Nonunion of the clavicle treated with plate fixation: a review of forty-seven consecutive cases

Forty-seven consecutive patients underwent superior plating for clavicular nonunion between 1995 and 2005. This retrospective analysis was performed to assess the efficacy of plate fixation and the need for iliac crest bone grafting. Forty-three patients were treated with pelvic reconstruction plates and four with straight dynamic compression plates. Of the patients, 30 were treated with local bone graft only, 14 with demineralized bone matrix, and 3 with distant autogenous bone graft. Of the fractures, 93% united after a single operation. Of the patients, 69% returned the Disabilities of the Arm, Shoulder and Hand questionnaire. The mean Disabilities of the Arm, Shoulder and Hand score was 14.6 (range, 0-53). Plate prominence or sensitivity resulted in removal in 20% of cases. We believe that superiorly applied plate fixation is effective for the treatment of clavicular nonunion. Distant autogenous bone graft is not necessary in most cases to obtain union.     

Functional outcome of four-corner arthrodesis for treatment of grade IV scaphoid non-union

Functional limitations and pain are end results of scaphoid nonunion with progressive carpal collapse and radiocarpal arthritis. The aim of this study was to assess the functional outcome of four-corner arthrodesis with scaphoidectomy for the treatment of grade IV scaphoid nonunion with Scaphoid Nonunion Advanced Collapse (SNAC) stages II and III. Ten patients with symptomatic grade IV non union of the scaphoid and a mean duration of non unions of 12.1 +/- 2.81 months were treated using the four-corner arthrodesis technique. A dorsal midline longitudinal approach centered over the third metacarpal-capitate-lunate-radius axis, excision of the scaphoid, neutral alignment of the remaining carpal bones, and arthrodesis of the capitate, hamate, lunate, and triquetrum, were performed. Kirschner wires were used to secure the arthrodesis in all cases. A below-elbow thumb spica cast was applied for 3 months. Follow up period ranged from 8 to 24 months, with a mean of 16 +/- 4.7 months. All patients were assessed both functionally for pain, range of motion and grip strength, and radiographically for evidence of fusion and carpal alignment. Good results were achieved in 7 patients (70%) according to the modified Mayo Wrist Scoring Chart. There were no intraoperative complications. Postoperatively, one patient suffered superficial wound infection One patient showed dorsal impingement of the capitate and radius. Also, two patients suffered reflex sympathetic dystrophy. No patients showed deep infection or nonunion. The Four-corner Arthrodesis technique is a motion-sparing, limited arthrodesis that reliably results in pain relief, improved grip strength, and overall patient satisfaction with low associated non union and complication rates.     

Health status after total wrist arthrodesis for posttraumatic arthritis

PURPOSE: Total wrist arthrodesis is regarded as the most predictable way to relieve the pain of posttraumatic wrist arthritis. Wrist arthrodesis also is believed to be compatible with a high level of upper-extremity function. This study evaluated the effect of total wrist arthrodesis on both general and upper-extremity-specific health status in patients treated for posttraumatic wrist arthritis. METHODS: By using an institutional review board-approved protocol 22 patients were evaluated an average of 6 years after total wrist arthrodesis for posttraumatic arthritis. Upper-extremity-specific and general health status were measured using the Disabilities of the Arm, Shoulder, and Hand questionnaire and the Short-Form 36 (SF-36) instruments, respectively. Patient satisfaction and interest in pursuing a wrist-mobilizing procedure should one become available also were assessed. Objective assessment included grip strength, digit range of motion, and radiographic fusion. RESULTS: Grip strength averaged 79% of the uninvolved wrist. The average Disabilities of the Arm, Shoulder, and Hand questionnaire score was 25. The average physical component score of the Short-Form 36 was 39 and the average mental component score was 52. Fourteen patients complained of wrist pain, including severe pain in 4 patients. Fifteen patients were satisfied or very satisfied with the result of the fusion, 5 patients were neutral, and 2 patients were mildly dissatisfied. Twenty patients would elect to have a procedure that could make their wrist move again if one were available. CONCLUSIONS: Substantial dysfunction was noted on both upper-extremity-specific and general health status measures after total wrist arthrodesis for posttraumatic conditions. Pain was improved but not eliminated.     

Results of Mannerfelt wrist arthrodesis for rheumatoid arthritis in relation to the position of the fused wrist

Purpose

The wrist is involved early in rheumatoid arthritis and is often severely affected. A stable wrist is crucial to good hand function, which often necessitates a fusion. One of the most commonly used techniques in rheumatoid patients is the Mannerfelt arthrodesis. In this retrospective study the outcome and the patient’s subjective satisfaction are presented and compared to other techniques. Also the influence of the position of the wrist following a fusion procedure is analysed.

Methods

Thirty-four wrists were retrospectively analysed using radiological measurements, functional scores such as the Disabilities of the Arm, Shoulder and Hand (DASH) and a pain assessment. The objective function of the hand with the fused wrist was assessed.

Results

In 92.6 % of wrists the patients rated their satisfaction as good or excellent. The mean DASH score post-operatively was 63.3. Of the wrists, 17 were fixed in a median flexed position of 13° and 17 wrists in a median extended position of 8°. There was no statistically significant correlation between the position of the wrist and the satisfaction or objective function. The rate of fusion was 94.1 %.

Conclusions

The Mannerfelt arthrodesis achieves good results and provides a high rate of satisfaction and pain relief in our study. It has major advantages compared to other wrist fusion techniques in the rheumatoid patient. We could not show clear statistical evidence for better results in either a flexed or an extended position, but the ratings of the patients indicated better subjective results with a slightly extended position of the arthrodesis.     

Evaluation of Fixation Techniques for Metatarsocuneiform Arthrodesis

First metatarsocuneiform joint arthrodesis has been used in foot and ankle surgery for the treatment of hallux abductovalgus deformity, among other pedal pathologic entities. The goal of the present retrospective study was to compare the fusion rates and complications of an intraplate compression screw fixation, crossing solid core screw fixation, and a single interfragmentary screw with a simple locking plate. All procedures were performed by a single surgeon, and all patients received an identical postoperative protocol. A medical record review was performed of 147 evenly distributed surgical methods. All patients were non-weightbearing by protocol for 4 weeks. The patient covariates included sex, age, nicotine status, osteoporosis, and diabetes. These variables were balanced among the treatment groups and were noncontributory, with the exception of sex. Male patients had a 6 times greater odds of experiencing nonunion. The overall nonunion rate was 6.7%, with 4% symptomatic and requiring revision. The individual nonunion rates for each method were 2% for intraplate compression screw fixation, 5% for single interfragmentary screw with locking plate fixation, and 9% for crossing solid core screw fixation. None of the differences reached statistical significance. The corresponding hardware removal rates were 12%, 11%, and 0%.     

Four-corner fusion of the wrist: clinical and radiographic outcome of 31 patients

Background

Four-corner fusion is a rational surgical option for the management of degenerative conditions of the wrist. Most related studies have compared four-corner fusion with scaphoid excision or proximal row carpectomy, with a variety of reported results. To enhance the literature, we performed this study to evaluate a series of patients with degenerative conditions of the wrist treated with four-corner fusion using 3 surgical techniques and to discuss the clinical and radiographic outcome of the patients.

Materials and methods

We retrospectively studied 31 patients (24 men, 7 women; mean age, 43 years; 9 heavy manual laborers) who underwent four-corner fusion of their wrists for degenerative conditions from 2005 to 2015. Internal fixation was done using multiple Kirschner wires (14 patients), headless compressive screws (8 patients), or a circular plate (9 patients). Mean follow-up was 4 years (1–11 years). We evaluated the clinical outcome with the Patient-Rated Wrist Evaluation (PRWE) score and fusion with radiographs.

Results

All patients experienced improvement of their pain, function, range of motion and grip strength (p < 0.05). Twenty-three patients (74 %) reported no pain, and eight patients reported mild, occasional pain. Twenty-one patients (68 %) were able to do usual and specific activities. Mean wrist motion improved to 70 % and mean grip strength improved to 85 % of opposite wrist. Two heavy manual labor patients requested a job modification because of wrist impairment. Radiographs of the wrist showed fusion of all fused joints in 28 (90.3 %) patients and partial fusion in three patients (9.7 %). No patient with partial fusion required a reoperation for symptomatic nonunion until the period of this study. Three patients experienced complications (10 %). Two patients treated with a circular plate experienced complex regional pain syndrome and painful implant impingement; another patient treated with Kirschner wires and headless compression screws experienced radiolunate arthritis from impingement of the lunate screw to the radius.

Conclusions

Four-corner fusion is a reliable limited wrist fusion technique that provides pain relief, grip strength and satisfactory range of motion in patients with degenerative conditions of the wrist. Partial union is more common with Kirschner wire fixation and complications are more common with circular plate fixation.

     

Management of Non-United Four-Corner Fusions

Purpose Wrist degeneration, resulting from scaphoid nonunion or scapholunate ligamentous disruption, is widely managed with scaphoid excision with four-corner fusion. There are no specific details in the literature regarding “salvage” of nonunion after attempted “four-corner fusions” or the patient outcomes. The purpose of this paper is to present the results of patients who underwent treatment for nonunion after four-corner fusion, the subsequent surgeries done for wrist salvage and the functional results. Methods We reviewed, retrospectively, 37 patients who underwent limited wrist fusion using circular plate fixation, of which eight cases (22%) went on to nonunion and necessitated revision surgeries with plate exchange and bone graft. (Table 1) Five of eight patients were available to return to the clinic, and the wrist range of motion and the disabilities of the arm, shoulder, and hand (DASH) score were recorded. Results The average DASH score was 46 (range, 15 to 60.8). Grip on the affected limb was, on the average, 62% of the contralateral limb. Average arc of wrist motion was 70° (35.7° of flexion and 34.3° of extension). Three of the five patients were laborers, and two returned to the previous employment. The remaining two patients returned to their previous sedentary jobs. All patients reported difficulty with recreational activities involving heavy activity. Conclusions Complications of four-corner arthrodesis using circular plate fixation were recorded, revealing a high number of nonunions and hardware failures. All nonunions were salvaged with allograft or autogenous grafting with plate revision; however, the patients did have considerable limitations.     

Scaphoid Excision and Limited Wrist Fusion: A Comparison of K-Wire and Circular Plate Fixation

The purpose of this study was to compare the clinical outcome, union rate, and complications of a consecutive series of Scaphoid excision and limited wrist arthrodesis performed by a single surgeon using distal radius bone graft and K-wires or circular plate fixation. A sequential series of ten patients(11 wrists) who were stabilized with temporary K-wires were compared to 11 patients (11 wrists) who were stabilized with a circular plate. Minimum follow-up was 1 year. One patient in the K-wire group was converted to a wrist fusion. Six of the remaining ten patients in the K-wire fixation group and 8 of the 11 patients in the circular plate fixation group returned for the following blinded evaluations: Quick DASH, analog pain scale, range of motion, grip and pinch strength, plain x-ray, and multi-detector computed tomography evaluation. One non-union occurred in the K-wire group. There were no non-unions in the circular plate fixation group. There was no difference in any of remaining measures or rate of complications. This study shows that equivalent results can be obtained using circular plate fixation compared to K-wires when equivalent bone graft source and fusion technique are used. If K-wire removal requires a return to the OR, circular plate fixation is more cost-effective.     

Long-term results of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-Wrist) and scapholunate advanced collapse (SLAC-Wrist)

SUMMARY: Outcome evaluation of midcarpal arthrodesis in the treatment of scaphoid nonunion advanced collapse (SNAC-wrist) and scapholunate advanced collapse (SLAC-wrist). PURPOSE: Scaphoid nonunion or scapholunate ligament instability results in carpal collapse and subsequent arthrosis. These conditions, termed SLAC-wrist and SNAC-wrist, are the most common patterns of arthrosis in the wrist. The purpose of this retrospective study was the evaluation of functional outcomes following midcarpal arthrodesis and of patients' satisfaction with these outcomes. METHODS: Forty-nine patients were reexamined at a mean follow-up time of 47 months. Active range of motion (AROM) was verified with a goniometer; grip strength was measured with a JAMAR-Dynamometer II. Pain was evaluated by a visual analogue scale from zero to 100 (VAS 0-100) for stress and under resting conditions. Patients' upper-extremity functioning was captured with the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Radiographic evaluation of bony consolidation was verified by conventional x-ray. RESULTS: Postoperative AROM was 56% and grip strength was 76% compared with the contralateral side. The DASH score was 29 points. Pain relief was 34% at rest and 31% after stress. Forty-five patients demonstrated bony consolidation in x-ray control. Six patients (12%) further required a total arthrodesis of the wrist because of pain or absence of bony consolidation. CONCLUSION: Our data demonstrate that midcarpal arthrodesis is a reliable procedure for treating SLAC- and SNAC-wrists in stages II and III and, furthermore, one which preserves some range of motion. Total wrist fusion should only be used in exceptional circumstances.     

Treatment of isolated injuries of the lunotriquetral ligament. A comparison of arthrodesis, ligament reconstruction and ligament repair

We studied 57 patients with isolated lunotriquetral injuries treated by arthrodesis, direct ligament repair, or ligament reconstruction. The outcomes were compared by using written questionnaires, the Disabilities of the Arm, Shoulder and Hand (DASH) score, range of movement, strength, morbidity and rates of reoperation. Isolated lunotriquetral injury was confirmed by arthroscopy or arthrotomy. The mean age of the patients was 30.7 years (15.4 to 53.7) and the injuries were subacute or chronic in 98.2%. Eight patients underwent lunotriquetral reconstruction using a distally-based strip of the tendon of extensor carpi ulnaris, 27 had lunotriquetral repair and 22 had lunotriquetral arthrodesis. The mean follow-up was 9.5 years (2 to 22). The probability of remaining free from complications at five years was 68.6% for reconstruction, 13.5% for repair, and less than 1% for arthrodesis. Of the lunotriquetral arthrodeses, 40.9% developed nonunion and 22.7% developed ulnocarpal impaction. The probability of not requiring further surgery at five years was 68.6% for reconstruction, 23.3% for repair and 21.8% for arthrodesis. The DASH scores for each group were not significantly different. Objective improvements in strength and movement, subjective indicators of pain relief and satisfaction were significantly higher in the lunotriquetral repair and reconstruction groups than in those undergoing arthrodesis.     

腕关节部分融合治疗退行性腕关节炎的疗效

目的评价头骨、月骨、三角骨及钩骨四关节融合治疗退行性腕关节炎的效果。方法1997年7月～2002年12月应用腕关节部分融合术创伤性腕关节炎治疗20例,术后随访15个月,随访检查包括术后腕关节疼痛程度、腕关节活动度、握力以及患侧X线检查。视觉模拟评分法评价疼痛程度。腕关节总体功能评价采用Krimmer腕关节评分表。结果腕疼痛值静息时为2.1,用力后为5.3;屈伸活动度为64°(对侧126°);尺桡偏为30°(对侧57°);平均握力为24kg(对侧40kg)。Krimmer腕关节评分值为67。X线检查头、月、三角及钩骨均融合。结论腕关节部分融合后能保存腕关节部分功能,是治疗退行性腕关节炎有效的方法。     

The outcome of intra-articular distal radius fractures treated with fragment-specific fixation

PURPOSE: To assess the clinical, radiographic, and functional outcome of treating intra-articular distal radius fractures with fragment-specific fixation. METHODS: A retrospective review of 81 patients with 85 intra-articular distal radius fractures who were treated with fragment-specific fixation was performed. Minimum time to follow-up evaluation was 1 year, with a mean time of 32 months. The immediate postoperative films were compared with those taken at the final follow-up evaluation. Radiographs of the uninjured wrist were also obtained at the final follow-up evaluation for comparison. Patients were examined for wrist and finger range of motion, deformity, and grip strength, and they completed a standard Disabilities of the Arm, Shoulder, and Hand outcome survey. RESULTS: According to Gartland and Werley scoring there were 61 excellent and 24 good results. Flexion and extension of the surgically treated wrist at the final follow-up evaluation averaged 85% and 91%, respectively, of the uninjured wrist; grip strength averaged 92% compared with the uninjured side. The average Disabilities of the Arm, Shoulder, and Hand outcome score for the injured wrist was 9. Sixty-two percent of patients achieved a 100 degrees arc of flexion and extension and normal forearm rotation by postoperative week 6. Radiographic alignment was maintained between immediate postoperative and final follow-up films, and there were no cases of symptomatic arthritis at the final follow-up evaluation. CONCLUSIONS: Fragment-specific fixation is a reasonable alternative for treating intra-articular fractures of the distal radius. At final follow-up evaluations, patients had good to excellent results with respect to range of motion, grip strength, radiographic alignment, and satisfaction scores. Stable fixation allowed starting active and passive motion of the wrist without compromising postoperative alignment. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Four-corner arthrodesis with a radiolucent locking dorsal circular plate: technique and outcomes

Background

Scaphoid excision and four-corner arthrodesis (FCA) is an acceptable motion sparing procedure used to treat wrist arthritis. Recently, a locking dorsal circular plate composed of polyether-ether-ketone has been introduced (Xpode®; TriMed Inc.). The purpose of this study is to assess the efficacy of this specific plate design with regard to FCA.

Methods

A retrospective chart review of all patients who underwent FCA with an Xpode® between January 1, 2008 and December 31, 2012 was conducted. Patients were contacted and asked to return to clinic for clinical and radiographic follow-up. Patient demographics, range of motion, grip strength, and complications were collected from medical records. Patients completed a patient-rated wrist evaluation (PRWE). A paired t test was used to compare means, and p values <0.05 were considered statistically significant.

Results

Twenty-six procedures (24 patients) were identified. One patient required full wrist fusion following the initial procedure. Of the 25 remaining wrists, arthrodesis was successfully achieved in 20 (80 %). Eleven patients (13 wrists, 52 %) returned to clinic for an average follow-up of 28 months. Mean wrist extension improved from 30 to 47°, and flexion decreased from 33 to 23°. Average grip strength was 77 % of the uninjured side. The mean PRWE scores for pain and function were 19.7 and 17.1, respectively. Five patients underwent additional operations (two hardware removals, two contracture releases, and one distal radial ulnar joint arthroplasty).

Conclusions

FCA with the Xpode® yielded reasonable results for pain and function and demonstrated a fusion rate of 80 %.     

Biomechanical comparison of three fixation techniques used for four-corner arthrodesis

Clinical results following four-corner arthrodesis vary and suggest that nonunion may be related to certain fixation techniques. The purpose of our study was to examine the displacement between the lunate and capitate following a simulated four-corner arthrodesis with the hypothesis that three types of fixation (Kirschner wires, dorsal circular plate, and a locked dorsal circular plate) would allow different amounts of displacement during simulated wrist flexion and extension. Cadaver wrists with simulated four-corner arthrodeses were loaded cyclically either to implant failure or until the lunocapitate displacement exceeded 1 mm. The locked dorsal circular plate group was significantly more stable than the dorsal circular plate and K-wire groups (p = 0.018 and p = 0.006). While these locked dorsal circular plates appear to be very stable our results are limited only to the biomechanical behavior of these fixation techniques within a cadaver model.     

Surgical correction of dorsally angulated distal radius malunions with fixed angle volar plating: a case series

PURPOSE: To report our experience using a fixed-angle volar plate in conjunction with a corrective osteotomy and cancellous bone graft for the treatment of distal radius malunions with dorsal angulation in 4 patients. METHODS: Four consecutive patients had a volarly based opening wedge osteotomy with a fixed angle volar plate and cancellous bone grafting for the treatment of a dorsally angulated distal radius malunion. Data collected retrospectively included a visual analog pain scale, grip strength, range of motion, radiographic parameters, and each patient's subjective functional outcomes as measured by the Disabilities of the Arm, Shoulder, and Hand questionnaire. Motion, strength, and radiographic values were compared with the contralateral arm for each patient. RESULTS: The average time from initial fracture to corrective osteotomy was 346 days. The average length of follow-up evaluation was 13.5 months. The flexion-extension arc of motion increased an average of 21 degrees to a value of 84% of the contralateral side; the pronation-supination arc of motion increased an average of 20 degrees to a value of 98% of the contralateral side. The average tilt of the radius improved from 26 degrees extension to 2 degrees extension; the average radial inclination improved from 22 degrees to 24 degrees; the average ulnar variance excluding the 1 patient who had a distal ulna resection improved from 5 mm to 1 mm. The average retrospective Disabilities of the Arm, Shoulder, and Hand score improved from 30 to 7; the average retrospective visual analog pain scale score improved from 4.5 to 1. The average grip strength increased from 20 to 29 kg, which corresponded to 73% of the contralateral extremity. CONCLUSIONS: The rigid characteristics of fixed angle volar plates can provide an alternative to the traditional techniques of distal radius osteotomy including structural bone grafting and dorsal plate fixation or external fixation. In addition these plates are strong enough to allow for early postoperative motion. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

First Tarsometatarsal Joint Fusion for Hallux Valgus Deformity: A Retrospective Comparison of Two Fixation Constructs Regarding Initial Maintenance of Correction and Complications: Traditional Crossing Screw Fixation Versus Dorsomedial Locking Plate and Intercuneiform Compression Screw

Various fixation constructs exist to address hallux valgus when performing a first tarsometatarsal joint arthrodesis. The goal of this present study is to compare complication rates, and degree and maintenance of angular correction between a dorsomedial locking plate with intercuneiform compression screw construct versus traditional crossing solid screw fixation construct. The plate plus intercuneiform compression screw construct fixation utilized a combined sagittal saw and curette method of joint preparation while the crossed screw fixation group utilized a curette and bur technique. A retrospective review was conducted of consecutive patients who underwent a midfoot fusion using either constructs. Sixty four total feet in 56 patients were enrolled in the study. Twenty four consecutive patients (32 feet) who underwent a midfoot arthrodesis using the locking plate and intercuneiform fixation were fully fused (100%) by 10 weeks postoperatively, with no incidents of nonunion and one deep vein thrombosis event. Thirty two consecutive patients (32 feet) who underwent midfoot arthrodesis with crossing screw fixation had 2 nonunion events, one that was asymptomatic and the other that required a revision midfoot fusion. There was a statistically significant improvement from the pre-operative intermetatarsal angle, hallux abductus angle compared to the 10 week and 1 year radiographs (p < .05) for the entire cohort for both fixation constructs. There was a statistically significant increase in American College of Foot and Ankle Surgery first ray scores from pre-op to 1 year follow-up for both fixation constructs. Overall, the dorsomedial locking plate plus intercuneiform compression screw fixation construct better maintains Intermetatarsal angle (IMA) correction at midterm follow-up compared to the traditional crossing screw construct. Both cohorts overall demonstrate similar fusion rates at 10 weeks, nonunion events, incidences of broken hardware, hardware removal, deep vein thrombosis, neuritis at 1 year postoperatively, and hallux varus.     

Treatment of malignant tumors of the proximal humerus with allograft-prosthesis composite reconstruction

Malignant tumors of the proximal humerus are challenging to treat. Reconstruction with a metallic implant or allograft is the most common method, but each has known risks and frequent complications. Allograft-prosthesis composite reconstruction has not been widely used and may avoid problems posed by metal prostheses or allografts used alone. Six patients with malignant tumors of the proximal humerus were treated with allograft-prosthesis composite reconstruction after excision of the intra-articular tumor. Outcomes were assessed by use of the Disabilities of the Arm, Shoulder and Hand questionnaire; the Short Form 36 (SF-36) Health Survey; and the American Shoulder and Elbow Surgeons Shoulder Assessment Form. Preoperative and postoperative scores at a mean of 55 months were compared. Disability increased after surgery based on the Disabilities of the Arm, Shoulder and Hand questionnaire and SF-36, although disability appeared to decrease with time. The mean mental component score on the SF-36 showed continued improvement with time after surgery. One asymptomatic nonunion was repaired, and painful loosening developed in one patient, requiring revision at 45 months. Allograft-prosthesis composite reconstruction is a safe method for treating some malignant tumors of the proximal humerus, providing stable reconstruction and preserving function of the shoulder joint.     

Tibiotalocalcaneal nail failure in a 60-year-old male: Case report and surgical technique

Tibiotalocalcaneal (TTC) arthrodesis is a hindfoot fusion that can treat numerous conditions including osteoarthritis, Charcot arthropathy, avascular necrosis of the talus, and severe deformity. The goal of fusion is to create solid union across the joint while correcting deformity, leaving a shoeable plantigrade foot. Multiple biomechanical studies have demonstrated similar performance when comparing the properties of plate and nail constructs for TTC arthrodesis. Plate fixation and retrograde intramedullary nailing (IMN) are successful in achieving TTC fusion and favorable postoperative outcomes. Despite generally favorable outcomes, TTC arthrodesis carries the risk of complications including nonunion, infection, hardware failure, and revision surgery. We present a case of an individual who presented with a complete break of the IMN after TTC arthrodesis. We also describe the technique used for extraction of the broken nail.     

Treatment of midclavicular nonunion: comparison of dynamic compression plating and low-contact dynamic compression plating techniques

In this study a comparison of patients with midclavicular nonunion, treated by a combination of internal fixation with dynamic compression plate (DCP) or low-contact DCP (LC-DCP) and application of autogenous corticocancellous chips or sculptured graft on nonunion areas, was performed. Time to union in the patients treated with LC-DCP fixation was shorter than in those treated with DCP fixation (P <.001). Union was obtained in all patients treated with LC-DCP fixation and in 87.5% of those treated with DCP fixation. All of those treated with LC-DCP fixation returned to their original jobs, whereas two patients treated with DCP fixation had to change jobs. According to the Disabilities of the Arm, Shoulder, and Hand functional score, at the last follow-up visit, functional outcomes of the patients treated with LC-DCP fixation were more satisfactory (P <.001). The addition of internal fixation of the clavicle with DCP or LC-DCP to application of autogenous corticocancellous chips, or sculptured graft on nonunion areas in patients with midclavicular nonunion, shortens the time to union, increases union rates, and provides satisfactory functional outcomes.     

Does delay matter? The restoration of objectively measured shoulder strength and patient-oriented outcome after immediate fixation versus delayed reconstruction of displaced midshaft fractures of the clavicle

Outcome after surgical treatment for nonunion and malunion of midshaft displaced clavicle fractures has generally been described as favorable and equal to results of acute repair. This assumption has been based on subjective criteria, however, and no direct comparison is available in the literature. This study used objective measurements of limb function to compare outcome in patients who underwent delayed operative intervention for nonunion and malunion with the outcome of patients who underwent immediate open reduction and internal fixation after displaced clavicle fracture. All patients had sustained completely displaced, closed, isolated midshaft clavicle fractures, of whom 15 had undergone acute open reduction and internal fixation with a compression plate at a mean of 0.6 months after injury (acute group). Another 15 patients had undergone delayed reconstruction with open reduction, bone grafting, and compression plate fixation for nonunion or malunion a mean of 63 months after injury (delayed group). The 2 groups were similar in age, gender, original fracture characteristics, and mechanism of injury. Complete assessment included standard history and physical examination, the Disabilities of the Arm, Shoulder and Hand (DASH) score and Constant Shoulder Score, subjective rating of outcome satisfaction, and objective muscle strength testing using a previously validated and published protocol on the Baltimore Therapeutic Equipment (BTE) work simulator. There were no significant differences between acute fixation and delayed reconstruction groups with regard to strength of shoulder flexion (acute, 94%; delayed, 93%; P = .82), shoulder abduction (acute, 97%; delayed, 97%; P = .92), external rotation (acute, 97%; delayed, 90%; P = .11), or internal rotation (acute, 98%; delayed, 96%; P = .55). Constant scores in the acute group were superior (acute, 95; delayed, 89; P = .02), but differences in DASH scores were not significant (acute, 3.0; delayed, 7.2; P = .15). Shoulder flexion muscle endurance was significantly decreased in the delayed group (acute, 109%; delayed, 80%; P = .05). Differences in muscle endurance in other planes were not significantly different (abduction endurance: acute, 107%; delayed, 81%; P = .24). Both groups rated their satisfaction with the procedure as excellent. Late reconstruction of nonunion and malunion after displaced midshaft fractures of the clavicle is a reliable and reproducible procedure that results in restoration of objective muscle strength similar to that seen with immediate fixation; however, there are subtle decreases in endurance strength and outcome compared with acute fracture repair. This information should not be used to justify primary operative repair in isolation but is useful in decision-making when counseling patients with displaced midshaft fractures of the clavicle.