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.     

Comparison of low, multidirectional locked nailing and plating in the treatment of distal tibial metadiaphyseal fractures

Purpose

The aim of this study was to compare the results of a new technique for low, multidirectional locked nailing with closed reduction and minimally invasive plating in the treatment of distal tibial metadiaphyseal fractures.

Methods

Forty-six matched patients were divided according to age, gender, Injury Severity Score, and fracture pattern into group A (expert tibial nailing) and group B (minimally invasive plating). Then, the patients were followed up, and the clinical and radiographic results were retrospectively analysed.

Results

The mean followed-up was 24.7 ± 2.7 months in group A and 25.8 ± 2.8 months in group B. No patient had nonunion, shortening, hardware breakdown, or deep-seated infection. Patients in group A had a significantly shorter mean operating time, hospital stay, full weight-bearing time and union time (76 ± 16.6 vs. 90 ± 20.3 minutes, p = 0.000; 5.8 ± 2.1 vs. 8.9 ± 3.1 days, p = 0.000; 9.0 ± 1.4 vs. 11.1 ± 1.7 weeks, p = 0.000; and 21.3 ± 3.5 vs. 23.1 ± 3.6 weeks, p = 0.047, respectively). Three patients in group A and one patient in group B presented with malalignment (p = 0.608). The mean Olerud-Molander Ankle score was 89.0 ± 7.1 in group A and 87.6 ± 8.4 in group B (p = 0.478).

Conclusions

Distal tibia metadiaphyseal fractures may be treated successfully with low, multidirectional locked nails or plates. However, low, multidirectional locked nailing may represent a superior surgical option, since it offers advantages in terms of mean operating time, hospital stay, full weight-bearing time and union time.     

Patient-reported outcomes after acute carpal tunnel release in patients with distal radius open reduction internal fixation

Background

Acute carpal tunnel syndrome (CTS) is a complication that can develop after distal radius fractures. Our hypothesis tested whether patient-reported outcomes after acute carpal tunnel release (CTR) performed in combination with distal radius fracture open reduction internal fixation (ORIF) are worse than patient-reported outcomes with only elective CTR as measured by the symptom severity and functional status scales of the Boston carpal tunnel questionnaire (BCTQ).

Methods

A retrospective assessment identified 26 patients treated with acute CTR at the same time as distal radius ORIF, no history of pre-existing CTS or CTR, no other injuries, and >12 months follow-up. Sixteen of these patients (Group A) could be contacted and answered the BCTQ. Group A was age- and sex-matched to control patients (Group B) treated with only elective CTR. A case–control study was performed comparing outcomes of both groups.

Results

The average age of patients was 51 ± 15 years, with an average follow-up of Group A at 49 ± 21 months versus Group B at 55 ± 20 months. The mean symptom severity scale score for Group A was 1.4 ± 0.4 and for Group B was 1.4 ± 0.4. The mean functional status scale score for Group A was 1.4 ± 0.5 and for Group B was 1.3 ± 0.4. The mean total BCTQ score for Group A was 26.5 ± 7.5 and for Group B was 24.9 ± 7.5. There were no statistical or clinically significant differences between Group A and Group B for symptom severity, functional status, and total BCTQ scores.

Conclusions

Patients with acute CTR performed at the same time with distal radius ORIF do as well in the long-term as those patients with only elective CTR as measured by the BCTQ. Patients should expect similar recovery of subjective nerve function from acute median nerve dysfunction when CTR is performed with distal radius ORIF as patients with only elective CTR.     

Atypical femoral fractures after anti-osteoporotic medication: a Korean multicenter study

Purpose

Increasing numbers of atypical femoral fractures have been reported among long-term bisphosphonate users. We evaluated clinical characteristics of atypical femoral fractures throughout Korean multicenter studies.

Methods

We retrospectively analysed the bone mineral density, prodromal symptoms before femoral fracture, and medication history of osteoporosis in 76 cases of atypical femoral fracture.

Results

The mean age of cases was 71.4 ± 8.8 (range, 43–89) years old. The mean follow-up period after the fracture operation was 24.5 ± 12.9 (range, 12–79) months. BMI was 23.2 ± 3.0 on average. The mean BMD of femur was −1.9 ± 1.4 (range, −4.8 to 1.3). Prodromal symptoms including thigh pain before femoral fracture appeared in 22 (28.9 %) of 76 patients. All patients included in the study used bisphosphonate. The duration of taking bisphosphonate before fracture was 36.8 ± 50.8 (one–204 months) months. Fifty-seven (75 %) of 76 patients were taking the medication for more than three years. Delayed union occurred in 43 (56.5 %) of 76 patients. Delayed union was defined as a fractured bone that did not completely heal within six months of injury. The group of having taken anti-osteoporotic medication for more than three years showed relatively longer union period compared to that for a shorter period medication group (4.8 ± 2.5 months vs 9.3 ± 3.7 months, p = 0.017). The delayed union developed in 43 (56.5 %) of 76 patients and showed a significantly higher incidence in the group with long-term therapy (five/43 vs 38/43, p = 0.021). The bilateral femoral fractures developed in 23 (30.2 %) of 76 patients and showed a high incidence in the group medicated more than three years (two/23 vs 21/23, p = 0.039).

Conclusions

The longer bisphosphonates are used, the more the cases of delayed union and the more frequent the development of bilateral fractures following unilateral fractures. With regard to the delayed union, the methods of the acceleration of fracture healing may be beneficial in atypical femoral fracture patients who had been receiving long-term bisphosphonates therapy. Careful observation is required for contra-lateral femurs due to a high incidence of bilateral atypical femoral fractures.     

Determinants of distal radius fracture management in polytrauma patients

Background

Over 640,000 distal radius fractures occur annually in the United States. No studies have been performed looking specifically at polytrauma patients who sustain distal radius fractures. We sought to determine variables affecting management of distal radius fractures in polytrauma patients.

Methods

An IRB-approved review of trauma patients from 2008–2011 was performed. Records for patients with distal radius fractures were examined, assessing age, gender, Glascow Coma Score, Injury Severity Score, mechanism, type, and characteristics of injury, as well as operative repair. A logistic regression was performed using SPSS 15.0.

Results

The database identified 12,054 patients, 434 sustaining a distal radius fracture. No statistically significant difference in operative repair based on mechanism of injury (p = 0.465) was identified. A total of 285 patients (65.7 %) underwent surgery for distal radius fractures. In univariate analysis, younger age was the only statistically significant demographic predictor of surgical intervention (p = 0.003). In both univariate analysis and logistic regression, open, intra-articular, displaced, and comminuted fractures, as well as those with concomitant ulna fractures were statistically significantly associated with operative repair. Fracture displacement was the most likely variable to be associated with surgical intervention (OR = 12.761, 95 % CI[7.219, 22.556]) (p < 0.001).

Conclusions

In polytrauma patients, surgery for distal radius fractures is associated with younger age, open, intra-articular, displaced, and comminuted fractures, as well as concomitant ulna fractures. Displaced fractures were almost 13 times more likely to undergo surgical intervention than non-displaced fractures. Gender and mechanism of injury are not predictive of surgical intervention.     

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.     

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     

Outcomes of distal humerus diaphyseal injuries fixed with a single-column anatomic plate

Purpose

The locking compression extra-articular distal humerus plate (EADHP) is an anatomically shaped, angular stable single-column fixation system for distal third humerus fractures. The purpose of this retrospective study was to evaluate clinical and radiographic outcomes after open reduction and internal fixation of distal humerus fractures with this device.

Methods

Twenty-one consecutive patients with distal humerus fractures were treated with the EADHP system between February 2006 and June 2012. Of these, 19 were clinically and radiographically evaluated after a mean follow-up of 10.4 months. Follow-up assessment included anteroposterior and lateral radiographs, assessment of range of motion (ROM), pain according to a visual analogue scale (VAS) and Disabilities of the Arm, Shoulder and Hand (DASH) score.

Results

All fractures demonstrated satisfactory reduction and healing at an average of 7.3 months. One patient showed post-operative sensory ulnar neuropathy that recovered completely, and nine patients had a preoperative radial nerve palsy, which recovered spontaneously following exploration and plating. Mean post-operative ROM was as follows: flexion 126°, extension −7°, pronation 82° and supination 83°. The VAS score was zero points in eight patients, while the mean DASH score was 25.8 points.

Conclusions

For extra-articular distal humerus fractures, including high-energy injuries often seen in gunshot wounds or motor vehicle injuries, the anatomically shaped angular stable single-column plate provides satisfactory clinical and radiographic results and serves as a valuable tool in the treatment of these injuries.     

Radiographic interpretation of distal radius fractures: visual estimations versus digital measuring techniques

Purpose

Distal radius fractures are a common injury. In the emergency room, trainees regularly assess these fractures using visual estimation. Our hypothesis is that assessment of radiographic parameters has sufficient accuracy for rendering treatment consistent with formal measurements.

Methods

This study compared visual measurements made by 25 orthopaedic residents and attending physicians to formal measurements made by a single fellowship trained musculoskeletal radiologist in a series of patients with distal radius fractures. A search was performed utilizing the ICD-9 code for distal radius fracture in all patients presenting to a single institution emergency department. Participants used visual estimation to rate 25 radiographs. Parameters estimated included radial inclination, radial height, volar tilt, and the presence of intra-articular displacement. Analysis using Lin concordance coefficients, Bland Altman plots, and the Kappa statistic evaluated the agreement between visual estimation and formal measurements. The proportion of raters whose estimates would have resulted in a course of treatment that conflicted with the formal reading quantified the potential impact of visual estimation on treatment.

Results

Concordance coefficients were poor for radial inclination (ρc = 0.13), radial height (ρc = 0.24), and volar tilt (ρc = 0.46). The Kappa statistic for intra-articular displacement was 0.4. Analysis performed according to level of training did not result in substantial improvements in these statistics. Treatment based on visual estimates conflicted with formal readings 34 % of the time for radial inclination, 38 % of the time for radial height, 27 % of the time for volar tilt, and 31 % of the time for intra-articular displacement.

Discussion

Visual estimation is not an adequate form of measurement for evaluation of patients with distal radius fractures. Physicians should be mindful of these results when developing treatment plans based solely upon visual estimation.     

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.     

The Use of Biologic DMARDS Identifies Rheumatoid Arthritis Patients with More Optimistic Expectations of Total Knee Arthroplasty

Background

Preoperative expectations of total knee arthroplasty (TKA) correlate with postsurgical satisfaction, and are linked to outcomes. Rheumatoid arthritis (RA), and other chronic diseases, may lower expectations, although new biologic medications have greatly enhanced patients’ quality of life.

Questions/Purposes

The purpose of this study is to compare preoperative expectations of RA to those of matched osteoarthritis (OA) patients undergoing TKA, and examine the subset of RA on biologic DMARD therapy.

Methods

For a cross-sectional study, RA and OA identified from an institutional TKA registry were matched on age, sex, prior TKA, and preoperative function. Expectations were measured using the Hospital for Special Surgery (HSS) Knee Expectations Survey. Expectations and quality of life measures were assessed preoperatively and scores were compared between RA and OA.

Results

One hundred fourteen RA cases, 46.5% on biologics, were matched to 228 OA cases. The average expectations score was not significantly lower for RA compared to OA (72.9 ± 20.7 vs. 77.2 ± 18.3, p = 0.040. RA on biologics had expectations similar to OA (total expectation score 76.3 ± 18.1 vs. 77.4 ± 17.4, p = 0.71), while RA not on biologics had expectations that were significantly lower (69.9 ± 22.4 vs. 77.1 ± 19.0, p = 0.03).

Conclusion

Use of biologics in RA patients was associated with higher expectations, similar to those of OA patients, but the effect on outcomes is not known. Further studies should assess the effect of higher expectations in RA patients on outcomes.

Electronic supplementary material

The online version of this article (doi:10.1007/s11420-014-9380-1) contains supplementary material, which is available to authorized users.     

Extra-articular dorsal closing-wedge osteotomy to treat late-stage Freiberg disease using polyblend sutures: technical tips and clinical results

Purpose

The purpose of this study was to evaluate the clinical outcomes regarding the dorsal wedge osteotomy fixed using a polyblend suture and describe the usefulness of this fixation method for the treatment of Freiberg disease.

Methods

The subjects consisted of 13 feet from 13 cases suffering from Freiberg disease that underwent extra-articular dorsal closing-wedge osteotomy using a polyblend suture. The average age was 31.7 (range 13–72) years. The average follow-up period was 17 (range 14–24) months. Regarding image findings, time to bone union and metatarsal shortening was reviewed. The investigation was carried out using the range of motion (ROM), visual analog scale (VAS), and Japanese Society of the Surgery of Foot lesser toe scale (JSSF score) in the MTP joint before surgery and at the latest follow-up.

Results

Calluses under the metatarsal head were not observed in any cases. The mean metatarsal shortening was 2.33 ± 2.07 mm at follow-up. The bone union required an average of 8.4 ± 0.8 weeks. The average ROM of dorsal flexion improved from 37.2 ± 5.3° before surgery to 73.6 ± 9.9° at latest follow-up (p < 0.0001). The average ROM of plantar flexion improved from 16.0 ± 10.1° before surgery to 19.5 ± 8.6° at latest follow-up (p = 0.35). The average VAS significantly improved from 75.3 ± 8.5 before surgery to 4.9 ± 4.2 at latest follow-up (p < 0.0001). The average JSSF score significantly improved from 67.3 ± 9.4 points before surgery to 98.8 ± 3.0 points at the latest follow-up (p < 0.0001).

Conclusion

Extra-articular dorsal closing-wedge osteotomy using a polyblend suture was carried out to treat Freiberg disease. The bone union was observed in all cases with improved clinical results. Fixation using a polyblend suture was considered to be useful.     

A distal femoral supra-condylar plate: biomechanical comparison with condylar plate and first clinical application for treatment of supracondylar fracture

Purpose

An anatomical supra-condylar plate is designed and analysed by biomechanical testing.

Methods

The biomechanical properties of the supra-condylar and condylar plate were compared in six matched pairs of cadaveric femurs. A transverse osteotomy gap was created to simulate an OTA/AO type A3 supracondylar fracture. The left and right specimens were fitted with supra-condylar and condylar plate, respectively. Nondestructive axial compression, three-point bending and torsion tests were performed, and the peak load of the bone-implant construction was measured. The fracture site suitable for supra-condylar plate application and its correlation with femoral length were calculated. The gender influence on it was also discussed.

Results

The difference of stiffness between the supra-condylar and condyle groups were not significant (P > 0.05) at 363.4 and 362.5 N/mm for compression, 229.5 and 237.6 N/mm in the sagittal plane and 195.5 and 188.4 N/mm in the coronal plane for three-point bending, and 7.5 and 7.9 Nm/deg for axial torsion, respectively. The peak load was 4438 ± 136.15 N and 5215 ± 174.33 N, respectively, for the two groups. The average extent of the fracture site suitable for the application of the supra-condylar plate was 70.86 ± 4.61 mm. The femoral length and gender showed no influence on it.

Conclusion

Despite the limited bone contact area provided by the supra-condylar plate, its construct stiffness is comparable to the condylar plate. The supra-condylar plate can be used to treat carefully-selected extra-articular supracondylar fractures.     

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.     

Internal fixation of femoral neck fractures with posterior comminution: a biomechanical comparison of DHS® and Intertan nail®

Background and purpose

Internal fixation is a therapeutic mainstay for treatment of undisplaced femoral neck fractures and fractures without posterior comminution. The best treatment for unstable and comminuted fractures, however, remains controversial, especially in older patients. The present study was designed to assess the utility of the Intertan Nail® (IT) for stabilization of comminuted Pauwels type III fractures compared to dynamic hips screw (DHS).

Methods

Randomized on the basis of bone mineral density, 32 human femurs were assigned to four groups. Pauwels type III fractures were osteomized with a custom-made saw guide. In 16 specimens the posteromedial support was removed and all femurs were instrumented with an IT or a DHS. All constructs were tested with nondestructive axial loading to 700N, cyclical compression to 1,400N (10,000 cycles), and loading to failure. Outcome measures included number of survived cycles, mechanical stiffness, head displacement and load to failure.

Results

Postoperative mechanical stiffness and stiffness after cyclical loading were significantly reduced in all constructs regardless of the presence of a comminution defect (p = 0.02). Specimens stabilized with the IT had a lower construct displacement (IT, 8.5 ± 0.5 mm vs. DHS, 14.5 ± 2.2 mm; p = 0.007) and sustained higher failure loads (IT, 4929 ± 419 N vs. DHS, 3505 ± 453 N; p = 0.036) than the DHS constructs.

Interpretation

In comminuted Pauwels type III fractures, the fixation with the IT provided sufficient postoperative mechanical strength, comparable rate of femoral head displacement, and a similar tolerance of physiological loads compared to fractures without comminution. The absence of the posteromedial support in comminuted fractures tended to reduce the failure load regardless of the fixation method.     

Expression of inducible nitric oxide synthase in muscle flaps treated with ischemic postconditioning

Background/Objective

Preconditioning has been considered promising for the treatment of ischemic flaps. In this study, the therapeutic effect of postconditioning was compared with that of preconditioning during ischemia/reperfusion (I/R) injury, and a role of inducible nitric oxide synthase (iNOS) in postconditioning treatment was also explored.

Methods

Sixty rats were randomly divided into four groups with 15 rats in each group. Ischemic injury was induced in a rat’s gracilis muscle flap model. Preconditioning and postconditioning were performed respectively on the flaps in the pre-con group and the post-con group. No treatment was given to the flaps in the control group, and flaps without I/R injury were used as a sham control. Muscle viability ratio, histology, and gene expression of iNOS were examined at different time intervals (3, 12, and 18 h).

Results

A significantly higher survival ratio was observed in both the pre-con group (78.98 ± 3.39, 62.74 ± 3.7, and 54.42 ± 4.45 %) and the post-con group (77.42 ± 4.14, 59.74 ± 6.67, and 49.52 ± 4.13 %) than the control group (45.22 ± 3.69, 42.44 ± 3.76, and 33.2 ± 3.29 %) at 3, 12, and 18 h postoperatively (P < 0.05). There was no statistical difference between the pre-con group and the post-con group (P > 0.05). Histological examination showed delayed and attenuated tissue damage in both the pre-con group and the post-con group when compared to that of the control group. A higher expression of iNOS was observed in both the pre-con group and the post-con group than the control group and the sham group (P < 0.05).

Conclusions

Significant improvement of flap survival could be achieved by both preconditioning and postconditioning treatments; however, better protection could be provided by preconditioning. The higher expression of iNOS may play an important role in the therapeutic effect of postconditioning during I/R injury.     

Preoperative classification assessment reliability and influence on the length of intertrochanteric fracture operations

Purpose

The accuracy of intertrochanteric fracture classification is important; indeed, the patient outcomes are dependent on their classification. The aim of this study was to use the AO classification system to evaluate the variation in classification between X-ray and computed tomography (CT)/3D CT images. Then, differences in the length of surgery were evaluated based on two examinations.

Methods

Intertrochanteric fractures were reviewed and surgeons were interviewed. The rates of correct discrimination and misclassification (overestimates and underestimates) probabilities were determined. The impact of misclassification on length of surgery was also evaluated.

Results

In total, 370 patents and four surgeons were included in the study. All patients had X-ray images and 210 patients had CT/3D CT images. Of them, 214 and 156 patients were treated by intramedullary and extramedullary fixation systems, respectively. The mean length of surgery was 62.1 ± 17.7 min. The overall rate of correct discrimination was 83.8 % and in the classification of A1, A2 and A3 were 80.0, 85.7 and 82.4 %, respectively. The rate of misclassification showed no significant difference between stable and unstable fractures (21.3 vs 13.1 %, P = 0.173). The overall rates of overestimates and underestimates were significantly different (5 vs 11.25 %, P = 0.041). Subtracting the rate of overestimates from underestimates had a positive correlation with prolonged surgery and showed a significant difference with intramedullary fixation (P < 0.001).

Conclusions

Classification based on the AO system was good in terms of consistency. CT/3D CT examination was more reliable and more helpful for preoperative assessment, especially for performance of an intramedullary fixation.     

Benefits of early intramedullary nailing in femoral metastases

Purpose

Pathological fractures of the long bones are common complications of metastatic disease; however, the outcome of different surgical techniques for the treatment of these fractures has not been clearly defined. The aim of this study was to evaluate differences in prophylactic and therapeutic intramedullary nailing in femoral metastasic implants.

Methods

Sixty-five patients with metastasis of the femur were analysed retrospectively (37 females; 28 males) between 1995 and 2011 (follow-up 15 months). Forty-four presented with pathological fractures and 21 impending fractures (Mirel ≥7). The operative treatments used were intramedullary fixation with reamed long Gamma nails. The studied parameters were survival, radiological and analytical findings, and functional outcomes.

Results

Prophylactic nailing resulted in immediate postoperative deaths in 5 % vs. 11.4 % in therapeutic, and one technical complication was detected in each group. Among the surviving patients 75.9 % of the fractures and 100 % of impending lesions were able to walk after the operation. The mean survival time was 11 months in the therapeutic (range 1–49) and 14 in the prophylactic group (1–34). The prophylactic intramedullary nails required a lower transfusion rate (1.4 concentrates vs. 3.0), mobilised earlier (day 4.0 vs. 9.7) and needed a shorter hospital stay (eight days vs. 16 days) compared to therapeutic nails (p < 0.05).

Conclusion

Femoral intramedullary nailing of metastasic lesions provides satisfactory results both clinically and radiologically. Early treatment of the metastases prevents fractures and gives better results, improving life quality of these patients.     

The functional outcome of forty-nine single-incision suture anchor repairs for distal biceps tendon ruptures at the elbow

Purpose

The objective of this retrospective study was to evaluate the functional results of distal biceps tendon repair using suture anchors via a single-incision approach.

Methods

Forty-nine patients were re-examined at a mean follow-up of 44.2 ± 32.1 months (range, 12–119 months). Subjective and objective criteria included patient’s satisfaction, active range of motion (ROM), maximum isometric strength in flexion (at 45° and 90°), and supination of both arms. Functional scoring included the Morrey elbow score (MES) and the QuickDASH. Furthermore, follow-up radiographs were performed.

Results

Eighty-six percent of patients were highly satisfied or satisfied with their outcome. Compared to contralateral, the active ROM of elbow flexion, extension, and pronation was not affected; however, supination was decreased by 3° (P < 0.001). The isometric maximum strengths showed significant deficits in all tested scenarios (at 45°, P = 0.002; at 90°, P < 0.001; for supination, P < 0.001). The MES and the QuickDASH were 97.2 ± 4.9 and 7.9 ± 13.9, respectively. Heterotopic ossifications (HO) were found in 39 % of patients; however, with respect to scores and strength, no significant differences were seen compared to patients without HO. Moreover, four anchor failures were detected.

Conclusions

Single-incision suture anchor repair provides high patient’s satisfaction and good results with respect to ROM and functional scoring. Nevertheless, based on presented data, the patient has to be informed of postoperative HO and especially for supination strength weakness after surgery. Distal biceps tendon repair should be reserved for experienced upper extremity surgeons to avoid procedure-related complications.     

A cohort study of one-year functional and radiographic outcomes following intra-articular distal radius fractures

Background

The purpose of this study was to describe the outcomes of a series of patients followed prospectively after intra-articular distal radius fractures.

Methods

One hundred forty-eight patients with intra-articular fractures (mean age, 47 years; age range, 44–54 years; gender distribution, 60 males and 88 females) were treated with cast only, arthroscopy/closed reduction plus pins, arthroscopy/closed reduction with external fixation, open reduction and internal fixation (ORIF) alone, and ORIF with external fixation according to surgeon preference and fracture characteristics. The 1-year outcomes across the groups were measured radiographically (n = 148) and functionally (n = 113; 1-year Wrist Outcome Measure score, Grip Strength, SF-36, and PRWE scores).

Results

Radiographically, the groups had statistically significant differences in radial inclination, volar tilt, intra-articular step-off, and radial shortening in the pre-treatment X-rays. However, following treatment, treatment groups demonstrated no difference statistically in their follow-up radiographic measures. One-year PRWE scores were found to be statistically different across groups. Across groups, the ORIF-alone treatment group had the highest PRWE score reflecting greatest amount of pain and disability. One-year wrist outcome measure scores and grip strength scores were also found to be significantly different across treatment groups. The general health status as measured by the SF-36 was not found to be different across treatment groups.

Conclusions

These findings are consistent with treatment by indication; suboptimal ORIF outcomes may reflect older practice patterns with dorsal plating. A randomized control trial that compares treatments controlling for fracture severity and studies that develop formal clinical prediction rules for treatment assignment are needed.