Critical analysis of tibial fracture healing following unreamed nailing

Purpose

Unreamed nails have revolutionised the treatment of tibial shaft fractures. Many authors, however, have reported increasing bone healing complications with these implants. Unfortunately, few studies have addressed the factors affecting bone healing after unreamed tibial nailing.

Methods

One-hundred and sixty tibial fractures in 158 patients (mean age 39.5 years) fixed using unreamed nails were reviewed. There were 78 AO type-A, 65 type-B and 17 type-C fractures (115 closed and 45 open fractures). Twelve patient, injury and surgery variables were analysed for their influence on fracture healing.

Results

Union occurred in all fractures after a mean time of 24.3 weeks. Additional surgery to achieve union, apart from dynamisation, was done in nine (6%) cases. The most important variables affecting healing were the mechanism of trauma (p = 0.005), fracture site gap (p = 0.01), degree of comminution (p = 0.0003), associated soft tissue injuries (p = 0.02) and the time to dynamisation (p = 0.0001).

Conclusions

High-energy trauma and fracture comminution have a negative impact on bone union and require close follow-up. It is essential to avoid distraction over three millimetres with unreamed nailing. Dynamisation is advised within ten weeks in axially stable fractures to encourage bone healing and avoid failure of the locking screws.     

Comparison of the efficacy of a distal clavicular locking plate versus a clavicular hook plate in the treatment of unstable distal clavicle fractures and a systematic literature review

Purpose

The purpose of this study was to retrospectively compare and review the clinical outcomes between the distal clavicular locking plate and clavicular hook plates in the treatment of unstable distal clavicle fractures; moreover, the relevant literature of the two fixation methods was reviewed systematically to identify the non-union, complications, or functional scores, according to the treatment methods and determine which treatment method is better.

Methods

Sixty-six patients with 66 unstable distal clavicle fractures who underwent open reduction and internal fixation with either a distal clavicular locking plate (36 patients) or a clavicular hook plate (30 patients ) were evaluated. The main outcome comparisons included Constant score, rate of non-union, rate of complication, and rate of returning to work three months postoperatively.

Results

No significant difference was found between locking plate and hook plate groups in union rate and Constant score (P > 0.05). However, the results indicated that the distal clavicular locking plate group had a significantly lower rate of complications (P < 0.05) and symptomatic hardware (P < 0.05). In addition, the distal clavicular locking plate facilitated the return to work better than the clavicular hook plate (P < 0.05).

Conclusions

Both distal clavicular locking plate and clavicular hook plate achieved good results in the treatment of unstable distal clavicle fractures; however, internal fixation with a distal clavicular locking plate had greater ability to return to their previous work after surgery in three months and fewer complications than the clavicular hook plate.     

Treatment of distal tibial shaft fractures by three different surgical methods: a randomized,prospective study

Purpose

A few studies focused on the methods of treatment for displaced distal tibial shaft fractures have been published, all of which compared two different methods. In this randomized, prospective study, we aimed to compare minimally invasive plate osteosynthesis, locking intramedullary nail stabilization and external fixation combined with limited open reduction and absorbable internal fixation for distal tibial shaft fractures by assessing complications and secondary procedures.

Methods

From November 2002 to June 2012, 137 skeletally mature patients with displaced distal tibial shaft fractures with or without fibula fracture were randomized to be treated by minimally invasive plate osteosynthesis (group A, n = 46), locking intramedullary nail (group B, n = 46) or external fixation combined with limited open reduction and absorbable internal fixation (group C, n = 45). Age, gender, mechanism of injury, fracture pattern and presence of open fracture were equally distributed among the three groups. Indexes for evaluation included hospital stay, operative time, time to radiographic union, union status, infection and the incidence of re-operation. Mazur ankle score was introduced for functional evaluation. Statistics Analysis System (SAS) 9.2 was used for analysis.

Results

A total of 121 patients were included in the final analysis (group A 42, group B 40 and group C 39) and evaluated after a mean of 14.8 months follow-up. There was no significant difference (P > 0.05) in hospital stay, time to radiographic union and the incidence of union status among the three groups. Although group C was associated with less secondary procedures versus groups A and B, it was related with more pin tract infections (15.4 %). Anterior knee pain occurred frequently after locking intramedullary nailing (37.5 %) and the irritation symptoms were more frequently encountered in group A (59.5 %). There was no difference in ankle function between the three methods after operation (P > 0.05).

Conclusions

We consider that the minimally invasive plate osteosynthesis, locking intramedullary nail stabilization and external fixation combined with limited open reduction and absorbable internal fixation techniques are all efficient methods for treating distal tibia fractures. With its wide indications, external fixation combined with limited open reduction and absorbable internal fixation leads to minimal soft tissue complication, good functional result and no local soft tissue irritation or implant removal.     

Three-dimensional computer-assisted navigation for the placement of cannulated hip screws. A pilot study

Purpose

Medial femoral neck fractures are common, and closed reduction and internal fixation by three cannulated screws is an accepted method for the surgical treatment. Computer navigation for screw placement may reduce fluoroscopy time, the number of guidewire passes and optimise screw placement.

Methods

In the context of a sawbone study, a computer-assisted planning and navigation system based on 3D-imaging for guidewire placement in the femoral neck was tested to improve screw placement. Three screws were inserted into 12, intact, femoral sawbones using the conventional technique and into 12, intact, femoral sawbones guided by the computer-based navigation system. Guidewire and subsequent screw placement in the femoral neck were evaluated.

Results

Use of the navigation system resulted in a significant reduction of the number of drilling attempts (p ≤ 0.05) and achieved optimised accuracy of implant placement by attaining significantly better screw parallelism (p ≤ 0.05) and significantly enlarged neck-width coverage by the three screws (p ≤ 0.0001). Computer assistance significantly increased the number of fluoroscopic images (p ≤ 0.001) and the operation time (p ≤ 0.0001).

Conclusions

Three-dimensional computer-assisted navigation improves accuracy of cannulated screw placement in femoral neck while increasing the number of fluoroscopic images and operation time. Additional studies including fractured sawbones and cadaver models with the goal of reducing operation time are indispensable before introduction of this navigation system into clinical practice.     

Proximal femoral nails compared with reverse distal femoral locking plates in intertrochanteric fractures with a compromised lateral wall; a randomised controlled trial

Purpose

There is no consensus about the best option of internal fixation for unstable intertrochanteric fractures. The aim of the present study was to compare proximal femoral nail (PFN) with contralateral reverse distal femoral locking compression plate (reverse-DFLCP) in the management of unstable intertrochanteric fractures with compromised lateral wall.

Method

In a randomized controlled study, from November 2011 to October 2012, 40 patients with unstable intertrochanteric fractures with compromised lateral wall (AO 31A 2.2 to 3.3) had osteosynthesis by PFN (n = 20) or reverse-DFLCP (n = 20). Intra-operative variables compared were duration of surgery, blood loss during surgery, fluoroscopy time and surgeons perception of the surgery. Patients were followed up clinically for a minimum of one year. Functional outcome was assessed by Parker Palmer mobility score (PPMS), Harris hip score (HHS), and Short Form-12. Failure was defined as any condition which would necessitate revision surgery with change of implant.

Results

Duration of surgery (p = 0.022), blood loss during surgery (p = 0.008) and fluoroscopy time (p = 0.0001) were significantly less in the PFN group than in the reverse-DFLCP group. No significant difference was found in type of reduction, difficulty in reduction and surgeon’s perception of surgery. The PFN group had better functional outcome than the reverse-DFLCP group. HHS for the PFN group was 81.53 ± 13.21 and for the reverse-DFLCP group it was 68.43 ± 14.36 (p = 0.018). SF-12 physical (p = 0.002) and mental component (p = 0.007) scores in the PFN group was significantly better than in the reverse-DFLCP group. There was one failure in the PFN group as compared to six in the reverse-DFLCP group (p = 0.036).

Conclusion

Due to favourable intra-operative variables, better functional outcome and lower failure rates, we conclude that PFN is a better implant than reverse-DFLCP for intertrochanteric fractures with compromised lateral wall.Keyword: Unstable intertrochanteric fractures, Lateral wall, Proximal femoral nail, Reverse distal femoral locking compression plate     

Cationised gelatin and hyaluronic acid coating enhances polyethylene terephthalate artificial ligament graft osseointegration in porcine bone tunnels

Purpose

The aim of this study was to investigate whether cationised gelatin and hyaluronic acid (CH) coating could induce polyethylene terephthalate (PET) artificial ligament graft osseointegration in the bone tunnel.

Methods

Surface modification of PET artificial ligament graft was performed by layer-by-layer (LBL) self-assembly CH coating. Six pigs underwent anterior cruciate ligament (ACL) reconstruction on the right knees, with three pigs receiving the CH-coated PET grafts and the other three pigs non-CH-coated PET grafts as controls. They were sacrificed at three months after surgery and the graft-bone complexes were acquired for computed tomography (CT) scan and histological examination.

Results

CT scans showed a significant difference at the distal femoral site (p = 0.031) or at the distal tibial site (p = 0.0078), but no significant difference in the bone tunnel areas’ enlargement at other sites (p > 0.05) between the CH group and the control group. Histologically, application of CH coating induced new bone formation between graft and bone at three months compared with the controls at the distal site. The interface width of the CH group was significantly lower than that of the control group at the distal femoral site (p = 0.0327) and at the distal tibial site (p = 0.0047).

Conclusions

The study has shown that CH coating on the PET artificial ligament surface has a positive biological effect in the induction of artificial ligament osseointegration within the bone tunnel at the distal site of the bone tunnel.     

Pain reduction following vertebroplasty and kyphoplasty

Purpose

To evaluate the clinical efficacy, especially the pain reduction, of vertebroplasty and balloon kyphoplasty in the treatment of osteoporotic vertebral compression fractures (OVCFs).

Methods

Eighty-six patients with OVCFs were treated with vertebroplasty or balloon kyphoplasty. All patients were followed up for seven–36 months. Visual analog scale (VAS), vertebral height, and local kyphotic angle were evaluated at pre-operation, postoperation, and final follow-up.

Results

The VAS pain score decreased significantly after surgery in both kyphoplasty and vertebroplasty groups (p < 0.001), and the improvement of VAS score had no significant difference between the two groups (p = 0.826). There was a significant difference in the improvement of vertebral height (p < 0.001) and local kyphotic angle (p < 0.001) between the two groups. Improvement of VAS score had no correlation with improvement of vertebral height (vertebroplasty: r = −0.029, p = 0.869; kyphoplasty: r = 0.175, p = 0.219) or local kyphotic angle (vertebroplasty: r = 0.159, p = 0.361; kyphoplasty: r = 0.144, p = 0.312) in either group.

Conclusion

Vertebroplasty and kyphoplasty are effective procedures for the reduction of pain in OVCFs, and they have the same efficient effect on pain reduction. Correction of vertebral height and local kyphosis may have minimal effect on pain reduction.     

Clinical outcome and changes in gait pattern after pilon fractures

Purpose

Axial burst fractures of the distal tibia are challenging to treat and often lead to restricted function of the lower limb. The purpose of this study was to investigate the clinical outcome and changes in gait pattern in such patients.

Methods

Thirty-five patients in a level 1 trauma centre were followed up clinically and by gait analysis. The American Orthopaedic Foot and Ankle Society (AOFAS), visual analogue scale (VAS) foot and ankle scale and Phillips scores were applied. Dynamic pedography (emed-M; Novel, Germany) with analyses of load, pressure and force-time integral were undertaken to investigate possible changes in gait pattern.

Results

Mean follow-up was 50 (19–100) months. Mean AOFAS, VAS foot and ankle and Phillips scores were 65, 63 and 55 points, respectively. There were clear correlations between fracture severity in the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification and functional outcome in AOFAS (−0.63; p < 0.01), VAS foot and ankle scale (−0.56; p < 0.01) and Phillips (−0.64; p < 0.01) scores. There was a high correlation of 0.74 (p < 0.01) between the severity of the injury in the AO-classification and onset of post-traumatic arthrosis. Dynamic pedography revealed lesser load bearing for the total foot, medial foot, heel, first metatarsal and medial forefoot for the affected limb, and increased load bearing was seen in the lateral midfoot region.

Conclusions

Fractures of the tibial pilon lead to restricted function of the lower limb. Clinical outcome correlates with fracture severity in the AO classification, the onset of post-traumatic arthrosis and changes in gait patterns.     

Implementing a clinical pathway for hip fractures; effects on hospital length of stay and complication rates in five hundred and twenty six patients

Purpose

Modern management of the elderly with a hip fracture is complex and costly. The aim of this study was to compare the treatment-related hospital length of stay (HLOS) before and after implementing a clinical pathway for patients undergoing hip fracture surgery.

Methods

This was a retrospective, before-and-after study. The first period ranged from June 21, 2008 to November 1, 2009 (N = 212), and the second was from January 7, 2010 to July 7, 2011 (N = 314). The electronic hospital system and patients records were reviewed for demographics, HLOS, mortality, complications and readmissions.

Results

In the first period 53 % had a femoral neck fracture, of which 57 % were treated with hemiarthroplasty. In the second period this was 46 % and 71 %. Pertrochanteric fractures were treated with a Gamma nail in 85 % in the first period, and in 92 % in the second period. The median HLOS decreased from nine to six days (p < 0.001). For the hemiarthroplasty group HLOS decreased from nine to seven days (p < 0.001); for internal fixation there was no significant difference (five versus six days, p = 0.557) and after Gamma nailing it decreased from ten to six days (p < 0.001). For mortality no statistically significant difference was found (6 % versus 5 %, p = 0.698). Complications decreased for the Gamma nail group (44 % versus 31 %, p = 0.049). Readmissions for the total group were not different (16 % versus 17 %, p = 0.720).

Conclusions

Implementing a clinical pathway for hip fractures is a safe way to reduce the HLOS and it improves the quality of care.     

Gait knee kinematic alterations in medial osteoarthritis: three dimensional assessment

Purpose

Although kinematic changes in the sagittal plane of the osteoarthritic knee (OA) have been elucidated, very few studies have analysed changes in the frontal and horizontal planes. Therefore, the aim of this study was to investigate in vivo 3D knee kinematics during walking in patients wth knee OA.

Methods

Thirty patients with medial knee OA and a control group of similarly aged individuals were prospectively collected for this study. All participants were assessed with KneeKG^TM system while walking on a treadmill at a self-selected speed. In each trial, we calculated the angular displacment of flexion/extension, abduction/adduction and external/internal tibial rotation. Statistical analysis was performed to determine differences between the knee OA group and the control group.

Results

Patients with knee OA had reduced extension during the stance phase (p < 0.05; 8.5° and 4.4°, OA and control group, respectively) and reduced flexion during pushoff and initial swing phase (p  < 0.05; 41.9° and 49.4°, respectively). Adduction angle was consistently greater for OA patients (p  < 0.05; 3.4° and −0.9°, respectively). Frontal laxity for OA patients was positively correlated with varus deformity (r = 0.42, p < 0.05). There was a significant difference (p)  < 0.05 in tibial rotation during the midstance phase; OA patients retained a neutral position (−0.4°), while the control group presented internal tibial rotation (−2.2°).

Conclusion

Weight-bearing kinematics in medial OA knees differs from that of normal knees. The knee OA group showed an altered “screw-home” mechanism by decreased excursion in sagittal and axial tibial rotation and posterior tibial translation.     

Fatigue performance of angle-stable tibial nail interlocking screws

Purpose

Tibial nail interlocking screw failure often occurs during delayed fracture consolidation or at early weight bearing of nailed unstable fractures, in general when high implant stress could not be reduced by other means. Is there a biomechanical improvement in long-term performance of angle stable locking screws compared to conventional locking screws for distal locking of intramedullary tibial nails?

Methods

Surrogate bones of human tibiae were cut in the distal third and distal locking of the 10 mm intramedullary tibial nail was performed with either two angle stable locking screws or two conventional locking screws in the mediolateral plane. Six specimens per group were mechanically tested under quasi-static and cyclic axial loading with constantly increasing force.

Results

Angle stable locking screw constructs exhibited significantly higher stiffness values (7,809 N/mm ± 647, mean ± SD) than conventional locking screw constructs (6,614 N/mm ± 859, p = 0.025). Angle stable locking screw constructs provided a longer fatigue life, expressed in a significantly higher number of cycles to failure (187,200 ± 18,100) compared to conventional locking screw constructs (128,700 ± 7,000, p = 0.004).

Conclusion

Fatigue performance of locking screws can be ameliorated by the use of angle stable locking screws, being especially important if the nail acts as load carrier and an improved stability during fracture healing is needed.     

Intramedullary repair device against volar plating in the reconstruction of extra-articular and simple articular distal radius fractures; a randomized pilot study

Purpose

This prospective randomized pilot study reports our institutional experience and early results using Sonoma Wrx (Sonoma Orthopedic Products, Santa Rosa, CA) in the treatment of extra-articular and simple intra-articular distal radius fractures.

Material and methods

A total of 64 patients, were enrolled in the study. They were considered eligible if they had; unstable extra-articular distal radius fractures and simple intra-articular distal radius fractures suitable for closed reduction (AO types; A2.2, A2.3, A3.1 C2.1, C2.2). Patients in group I received intramedullary fixation using the Sonoma Wrx® device and patients in group II received standard volar locking plate fixation. Radiographic criteria of acceptable healing were used for evaluation.

Results

Two groups were similar in terms of baseline characteristics. Mean time of operation was significantly shorter in Group 1 vs. in group 2 (36.81 ± 7.11 vs. 48.97 ± 5.9 minutes, p = 0.001). Time to healing of the fracture was not different between two groups (5.45 ± 1.09 vs. 5.70 ± 1.04 weeks for Group 1 vs. 2, respectively p = 0.36). Overall complications occurred in 9 patients in group 1 and in 15 patients in group 2 (p = 0.17). Follow-up was completed in all patients with a median time of 12 months and 13 months in group 1 and 2, respectively. On radiographic evaluation radial inclination, radial height and volar tilt were not significantly different between group 1 and 2, respectively. There were no significant differences between two groups in regard to wrist rotational degrees measured in last follow-up visit.

Conclusion

Sonoma Wrx Device is reliable and effective in terms of achieving satisfactory outcomes in treatment of distal radius fractures. It may be reasonable to use this device to prevent complications that are related to extensive soft tissue dissection.     

Precise nail tip positioning after tibial intramedullary nailing prevents anterior knee pain

Purpose

Anterior knee pain (AKP) is a common complication following intramedullary nailing of tibial shaft fractures. Our aim was, by analysing the postoperative lateral knee X-rays and clinical status (VAS score), to find the best intramedullary tip position of a non protruded nail that will provide the best postoperative outcome avoiding AKP.

Methods

We evaluated the postoperative outcome of 221 patients, from the last four years, with healed fractures initially treated with intramedullary reamed nails with two or three interlocking screws proximally and distally through a medial paratendinous incision for nail entry portal. Our aim was to analyse a possible relationship between AKP according to the VAS scale, and nail position marked as a distance from tip of nail to tibial plateau (NP) and to tibial tuberosity (NT), measured postoperatively on lateral knee X-rays.

Results

Two groups of patients were formed on the basis of presence of pain related to AKP (the level of pain was neglected): group A were patients with pain and group B without pain. The difference between the two groups concerning NP and NT measurements appeared to be statistically significant concerning NT measurement (p < 0.05), with high accuracy according to the classification tree.

Conclusions

We presume that the position of the proximal tip of the nail and its negative influence on the innervation pattern of the area dorsal to patellar tendon could be the key factor of AKP. We conclude that the symptoms of AKP will not appear if the tip of the nail position is more than 5.5 mm from the tibial plateau (NP) and more than 2.5 mm from the tibial tuberosity (NT).     

Impact of the tibial slope on range of motion after low-contact-stress,mobile-bearing,total knee arthroplasty

Purpose

The aim of this study was to analyse a possible correlation between the tibial slope and range of motion (ROM) after implantation of the low-contact-stress (LCS), mobile-bearing, total knee arthroplasty (TKA) after a minimum follow-up of ten years.

Methods

Eighty-three TKAs in 66 patients were investigated in this retrospective correlation analysis at a minimum follow up of ten years. Out of these 66 patients, 50 were women (76 %) and 16 (24 %) were men. The average age of these patients at the time of the examination was 76 years [standard deviation (SD) 11 years, range 37–95 years]. A lateral X-ray was taken at follow-up in order to analyse the tibial slope with respect to inter- and intra-observer agreement. ROM was measured and correlated with the tibial slope.

Results

The mean active ROM was 96.1° (SD 18.8) and the mean tibial slope after four measurements was 7.65° (SD 4.23), with substantial inter- and intra-observer agreement. We found no significant correlation between tibial slope and ROM in patients with a minimum follow-up of ten years [correlation 0.196 (p > 0.05) and 0.152, (p > 0.05), respectively].

Conclusions

Alteration of the tibial slope does not significantly influence ROM after implantation of the LCS TKA at a minimum follow-up of ten years. We conclude that the tibial slope is not the primary influencing factor for ROM in patients ten years after primary TKA and believe that it should not substantially be altered during surgery.     

Failed less invasive lumbar spine surgery as a predictor of subsequent fusion outcomes

Purpose

It is not uncommon for patients to undergo less invasive spine surgery (LISS) prior to succumbing to lumbar fusion; however, the effect of failed LISS on subsequent fusion outcomes is relatively unknown. The aim of this study was to test the hypothesis that patients who suffered failed LISS would afford inferior subsequent fusion outcomes when compared to patients who did not have prior LISS.

Methods

After IRB approval, registry from a spine surgeon was queried for consecutive patients who underwent fusion for intractable low back pain. The 47 qualifying patients were enrolled and split into two groups based upon a history for prior LISS: a prior surgery group (PSG) and a non-prior surgery group (nPSG).

Results

Typical postoperative outcome questionnaires, which were available in 80.9 % of the patients (38/47) at an average time point of 40.4 months (range, 13.5–66.1 months), were comparatively analysed and failed to demonstrate significant difference between the groups, e.g. PSG v. nPSG: ODI—14.6 ± 10.9 vs. 17.2 ± 19.4 (P = 0.60); SF12-PCS—10.9 ± 11.0 vs. 8.7 ± 12.4 (p = 0.59); bNRS—3.0 (range −2–7) vs. 2.0 (range −3–8) (p = 0.91). Patient satisfaction, return to work rates, peri-operative complications, success of fusion and rate of revision surgery were also not different.

Conclusions

Although limited by size and retrospective design, the results of this rare investigation suggest that patients who experience a failed LISS prior to undergoing fusion will not suffer inferior fusion outcomes when compared to patients who did not undergo prior LISS.     

An in vitro comparison of tibial tray cementation using gun pressurization or pulsed lavage

Purpose

Aseptic loosening of the tibial component remains a limitation to the highly successful procedure of total knee arthroplasty (TKA). Pulsed lavage improves bone cement penetration and interface strength in tibial tray cementation. This study tested whether pressurized cement application with a cement gun can compensate the use of jet lavage for bone surface preparation.

Methods

Tibial components were implanted in six pairs of cadaveric tibiae. On one side, pulsed lavage of the tibial bone was combined with finger packing of bone cement; on the other side, syringe lavage and gun cementing was used. Cement penetration into the bone was determined from computed tomography scans, and Interface strength was determined by pull-out testing.

Results

Cement penetration was greater (p = 0.004) and interface strength was higher (p = 0.028) in the pulsed lavage group.

Conclusion

Pressurization of cement by gun application could not compensate for the omission of pulsed lavage. Thus, pulsed lavage should be considered a crucial factor in TKA to improve implant fixation, which cannot be compensated for by cement application technique.     

The analysis of spinopelvic parameters and stability following long fusions with S1, S2 or iliac fixation

Purpose

The purpose of this study was to analyse changes of spinopelvic parameters and stability in the treatment of degenerative lumbar deformity.

Methods

A retrospective review was carried out on 70 cases of degenerative lumbar deformity treated by long fusion with uni-cortical S1 fixation alone (US1F group, n = 20), bi-cortical S1 fixation alone (BS1F group, n = 20), additional diagonal S2 fixation (DS2F group, n = 14), and additional iliac fixation (ILF group, n = 16) from July 2003 to April 2010. The sagittal vertical axis (SVA), lumbar lordosis (LL), sacral slope (SS), pelvic tilt (PT), pelvic incidence (PI), and stability were used to evaluate radiologic outcomes. The clinical outcome was evaluated using the Oswestry Disability Index (ODI).

Results

In all groups, the LL was significantly increased at three months (p < 0.05). The PI and the SS of ILF patients significantly increased at three months (p < 0.05), while none of these values changed over time in non-ILF patients. The PT did not change postoperatively in any groups. The LL, SS, and PI were significantly greater in the ILF group at three months postoperatively and later (p < 0.05). DS2F and ILF had statistically significant stability compared to US1F and BS1F (p < 0.05). The ODI scores were significantly improved after surgery in all groups compared to before surgery (p < 0.05).

Conclusions

Patients who had ILF in long fusion for the treatment of degenerative lumbar deformity had significant restoration of spinopelvic parameters compared to the other groups. In addition, DS2F and ILF provided more stability of distal instruments.     

Distal tibia fractures and medial plating: factors influencing re-operation

Purpose

We compared types of complications leading to re-operations in open and closed distal tibia fractures treated by locking or nonlocking medial plates.

Methods

Ninety-three patients from 2002 to 2012 who underwent open reduction and internal fixation (ORIF) and medial plating for distal extra-articular or partial articular tibia fractures were identified. Charts were retrospectively reviewed to determine the incidence of re-operation based on the type of complication that developed. Fisher’s exact and chi-square tests were performed to analyze the incidence of complications based on injury and type of plate used.

Results

Thirty-three (35.5 %) patients required re-operations: 28.6 % (n = 16) with closed injuries had complications leading to re-operations compared with 45.9 % (n = 17) of patients with open injuries (p = 0.12). Patients with closed injuries were more likely to require re-operation due to hardware pain/prominence (p = 0.03), whereas patients with open injuries were more likely to require re-operation due to nonunion (p = 0.04). There were no significant differences in infection (p = 0.66) or malunion (p = 0.99) between groups. Locking plates showed higher costs but were not associated with decreased risk of re-operation.

Conclusions

There was a high re-operation rate associated with distal tibia medial plating, with significant differences in the reason for re-operation between open versus closed groups. Complication rates were not influenced by the use of locking plates. Results of this study suggest that methods be considered to reduce re-operation based on type of fracture, such as early bone grafting or the use of alternate implants for open fractures.     

S-osteotomy with lengthening and then nailing compared with traditional Ilizarov method

Purpose

The purpose of this study was to explore the clinical effect of the novel method combined longitudinal S-osteotomy and Lengthen And Then Nail (LATN) technique for leg lengthening and compare with the classic Ilizarov method.

Methods

This retrospective study was performed from March 2008 to April 2012. A total of 176 leg lengthenings (88 consecutive patients) were performed at our institution. The mean duration of follow-up was 2.2 years (range, one to four years). In group A, 78 tibial lengthenings were performed with longitudinal S-osteotomy and LATN technique. In group B, 98 tibial lengthenings were performed with the classic method. The final gain in length, mean surgical time for bilateral tibial osteotomy, the external fixation index and the radiographic consolidation index were calculated and compared. The complications encountered during operation and follow-up were documented.

Results

There was no significant difference in the final gain in length between the two groups. Mean surgical time in group A (130.05 ± 6.60 min) was significantly longer than that in group B (91.4 ± 6.61 min; P < 0.05). External fixation index in group A (21.02 ± 3.16 days/cm) was significantly lower than that in group B (76.19 ± 8.32 days/cm; P < 0.05). Consolidation index was significantly lower (more rapid healing) in group A (43.38 ± 5.35 days/cm) than that in group B (76.19 ± 8.32 days/cm; P < 0.05). There was a significant difference in pin-tract problems and axial deviation between the two groups.

Conclusion

The novel method combined longitudinal S-corticotomy and LATN technique safely reduces the consolidation time, rate of pin-tract problems and axial deviation during leg lengthening, compared with the classic Ilizarov method.     

Extracortical plate fixation with new plate inserts and cerclage wires for the treatment of periprosthetic hip fractures

Purpose

Fixation of periprosthetic hip fractures with intracortical anchorage might not be feasible in cases with bulky implants and/or poor bone stock.

Methods

Rotational stability of new plate inserts with extracortical anchorage for cerclage fixation was measured and compared to the stability found using a standard technique in a biomechanical setup using a torsion testing machine. In a synthetic PUR bone model, transverse fractures were fixed distally using screws and proximally by wire cerclages attached to the plates using “new” (extracortical anchorage) or “standard” (intracortical anchorage) plate inserts. Time to fracture consolidation and complications were assessed in a consecutive series of 18 patients (18 female; mean age 81 years, range 55–92) with periprosthetic hip fractures (ten type B1, eight type C-Vancouver) treated with the new device between July 2003 and July 2010.

Results

The “new” device showed a higher rotational stability than the “standard” technique (p < 0.001). Fractures showed radiographic consolidation after 14 ± 5 weeks (mean ± SD) postoperatively in patients. Revision surgery was necessary in four patients, unrelated to the new technique.

Conclusion

In periprosthetic hip fractures in which fixation with intracortical anchorage using conventional means might be difficult due to bulky revision stems and/or poor bone stock, the new device may be an addition to the range of existing implants.