by anterior plating using one or two plates in parallel through a median approach to the sternum. Follow up was performed after six weeks, 12 weeks and six months.

Results

Follow up revealed no serious complications. One patient suffered from postoperative wound seroma. No problems were caused by the plates.

Conclusions

Sternal plating using low profile locked titanium plates seems to be a safe and stable method with a high level of patient comfort.     

Aortic erosion during negative pressure therapy in a pediatric heart transplant recipient

A happy-ending "series of unfortunate events" is reported of the successful emergency treatment of an erosion of the ascending aorta during negative pressure sternal wound therapy for a relapse of Berlin Heart driveline infection in a pediatric transplant recipient. Several key issues related to assist device-related infections and negative pressure complications are discussed in this peculiar setting.     

The nuts and bolts of sternal dehiscence

An eight-year experience (11 patients) with the Knodt rod compression system for sternal reclosure is presented. The system provides a simple, rapid, and safe method for sternal fixation after dehiscence.     

Plattenosteosynthesen am distalen Unterarm

Operative treatment of distal radius fractures

Following the successful introduction of locking plate systems for the treatment of distal radius fractures, plating of distal forearm fractures has become a frequently used procedure of open reduction and internal fixation. However, hardware failures and loss of reduction remain a challenging problem. Recent trends in distal radius fracture fixation emphasize anatomic reduction and rigid fixation, thus, allowing early mobilization and return to functional activities, especially in many older patients. This, coupled with greater patient demands, has stimulated a closer look at fixation systems. Implant stability as well as its contact to the bone have well been studied, which has led to even more advanced and more stable locking plate systems. Multiple complex fractures and osteoporosis remain the Achilles’ heel of plating distal forearm fractures and should be placed into the focus of experimental and clinical research.

Complications

Using the biomechanical aspects of the fixed angle systems that are described in the first part of this paper, specific patterns of failure are highlighted and analyzed in the second part based on several case reports. The aim of this paper is to encourage surgeons to critically evaluate their own surgical procedures in order to minimize the number of avoidable complications, and not least to benefit the patients.     

Rigid fixation of the sternum using a new coupled titanium transverse plate fixation system

Restoration of sternal integrity after median sternotomy for cardiac interventions better ensures optimal postoperative pulmonary function and minimizes overall morbidity. Sternal dehiscence or nonunion mitigates against such a successful outcome. Under such circumstances, if enough viable and uninfected sternum remains, an anatomic reduction should be attempted. Rewiring usually proves unsuccessful, and rigid plate fixation is more rewarding. A new titanium sternal fixation system that permits transverse orientation of plates has been used in 4 patients who had sterile complete or imminent sternal dehiscence to allow eventual sternal union. The specific advantage of this new system is the presence of a releasing pin in the center of coupled plates to allow rapid chest reentry if required without the specific need for cumbersome plate removal. One patient had delayed removal of an infected plate after sternal union was achieved.     

Treatment of fractures of the femur with the Grosse-Kempf rod

Intramedullary rod placement provides excellent fixation for many fractures of the femur. It also carries a high union rate, a low infection rate, and a shortened hospital stay for the patient. Certain fractures of the femur are not suitable for fixation with a standard intramedullary and alone. Use of the Grosse-Kempf rod, with interlocking screws, allows for stable fixation for long oblique fractures, spiral fractures, comminuted fractures, segmental fractures, fractures with a butterfly fragment, and fractures located in the proximal or distal shaft of the femur. The Louisiana State University (LSU) Orthopedic experience in the use of the Grosse-Kempf rod is presented in this article. We have treated a total of 60 fractures of the femur in 58 patients with this fixation system. This series consists of 58 acute fractures, one established nonunion, and one established infected nonunion. All patients in the group of acute fractures and who have had adequate follow up and time have healed. This group consists of 29 healed fractures and four fractures which are healing, but have recently had the static screw removed. Eight patients were lost to follow up, two died of causes unrelated to the treatment, and 17 have been placed recently and have not had time to heal. There was one instance of wound infection in the acute fracture group, associated with the distal screws, but this has not required rod removal. The Grosse-Kempf rod provides the treating physician with another option in the treatment of fractures of the femur not suitable for use by the standard intramedullary rod. The procedure is difficult, but we have found it to be reliable in treatment of difficult fractures.     

Off-pump repair of a giant pseudoaneurysm of a distal saphenous vein bypass graft

Pseudoaneurysm of a saphenous vein bypass graft is a rare occurrence after coronary artery bypass grafting but may have lethal consequences. We treated a giant pseudoaneurysm of a saphenous vein graft to the right coronary artery in an 80-year-old male Jehovah's Witness who had undergone coronary artery bypass grafting 4 and a half years earlier. His history revealed a recurrent sternal wound infection. By using a venous patch to close the damaged graft, we were able to perform a successful surgical repair without the need for extracorporeal circulation.     

Management of supracondylar fractures of the femur with the GSH intramedullary nail: preliminary report

The GSH supracondylar nail is a closed section rigid intramedullary device that combines the biomechanical advantages of intramedullary fixation with the stability of rigid internal fixation for the management of supracondylar fractures of the femur. The use of this implant is indicated in the management of distal comminuted nonarticular fractures and fractures with intraarticular extension. Intramedullary fixation provides improved fracture stabilization in both elderly patients with osteoporotic metaphyseal bone and in younger patients with extensively comminuted fractures. The experience with the GSH supracondylar nail has shown that it provides better results than supracondylar plating for the stabilization of acute fractures or revision of failed internal fixation.