Sekundäre Rekonstruktion des digitalen A2-Ringbands

Objective

Secondary reconstruction of A2 flexor pulley for after closed rupture.

Indications

Persisting impairment of finger function and strength after combined injury of A2 and C1 pulley. Passive free movement of all finger joints.

Contraindications

Fixed flexion contractures of interphalangeal joints after complex finger injuries. Degenerative arthrosis of interphalangeal joints.

Surgical technique

A strip of extensor retinaculum approximately 10 mm in width together with the periosteum from the second floor of the extensor tunnel was used for reconstruction of the A2 pulley. After drilling bilateral burr holes in the palmar aspect of the phalanx at the distal and proximal ends of the A2 pulley, the graft was fixed by the periosteum to the bone of the phalanx, placing the synovial layer innermost.

Postoperative management

Postoperatively, patients in both treatment groups wore a palmar splint which extended from the distal interphalangeal joint to the proximal palmar crease for 4 weeks. The metacarpophalangeal joint and the proximal interphalangeal joint were held in full extension. After removing the splint, physiotherapy was started. Full load-bearing, hard manual work and sport activities were not permitted for 3 months.

Results

Fifteen patients were treated using the extensor retinaculum for reconstruction of the A2 flexor pulley. The mean follow-up time was 48 months. The average range of motion of the PIP joint was 97?%, the average power grip strength 96?%, the finger pinch strength 100?%, and the average circumference 95?% of the uninjured contralateral side. The Buck–Gramcko score showed the following results: 10 excellent, 2 good, and 1 fair.     

Arthrodese der Mittel- und Endgelenke der Kleinzehen

Objective

Elimination of the fixed lesser toe deformity by arthrodesis of the proximal or distal interphalangeal joints (PIP and DIP, respectively).

Indications

Painful fixed deformity. PIP joint: fixed hammer toe or clawtoe. DIP joint: fixed mallet toe. Relative indication: flexible hammer toe, clawtoe or mallet toe.

Contraindications

General operative contraindications. Relative contraindications also include severe deformities affecting the metatarsophalangeal (MTP) joint, for which the arthrodesis should combine an operative procedure of the MTP joint.

Surgical techniques

PIP arthrodesis: Dorsal incision centered over the PIP joint, exposure of the PIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles, resection of the head of the proximal phalanx and the articular surface of the middle phalanx. The arthrodesis should be stabilised in mild plantar flexion. The tip of the toe should have contact with the surface when the push up test is done. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed. DIP arthrodesis: dorsal incision centered over the DIP joint, exposure of the DIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles. Resection of the head of the middle phalanx and the articular surface of the distal phalanx. The arthrodesis should be stabilised in straight position. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed.

Postoperative management

Postoperative full weight bearing for 3–6 weeks, depending on the arthrodesis technique used.

Results

Stabilisation of the toe with adequate alignment is achieved by arthrodesis of the affected joint. In general, digital fusion of the fixed lesser toe pathology shows a high subjective satisfaction rate among the patients, although the rate of pseudarthrosis in attempted PIP or DIP arthrodesis is quite high. Major reasons for postoperative dissatisfaction were swelling, wound necrosis, pin infection, floating toe, shortening and angulation of the toe.     

A novel closed reduction with extension block and flexion block using Kirschner wires and microscrew fixation for mallet fractures

Background

Some patients with mallet fractures who undergo extension block pinning complain of exposed wires, which delay their return to sports and causes inconvenience while performing tasks that require the use of hands during the early postoperative period. The purpose of this retrospective study was to present and evaluate a novel surgical procedure for mallet fractures.

Methods

We treated 20 patients (14 males and six females; mean age, 38.4 years; range 17–68 years) with displaced mallet fractures involving >30 % of the articular surface using the closed reduction and microscrew fixation between January 2009 and January 2012. The distal interphalangeal joint (DIP) joint was immobilized with a splint for 1–3 weeks on an individual case basis. According to Wehbe and Schneider’s classification, there were 12 type IB, six type IIB, and two type IA fractures. The mean follow-up duration was 12.6 months (range 6–31 months).

Results

Bone union was achieved in all patients within a mean period of 6.8 weeks, with no incidence of infection, skin necrosis, permanent nail deformity, or secondary osteoarthritis. Only two complications—temporary nail ridging in one patient and a dorsal bump caused by the screw in one patient—were observed. Minimum postoperative displacement was observed in one patient, for whom immobilization with a splint was continued for 4 weeks. Articular incongruity was <1.0 mm in four patients and 1.0–2.0 mm in two patients. Mean DIP joint extension loss was 6.5° and mean flexion was 67.8°. The surgical outcomes were excellent in seven patients, good in nine, and fair in four according to Crawford’s evaluation criteria.

Conclusion

Our novel surgical procedure combining closed reduction with extension block and flexion block using Kirschner wires and microscrew fixation produces good clinical results with relatively few complications.     

Minimal-invasive Plattenosteosynthese am distalen Tibiaschaft

Objective

Minimally invasive plate osteosynthesis of distal metaphyseal and/or diaphyseal tibial fractures.

Indications

Extraarticular tibial fractures or distal tibial fractures with simple intraarticular components (AO 42 A–C + AO 43 A, C1, C2) of the distal tibia shaft. Closed or open soft tissue conditions, most suitable for closed soft tissue damage Oestern–Tscherne grade I–II.

Contraindications

High degree open fractures, where the plate would not be covered by soft tissue. Comminuted Pilon fractures.

Surgical technique

Closed reduction manually, over the plate or the external fixator/large distractor. Short incision on the medial malleolus. Epiperosteal insertion of the plate anteromedial. Improve reduction stepwise and insertion of screws on each main fragment. Relative stability is achieved by using bridging techniques. Fibula fixation in special cases.

Postoperative management

Mobilization after 1–3?days with toe-touch weight bearing. Full weight bearing after 8–10?weeks. Implant removal optional after 1–2?years in cases of soft tissue irritation.

Results

Uneventful healing with good function was observed in 85% of patients within 4?months. Delayed unions were observed in 5–10% of cases and nonunions or malalignment were observed in 5% of patients. All patients were satisfied with function at the 2-year follow-up.     

The Meniscus Arrow® as a fixation device for the treatment of mallet fractures: results of 50 cases

Background

The treatment of mallet fractures is a controversial and challenging problem. Generally, mallet fractures are treated conservatively except those involving more than one third of the base of the distal phalanx. Many different surgical fixation techniques have been published. This paper describes a new fixation procedure using ultimate bioresorbable meniscal fixation nails (Meniscus Arrows®).

Methods

Mallet fractures in 50 digits of 49 patients were fixed with this nail in an outpatient surgical procedure, mostly under local (Oberst-block) anaesthesia. The average operation time was 21 min.

Results

According to the Crawford criteria, patient outcome was graded as excellent in 48 %, good in 22 %, and fair in 28 %. In one patient, the outcome was graded as poor, but the fracture was in a pre-existent arthritic joint. All fractures were consolidated without recurrent dislocation. Complications included one wound infection, which was successfully treated with antibiotics and without further consequences. No nail deformities occurred. Two times, the nail spontaneously and gradually dislocated during intensive use of the hand after, respectively, 3 and 6 months and could easily be removed under local anaesthesia without any functional sequelae.

Conclusion

The bioresorbable meniscal nail fixation technique provides a fast and successful surgical treatment for mallet fractures with a minimum of adverse events.     

Versorgung von Fingerfrakturen mit der Minihakenplatte

Background

Fixation of the small bony fragments of the phalanges is often difficult. In this study a clinical and radiological evaluation was carried out after operative treatment using the mini-hook plate.

Patients and methods

Between 2003 and 2006 a total of 36 fractures were treated operatively using the mini-hook plate. Of the patients 24 had an basal avulsion fracture of the distal phalanx and 11 patients (12 fractures) had other bony avulsion fractures of the phalanges. The patients were evaluated clinically and radiologically as well as using the disabilities of the arm, shoulder and hand (DASH) questionnaire.

Results

A total of 29 patients with 30 fractures were examined. The mean follow-up was 13.6 months. The mean range of motion in the affected finger joint was 60.3?° and the mean DASH score was 2.8 points. Postoperatively five nail growth defects, one infection and one secondary dislocation of the implant were observed.

Conclusion

Using the mini-hook plate, preservation of the joint and stable internal fixation with no need for temporary arthrodesis is possible; however, prerequisites are experience and skill of the surgeon with a difficult surgical technique.     

Outcomes Following Operative Treatment of Adolescent Mallet Fractures

Background

Many surgeons advocate for surgical intervention of adult mallet fractures that involve either subluxation of the distal interphalangeal (DIP) joint or those that involve more than one-third of the articular surface. However, the efficacy of operative treatment and complication rates are unclear regarding the adolescent population.

Questions/Purposes

The goal of this study is to evaluate the clinical outcomes following operative fixation of bony mallet fractures in the adolescent population.

Methods

Seventeen patients with bony mallet fractures treated surgically were retrospectively reviewed. Twelve patients were treated by closed reduction with extension block pinning. The other patients underwent an open reduction and pin fixation. The average age was 15.2 years (13–18). Most injuries were sport related. The average time from injury to presentation was 17 days and from injury to surgery was 24.5 days. Nine patients had subluxation at the DIP joint and all involved at least one-third of the articular surface.

Results

The average time from surgery to pin removal was 28 days (19–46). All distal phalanx physis were closed or nearly closed. One patient reported pain at the final follow-up. Two patients (11.8%) had major complications. One had an extension contracture postoperatively, did not attend therapy, and re-fractured 5 months later requiring reoperation. The second was treated delayed (32 days) and lost fixation, requiring revision surgery and antibiotics for a superficial infection. Two patients with delayed treatment (32 and 44 days) had an extensor lag (11.8%).

Conclusions

Operative treatment of mallet fractures with subluxation or involving more than one-third of the articular surface appears effective. Pin removal 4 weeks postoperatively appears adequate. Complications occurred with delayed presentation and non-compliance.

     

Minimal-invasive Plattenosteosynthese des distalen Femurs

Objective

Minimally invasive stabilization of articular and extra-articular fractures of the distal femur with anatomically preshaped, locking compression plates.

Indications

Distal extra-articular femoral fractures. Distal periprosthetic or periosteosynthetic femoral fractures. Multifragmentary articular fractures of the distal femur.

Contraindications

Local soft tissue infection or osteitis.

Surgical technique

Patient in a supine position on a radiolucent table with both legs draped free. Fractured leg supported with a towel to release traction of the gastrocnemius muscles onto the distal fragment. Reduction and fixation of articular fractures with 3.5?mm lag screws. Indirect reduction of the metaphyseal fracture component and temporary fixation with different instruments (e.g. cerclage) or reduction to the plate with special tools (e.g. collinear reduction clamp). Submuscular epiperiosteal introduction of the plate. Plate fixation through the aiming device. Intraoperative image intensification control to check plate position and reduction with special emphasis on rotation and longitudinal axes.

Postoperative management

Continuous passive motion without range limitations from day 1. Mobilization on crutches with toe-to-tip weight bearing during the first 6 weeks. No full weight loading until osseous consolidation.

Results

Between January 2009 and November 2011, minimally invasive plate osteosynthesis using the minimally invasive cerclage passer or the collinear reduction clamp was performed in 21 patients with 23 distal femoral fractures. None of the patients suffered from postoperative malalignment or malrotation. Mean time to adequate fracture consolidation was 128 days (range 53–470 days).     

Die Versorgung der distalen Radiusfraktur

Background

How effective is open reduction and internal fixation with palmar locking plates compared to closed reduction and internal fixation with K-wires in the treatment of fractures of the distal radius?

Method and materials

A systematic review of the literature was performed for the years 2002 to 2012 to find controlled studies comparing K-wires and locking palmar plates. Follow-up, complications, functional results, radiographic results and peculiarities of the studies were analyzed.

Results

A total of five controlled studies could be found and additionally the data of one unpublished controlled prospective study were added. In two studies a better function (DASH) could be achieved following palmar locking plate osteosynthesis, in one study better results were found following K-wire osteosynthesis and three studies found no significant differences. Ulna variation was found to be better restored following palmar locking plate osteosynthesis in two, palmar inclination in two and radioulnar inclination in one study. There were 7.3% complications following palmar locking plate osteosynthesis compared to 20% following K-wire fixation; however, the complications following plate osteosynthesis were more severe.

Conclusions

Palmar locking plates as well as K-wire fixation are suitable techniques for the treatment of fractures of the distal radius. The higher stability of locking plates seems to lead to an earlier functional recovery but this possible advantage disappears in the long-term follow-up.     

Conservative treatment of the distal radius fracture using thermoplastic splint: pilot study results

Introduction

Fractures of the distal radius are common accounting for approximately one-sixth of all fractures treated in the emergency room. This study reviews a series of patients with stable distal radius fractures who have been treated with thermoplastic splint.

Methods

This study was undertaken between November 2009 and May 2010 in a single orthopaedic fracture outpatient clinic. All patients had undisplaced or minimally displaced distal radius fractures. Children and open fractures were excluded. Patients had been reviewed in the outpatients with radiographs on 1, 2, 6 and 12 weeks after injury. Skin condition and satisfaction were assessed on splint removal. Radiological parameters of radial inclination, radial length and palmer tilt were measured.

Results

In total, 26 patients were treated with the splint. The average age of the patients was 45.1 (range, 21–73), and male/female ratio was 12:14. On average, the splint was removed at 5.1 weeks (mode = 6 weeks). The right- to left-side ratio was 11:15. Eleven of those fractures were on the dominant side. There was no significant difference in the radiological outcomes pre- and post-splinting. Nearly all patients had been satisfied with the splint. Two patients had minor cast complications whilst 23 patients were able to shower whilst in splint.

Conclusion

Patients treated with thermoplastic splint showed no deterioration in their radiological outcomes. Nearly all the patients had been satisfied with the splint.     

The use of T-LCP (locking compression plate) for the treatment of the lateral malleolar fractures

Background

The authors evaluated results and hardware-related complications after the fixation of Danis-Weber (D-W) types A and B lateral malleolus fractures using a 3.5-mm T-shaped locking compression plate (T-LCP) for distal radius.

Methods

Twenty-six patients with Danis-Weber type A or B lateral malleolar fractures treated between January 2001 and February 2008 were included in this study. Mean age of the patients was 52.6 (28–77) years. All patients were treated using a 3.5-mm T-shaped locking plate for distal radius fractures. The distal fragment was fixed with at least 2 locking screws more. Ankle motion was allowed early after surgery. The authors evaluated serial radiographs, range of motion, skin irritation, and AOFAS scores at final follow-ups.

Results

All fractures united during follow-up. Eight cases were of D-W type A, and 18 were of D-W type B. A mean number of three screws were placed at the distal fragment (2–4). There were 6 cases (23.1%) of implant irritation over the operative site, but no other complications were encountered. At final follow-ups, the AOFAS score of affected ankles was 97.1 ± 4.4.

Conclusion

T-LCP use for type A or B lateral malleolar fractures resulted in low hardware-related complications and produced good results at follow-up.     

Ergebnisse der konservativen Therapie beim frischen und alten ligamentären Mallet-Finger

Background

In the treatment of the acute ligamentous mallet finger, conservative therapy with a Stack or Winterstein splint is an established approach, though there are many different conservative therapy regimes. There are even more therapy options for the chronic mallet finger (more than 4 weeks old) including different operation techniques.

Material and methods

In a retrospective study, 44 patients with an acute and 33 patients with a chronic ligamentous mallet finger treated with a Stack or Winterstein splint were investigated.

Results

The results in both groups are satisfactory (SD <10°: 70.5% in the acute, 87.9% in the chronic lesions). The subjective satisfaction (scale 1–6) was high in both groups. It was even significantly higher in the group with the chronic lesions (acute: 2.55±1.63, chronic: 1.82±1.38). In both groups there was no correlation between an initially high extension deficit and a bad therapy outcome.

Conclusions

Also in chronic ligamentous mallet finger, conservative therapy should be attempted before an operation, irrespective of the initial extension deficit, especially because the stress and the therapy risk for the patient with this therapy is small.     

Curvatures of the DIP joints of the hand

Background

The distal interphalangeal (DIP) joints of the hand are highly susceptible to osteoarthritis and trauma. Surgical treatment options mandate accurate characterization of their osseous anatomy; however, there are few studies that describe this. We describe the curvatures of the DIP joints by measuring the bone morphology using advanced imaging and modeling methods.

Methods

The fingers of 16 right hand fresh frozen human cadavers were analyzed. Fingers showing signs of DIP joint arthritis were excluded. The fingers were scanned using microtomography (microCT). Measurements of the bony morphology were made using models created from the scans.

Results

In each finger, there is no statistically significant difference between the radii of curvature of the ulnar and radial condyles of the middle phalanx head. Conversely, the radius of curvature of the distal phalanx ulnar groove is significantly greater than that of the radial groove. The radii of curvature of the groove of the distal phalanx and the condyles of the middle phalanx displayed nonconformity with disparity increasing from the index to small fingers. Remarkably, the radius of curvature of the distal phalanx central ridge and the mean radius of the middle phalanx condyles are essentially the same.

Conclusion

The purpose of this study is to gain better insight into the DIP joints of the hand. The asymmetry between the distal phalanx grooves and the middle phalanx condyles suggests that there may be a translational component to DIP joint motion. Our understanding of morphology may lend insight into the biomechanics and disease progression within the DIP joints.     

Die Fraktur der Gegenkortikalis bei der aufklappenden Osteotomie des Tibiakopfes

Background

Open wedge high tibial osteotomy (HTO) is an increasingly more common surgical method. A typical problem of this procedure is fracture of the lateral hinge.

Objectives

The aims of this article are to present the special issue of fractures of the lateral hinge after HTO and to discuss surgical hints on how to prevent and treat this problem.

Methods

The results of recently published clinical studies are summarized and tips from own clinical experiences are given.

Results

Type II fractures of the lateral hinge are unstable and can create a major problem. Using short spacer plates results in a problem of stability for all types of fractures.

Conclusion

The classification into Takeuchi grades I-III has been proven to be suitable for fractures of the lateral hinge. The TomoFix? plate is a safe implant to stabilize the osteotomy in type I and III fractures with which healing can be achieved with no problems. Type II fractures can be stabilized with the TomoFix? plate; however, an autologous bone graft has to be taken into consideration. For fractures of the lateral hinge short spacer plates are not recommended due to stability issues.     

Plate fixation of proximal humerus fractures using the minimally invasive anterolateral delta split approach

Objective

Minimally invasive plate osteosynthesis of proximal humerus fractures via an anterolateral delta split approach.

Indications

All proximal humerus fractures classified as 11-A1-3, 11-B1-2 (B3), and 11-C1-2 (C3) according to the AO/OTA system.

Contraindications

Head split and closed irreducible dislocation type fractures, fractures with primary neurovascular impairment, and fractures in children with open growth plate.

Surgical technique

Beach chair position. Anterolateral delta split approach. Maintain rotator cuff insertions with nonabsorbable sutures. Reduction and K-wire retention of the tuberosities to the head fragment. Establish a tunnel along the anterolateral aspect of the proximal humerus with a blunt instrument (e.g., elevatorium). Attachment of the rotator cuff sutures to the corresponding plate holes of a 5-hole PHILOS? plate. Insertion of the plate underneath the deltoid muscle along the prepared tunnel. Preliminary fixation of the plate to the humerus head. Distal alignment of the plate and preliminary fixation. Reduction of the fracture onto the plate with a cortical screw in the shaft segment. Definitive plate fixation in the shaft and head segment. The nonabsorbable sutures are then tightened onto the plate.

Postoperative management

Immediate guided active exercise is encouraged. Weight bearing is increased according to radiological signs of consolidation.

Results

In a prospective evaluation from 2003?C2006, 29?patients (8?male and 21?female) with a mean age of 64?years (16?C91?years) were analyzed. The mean follow-up time was 12?months (6?C32?months). The operation was accomplished in 75?min (55?C155?min) with an image intensifier time of 160?s (48?C807?s). All fractures healed in a timely manner. The median Constant score reached 78?points (28?C93?points). In one case (3%), clinical evidence of a lesion of the anterior branch of the axillary nerve was found.     

Wiederherstellung der Daumenendgelenkbeugung durch Transposition der oberflächlichen Beugesehne des Ringfingers

Objective

Restoration of active thumb flexion at the distal joint.

Indications

Loss of active flexion of the interphalangeal (IP) joint of the thumb if there is a transection of the flexor pollicis longus (FPL) tendon at the tendon channel of the thumb or thenar and direct suture is not possible but the tendon channel is intact, as alternative procedure to a free tendon graft if the transection is proximal to the tendon channel and the muscle of the FPL is contracted/injured or the FPL tendon is unharmed but the FPL muscle is partially or complete paralyzed.

Contraindications

Insufficiency of the FPL tendon channel, impairment of the superficial or deep flexor tendon of the ring finger, limited passive motion of the proximal and distal thumb joints, acute local general infection and non-compliance or incapacity of the patient.

Surgical technique

The surgical technique depends on the necessity of transosseous refixation of the FDS IV at the base of the distal phalanx of the thumb or the possibility of woven sutures through the FPL proximal to the tendon channel. If the tendon channel is intact the distal part of the FPL tendon is shortened to 1 cm, the FDS IV tendon is cut distal to the chiasma of Camper, pulled through the carpal tunnel and moved into the channel of the FPL tendon and fixed transosseously through the base of the distal phalanx of the thumb. If the transection of the FPL tendon is located proximal to the tendon channel and muscle of the FPL is injured, FDS IV tendon will be woven using the Pulvertaft technique through the FPL tendon at the distal forearm.

Postoperative management

Postoperative 6 weeks motion of thumb flexion without resistance in relieved position of the thumb through a thermoplast splint and 6 weeks of functional use of the hand with increasing weight bearing.

Results

In this study 10 patients with FDS IV transposition to reconstruct an isolated rupture of the FPL tendon could be followed for an average of 4.1 years postoperatively. The active range of motion of the IP joint of the thumb averaged 65° (10–100°), 8/10 patients achieved an equal active and passive range of motion of the IP joint of the thumb, in 2 patients some flexion insufficiency remained, 9 patients could reach the fingertip of the small finger with the thumb and 1 patient lacked 3 mm. Contracture of the proximal thumb joint developed in two patients. After removal of the FDS IV tendon two patients developed contracture of the PIP joint of the ring finger. The grip force was reduced to 81?%, lateral grip to 83?% and pinch grip to 77?%. The DASH score averaged 18 (0–31) and 8/10 patients would choose to undergo this surgery again.     

Treatment of proximal and middle one-third humeral fractures with lateral distal tibial helical plate

Objective

To evaluate the outcomes of treating patients with proximal and middle one-third humeral fractures treated with lateral distal tibial helical plate.

Materials and methods

From June 2004 to January 2009, 12 patients (8 men, 4 women: average age: 46.8?years, range: 25–63) with proximal and middle one-third humeral fractures were treated with open reduction and internal fixation using lateral distal tibial helical plate. Standard anterior–posterior and lateral radiographs were obtained and evaluated. Shoulder function was assessed according to the Constant–Murley score.

Results

At follow-up (average: 18?months), all fractures had healed (average: 15?weeks, range: 9–23). There were no cases of intraoperative complications, implant failures, infections, or iatrogenic intra- or post-operative nerve lesions. All patients achieved at least 100° of abduction by 3?months post-surgery and full range of movement by 12?months post-surgery, with the exception of one patient who had an impingement symptom with moderate loss of abduction and external rotation. The average Constant–Murley score was 88 points at 12-month follow-up. According to Constant–Murley score, 28% of patients had excellent functional outcome, 64% had good outcome, 8% had moderate outcome, and none had failure. According to self-reporting, all patients had returned to the pre-injury level of activity.

Conclusions

The lateral distal tibial helical plate promotes bone healing and minimizes the damage to the deltoid muscle insertion region, thereby facilitating rapid and good functional recovery. In addition, the helical plate design avoids affecting sliding of the biceps tendon and maintains good reduction position. The lateral distal tibial helical plate is an effective surgical option for proximal and middle one-third humeral fractures.     

Minimally invasive periprosthetic plate osteosynthesis using the locking attachment plate

Objective

Stable fixation of periprosthetic or periimplant fractures with an angular stable plate and early weight bearing as tolerated.

Indications

Periprosthetic femur fractures around the hip, Vancouver type B1 or C. Periprosthetic femur and tibia fractures around the knee. Periprosthetic fractures of the humerus. Periimplant fractures after intramedullary nailing.

Contraindications

Loosening of prosthesis. Local infection. Osteitis.

Surgical technique

Preoperative planning is recommended. After minimally invasive fracture reduction and preliminary fixation, submuscular insertion of a large fragment femoral titanium plate or a distal femur plate. The plate is fixed with locking head screws and/or regular cortical screws where possible. If stability is insufficient, one or two locking attachment plates (LAP) are mounted to the femoral plate around the stem of the prosthesis. After fixing the LAP to one of the locking holes of the femoral plate, 3.5 mm screws are used to connect the LAP to the cortical bone and/or cement mantle of the prosthesis.

Postoperative management

Weight bearing as tolerated starting on postoperative day 1 is suggested under supervision of a physiotherapist.

Results

In 6 patients with periprosthetic fractures and 2 patients with periimplant fractures, no surgical complications (e.g., wound infection or bleeding) were observed. The mean time to bony union was 14 weeks. No implant loosening of the locking attachment plate was observed. At the follow-up examination, all patients had reached their prefracture mobility level.     

Distal radius fractures and the volar lunate facet fragment: Kirschner wire fixation in addition to volar-locked plating

Background

The volar lunate facet fragment of a distal radius fracture may not be stabilized with volar-locked plating alone due to the small size and distal location of the fragment. Identification and stabilization of this small fragment is critical as unstable fixation may result in radiocarpal and radioulnar joint subluxation. The addition of spring wire fixation with volar plating can provide stable internal fixation of this critical fracture fragment.

Methods

A retrospective review (2006–2011) identified nine patients with distal radius fractures with an associated volar lunate facet fragment that were treated with volar-locked plating and spring wire fixation of the volar lunate facet fragment. Radiographic indices, range of motion, grip strength, and postoperative Patient-related wrist evaluation (PRWE) scores were obtained to assess pain and function.

Results

All distal radius fractures healed, and the volar lunate facet fragment reduction was maintained. The mean follow-up was 54 weeks. Mean active range of motion was 46° wrist flexion, 51° wrist extension, 80° pronation, and 68° supination. The mean grip strength was 21 Kg, achieving 66 % of the uninjured limb. The average PRWE score was 17. No patient required removal of hardware or had evidence of tendon irritation.

Conclusions

The addition of spring wire fixation to volar-locked plating provided stable fixation of the volar lunate facet fragment of distal radius fractures without complication. This technique addresses a limitation of volar-locked plating to control the small volar lunate facet fragment in distal radius fractures otherwise amenable to volar plating.

Level of Evidence

A retrospective case series, Level IV.     

Die Stabilität von distalen Radiusfrakturen mit volaren winkelstabilen Plattenosteosynthesen

Background

Distal radius fractures continue to show significant complication rates after operative treatment with locked plating. Failure occurs by screw loosening or screw penetration in the distal fragment. Placement of additional screws may enhance the stiffness of fracture fixation. The aim of this study was to determine the fatigue properties of different screw configurations in distal radius plate osteosynthesis with biomechanical tests and finite element analysis (FEA).

Material and methods

Unstable distal radius fractures were created in 12 human cadaveric bone specimens and were fixed with volar locking plates. Group 4SC was fixed with four screws in the distal row and group 6SC with two additional screws the row below. Dynamic loading was applied physiologically. The radial shortening, the angulation of the distal fragment and the failure mechanism were determined by experimental tests and were further elucidated by FEA.

Results

Group 6SC showed a significantly lower radial shortening and inclination. Breakage of the screws within the plate was noted in group 4SC, while moderate screw penetration was observed in group 6SC. FEA confirmed the biomechanical tests. In group 4SC elevated von Mises strain in the locking mechanism explained the inclination of the screws and the distal fragment. The elastic strain in group 6SC was increased at the screw-bone interface which explained the resulting screw penetration.

Conclusion

The failure mechanism in volar plating of distal radius fractures depended on the number of screws and their configuration. Using two more screws increases construct stiffness and angular stability under dynamic loading. However, increased stiffness also promoted screw penetration mainly in osteoporotic bone. Compared to screw penetration, loss of reposition and inclination of the distal fragment observed in the 4SC configuration is more likely to result in clinical complications.