Healing process after rigid plate fixation of humeral shaft fractures revisited

Objective

The purpose of this study was to describe the radiological healing process after open reduction and internal fixation (ORIF) of humeral shaft fractures with plate.

Materials and methods

We reviewed the data of 53 consecutive patients who had undergone rigid plate fixation of OTA 12 A or B humeral shaft fracture. The mean age of the patients at the time of surgery was 39.4 (range 16–82). Quality of reduction and healing process was analysed on radiographs. Clinical symptom and disabilities of the arm, shoulder and hand (DASH) scores were recorded at follow-up visits.

Results

There were 28 compression and 25 neutralization platings. The mean gap size on the postoperative radiograph was 1.4 (range 0.1–6.1). 50 cases (94.3 %) healed, while three cases ended up with non-union. 28 (52.8 %) cases showed primary healing and 22 cases (41.5 %) showed secondary healing with callus bridging. Among the cases with secondary healing, callus formation with resorption was identified in 13 cases. The type of fracture, mode of compression and size of gap on radiographs after rigid plate fixation were found to be statistically significant factors for healing type (p = 0.026, 0.002, and <0.001, respectively). Three cases with non-union showed no improvement in DASH scores.

Conclusion

Both primary and secondary healing processes were observed after rigid plate fixation of OTA 12 A or B humeral shaft fractures. Our study revealed that size of gap, mode of compression, type of fracture could affect the type of healing, and that periosteal callus formation can occur after rigid plate fixation.     

Periprosthetic supracondylar femoral fractures following total knee arthroplasty: clinical comparison and related complications of the femur plate system and retrograde-inserted supracondylar nail

Background

The purpose of this study is to analyze the clinical results and related complications of the femur plate system (FP) and the retrograde-inserted supracondylar nail (RISN).

Materials and methods

The study included 42 cases of periprosthetic supracondylar femoral fractures (PSF) proximal to posterior stabilized total knee arthroplasty between 2005 and 2009. Twenty-four cases of PSF were treated with the FP, and the other 18 cases were treated with the RISN. This study cohort was divided into subgroups according to the AO classification. We retrospectively compared the clinical results between the FP and RISN group.

Results

There were no significant differences between the two groups in terms of time of clinical union (p = 0.649). In the subgroup analysis, the mean operation time was significantly different only in subgroup A1 (p = 0.03). Complications were seen in 29.2 % (7/24) of patients in the FP group and 27.8 % (5/18) in the RISN group. The age during the index TKA and fracture fixation was a significant risk (p = 0.008) factor for complications between the two groups. No significant differences were found in the other factors between the two groups. The p value for operative time (p = 0.223), immobilization period (p = 0.129), ROM (p = 0.573), KSS (p = 0.379), KSS functional scores (p = 0.310) and time to union (p = 0.649).

Conclusion

Clinical results did not differ according to the treatment methods used. Fixation method and fracture type did not cause an increase in the complication rate, but there was a trend toward higher non-union rates with the FP method and higher re-fracture rate with the RISN method. Noting the fact that only increasing age correlated with an increased complication rate, more careful attention should be paid to elderly patients in terms of both prevention and surgical care.

Level of evidence

Level III, therapeutic study.     

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.     

Internal fixation of humeral shaft fractures using minimally invasive plating: comparative study of two implants

Purpose

We compared the results of two types of implants, dynamic compression plates (DCPs) and locking compression plates (LCPs), applied to correct mid-distal third humeral shaft fractures using minimally invasive plating osteosynthesis (MIPO).

Methods

Data of 43 patients with mid-distal third humeral shaft fractures treated using MIPO were retrospectively analyzed. Patients were divided into two groups according to the implants applied: group A (n = 26), those whose fractures were fixed with 4.5-mm DCP, and group B (n = 17) fixed with 4.5-mm LCP or metaphyseal LCP. The outcomes of the two groups in terms of operative time, time of fracture union, occurrence of early and late postoperative complications, University of California—Los Angeles (UCLA) End-Result score and the Mayo Elbow Performance Index (MEPI) were compared.

Results

The mean operative time was 107.8 ± 33.1 min in group A and 91.2 ± 40.4 min in group B (p > 0.05). The mean time of fracture union was 16.77 ± 6.01 weeks in group A and 14.59 ± 5.73 weeks in group B (p > 0.05). Seven (26.9 %) patients had postoperative complications in group A and 3 (17.6 %) in group B (p > 0.05). The mean UCLA End-Result score in group A was 34.31 ± 1.26 points and 33.12 ± 2.76 points in group B (p > 0.05). The mean MEPI was 100.00 ± 0.00 points in group A and 97.35 ± 7.52 points in group B (p > 0.05).

Conclusions

In surgical stabilization of mid-distal humeral shaft fractures using MIPO, application of DCP or LCP resulted in good outcomes, there were no significant differences between the outcomes of these two types of implant.     

Prediction of outcome after humeral diaphyseal fracture

Purpose

The aim of this study is to examine the demographic factors, functional outcome and radiological data to predict the outcome of humeral diaphyseal fractures.

Methods

We performed a prospective study on a consecutive series of 110 patients of 16 years or over, who had sustained a humeral diaphyseal fracture. There were 42 males and 68 females, with an average age of 59 years (range 16-93 years). A total of 72% sustained low-energy injuries, and 89 patients (81%) were primarily treated non-operatively.Shoulder function was assessed using the Neer's and Constant's scores at 8 weeks, 3 months, 6 months and 1 year after injury. Muscle strength was determined isokinetically using a Biodex System 2 dynamometer. Non-union was defined as a failure to bridge at least three cortices and persistence of tenderness or mobility at the fracture site 16 weeks after fracture.

Results

Sixteen patients (17%) had non-union at 16 weeks, while 80 had achieved union and a further 14 were lost to follow-up. After stepwise multiple linear regression was performed to isolate independent factors affecting outcome, only the presence of a proximal diaphyseal fracture was found to predict non-union along with a poor Neer's score at 8 and 12 weeks. Poor Neer's scores could be predicted at 26 weeks by age (P < 0.05), previous stroke (P < 0.001) and non-union (P < 0.001). At 52 weeks both age (P < 0.01) and previous stroke (P < 0.01) were independently predictive of poorer Neer's scores. Malunion of any degree had no detectable effect on function.

Conclusions

Our results indicate that non-union of humeral diaphyseal fractures can be predicted in the presence of a proximal third fracture with a Neer's score of less than 45 by 12 weeks after fracture. Early surgery improves early function, but this is not a lasting effect. Poor shoulder function is predicted by increasing age, proximal third fractures and non-union. We recommend that surgery to promote union be considered at 12 weeks after fracture in fit patients with fractures of the proximal third of the humerus, poor Neer's scores and no radiographic progression to union.     

Position of polyaxial versus monoaxial screws in locked plating for proximal humeral fractures: analysis of a prospective randomized study

Background

Aim of the study was to compare the chosen position of polyaxial locking screws with the position of monoaxial screws in the humeral head of proximal humeral fractures treated by locked plating.

Methods

In a prospective randomized observational study, 124 consecutive patients (mean age 70.9 ± 14.8 years) sustaining a displaced proximal humeral fracture were treated with either monoaxial or polyaxial screw-inserted locking plate fixation. The chosen positions of locking screws were identified from standardized postoperative radiographs in anteroposterior and outlet-view, with regard to a regional mapping of the humeral head.

Results

In monoaxial locking technique, a mean of 6 screws purchased the humeral head (95 % CI 5.1–6.2), and in polyaxial locking technique, a mean of 4 screws (95 % CI 3.3–4.5), respectively. Screws were placed in the regions superolateral: monoaxial 24.8 %, polyaxial 20.7 % (p = 0.49); superomedial: monoaxial 21.9 %, polyaxial 20.0 % (p = 0.433); inferolateral: monoaxial 32.5 %, polyaxial 35.0 % (p = 0.354); inferomedial: monoaxial 20.8 %, polyaxial 24.2 % (p = 0.07), superoposterior: monoaxial 45.5 %, polyaxial 30.8 % (p = 0.57); superoanterior: monoaxial 4.4 %, polyaxial 8.3 % (p = 0.33); inferoposterior: monoaxial 22.5 %, polyaxial 29.8 % (p = 0.49) and inferoanterior: monoaxial 27.5 %, polyaxial: 31.2 % (p = 0.09).

Conclusion

The chosen screws’ position in monoaxial and polyaxial locking plate fixation of displaced proximal humeral fractures do not differ significantly. However, loss of fixation is observed more frequently if the fixation did not include at least one screw within the superoposterior region of the humeral head, suggesting that a screw purchasing the superoposterior region is beneficial in locked plating of proximal humeral fractures.

Level of evidence

Treatment Study, Level II.     

The effect of delayed treatment on clinical and radiological effects of anterior wedge grafting for non-union of scaphoid fractures

Introduction

The aim of the treatment of displaced scaphoid non-unions is the restoration of normal scaphoid anatomy. Restoration of normal scaphoid anatomy at an earlier stage might have functional benefits as maladaptive carpal ligament contractures and the development of preliminary osteoarthritis could be avoided. The purpose of this retrospective study was to determine if late reconstruction (delayed reconstruction group) was as effective as early reconstruction (early reconstruction group) of scaphoid non-union in restoring clinical and radiological outcome.

Patients and methods

The early reconstruction group included patients who underwent surgery between 6 and 12 months after the original fracture. This group consisted of 14 male and 2 female patients. The delayed reconstruction group included patients who underwent surgery 12 or more months after the original fracture. This group consisted of 9 male and 1 female patients. Average time from injury to surgery in the early reconstruction group was 10 months (range 6–12 months) and mean postoperative follow-up period averaged 58 months (range 19–72 months). Average time from injury to surgery in the delayed reconstruction group was 69 months (range 12–88 months) and mean postoperative follow-up period averaged 62 months (range 24–80 months). All patients showed a humpback deformity as well as a DISI deformity with the radiolunate angle being greater than 15°. The outcome was assessed on the basis of measurement of active wrist range of motion and grip power. Wrist pain was evaluated using a visual analogue scale. Functional subjective outcome was evaluated with the DASH and PRWE scores. Results were compared to preoperative measurements as well as to the uninjured contralateral side. Pre- and post-operative radiographs were assessed for scapholunate angle (SLA) as a measure of palmar rotation and radiolunate angle (RLA). The presence of DISI was defined by a difference of >60° for the SLA or of >10° for the RLA between the affected and unaffected wrist.

Results

In the early reconstruction group bone union and correction of DISI deformity could be achieved for all patients (n = 16). In the delayed reconstruction group bone union could only be achieved without correction of the DISI deformity in six patients (60 %). In four patients (40 %) of the delayed reconstruction group non-union persisted. For the early reconstruction group at final follow-up mean flexion–extension arc, mean ulnar–radial-deviation arc and mean grip strength were 82, 91.5 and 82 % of uninjured side, respectively. Mean pain level decreased from 6 points before surgery to 1 point at final follow-up. The preoperative DASH changed from 48 to 17 and the preoperative PRWE changed from 30 to 14. The SLA changed from 51° to 48° and the RLA from 18° to 9°. Six patients from delayed reconstruction group showed bone union, but no correction of DISI deformity at final follow-up. Functional and radiological results showed only slight improvement. The remaining four patients from delayed reconstruction group with a persistent non-union continued to experience pain, reduced grip strength and limited range of wrist movement and DISI deformity persisted.

Conclusion

In conclusion, wedge-shaped bone grafting of scaphoid non-union leads to increased functional scores as well as to improved carpal angles as long as bony union can be achieved. Remaining non-union and the inability to correct DISI deformity are severely correlated with an increased time frame between fracture and surgical treatment. Furthermore, the vascularization of the proximal fragment and patients’ smoking habits has to be taken into consideration preoperatively.     

Revision with plates of humeral nonunions secondary to failed intramedullary nailing

Purpose

The objective of this study was to evaluate the results achieved after revision with plates of humeral nonunions secondary to failed intramedullary nailing.

Methods

We retrospectively evaluated 32 patients with humeral nonunions secondary to failed intramedullary nailing, treated by internal fixation with plates between 1998 and 2012. Nonunions were diaphyseal in 19 cases, they were located in the proximal humeral metaphysis in nine cases, and in the distal humeral metaphysis in four cases. There were 11 atrophic nonunions and 21 oligotrophic nonunions. Initial treatment was performed with static locked nails in 12 cases, nails with expansive locking systems in 11 cases, and using thin elastic nails in nine cases. The nails were placed antegrade in 18 cases and retrograde in 14 cases. Time between initial surgery and revision surgery averaged 14.5 months. In seven diaphyseal nonunions, the intramedullary nail was left in-situ. Bone graft was added in 25 cases.

Results

Follow-up averaged 35 months. Union was achieved in all cases, after an average of 3.8 months. Disabilities of the Arm, Shoulder and Hand (DASH) score at last follow-up averaged 14 points, and Constant’s score averaged 82 points. The analogue scale of pain averaged 0.8 points. Out of seven patients with radial nerve compromise, six recovered completely and one needed tendon transfers.

Conclusions

Revision with plates after failed intramedullary humeral nailing achieved union and good predictable objective and subjective results in all cases. Adequate implant selection and meticulous surgical technique are necessary to achieve successful osteosynthesis and bony union.     

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.     

Three key factors affecting treatment results of low-intensity pulsed ultrasound for delayed unions and nonunions: instability, gap size, and atrophic nonunion

Background

If some predictable factors that affect the treatment results of low-intensity pulsed ultrasound (LIPUS) for delayed union or nonunion could be determined, these might provide us with suggestions for whether LIPUS should be used as an alternative treatment for surgery or an adjuvant therapy after surgery. Therefore, the objective of the present study was to determine what factors affected failure of fracture healing after LIPUS for delayed unions and nonunions.

Methods

A one-year observational retrospective cohort study was conducted with a consecutive cohort of 101 delayed unions and 50 nonunions after long bone fractures that were treated with LIPUS between May 1998 and April 2007. The main outcome measure was radiographic determination of osseous bone union status within one year after start of LIPUS therapy. Statistical evaluation was used to recognize predictable factors that affect treatment results of LIPUS for delayed union and nonunion.

Results

Delayed union group (n = 101): Seventy-five delayed unions (74.3 %) united without an additional major surgical intervention. Failure of LIPUS therapy was associated with types of nonunion (atrophic/oligotrophic vs. hypertrophic, relative risk 23.72 [95 % CI 1.20–11.5], p < 0.01), instability at fracture site (unstable vs. stable, relative risk 3.03 [95 % CI 1.67–5.49], p < 0.001), and maximum fracture gap size not less than 9 mm (relative risk 3.30 [95 % CI 1.68–6.45]). Nonunion group (n = 50): Thirty-four nonunions (68.0 %) united without an additional major surgical intervention. Failure of LIPUS therapy was associated with method of fixation (intramedullary nail vs. others, relative risk 4.50 [95 % CI 1.69–12.00], p < 0.001), instability at fracture site (unstable vs. stable, relative risk 4.56 [95 % CI 2.20–9.43], p < 0.0001), and maximum fracture gap size not less than 8 mm (relative risk 5.09 [95 % CI 1.65–15.67]).

Conclusions

LIPUS should be applied as an adjuvant therapy in combination with surgical intervention for an established atrophic nonunion with instability and/or with larger fracture gap.     

Does spinopelvic alignment affect the union status in thoracolumbar osteoporotic vertebral compression fracture?

Purpose

In the healing of osteoporotic vertebral fracture, global spinal mal-alignment might increase the load sharing at the fracture site and deteriorate the fracture healing. This study aimed to evaluate the effect of spinopelvic alignment on the union status of thoracolumbar osteoporosis-related vertebral compression fracture (OVCF).

Methods

Consecutive 48 patients with a single-level thoracolumbar fresh OVCF were treated non-operatively. Union was judged by three independent observers at 6 months, and patients were divided into union group and non-union group. Spinopelvic alignment was measured using upright whole spine radiograph before treatment as follows: pelvic incidence (PI), pelvic tilt (PT), lumbar lordosis (LL), thoracic kyphosis (TK), sagittal vertical axis (SVA), and DSVA, defined as the distance from a plumb line dropped from the center of the C7 body to the center of fractured vertebral body.

Result

Global spinal alignment was different in union group and non-union group: SVA (4.7 ± 0.7 cm in union group vs. 8.9 ± 1.3 cm in non-union group, P = 0.007), DSVA (4.2 ± 0.6 cm in union group vs. 9.5 ± 1.0 cm in non-union group, P < 0.001), and PI–LL (18.9° ± 2.2° in union group vs. 30.3° ± 3.9° in non-union group, P = 0.014). Over 5 cm of DSVA [P = 0.022, adjusted odds 7.9 (95 % CI 1.3–77.0)] and/or over 30° of PI–LL [P = 0.026, adjusted odds 6.6 (95 % CI 1.5–44.2)] showed the significant risk factors for non-union using multivariate logistic regression analysis in the other background status.

Conclusions

Global spinal mal-alignment, showing over 5 cm of DSVA and/or over 30° of PI–LL, affected the union status of OVCF.

     

Does timing of surgery affect the outcome of open articular distal humerus fractures

Background

Open intraarticular distal humerus fractures classified as Orthopaedic Trauma Association (OTA) 13 C may have devastating consequences for patient’s quality of life, especially if leading arm in younger active patient is involved. We conducted a study to determine whether the timing of open reduction and internal fixation of open intraarticular distal humerus fractures affects the outcomes.

Patients and methods

Multicentric prospective study: In the first group, there were 15 patients, 10 men and 5 women, mean age 38.7 years, operated in <6 h of injury. In the second group 17 patients, 11 men and 6 women, mean age 42.3 years operatively treated in delayed settings, mean delay to operation 4.6 days of injury. In both groups, patients had open distal humerus articular metaphyseal multifragmentary fractures classified as OTA 13.C2 or 13.C3. Functional outcome was assessed with Mayo elbow performance score and Disabilities of Arm and Shoulder and Hand (DASH). Mean Mayo elbow performance (MEP) score in the first group was 71 (range 30–100); in the second, mean MEP was 64.3 (range 25–100). The mean DASH in the first group was 27.89 (range from 1.7 to 75.8), and in the second, mean DASH score was 32.6 (range 5.8–77.5). There were no statistically significant differences between two groups, MEP t(28) = 0.935, p < 0.358; DASH t(28) = ?0.636, p < 0.530.

Conclusion

Our study shows that early open reduction and internal fixation of open distal articular humerus fractures reduces the hospital stay, but does not significantly affect the overall outcomes and complications.     

Vergleich von Versorgungszeitpunkt und verwendetem Implantat bei der endoprothetischen Versorgung von proximalen Humerusfrakturen und deren Folgezuständen

Background

The present study evaluated and compared the clinical results of endoprosthetic treatment of proximal humeral fractures and their sequelae in terms of implantation timing and extent of post-traumatic deformity.

Patients and methods

A total of 69 patients with a mean age of 73 years were enrolled in this retrospective study.Of the patients 37 with a non-reconstructable acute proximal humeral fracture were treated with a primary fracture prosthesis, 32 patients received a secondary prosthesis due to fracture sequelae while 14 patients were treated with an anatomical implant and 18 patients with a reverse prosthesis. The constant scores (CS) and DASH scores were analyzed after a mean follow-up of 29 months.

Results

The total group showed an age and gender-adapted constant score (agCS) of 71 % and a mean DASH score of 40 points. Between the groups (primary prosthesis fracture, anatomic prosthesis and reverse prosthesis) there were no significant differences in the scores; however, the distribution of results was heterogeneous in the group with a primary fracture prosthesis.

Conclusions

Basically, endoprosthetic treatment of proximal humeral fractures, both primary and secondary leads to satisfactory results. The disadvantage of any necessary second intervention in secondary care has to be compared to the lower predictability of the functional outcome in primary fracture prostheses.     

Effect of untreated triangular fibrocartilage complex (TFCC) tears on the clinical outcome of conservatively treated distal radius fractures

Objective

The purpose of this study was to investigate the effect of untreated triangular fibrocartilage complex (TFCC) tear on the clinical outcome of conservatively treated distal radius fractures.

Materials and methods

This prospective study comprised 47 consecutive patients who presented at our clinic between January 2009 and January 2010 with displaced radius distal fracture and were treated with closed reduction and casting. During the first 15 days of treatment, all patients underwent wrist MR imaging to detect traumatic TFCC tears. At the final follow-up, all patients were evaluated with Mayo wrist function score and wrist radiographs. Patients were divided into two groups according to presence of TFCC tear, and two groups were analyzed statistically.

Results

The mean follow-up period was 38.9 ± 3.5 months (range 36–48). TFCC tear was detected in 24 cases, and remaining 23 cases had no TFCC tear. Both groups were statistically similar regarding age (p = 0.574), gender (p = 0.108), dominant side involvement (p = 0.339), fracture type (p = 0.709) and immobilization period (p = 0.514). According to Mayo wrist score, excellent results were obtained in 21 (44.7 %) cases, good in 16 (34.0 %) and satisfactory in 10 (21.3 %). No significant difference was observed between groups in wrist function scores (p = 0.451). Radiographic measurements were similar between groups (radial length p = 0.835, volar til p = 0.464, radial inclination p = 0.795).

Conclusions

Traumatic TFCC tears which are frequently seen together with distal radius fractures do not affect the long-term functional results. Therefore, further diagnostic tests and treatment of TFCC tears in patients with stable distal radius fractures may be unnecessary. However, it should be borne in mind as a reason for continuing wrist pain and instability after distal radius fractures despite proper radiologic recovery.     

Histopathological, radiological and clinical aspects of the temporal assignment of scaphoid non-union

Objective

The aim of this study was to evaluate the correlation between clinical, radiological and histopathological signs of scaphoid non-unions (SNU) with regard to the age of the fracture, primarily because this is relevant for therapy and compensation claims.

Materials and methods

Thirty-eight patients with SNU underwent clinical and radiological examination of the wrist prior to surgery. Preoperative X-rays of the wrist were analysed using the scores of Herbert and Fisher, Filan and Herbert, Trojan and Jahna, Gupta as well as scaphoid non-union advanced collapse. Sclerotic bone of the SNU was resected during surgery. Resected material was evaluated histologically after staining with hematoxylin–eosin and periodic acid-Schiff reaction. Radiological and histological examinations were performed by independent investigators in a blinded fashion.

Results

The preoperative range of motion of the injured compared to the contralateral wrist was significantly reduced for the dorsi- and palmar flexion and for the radial and ulnar deviation; however, this reduction was not time dependent. There was no significant correlation between the radiological results and the age of the SNU, while fibrous tissue or fibrocartilage in the fracture gap was present in all cases. Significantly less fibrous or fibrocartilage bone cysts (p = 0.041) and bone remodelling (p = 0.031) were seen in older SNU (at 45 months). Definitive sclerotic bone covering of the fracture edges was significantly more common in older SNU (p = 0.035).

Conclusion

Radiological and most of the conventional histological findings do not correlate with time after initial injury.     

Ergebnisse der multidirektional-winkelstabilen Versorgung distaler Humerusfrakturen

Background

The treatment of patients with distal humeral fractures and reduced bone quality or complex fracture patterns is still complicated. Using angular stable implants should lead to better functional results.

Objective

The clinical and functional results were analyzed as well as the complications after treatment of patients with distal humeral fractures using angular stable plate osteosynthesis.

Material and methods

A questionnaire was sent to patients treated in our hospital for distal humeral fractures and they were invited for a follow-up examination. We investigated the DASH (Disability of the Arm, Shoulder and Head) score, Mayo Elbow Performance Score (MEPS) and EQ-5D-3?L for evaluation of functional results, as well as the VAS (“visuelle Analogskala”) score for evaluation of pain. Using radiographs the fracture patterns were classified and interpreted for complications.

Results

A total of 28 patients returned the questionnaire after a minimum of 6 months following the operation and 10 attended a follow-up examination in our clinic. The DASH score was 38.40 and the MEPS 72.31. The results for 15 patients were good to excellent. The EQ-5D-3?L was 0.790 and the VAS 2.76. We found a significant correlation between the DASH score and patient age (p = 0.028), as well as an inverse correlation of the DASH score and the EQ-5D-3?L (p < 0.001). The complication rate was 53.6%. The three biggest groups of complications were neuronal complications, healing disorders and problems with the osteosynthesis material.

Discussion

The treatment results showing that unsatisfactory results are possible even if angular stable plates are used. An inferior functional result as assessed by the DASH score reduces the quality of life measured by EQ-5D-3?L. A follow-up after 6 months appears to be sufficient to assess the outcome after complicated distal humeral fractures.

     

A prospective comparative study of pin site infection in pediatric supracondylar humeral fractures: daily pin care vs. no pin care

Introduction

Pin site infection is a critical issue for patients’ safety in skeletal fixation using percutaneous pins or wires. Closed reduction and percutaneous Kirschner wires fixation are the mainstay of treatment in pediatric supracondylar humeral fractures. Little information is available in the literature about the optimal regimen of pin site care in children.

Materials and methods

We performed a prospective comparative study of 61 children with supracondylar humeral fractures between June 2011 and March 2013 after approval by the institutional review board. They were allocated into two groups of different postoperative pin site care methods by the emergency department arrival date and received fracture fixation within 24 h. Postoperatively, 30 children underwent pin site cleaning every day whereas the other 31 patients did not have the pin sites cleaned until the pins removal 4–6 weeks later.

Results

Demographic data were not significantly different between the two groups. The infection rate was significantly higher in patients who underwent daily pin site care (90.3 vs. 53.3 %, p = 0.001). Of the 144 pin sites, infection occurred at 42 (57.5 %) pin sites in the daily care group and at 19 (26.8 %) pin sites in the non-care group. The number of telephone consultations for postoperative care was significantly higher in the daily care group (1.0 vs. 0.27 call/case, p = 0.007).

Conclusions

Daily pin site care was associated with a higher infection rate and greater stress in postoperative care that required more telephone consultations. The study results could not support daily pin site care. Careful observation of pin sites was recommended in the treatment of pediatric supracondylar humeral fractures.     

Distal medial tibial locking plate for fixation of extraarticular distal humeral fractures; an alternative choice for fixation

Objective

The aim of this study was to describe an alternative fixation method for distal humeral extra-articular fractures through posterior approach using distal tibia anatomic locking plate; and to evaluate the patient's functional outcome and union condition.

The clinical outcomes of extracorporeal irradiated and re-implanted cemented autologous bone graft of femoral diaphysis after tumour resection

Purpose

We report the outcome of intercalary resection of the femoral diaphysis and extracorporeal irradiated autologous bone graft reconstruction, without the use of vascularized fibular graft.

Methods

Six patients with Ewing sarcoma of the mid-shaft femur who were treated by limb sparing tumour resection and reconstruction with extracorporeal irradiated autologous bone graft with intramedullary cement between 2002 and 2010 were studied.

Results

Mean age at the time of surgery was ten years (range, four–23). The length of resected femoral bone averaged 23 cm (15–32 cm). The ratio of bone resection length to total femoral length averaged 60 % (56–66 %). The patients had been followed up for between 16 and 79 months (mean, 41 months) at the time of the study. There was no infection nor fracture in this series. Primary union of the distal and proximal osteotomy sites was achieved in three patients. Delayed union of the proximal osteotomy site occurred in one patient that was successfully treated with iliac crest bone grafting. One patient developed non-union at the distal osteotomy site which failed to heal with bone grafting and was therefore converted to endoprosthetic replacement, and another patient was converted to rotationplasty at five months post-surgery because of contaminated margins. Function was excellent in all patients with surviving re-implanted bone. Local recurrence arose in one patient.

Conclusion

Our experience suggests that cement augmentation of extracorporeal irradiated and re-implanted bone autografts offer a useful method of reconstructing large femoral diaphyseal bone defects after excision of primary malignant bone tumours.