Osteosynthesis aims to maintain fracture reduction until bone healing occurs, which is not achieved in case of mechanical fixation failure. One form of failure is plastic plate bending due to overloading, occurring in up to 17% of midshaft fracture cases and often necessitating reoperation. This study aimed to replicate in-vivo conditions in a cadaveric experiment and to validate a finite element (FE) simulation to predict plastic plate bending. Six cadaveric bones were used to replicate an established ovine tibial osteotomy model with locking plates in-vitro with two implant materials (titanium, steel) and three fracture gap sizes (30, 60, 80 mm). The constructs were tested monotonically until plastic plate deformation under axial compression. Specimen-specific FE models were created from CT images. Implant material properties were determined using uniaxial tensile testing of dog bone shaped samples. The experimental tests were replicated in the simulations. Stiffness, yield, and maximum loads were compared between the experiment and FE models. Implant material properties (Young's modulus and yield stress) for steel and titanium were 184 GPa and 875 MPa, and 105 GPa and 761 MPa, respectively. Yield and maximum loads of constructs ranged between 469–491 N and 652–683 N, and 759–995 N and 1252–1600 N for steel and titanium fixations, respectively. FE models accurately and quantitatively correctly predicted experimental results for stiffness (R2=0.96), yield (R2=0.97), and ultimate load (R2=0.97). FE simulations accurately predicted plastic plate bending in osteosynthesis constructs. Construct behavior was predominantly driven by the implant itself, highlighting the importance of modelling correct material properties of metal. The validated FE models could predict subject-specific load bearing capacity of osteosyntheses in vivo in preclinical or clinical studies. Acknowledgements: This study was supported by the AO Foundation via the AOTRAUMA Network (Grant No.: AR2021_03)

Introduction- Proximal humeral fractures remain a challenging problem. Most authors agree that anatomical reduction and stable fixation are essential to allow early range of motion. A variety of techniques have been described such as threaded pins, tension band wiring, screws, nails, plates and primary prosthesis. Locking plates score over other implants by the virtue of providing greater angular stability and better biomechanical properties. The Aim of the Study is to evaluate the functional outcome of PHILOS plate Osteosynthesis of displaced proximal humeral fractures. Materials and Methods- A retrospective study of 50 patients treated with PHILOS plating for the 2 part, 3part and 4 part proximal humeral fractures with a minimum follow up of 1 year. All the patients were assessed in clinic by Constant Murley and ASES scoring systems. X-ray evaluation was done for fracture healing, AVN, mal-union, non-union, collapse of head, screw penetration and impingement of plate. Results- Total of 50 acute displaced fractures of proximal humerus treated with PHILOS plating between 2003–2005 were assessed. Mean age was 64 years (15–86) Male to female ratio was 12:38, dominant to non-dominant ratio was 32:18. According to Neer’s classification 16 fractures were 2 part, 24 fractures were 3 part and 10fractures were 4 part. The overall mean Constant score was 73.4(range20–100) and ASES score was 71.7(range 25–98). Under 60 years of age the mean Constant and ASES scores were 83.5 and 83, over 60 years of age scores were 63.1 and 60.4 respectively. The complications include two deep infections which needed excision arthroplasty, one malunion, one subacromial impingement which needed plate removal after fracture healing. No mechanical failure, no non-union, no ANV was noted. Conclusions- PHILOS plate Osteosynthesis is a reliable method of treating complex proximal humeral fractures. It provides good mechanical stability and allows rapid mobilization with out compromising fracture healing

Introduction. Osteosynthesis to conserve femoral head following neck of femur (NOF) fractures has reported failure rates of 36 to 47% at 2 years. However, the long-term outcomes of THAs performed for failed osteosynthesis is yet to be elucidated. This study aims to report on long term outcome of primary THAs post failed osteosynthesis for NOF fracture. Methods. Consecutive patients with THA for failed NOF osteosynthesis managed by a single unit between January 1974 and December 2009 were included. Clinical and radiological outcomes of all 72 patients were analysed. Patients with minimum follow-up of 5 years were included. Those with less than 5 years of follow-up were reviewed for failures. Results. Mean age at the time of THA was 56. (range − 18–79). Mean follow-up was 12.9 years (range − 5 to 35.5). All patients had cemented THA. The major late complications included stem loosening in 4, stem fracture - 1, cup loosening - 7, deep infection − 3 and dislocations in 4. Thirteen (18.1%) patients had revisions. Cumulative survival rate is 80.3% (CI: 91.6–69.1) at 10 years. Conclusion. The outcomes for patients with THA for failed osteosynthesis post NOF fracture is worse in comparison with reported revision rates of THA for acute NOF fracture. The risks of poorer outcomes following salvage THA and morbidity of failed osteosynthesis need to be factored in for NOF fracture management

Background. Stress fractures at tracker after computer navigated total knee replacement are rare. Periprosthetic fracture after Minimally Invasive Plate Osteosynthesis (MIPO) of stress fracture through femoral tracker is unique in orthopaedic literature. We are reporting this unique presentation of periprosthetic fractures after MIPO for stress fracture involving femoral pin site track in computer assisted total knee arthroplasty, treated by reconstruction nail (PFNA). Methods. A 75-year old female, who had computer navigated right total knee replacement, was admitted 6 weeks later with increasing pain over distal thigh for 3 weeks without trauma. Prior to onset of pain, she achieved a range of movements of 0–105 degrees. Perioperative radiographs did not suggest obvious osteoporosis, pre-existent benign or malignant lesion, or fracture. Radiographs demonstrated transverse fracture of distal third of femur through pin site track. We fixed the fracture with 11-hole combihole locking plate by MIPO technique. Eight weeks later, she was readmitted with periprosthetic fracture through screw hole at the tip of MIPO Plate and treated by Reconstruction Nail (PFNA), removal of locking screws and refixation of intermediate segment with unicortical locking screws. Then she was protected with plaster cylinder for 4 weeks and hinged brace for 2 months. Results. Retrograde nail for navigation pin site stress fracture entails intraarticular approach with attendant risks including scatches to prosthesis and joint infection. So we opted to fix by MIPO technique. Periprosthetic fracture at the top of MIPO merits fixation with antegrade nail in conjunction with conversion of screws in the proximal part of the plate to unicortical locking screws. Overlap of at least 3cms offers biomechanical superiority. She made an uneventful recovery and was started on osteoporosis treatment, pending DEXA scan. Conclusion. Reconstruction Nail (PFNA), refixation of intermediate segment with unicortical locking screws constitutes a logical management option for the unique periprosthetic fracture after MIPO of stress fracture involving femoral pin site track in computer assisted total knee replacement

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders’ classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale. There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler’s angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders’ classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler’s angle

Introduction. Osteosynthesis with open reduction techniques in comminuted subtrochanteric femoral fractures can further devitalise fragments and lead to increased rate of non-union, infection, and implant failure. Therefore, these fractures require indirect reduction techniques that do not further damage the vascular supply or soft tissue attachments of the fragments. Dynamic condylar screw (DCS) using indirect reduction and minimally invasive technique may be a good alternative to avoid these complications in such fractures. Material & methods. Forty-three patients with comminuted subtrochanteric fractures underwent indirect reduction and biological internal fixation with DCS. Mean age was 43.9 (range 25–65) years. There were six Seinsheimer type III, 15 type IV and 22 type V fractures. Results. All fractures united without bone grafting at average union time of 16.16 weeks (range, 13–22) weeks. There were no cases of non-union or implant failure at mean follow-up of 25.13 months. We observed technical difficulties in six patients such as: inaccurate placement of guide pin in two patients, difficulty in sliding the plate due to obesity in one patient, difficulty in gliding barrel plate over condylar screw in one patient and technical failure in a further two patients. Seven patients had mean limb length discrepancy of 1.48 cm (range, 1–2). Mean Harris hip score was 88.2 (range 80–90) points. Two patients had coxa vara and persistent limp. Discussion. Stripping of the soft tissues to the lateral cortex is kept to a minimum in indirect reduction. The vitality of the medial fragments is not further compromised since they are not exposed. Viable bone rapidly unites by callus formation. Conclusions. Osteosynthesis of comminuted subtrochanteric fractures is desirable using indirect reduction and minimally invasive technique. Dynamic condylar screw can be used based on these principles; however, proper planning and execution of the technique is required to achieve good functional outcome and to avoid complications

Lateral tibial plateau fractures are articular fractures that can have a severe prognosis involving a joint biomechanically and functionally very important. Osteosynthesis is very often required as the articular surface must be accurately restored. In many cases rigid devices were implanted, often sacrificing lateral meniscus and leading to osteoarthritic changes in the following years. In the recent years new diagnostic tools as TC and MRI and the growing role of arthroscopy have allowed a more precise diagnosis and the possible use of less invasive devices. Considering all fractures classified as B3 according AO (or type 2 by Schatzker), we considered 10 cases treated with Barr screw and 8 cases treated with K-wires positioned as a shelf after reduction and bone grafting. All patients underwent an accelerated rehabilitation protocol with immediate mobilization and full weight bearing within 10 weeks. At the follow-up at 24 months, both the groups showed very good and comparable clinical, radiographical and functional results. We can conclude that after an accurate preoperative planning also the use of less invasive devices allow a quick recovery of range of motion without compromising the stability of osteosynthesis and the morphology of knee joint

Aim: To compare 2 methods of osteosynthesis (pinning and plate and screws) in displaced intraarticular fractures of the calcaneus. Material and method: Between 2001 and 2005, 82 displaced intraarticular fractures of the calcaneus were surgically treated in our department. Fractures were classified according to Bohler’s classification: 18 Bohler type II and 64 Bohler type III fractures. Open reduction and reconstruction with osseous grafts (autologous grafts in 22 cases and heterologous grafts in 52 cases) were used in 74 cases. In 8 cases (all of Bohler II type) grafts weren’t used. Osteosynthesis with plate and screws was performed in 26 cases and with pins in 56. The 2 groups were similar in what concerns age, sex ratio, BMI, degree of comminution. The surgical procedure was delayed in both groups (average − 6 days). Pins were removed at 6 weeks and the plates at 12 months. Results: A number of clinical parameters (pain evolution, moment of partial and full weight bearing, achievement of clinical and radiological union, ankle and forefoot mobility, etc.) were similar in both groups. Skin complications were more frequent in the plate group even if similar lateral surgical approaches were used. Pain along peroneal tendons was much more frequent in the plate group. Conclusions: Even if theoretically osteosynthesis with plate and screws assures a better fixation, in practice it has similar clinical results with the pinning. The number of complications is higher after plate osteosynthesis. The pins can be extracted with local anesthesia, while plate extraction requires lumbar or general anesthesia and a full extent surgical procedure

Purpose of the study: Osteosynthesis material adapted to a mini-invasive approach certainly reduces surgical trauma. The purpose of this work was to establish the osteosynthesis equivalence for pertrochanteric fractures using a dynamic hip screw, inserted according to the conventional technique versus a mini-invasive screw system (MISS), in terms of healing without loss of reduction. Material and methods: This was a prospective pilot study in a single centre. From May 2006 to April 2007, 78 patients (mean age 83 years, 70% women) were included (38 MISS, 40 DHS). There was one exclusion criteria: poor reduction on the orthopaedic table before incision. Radiographic and clinical follow-up for six months. The main outcome was the quality of the reduction and healing at three months. Results: Eight patients were lost to follow-up and two had died at three months. The two groups were comparable regarding mean age, ASA, fracture type, operator experience, and centring of the head screw. In the MISS group, there was a 20% reduction in blood loss, a shorter incision (9 cm) and shorter operative time (16 min). The differences were not significant. The healing rate without loss of reduction at three months was the same in both groups: 82%. There were three revisions in the MISS group: one infection and two material disassemblies. This problem disappeared with the addition of a locking screw on the nail. There were no revisions for haematoma. Discussion: There were several biases. The series was not really randomised because the type of material used depended on the availability of the instrument sets. The MISS implant evolved during the course of the study. The operators were more familiar with the DHS. Inclusion criteria were too restrictive. Multiple-injury patients with bleeding had a false impact on blood loss data. None of the differences were statistically significant. Revision for infection was not directly attributable to the material. Nail locking never failed after use of the locking screw. Conclusion: The main outcome was validated: the healing rate without reduction at three months is equivalent with the two methods (82%). A multicentric study should be conducted to confirm that the mini-incision and the MISS reduces blood loss. It could be expected that this mini-invasive approach will become the rule for osteosynthesis of these fractures with a dynamic hip screw

Aim

The most frequent mechanical failure in the osteosynthesis of intertrochanteric fractures is the cut-out. Fracture pattern, reduction quality, tip-apex distance or the position of the cervico-cephalic screw are some of the factors that have been associated with higher cut-out rates. To date, it has not been established whether underlying bacterial colonization or concomitant infection may be the cause of osteosynthesis failure in proximal femur fractures (PFF). The primary objective of this study is to assess the incidence of infection in patients with cut-out after PFF osteosynthesis.

Purpose of the study: This study was conducted to assess short- and mid-term radiographic outcome of percutaneous posterior osteosynthesis (Sextant®)of thoracolumbar spine fractures and to identify indications and complications. Material and methods: The Sextant® material was used for 14 patients with a lumbar spine or low thoracic spine fracture. Mean patient age was 40 years (range 19–84). Outcome was reviewed retrospectively. Osteosynthesis was performed for 11 fractures Mager 1 A3, 2 B2, 1 C1 with no neurological deficit. A complementary graft and anterior decompression were used 11 times (9 fibular, 1 posterior crest + rib, 1 cage). The pre- and postoperative and 3 month ART were noted. The position of the implants was assessed on the postoperative CT. Results: Mean follow-up was 9.2 months (range 2–16). On average, ostheosynthesis was performed 15 days after trauma (range 1–90 days). There were no neurological or infectious complications. Sutures had to be resected in two cases due to cutaneous suffering. Nine patients wore a corset for three months. The absolute ART score improved from 18 preoperatively to 7 postoperatively and was noted at 14 at three months. Seven patients required heterologous blood transfusion after the anterior approach. Three screws (5.3%) were ectopic but without consequence. Discussion: Indications for percutaneous osteosynthesis include spinal fractures without neurological complications with sagittal deformation for which an anterior approach is planned initially for mechanical reasons. An isolated anterior approach is possible in this type of fracture; nevertheless, percutaneous posterior osteosynthesis enables emergency reduction and fixation of the fracture, a simplified secondary minimal anterior approach for release, and bone grafting without anterior instrumentation. Three patients did nor require complementary anterior stabilization as the percutaneous oseosynthesis played the role of «internal fixation». The advantages of percuteneous osteosynthesis are the absence of bleeding and damage to the paravertebral muscles which limits morbidity, particularly infection. This technique can be performed in the emergency setting, especially for multiple trauma victims. The drawbacks of percutaneous osteosynthesis are the impossibility of performing a posterior fusion and release the spinal canal. The loss of correction observed were probably related to the type of graft (fibular). Use of a cage should limit graft impaction and loss of correction

Purpose of the study: The treatment of thoracolumbar fractures has evolved over the last five years with cementoplasty percutaneous osteosynthesis in addition to the gold standard orthopaedic or surgical treatments. This percutaneous method preserves muscles and maintains reduction to healing. The purpose of this work was to evaluate our results in traumatology patients after five years experience, deducting our current indications. Material and methods: From February 2004 to February 2009, we included 60 patients with a type A or B2 thoracolumbar fracture free of neurological problems and who had more than 10° kyphosis. Reduction was achieved in hyperlordosis before the percutaneous procedure. In other cases we used open arthrodesis. This was a retrospective analysis of a consecutive monocentre series including 37 men and 23 women, mean age 37 years. The injury was L1 and T12 in the majority. Classification was A1 and A3 for the majority. Osteosynthesis was achieved with an aiming compass and radioscopy. A removable corset was used as needed. Reduction and position of the screws as well as need for a complementary anterior fixation were assessed on the postoperative scan. Clinically, follow-up measured pain and quality of life (VAS and Oswestry), radiographically, vertebral kyphosis. Results: Mean follow-up was 24 months. At last follow-up, the VAS was 15/100 and the Oswestry 16/100. Material was removed in ten patients. Early in our experience one patient developed neurological problems postoperatively requiring revision surgery. Postoperative vertebral kyphosis was stable at three months and was sustained at two years. Body healing was successful in all cases. There were no cases of material failure. Discussion: This is a reliable reproducible technique in the hands of a spinal surgeon. Material removal can be proposed about one year after implantation. After the age of 65 years, we favour cementoplasty. For others, we propose a sextant for A1, A2, A3 or B2 fractures with more than 15° vertebral kyphosis. This percutaneous material had major advantages for tumour surgery, for multiple injury patients and for traumatology (especially when a double approach is used). Conclusion: Percutaneous osteosynthesis of vertebral fractures is now the gold standard for well defined indications. Two therapeutic fundamentals are reduction on the operative table and preservation of the muscle stock. These satisfactory results should be confirmed after removal of the implants

Introduction:. Percutaneous fixation of intraarticular calcaneal fractures adequately restore the subtalar joint with lower soft tissue complications and equivalent short-term results compared to open fixation. However, studies have largely focused on less severe fracture types (Sanders types 2/3). We report our initial experience of this relatively new Mini-open Arthroscopic-assisted Calcaneal Osteosynthesis (MACO) technique for more comminuted calcaneal fractures (Sanders types 3/4). Methods:. We prospectively studied consecutive patients with intraarticular calcaneal fractures requiring surgical fixation between April 2012 and June 2013. MACO involves initial subtalar arthroscopic debridement, with subsequent fluoroscopic-assisted, mini-open reduction and fixation of depressed fragments using cannulated screws. Outcome scores (Manchester-Oxford Foot(MOXFQ), AOFAS Hindfoot and SF-36 questionnaires) and radiological parameters were recorded with a mean follow-up of 12 months (7–13). Results:. There were 9 patients (7 M:2 F) with a mean age of 45.4 years (24–70). All had intra-articular joint depression-type fractures: 5 Sanders type 3 and 4 Sanders type 4. Mean time to surgery was 6.6 days (1–13), operating time was 89.4 minutes (66–130) and inpatient stay was 1.7 days (1–4). All wounds healed without complication and one patient required change of a long screw 11 days post-operatively. There were significant post-operative improvements in the mean Bohler's angle (−2°[−27.2–14.8] to 30°[10.2–41.3], p<0.0002) and angle of Gissane (95°[66.2–111.7] to 111°[101.6–120], p=0.004). Mean outcome scores were 60.8(41–86) for MOXFQ and 75.3(55–92) for AOFAS Hindfoot, with 55.9% developing moderate/severe subtalar joint stiffness. Mean physical and mental SF-36 summary scores were 35.5(24.5–41.5) and 51.7(40.8–61.7) respectively. Conclusion:. We describe the MACO technique for Sanders types 3/4 calcaneal fractures. There were no soft tissue complications with good short-term outcomes, despite a reduction in hindfoot mobility. Restoration of the joint and bone stock without infection is desirable in the event of subsequent arthrodesis. We propose MACO is a valuable alternative technique to open fixation

Abstract

Introduction: Proximal humeral fractures have been increasing in recent years with the increase in population over 60 years old. 20 to 30% of these fractures require surgical treatment according to the Neer criteria: fragments dislocation greater than 1 cm and/or an angle greater than 45°. A rigid fixation of proximal humeral fractures in elderly patients with osteoporotic bone is not satisfactory; new solutions are sought. The authors describe a minimally invasive technique that uses an intramedullary elastic implant – helix wire. Objective: Evaluate functional outcomes and complication rates in patients with humeral subcapital fractures who underwent fixation with helix wire. Material: Cross-sectional study evaluating patients with subcapital fracture of the humerus who underwent fixation with helix wire. Methods: There were operated 32 patients with proximal humeral fractures with helix wire implant, with an average age of 71 years old (41–90). 9 men and 23 women. According to Neer’s classification: 18 two parts fractures, 12 three parts and 2 four parts. Osteosynthesis with cannulated screws was associated to the helix wire in three and four parts fractures. In all patients the shoulder was immobilized for 3 weeks. After 3 weeks patients started rehabilitation. Results: Of the 32 fractures, 30 consolidated and there were no avascular necrosis of the humeral head. A fracture has evolved to pseudarthrosis. One patient abandoned follow-up 4 weeks after surgery, and was therefore not possible to assess the consolidation. 17 patients were assessed with mean follow-up of 18 months (4–52 months). The mean Constant score obtained was 66.2 points (53–90). 3 months after surgery all patients resumed their daily activities to the level before the fracture. Discussion and Conclusion: This minimally invasive technique provides good stability, with minimum damage of soft tissue and vascular preservation of the humeral head. Our choice is based on the number of consolidations achieved through this technique and functional evaluation of these patients, which we consider satisfactory, taking into account that the functional requirements are lower than those of a young person. Intramedullary helical implant (helix wire) is simple and biological, suitable for elderly patients with poor bone, which enables percutaneous osteosynthesis using the techniques of indirect reduction and the association, when appropriate, of cannulated screws

Purpose: The purpose of this biomechanical study is to compare the double reconstruction plate osteosynthesis versus double tension band osteosynthesis in the fixation of osteoporotic supracondylar humeral fractures.

Materials and Methods: Sixteen fresh cadavers (mean age: 75, range:70–80) were randomized into two experimental groups. Same supracondylar transverse humeral fractures were formed in both groups. Fractures in the first group, were fixed with double tension band technique using 2mm in diameter Kirschner wires and 1mm in diameter tension wires. Fractures in the second group, were fixed with double reconstruction plate osteosynthesis using 3,5mm reconstruction plates each fixing medial and lateral columns. Distal fragment was fixed with only one screw. Axial loading, maximum load, failure load and failure patterns were analysed. Statistical analysis was performed with SPSS 13.90 soft ware program. Groups were compared with Mann Whitney U test.

Results: Minimum load reqired for fracture displacement was statistically higher in double reconstruction plate osteosynthesis group (p< 0.005). Minumum load reqired for fixation failure was statistically higher in double reconstrution plate osteosynthesis group (p< 0,020).

Conclusion: Fracture healing mainly depends on a stable fracture fixation. Double plate ostesynthesis should be preferred over double tension band technique in osteoporotic supracondylar humeral fractures as it provides more stability.

Aim

The purpose of this study is to analyze the demographic and microbiological variables of acute ankle infections posterior to ankle osteosynthesis and to determine the different characteristics of patients withE. cloacae infection.

Fractures of the ankle are common, and they mostly affect young adults. Wound complications are not uncommon following the fixation of these fractures. This study evaluated the impact of HIV on wound healing after plate osteosynthesis in patients with closed ankle fractures.

This is an observational retrospective study of patients operated on at a tertiary level hospital. We reviewed hospital records for patients above 18 years of age who presented with wound breakdown following ankle open reduction and internal fixation. The patients’ hospital records were retrieved to identify all the patients treated for closed ankle fractures and those who developed wound breakdown. Patients with Pilon fractures were excluded. The National Health Laboratory System (NHLS) database was accessed to retrieve the CD4 count, viral load, haematology study results, and biochemistry results of these patients at the time of surgery and subsequent follow-up. The x-rays were retrieved from the electronic picture archiving system (PACS) and were assessed for fracture union at a minimum of 3 months follow-up.

We reviewed the medical records of 172 patients with closed ankle fractures treated from 2018 to 2022. Thirty-one (18.0%) developed wound breakdown after surgery, and they were all tested for HIV. Most of the patients were male (58.0%), and the average age of the cohort was 43.7 years (range: 21 years to 84 years). Ten of these patients (32.2%) were confirmed HIV positive, with CD4 counts ranging from 155 to 781. Viral load levels were lower than detectable in 40% of these patients. All patients progressed to fracture union at a minimum of 3 months follow-up.

We observed no difference between HIV-positive and HIV-negative patients in terms of wound breakdown and bone healing post-plate osteosynthesis for closed ankle fractures.

Abstract

Aim

Management of infection after osteosynthesis (IAO) poses a significant challenge in the setting of multidrug resistant organisms (MDRo). We have analysed whether IAO with MDRo has an adverse outcome.

Aims

Proximal humeral fractures (PHFs) are common. There is increasing evidence that most of these fractures should be treated conservatively. However, recent studies have shown an increase in use of operative treatment. The aim of this study was to identify the trends in the incidence and methods of treatment of PHFs in Finland.

The influence of rigid fixation and permanent compression on the results, the timing of fusion and rehabilitation after fractures of the femoral neck was investigated.

A hip fracture is 60–80% of all fractures of the proximal femur. Despite recent advances in the treatment of this disease, the percentage of unsatisfactory outcomes as high as 25–35%. The choice of surgical treatment in femoral neck fractures in the elderly remains as controversial as it was almost 50 years ago when Speed called him as “the unsolved fracture. Hip replacement is currently the gold standard in the treatment of femoral neck fractures. But compared with the osteosynthesis operation takes more time, is accompanied by massive blood loss, sometimes the need for transfusion and a higher risk of deep wound infection. Given these facts the best is an indoor low-traumatic method of osteosynthesis locking.

Compare of the results of femoral neck fractures using of osteosynthesis 3 blade nail, spongious screws and nail for permanent compression.

A retrospective analysis of treatment of 252 patients from 1982 to 2015 with subcapitale and transcervical fractures of the femoral neck on the basis “RCTO named by H.J. Makazhanova”. In the research locales patients older than 40 years. All patients were divided according to the applied method of treatment: 1 group of 95 patients operated using a 3-blade-nail, in the 2nd group of 105 patients operated on spongious screws, in the 3 group of 52 patients operated nail for the permanent compression, authoring. All patients underwent x-ray examination before and after surgery. The average period from time of injury before performing the osteosynthesis amounted to 4–7 days. The follow-up period was 6–12 months. The results obtained clinically and radiographically divided into good, satisfactory, poor. Good and satisfactory results were regarded as positive, and poor results as negative.

The average age of patients was 67.5 years. Among these female patients − 174 (69%), the male − 78 (31%). Traumatization more prone to elderly accounting for 206 (81.7%) cases, and only 46 (18.3%) in the middle age group. Analysis of the results of treatment showed positive results in 1 group − 69.5 %, in group 2 − 83.8 %, in group 3 − 96.2 %. In the first group of 29 (31.5 %) and in the second group of 17 (16.2 %) patients have postoperative complications: secondary displacement, nail migration, pseudarthrosis, necrosis of head. The patients of third group have postoperative complications in 2 cases (3.8 %): displacement of bone fragments according of retraumatization. Employability was restored in 1 group − 7–9 months, in group 2 - in 6–8 months, 3 group - through 6–6.5 months.

1)

The method of choice for fresh fractures of the femoral neck, especially subcapital fractures in the elderly, is a minimally invasive method of closed compression osteosynthesis.

Implant-related infection is one of the leading reasons for failure in orthopaedics and trauma, and results in high social and economic costs. Various antibacterial coating technologies have proven to be safe and effective both in preclinical and clinical studies, with post-surgical implant-related infections reduced by 90% in some cases, depending on the type of coating and experimental setup used. Economic assessment may enable the cost-to-benefit profile of any given antibacterial coating to be defined, based on the expected infection rate with and without the coating, the cost of the infection management, and the cost of the coating. After reviewing the latest evidence on the available antibacterial coatings, we quantified the impact caused by delaying their large-scale application. Considering only joint arthroplasties, our calculations indicated that for an antibacterial coating, with a final user’s cost price of €600 and able to reduce post-surgical infection by 80%, each year of delay to its large-scale application would cause an estimated 35 200 new cases of post-surgical infection in Europe, equating to additional hospital costs of approximately €440 million per year. An adequate reimbursement policy for antibacterial coatings may benefit patients, healthcare systems, and related research, as could faster and more affordable regulatory pathways for the technologies still in the pipeline. This could significantly reduce the social and economic burden of implant-related infections in orthopaedics and trauma.

Cite this article: C. L. Romanò, H. Tsuchiya, I. Morelli, A. G. Battaglia, L. Drago. Antibacterial coating of implants: are we missing something? Bone Joint Res 2019;8:199–206. DOI: 10.1302/2046-3758.85.BJR-2018-0316.

Aims

Evaluate if treating an unstable femoral neck fracture with a locking plate and spring-loaded telescoping screw system would improve construct stability compared to gold standard treatment methods.

Purpose of the study: Correct implant position is one of the factors of long-term success of total hip arthroplasty (THA). Acetabular architectural defects caused by trauma can create difficult situations leading to potential complications and poor outcome. The purpose of this study was to examine retrospectively the results of THA implanted after fracture of the acetabulum treated surgically. The objective was to analyse the specific features and search for factors favouring poor outcome.

Material and method: The series included 43 patients who had a THA implanted after treatment of an acetabular fracture. Mean age at trauma was 44.5 years (range 16–87). Five patients had a THA immediately, mean age 75 years (63–87). Thirty eight patients had osteosynthesis. According to the Letournel classification, the fracture was elementary in 12 cases and complex in 26. In ten patients, there was residual joint incongruence measuring more than 2 mm after osteosynthesis. The hips evolved to degenerated joint (n=34) and or necrosis (n=10).

Results: Mean time from acetabular osteosynthesis to THA was 94.6 months (range 3–444), excluding those patients whose THA was implanted at the time of the osteosynthesis. Arthroplasty required removal of the osteosynthesis material (n=11), insertion of a supportive ring (n=14) associated with a bone graft (n=13). The acetabular implant was considered to be well positioned according to the Pierchon criteria in 16 hips and was lateralised (n=21) and/or ascended (n=17) in the other hips. Inclination was 42.8 on average, range 10–18. The five-year survival was 80%.

Discussion: Arthroplasty after surgical treatment of an acetabular fracture is a difficult procedure. Complementary procedures are often necessary complicating the surgery and increasing the risk of perioperative complications, particularly infection. It is difficult to position the acetabular implant, increasing the risk of postoperative instability and early loosening. This study demonstrated the difficulties of implanting a THA in this context where the revision rate is significantly higher than in first-intention THA.

In this retrospective study, we re-evaluated the case histories of patients treated for diaphyseal and meta-epiphyseal fractures of the humerus by fasciculated nailing, using the Hackethal method. Our experience, beginning in 1992 through to the present, includes over 400 cases of fractures treated using this method. Among these cases, there were 250 meta-epiphyseal fractures and 200 diaphyseal fractures. Follow-up was possible in 250 cases.

The number of complications encountered in the case studies considered was relatively low, including five cases of a delayed union and four cases of non-union. There were no deep or articular infections, five cases of superficial infection, four cases of fracturing of the means of synthesis, 10 cases of procidence of the wires at the level of the insertion site, and two cases of distal migration at the level of the articular cartilage of the humeral head. We did not encounter any cases of periarticular ossification or iatrogenic palsy of the radial nerve.

Our methodology foresaw in all cases closed reduction of the fracture as well as epicondylar access distal to the humerus, which in some instances of multi-fragmented fractures was performed bilaterally, with the Eiffel Tower assembling method and four or five retrograde bundle wires. By using the epicondylar point of insertion, the fracture could be reduced and and torsional stability obtained, which together with the bone defect filling contributed to the primary stability of the fracture.

In this retrospective study, we wanted to demonstrate the validity of the bundle nailing according to Hackethal’s method, which is distinguished by being a minimally invasive technique as well as by providing good consolidation and a low rate of complications.

This article is based on the analysis of surgical treatment peculiarities of 641 patients with post-osteomyelitis long bones defects. The average age of patients at the time of hospital admission was 32,4 ± 0,7 and ranged from 4 to 70 years. Most of them were people of active working age (476 (74.3%)) and male (523 (81.1%)).

In this observation group 566 (88.3%) patients had the osteomyelitis process of the traumatic origin, including post-surgical (n = 155) and post-gunshot injuries (n = 13). Chronic hematogenous osteomyelitis was diagnosed in 75 (11.7%) patients. Most patients had lower extremity bones problems, including 444 tibia defects and 142 femoral bone defects. Much fewer patients had the osteomyelitis process of the upper extremity (humerus, radius, ulnar bone – 18, 19 and 18 respectively).

Purulent necrotic process was accompanied by nonunion bone fragments in 160 (24%) patients, delayed union in 95 (14.6%) patients, false joint in 178 (27.6%) patients, segmental bone defect in 75 (11 5%) patients and bones union with edge defects and cavities in 143 (22.3%) patients.

340 (53%) patients were operated using the method of free bone grafting, and 301 (47%) patients were operated using the distraction method.

The need to use the bilocal for external fixation on upper extremities occurs quite seldom (twice in our observations). Even when there is an upper extremity bone defect of several centimeters the preference should be given not to bilocal external fixation.

When treating the lower extremities taking the above mentioned into consideration, segmental defects predominated, that is why the bilocal distraction-compression method of surgical treatment prevailed (98.6%).

Thus, the main method of upper extremities long bones defects replacement is free bone grafting with segment fixation by the external fixation device, for lower extremities the is not-free main Ilizarov method, which allows to get positive results in 84.6% of patients with femoral bone problems and in 96.4% of tibia problems, mainly due to one-step treatment, directed simultaneously to inflammatory process elimination and maximum possible anatomical and functional restoration of the affected extremity.

Clinical Problem

Pilon fractures and distal metaphyseal fractures of the tibia are associated with a high rate of soft tissue and bone healing problems.

We started to use the XS and XS nail as minimal invasive procedure for the management of these fractures in July 2000 first for the fibula and since for the fibula and pilon itself but extended metaphseal comminution are contraindication for the XS nail.

Because of soft tissue problems and higher loading capacity of intramedullary implants the XS Nail was also used for ankle fracture osteosynthesis but as in all articular fractures with open reduction,

The so called “floating knee” is the result of ipsilateral fractures of femur and tibia.

The definition of floating knee dates back to 1974, when Blake and Mc Bryde proposed it in order to move the attention from the skeletal plane of the lower limb to the articular and vasculonervous plane of the knee, where complications are more frequent and dreadful: lesions of popliteal artery or sciatic nerve, stiffness or instability of the knee.

The timing of surgical treatment is still debated: in fact it may be immediate but provisional, with necessity of a second operation, or delayed but definitive.

Also the strategy of osteosynthesis may be controversial, because of the association of fractures.

We present a series of 3 cases (among them there were also 2 ipsilateral fractures of patella) with both femur and tibia treated by osteosynthesis with plate (1 case, with complications) or nail (2 cases, without complications): the patients were followed-up clinically and with X-rays for 1 year.

Our experience confirms the gold standard for this kind of fractures is locked intramedullary nailing, retrograde for femur and antegrade for tibia.

Purpose: Cephalo-tuberosity (CT) fractures are complex fractures with a serious prognosis. Appropriate treatment is highly debated. We report long-term clinical and radiological results in a series of 34 patients treated by osteosynthesis.

Material and methods: The series included 34 patients (21 women and 13 men) who underwent surgery between 1987 and 1997. Mean age was 61 years. The dominant side was involved in 18 cases. There were 14 traffic accident victims and 20 fall victims. Fracture types (Duparc classification) were: CT2 (n10), CT3 (n=18), CT4 (n=6). Nervous complications were associated in five cases. Treatment consisted in closed osteosynthesis for 16 cases and open plate fixation or pinning for 18 cases. Constant score was used to assess functional outcome using the pain, activity, motion, and force scales. Radiological results were assessed on the AP and lateral axillary views. Statview was used for statistical analysis. Immobilisation was maintained for 28 days.

Results: All patients were seen for physical examination and radiographs at a mean follow-up of 40 months. Only four patients were fully satisfied with the outcome. The Constant pain score was rated 9 points. Thirteen patients contralateralised since their trauma. Active antepulsion was 97 and external rotation 30 without a statistical correlation between mobility and type of fracture. The overall mean Constant score was 60 points. Reduction was considered anatomic in 12 cases with a deformed callus in 14 cases. There were eight cases of secondary cephalic necrosis (four among the CT4). The most common complication was pin migration (n=15) and disassembly (n=7) with a significant correlation between complications and age.

Conclusion: The objective and subjective results of this series demonstrated that complications increase with age. There is a significant correlation between external rotation and reduction of the greater tubercle. We did not find any radio-clinical correlation. Although the overall results were not satisfactory, they must be compared with those of arthroplasty.

Despite the increase of surgical procedures for extremities injuries and improvement of various fixation devices and surgical methods, the number of unsatisfactory osteosynthesis results reaches 2–7%. Chronic osteomyelitis after lower extremities long bones osteosynthesis occurs in 1.3–23% of cases, and the percentage of bone nonunion due to infections reaches 83%.

We conducted a retrospective analysis of 237 patient treatment with chronic osteomyelitis following tibial and femoral bone osteosynthesis. Two groups were selected for the analysis: the first group contained 194 patients treated with sheets and the second one contained 43 patients treated with intramedullary locked nails.

In cases of unconsolidated fractures and false joints, the necrectomy was performed with single-step or two-step replacement of internal fixation for external fixation. In this case segmental bone defects reached 20.9% in the first group and 3.6% in the second one. Here the treatment was performed using the Ilizarov method with the bone defect distraction replacement.

Conclusions. 1. Chronic osteomyelitis following sheets usage, unlike the osteomyelitis following the intramedullary locked osteosynthesis, leads more often to the formation of edge and segmental bone defects, which significantly prolongs the treatment duration.

2. External fixation application for postoperative osteomyelitis treatment in case of the bone nonunion made it possible to eliminate the purulent process and restore the extremity support function.

3. The inflammatory process relapses reached 14.9% in the first group and 3.1% in the second one.

This work refers to a male patient, 25 years of age, admitted in the Emergency Department following a bicycle accident, of which resulted an open fracture of the right forearm bones – Gustillo & Anderson I.

With this work, the authors have as objective the description of the patient's clinical condition – starting with the fracture, over to the osteomyelitis – as well as the surgical procedures and remaining treatments he was submitted to.

The authors used the patient's records from Hospital's archives, namely records from the Emergency Department, Operating Room, Infirmary and Consultation, and also the diagnostic exams performed throughout the patient's clinical evolution.

This clinical case began in May 2013, when the patient suffered an open fracture of the right forearm bones – Gustillo & Anderson I – due to a bicycle accident. At the time, the exposure site was thoroughly rinsed, a cast immobilization was made, and antibiotics were prescribed. In the fifth day following the trauma, the patient was submitted to an open reduction with internal fixation with plate and screws of both forearm bones. In the following period, the distal segment of the suture suffered necrosis, exposing the radial plate and the tendons of the first dorsal compartment. The Plastic Surgery team was then contacted, proposing the execution of a graft over the exposed area, which was made in August 2013. In the postoperative period, about half the graft lost its viability and it was noted that a radial pseudoarthrosis had developed – in the context of osteomyelitis – with a defect of about 9 centimeters. This condition prompted the extraction of the osteosynthesis material, about 4 months after its application, and at the same time the first stage of a Masquelet Technique was performed. The second stage of the aforementioned procedure was carried out two months later. Currently, the patient is clinically stable, with right hand mobility acceptable for his daily living activities.

Analyzing the patient's clinical evolution, we concluded that, even though the adequate therapeutic decisions have been made in each stage, the development of osteomyelitis was inevitable. This realization, in association with the patient's young age, raises debatable questions of therapeutic order.

Introduction: For plate osteosynthesis (OS) many surgeons use a rigid fixation which prevents callus formation. The present paper applies biomechanical laws and a FE analysis for optimal screw placement to turn a rigid plate OS into a dynamic and biological OS.

Methods: A Finite Element Analysis was performed. The bone was modeled as a cylinder with an outer diameter of 30 mm and an inner diameter of 22 mm. An E-modul of 18 GPa was assumed for cortical bone. A DC steel plate was modeled with a preload of 300 N for each screw. Fracture motion and stress on the screw head was calculated for different screw placements and a load of 300 N angulated at 30 deg.

Results: The number of screws did not influence fracture motion. This could only be controlled by the distance of the first screw to the fracture site, the use of a lag screw and the material of the plate. When one screw hole was omitted close to the fracture site, motion doubled. Using A lag screw reduced fracture motion dramatically. The stress was greatest at the screw closest to the fracture site.

Conclusions: In order to achieve a dynamic plate OS with callus formation a long plate with a minimal amount of screws and no lag screws should be used. To adjust the flexibility of the OS, the distance of the first screw to the fracture site is the most crucial parameter. Additional screws do not influence the stiffness. The stress is highest at the screw head close to the fracture site. This screw is endangered for fatigue failure. To reduce the stress on this screw it must not be placed oblique and also not eccentric. However, the last screw has little stress and should be placed oblique to increase the pull out strength.

Introduction and Objectives: Volar osteosynthesis with plates with angular stability in dorsal fractures has revolutionized the treatment of wrist fractures, since fixation is sufficiently stable to allow early physiotherapy and prevent fracture collapse, avoiding the great drawbacks of alternative treatments in unstable fractures.

Materials and Methods: Retrospective study of 64 cases of wrist fracture with instability and dorsal deviation treated by means of a volar plate with angular stability. We carried out a clinical assessment that included: a quick-dash functional questionnaire, range of mobility, pain using a Virtual Analog Scale, fist grasping strength (Jamar dynamometer), associated lesions and postoperative complications. Radiological assessment included radiometry of the distal radius, time to radiological consolidation, and radiological post-traumatic complications. The statistical assessment of variables was carried out with an SPSS program version 15.0 for Windows.

Results: We found that 86% of the patients were satisfied with the functional results, with a mean quick-dash score of 3.5. Radiological consolidation was achieved in all cases, without any need of a dorsal graft. Radiometry showed a morphology of the distal radius with no statistical differences when compared to the contralateral wrist.

Discussion and Conclusions: This is an effective, reliable, reproducible method for the surgical treatment of unstable fractures of the distal radius, with minimum morbidity and early functional recovery.

1. The healing of the radius and tibia in dogs after compression plating of osteotomies made by a Gigli saw was studied.

2. The methods used were indian ink microangiography and terramycin labelling. The Spalteholz technique and azane colouring were used.

3. Revascularisaton of the fracture region took place both from newly formed vessels in the Haversian systems and from periosteal and endosteal vessels.

4. The fracture gap was filled at an early stage by a vascular network. Under stable conditions direct angiogenic bone formation took place around this network.

5. Rebuilding of the cortical bone in the fracture region occurred by osteoclastic activity. Groups of osteoclasts made cavities in the necrotic bone and were immediately followed by loops of vessels; behind and around the loop new bone was formed. Another form of bone absorption consisted of bundles of vessels which eroded necrotic cortical bone without new bone formation.

6. The new bone was initially oriented along the fracture gap but, by conversion into secondary osteones, it became progressively oriented longitudinally in the direction of the original bone.

7. Under stable conditions some periosteal and endosteal callus formation occurred though it was of slight importance. It regressed very soon and was seldom seen in the radiographs.

Purpose of the study: Since 2001, we have used arthroscopy systematically to control the treatment of distal radius fractures. We report our three years experience.

Material and methods: Arthroscopic control was used for all patients aged less than 65 admitted to our unit for treatment of an articular fracture of the distal radius. The same operator performed all procedures. Fixation methods were: K-wire pinning, locked plating (Synthes) or a combination of these two methods. The arthro-scope had a 2.4 mm optic. Bony lesions were noted according to the Cataign, Fernandez and AO classifications. The DASH, Green and O’Brien, and PWRE scores were noted.

Results: Intraoperative arthroscopic control was performed for 61 patients between November 2001 and November 2004. Mean follow-up was 17 months (range 6–36 months). Arthroscopic exploration revealed: scapholunate ligament tears (n=11), lunotriquetral ligament injuries (n=3), pathological perforations of the triangle complex (n=4), damage to the radial cartilage (n=15), and mirror involvement of the carpal cartilage (n=4). An arthroscopic procedure was necessary to treat a bone or ligament lesion in 28 cases. At last follow-up, the DASH score was 19.3 and the PWRE 37.6.

Discussion: Arthroscopic evaluation of articular fractures of the distal radius, a routine practice in English-speaking countries, remains a limited practice in France. There is nevertheless a real advantage of using intraoperative arthroscopy. The particular anatomy of the radial surface makes it impossible to achieve proper assessment on the plain x-ray for a quality reduction of the fracture. Recent ligament injuries are rarely detectable on a wrist x-ray. An intra-articular stair-step or an untreated ligament injury can pave the way to short-term development of osteoarthritic degeneration. Intraoperative arthroscopic control is the only way to diagnosi and treat these osteoligamentary lesions observed in patients with an articular fracture of the distal radius. For us, non use of intraoperative arthroscopy constitutes a lost chance for patients with an articular fracture of the distal radius.

Aim

Aim of this study is to present the first clinical trial on an antibiotic-loaded fast-resorbable hydrogel coating*, in patients undergoing internal osteosynthesis for closed fractures.

Purpose: Treatment of radial head fractures of Mason Type II and III involving the neck of the radius is still controversial, especially in the presence of comminution. ORIF often gives unsatisfactory results because of the difficulty in restoring the head-neck off-set and the radial head inclination relative to its neck. In these cases radial head replacement may be indicated ; however, there are no long-term studies on complications and survival of the implant. Recently precontoured plates for the proximal radius has been introduced but no trials have determined whether they are able to restore the normal anatomy of the radius. The latter is still partially unknown because no studies have analyzed the morphology of posterolateral aspect of radial head and neck (“safe zone”). Our study was aimed at:

determining the possible presence of anatomical variations of the safe-zone and

Material and Methods: Measurements, performed on 44 cadaver dry radii of adults, included: length of the radius, diameters and height of the radial head, and height and diameter of the neck of the radius. The radius of bending of the safe zone was also calculated.

Results: The morphological evaluation of the “safe zone” of the radius revealed 3 different morphological types of this zone:

(flat) (25 %),

Adherence of a precoundered plate (Acumed) to the bone surface of the safe zone was performed independently by three of us, and the gap between plate and bone was measured. Plate adaptability was good in Type B, scarce in Type C and absent in Type A.

Conclusion: In conclusion, we identified 3 different morphologies of the safe zone, not previously described, and we found that the precountered plates now available can ensure a good restoration of anatomy only in the half of the human radii.

Introduction: Open reduction and internal fixation (ORIF) is considered the treatment of choice in dislocated unstable pelvic fractures. However ORIF has several drawbacks, such as considerable soft tissue trauma, a substantial intraoperative blood loss and up to 25% infectious complications. To overcome these problems mini-invasive osteosynthesis techniques have been developed.

Methods: Analysis of the problem revealed necessary changes on the level of intraoperative imaging, surgical approach, reduction devices and technology integration. Intraoperative imaging with computertomography gives all the time an appropriate representation of the real position of bony fragments of the pelvis. A new type of axial reduction clamps allows fracture reduction through small incisions. Preshaped plates can be pushed underneath the soft tissue. Computer navigation helps to place screws in a save manner percutaneously.

Results: We present the setting of a new multifunctional image guided therapy suite, which is an optimal platform for mini-invasive treatment of fresh dislocated anterior and posterior pelvic ring fractures, as well as for percutaneous treatment of pelvic non unions. The technique of reduction and fixation of an anterior pelvic ring fracture through two small incisions instead of a full ilio-inguinal approach is shown. A case of percutaneous bone grafting of a delayed union of the sacrum is presented.

Conclusions: Mini-invasive osteosynthesis techniques require appropriate imaging tools, new reduction devices and most notably special skills. However all together may reduce severe side effects of conventional pelvic surgery.

The olecranon is exposed to high tension and bending forces. In 2/3 multifragment fractures occur. Tension belt and plate fixation in these not only transverse but also sagital and frontal plane fractures is often not possible. As a central weight bearing device the XS 4,5mm nail is exposed to a lower bending moment and a angle stable transverse fixation with 2,4mm threaded wires every 9mm is possible. Also a soft tissue independent fracture compression with a set screw (proximal longitudinal holes) is possible. Additional frontal and sagital plane fragments can be fixed to the system with fibre wire hemicerclages.

From 5.1999 to 12.2002 80 consecutive cases with XS nail osteosynthesis of a olecranon fracture were treated and 73 (91%) could be re-examined clinically and radiological 15 months after surgery. 13,7% were open fractures 67% were 3 or more part fractures. For evaluation the Murphy score was used.

The mean time for surgery was 37min for two part and 56 min. for more part fractures. The Murphy score showed in 64% very good and in 29% good results. Only in 4 patients with more part fractures with additional radius head fractures and previous surgery had fair or unsatisfactory results.

The XS nail is a new concept for stabilisation of all but specially of complex and very comminuted olecranon fractures with a very low complication rate and good functional results.

Introduction and Objectives: In this retrospective study, we have evaluated the results of treatment of non-unions of the humeral diaphysis using plate osteosynthesis.

Materials and Methods: This is a retrospective study covering the years 1997–2002, with a total of 135 fractures of the humeral shaft: 84% were treated orthopaedically and 16% surgically by means of plate osteosynthesis. We present 14 cases of humeral non-union, all of which occurred after orthopaedic treatment, and 12 of which were surgically treated by means of plate osteosynthesis (the other 2 declined surgical treatment). The most common cause of fracture was accidental fall, and of the 12 cases, 11 were female, and 1 was male. Mean age was 67.6 years. Initial orthopaedic treatments included the following: in 9 cases U-splint + sling, in 1 case U-splint + Velpeau sling, in 2 cases hanging cast + Poulipen. Of these, the initial bandaging was replaced with braces after 2.5-3 months. Definitive surgical treatment was delayed an average of 8.1 months. We used the Müller-AO fracture classification system. There were 4 cases with 12B12, 3 cases with 12A12, 1 case with 12A11, 1 case with 12B22, 1 case with 12B11, 1 case with 12B21, and 1 case with 12A21. Surgical treatment was performed in 7 cases with LD-DCP plates, in 3 cases with DCP plates, in 1 case with a T-plate, and in 1 case with a straight plate. Corticocancellous bone grafts were transferred from the iliac crest in 9 of 12 cases.

Results: Bone healing was achieved in 11 of 12 surgical cases (one case without radiographic consolidation due to detachment of the plate due to trauma). In 2 cases there was a limitation of shoulder abduction at 85° and elbow extension -10°. In one case, there was repeat treatment due to failure of osteosynthesis. In two of the surgical cases, definitive BA will be measured upon completion of rehabilitation. Complications included 2 temporary radial palsies that recovered both motor and sensory function, one distal detachment of the plate due to previous trauma that had borderline BA and was non-painful. There was one case in which consolidation did not occur and where the humeral artery was injured iatrogenically during surgery (the same one that required repeat surgical intervention). There was one case of infection of the site of osteosynthesis due to Pseudomonas aeruginosa, which responded well to initial antibiotic treatment, and no material needed to be removed.

Discussion and Conclusions: Plate osteosynthesis is an effective treatment for non-unions of the humeral shaft and yields good joint mobility and few complications (similar to the results of other treatment methods) and must be performed by experienced surgeons.

Introduction and Objectives: Periprosthetic fractures present some difficult problems: the inability to use intramedullary implants, difficulty in inserting screws (since the cavity is occupied), bone fragility, great mechanical demands, elderly patients, and associated conditions. We have used two osteosynthesis reinforcement techniques in these cases: massive intramedullary cementation and implantation of bone allograph counterplates. Both techniques give a simple solution for complex peri-prosthetic fractures.

Materials and Methods: We used this technique to treat 9 periprosthetic fractures of the femur between 1999 and 2003. In 3 cases, massive intramedullary cementation was used (Johansson type III, distal to the prosthetic stem) and in 6 cases a bone allograft counterplate (Johansson type II, around the prosthesis), associated with the stem replacement in 2 cases. Allografts came from the Tissue Bank of the Institut Clinic de l’Aparell Locomotor (ICAL). There were 7 females and 2 males, with an average age of 76 years (range: 66–83). Average follow-up time was 14 months (range: 6 months to 3.5 years).

Results: In 8 of 9 cases (89%), fracture consolidation was achieved in 3.5 months, with patients regaining the same ability to walk as before the injury. In one case with intramedullary cementation, non-union developed with breakage of the plate at 10 months post-intervention. This case was treated with compression osteosynthesis with a new plate and bone allograft counterplate, and final outcome was satisfactory (consolidation at 4 months) with the patient walking with full weight bearing without crutches.

Discussion and Conclusions: We believe both techniques are useful in the resolution of periprosthetic fractures of the femur over porous bone. However, a very precise surgical technique is necessary, as well as respect for the classical principles of osteosynthesis: fracture fixation with anatomic reduction, interfragmentary compression, and maximum care afforded soft tissue.

Introduction

Fracture of the proximal femur frequently occur in children with osteogenesis imperfecta(O.I.) or fibrous dysplasia and may lead to progressive coxa vara and a “shepherds crook” deformity. In adults, these changes introduce difficulties that are not ordinarily encountered with routine osteosynthesis. There is minimal literature on this topic and the cases reported are few in number.

Intraarticular fractures of the distal humerus comprise 1% of all fractures in adults. Triceps reflecting and olecranon osteotomy approach provide adequate exposure in intraarticular fracture with its own advantage and disadvantages. Forty consecutive patients with fractures of the distal humerus were treated over a 36-month period. The patients were randomly allotted into two groups; group A consists of twenty patients with olecranon osteotomy and group B consists of twenty patients with triceps reflecting approach. In both the groups fracture was fixed using orthogonal or parallel plating techniques. Clinical outcome was assessed using the DASH SCORE, radiological union and complications was noted in both the group and compared. In group A the mean DASH score was 15.9 points. Three patients underwent a second procedure for hardware removal, 2 patients had non-union at osteotomy site, one patient had transient ulna nerve neuropraxia and one patient had superficial infection. In group B the mean DASH score was 14 points. There was no statistical significance between both groups regarding final outcome except complications were more in osteotomy approach. We conclude both approach is an effective procedure with an excellent or good functional outcome but osteotomy approach has more complications.

Until recently, diaphyseal fractures in children aged 4–12 years were treated conservatively. Although Prof. Havránek recommended oblique bilateral skin traction in his monograph entitled Split Russell Traction, he is currently inclined to use skeletal traction through the proximal tibia (Goteborg traction). The author himself stresses that this therapy requires great expertise from the medical staff. In addition, patients are immobilised for several weeks in hospital.

The Pediatric Traumatology School in Nancy, France prepared a method of intramedullar elastic ostheosynthesis according to Métaizeau and Prévote.

After our experience with intramedullary fixation using Prévote’s nails in diaphyseal fractures of adults and diaphyseal forearm fractures, we also decided to use this ostheosynthesis in diaphyseal femoral fractures of children.

Our group includes four patients (2 boys, 2 girls) with a mean age of 4.2 years (range 4–11). Average time from injury to operation was eight hours.

The patient is in a supine position and given a general anaesthesia. After repositioning, two or more Prévot nails are inserted above the distal physis from the medial and lateral side towards the femoral diaphysis. The nails cross distally and proximally to the fracture line and are anchored in the intertrochanteric area. The operative procedure usually lasts approximately thirty minutes.

The patient is hospitalised from two to five days. The child walks with crutches after discharge, and trains the operated lower extremity. According to the parents, these children began to load the extremity spontaneously after two weeks. After four weeks we perform a radiographic check and permit full loading. The bars are removed in eight weeks in children up to the age of seven years, and 12 weeks in older children.

All of the children recovered without any problems. The schedule for follow-up is from nine to twelve months. The extremities do not appear to have a tendency to overgrow.

The method of mini-invasive osteosynthesis of diaphyseal femoral fractures in children aged from four to twelve years is a modern alternative to conservative treatment. It is more comfortable for the patients, avoids the skin complications of traction therapy, and significantly shortens the time of treatment. This method will also be particularly useful in treating polytraumatised patients.

Unstable intertrochanteric fractures may be treated by several types of implants, most frequently by dynamic sliding hip screw or some form of intramedullary implant. Intramedullary implants began to be used in cases with an expectation of further improvement of osteosynthesis stability. A need to determine the advantages of single implants for selected types of fractures in randomized trials was defined. In addition to biomechanical principles, bone quality is considered, together with increasing possibilities in recent years of further improving density measurements, especially qCT with respect to local specificity. A series of 86 patients (24 men, 62 women, average age 77,6 years) was operated on from September 6, 2005 to June 30, 2009 for unstable intertrochanteric fracture (31 A2.1, A2.2, A2.3), either by DHS of PFN osteosynthesis after randomization. A CT examination of both hip joints in a predefined manner was performed before surgery. Using special software the relative density of the central spherical part of the femoral head 2 and 3 centimetres in diameter was determined. After fracture healing, the dynamization of the neck screw of both implants and the reduction of vertical distance between the tip of the neck screw and subchondral bone of the femoral head were determined. In addition to evaluation of osteosynthesis stability and osteosyntheis failure, clinical parameters such as surgical time, blood loss and length of hospital stay were compared between the two groups of patients. Survival of patients was evaluated with respect to April 21, 2010. In the patient series, 4 failures of DHS osteosynthesis (cut out) and 2 failures of PFN osteosynthesis (cut out) were noted. Sliding of the DHS was on average 11,9 mm, and was significantly higher in comparison to dynamization of the PFN neck screw, which was 6,9 mm (p=0,005). When comparing the vertical distance between the tip of the neck screw and subchondral bone of the femoral head immediately after surgery and after fracture healing the average reduction of the vertical distance was 1,6 mm in DHS osteosynthesis and 0,8 mm in PFN osteosynthesis. The difference was statistically significant (p=0,025). PFN seems to provide a more stable fixation, based on the measurements. The number of failed DHS osteosyntheses is higher in comparison to the number of failed PFN osteosyntheses but the difference is not statistically significant. The influence of femoral head density on osteosynthesis failure could not be determined due to a low number of failed osteosyntheses in both patient groups. At the same time, after statistical analysis, influence of the relative femoral head density on vertical distance reduction between the screw tip and femoral head subchondral bone in healed fractures was not proven. Statistically, average length of surgical time, length of hospital stay, mean blood loss and survival did not differ significantly between the two patient groups.

The aim of the study was to evaluate the results of subtrochanteric femoral fractures treatment with a 90 degrees condylar blade plate, using indirect reposition technique.

Introduction: Fractures in the subtrochanteric zone of the proximal femur present complex treatment challenges. These treatment difficulties are related to the anatomic and biomechanical features that are unique to this area.

Methods: Between 1992 and 2002 76 patients with a mean age of 36 (17–80 years old) were treated with condylar blade plate in our hospital. Fractures resulting from traffic accidents accounted for 76% (58) of the cases, falls from heights for 18% (14), and the remaining cases had other causes.

Results: Union was achieved in 89,5% (68) patients (with full weight-bearing after a mean of 3 months (2–4 months)). Malunion was observed in four, and nonunion in two cases. Deep infection occurred in three cases, which required repeated debridements, bone grafting and decortication. The fractures were stabilized with a replacement condylar blade plate and healed uneventfully.

Conclusion: Subtrochanteric fractures are usually the result of high-energy trauma. The medial cortex of the proximal femur is exposed to high compressive force, which makes fracture stabilization a difficult problem. The reduction technique, which does not cause additional damage to the vitality of the bone, and the use of condylar plate improve significantly the outcome of the treatment.

Aim: The operative management of proximal humerus fractures is still viewed as an unsolved question.

Surgical treatment aims at restoring anatomical elements to a condition stable enough, to allow early mobilization to avoid secondary displacement. The blood supply of the humeral head should not be damaged, so the risk of avascular necrosis will be minimal.

This work offers a new surgical technique that dramatically reduces the need for dissection of soft tissues while using a new locked plate.

Material and Method: This prospective study was carried out between August 2002 and March 2004. 47 fractures of the humerus proximal were operated on 47 patients aged 63 as an average. There were 9 four part fractures, 18 three part and 17 two part fractures.

The two arms of this Y shaped plate embrace the humeral head. The anterior arm overbridges the biceps longus tendon and fixes the lesser tuberosity, with a locked screw in the head. The posterior arm fixes the greater tuberosity with an another locked screw. These two screws cross each other at nearly right angle thus giving optimal fixation in the head.

Results: Fourty four patients (44 shoulders) were later re-examined with 10,3 months mean delay. Re-education was made immediate for 85% of the cases. The final evaluation was made with the functional Constant score and X ray control.

The main complications were 3 algodystrophies, 1 hematoma, 4 failures of fixation, 2 nonunions and only one necrosis.

Conclusion: This first clinical experience with this new implant is stimulating, since it provides a reliable fixation, even into the osteopenic bone.

Introduction

We present a consecutive series of 19 patients with 22 intra-articular calcaneal fractures treated by percutaneous arthroscopic fixation (percutaneous arthroscopic calcaneal osteosynthesis “PACO”). Traditional open reduction and fixation regularly has significant wound complications. PACO has the advantage of direct visualization of the joint surface reduction with the benefit of minimal soft tissue trauma and wound complications.

Aims and Methods: Hungary, 60% (3500 cases annually) of all fresh intracapsular femoral neck fractures are traditionally treated by osteosynthesis. Since 1990 nailing has been replaced: from 01.11.1990 to 31.08.2002 the authors performed 3092 procedures using percutaneous double cannulated screw fixation combined with a special tension band plate. The authors based the development of their In technique on results from research done by Woodhouse and Rösing. They proved by animal experiment that total femoral head ischaemia will already lead to irreversible necroses after just 6 hours. Results: The rate of late femoral head collapse at 3–6 years follow-up assessment is significantly lower if osteosynthesis is performed within 6 hours after the accident, i.e. in the phase of reversible ischaemia (p< 0,001). Followup assessment after 3–4 years was possible within the frame of international collaborations (SAHFE) with the same initial results for two groups treated by cannulated screw in 1993–94 and 1997–98 respectively. Emergency treatment also has a favourable somatomental effect on elderly patients. Conclusions: In a work-up of the 3 year follow-up results of 486 femoral neck fracture patients operated over a 2 year period, it was found that reposition and osteosynthesis done within 6 hours significantly decreased the ratio of the development of late femoral head necrosis and non-union. In addition to surgery performed within a short period of time, we consider that the exact anatomical repositioning and the correct placing of the osteosynthesis materials, that is, a good surgical technique is very important.

Aim of study: The aim of our study is to deposit our experience from the confrontation of the fractures of the femur with external osteosynthesis as a provisional method, but also in some times, as a final treatment. Materials and method: Between the years 1998 – 2002, we treated 20 patients (19 men) with fractures of the femur, from which 6 were open, 11 were in polytrauma patients, aged from 17 to 70 years with M.O of age of 26 years, which were faced with external osteosynthesis as the first method of confrontation.

Results: We changed the method of treatment in 8 patients from external to internal fixation and concerned higher ages patients. In all the others in regular time intervals we realised corrections of axis of crural. In 9 patients of age from 16 to 18 years, the callus formation was found in 5 months with most excellent mobility of adjacent articulations. In three patients we had problems with the union, who was realised in the 7th month, with enough problems from the knee, which were restored after long-lasting physioterapy. In three patients we had pin track infection.

Conclusions: The external osteosynthesis is a method of provisional stabilisation of femur’s fractures, which offers solution in polytrauma patients protecting them from direct complications. In the young adolescents it is possible to constitute also the final treatment, while for higher ages it is not recommended as a final treatment.

Introduction and Objectives: Periprosthetic fractures are a common phenomenon in revision surgery and following trauma. Treatment strategies range from replacement with a larger stem, metal plates with Dall-Miles wires, and Partridge straps. Our objective is to evaluate the clinical use of Partridge osteosynthesis in periprosthetic femoral fractures.

Materials and Methods: In a period of 6 years (1997–2003), 45 patients presenting with femoral fractures with a hip prosthesis were treated with the Partridge system using nylon material for cerclage and flexible nylon plates (Stryker-Howmedica). Of these, 20 were localised proximal to the tip of the prosthesis (Whittaker Type I), 12 on the tip (Type II), and 13 distal to the tip of the prosthesis (Type III). The study group consisted of 25 females and 20 males, with a mean age of 79.5 years. Mean time between implantation and fracture was 4.5 years. In 78% of the patients (35 of 45), surgery was performed within 48 hours. Open reduction of the fracture was performed, and 6–8 nylon straps were used in most cases. Partridge plates were used in 5 cases. Mean surgical time was 55 minutes, with a mean blood loss volume of 500 milliliters.

Results: There were minor recovery complications in 8 patients (12.6%). There were no deep wound infections. Of the 45 patients, 60% regained their pre-fracture level of function within 6 months. Mean hospital stay duration was 19 days, and 93% of the fractures consolidated with an exuberant callus within the one-year follow-up period. A higher level of care was required by 25% of patients.

Discussion and Conclusions: This simple method of osteosynthesis is indicated for rapid recovery following stabilisation of a periprosthetic femoral fracture. Even with a mobilised prosthesis, the fracture often consolidates with an abundant callus, and the patient is then able to move.

Minimally invasive plate osteosynthesis is a technically feasible surgical alternative to treat displaced diaphyseal fractures of the tibia. In recent years, this technique has evolved in response to the poor results following tibial fracture stabilization using the traditional open method of plate fixation. Devascularisation with periosteal stripping of bone fragments using open reduction and internal fixation to ensure adequate fracture visualisation led to a substantial percentage of complications including deep infection, delayed union or non union, and refractures after plate removal. Using the technique of minimally invasive plate osteosynthesis, fracture management is achieved with closed reduction followed by stabilisation using a subcutaneous epiperiosteal LC-DC-plate.

Twenty-four patients with 25 tibial fractures were treated by minimally invasive plate osteosynthesis at the Kantonsspital, Fribourg, Switzerland, between 1997 and 1999. These cases were retrospectively reviewed.

There were 11 male and 13 female patients with a mean age of 41 years (range 16 -64). Nineteen tibial diaphyseal fractures (7 type A, 11 type B, and 1 type C) and six tibial epiphyseal-metaphyseal fractures (4 type A, 1 type B, and 1 type C) were surgically treated. Three fractures were open (grade I). Twenty-four fractures were treated using a 4.5 mm titanium LC-DC-plate, and in one fracture a 4.5 mm stainless steel DC-plate was used for tibial fixation. Open reduction and internal fixation of the fibula was necessary in eleven fractures, nine of which were stabilized with a one-third tubular plate and two with a 3.5 mm LC-DC-plate. The postoperative regimen included partial weight bearing for eight weeks followed by progressive and protected weight bearing until fracture union was achieved. Fracture union was confirmed with radiographs obtained at six to eight weeks, twelve to sixteen weeks, and at final follow-up. The mean time to final follow-up was eighteen months.

All fractures had solidly united within four months postoperatively. Radiographically, healing was characterised by callus formation located on the lateral and posterior aspects of the tibial diaphysis, and was similar to that which is usually seen after stabilisation of tibial fractures using an intramedullary rod. Both ankle and knee range of motion were similar to the uninjured side by final follow-up. There were eight cases of residual valgus malalignment of less than five degrees, and were associated with distal third tibial diaphyseal fractures with concomitant fibula fractures which were not rigidly stabilised. Postoperative complications included two deep wound infections and one postoperative compartment syndrome.

Overall good results were obtained by using minimally invasive plate osteosynthesis of diaphyseal fractures of the tibia. Although this technique is more technically demanding than standard open reduction and internal fixation of tibial diaphyseal fractures, preservation of the soft tissue envelope and periosteal blood supply is beneficial for fracture healing. Surgical indications for minimally invasive plate osteosynthesis of the tibial diaphysis include a narrow tibial medullary canal as well as distal and proximal metaphyseal fractures not suitable for intramedullary rodding, and associated intra-articular tibial fractures. Minimally invasive plate osteosynthesis should be considered as a surgical alternative for the treatment of displaced diaphyseal fractures of the tibia.

Aims

The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization.

We have performed simple bone grafting in four elderly patients with pain due to unstable pseudarthroses in the osteoporotic spine after compression fracture.

At operation, we observed abnormal movement of the affected vertebral body which was covered with a hypertrophic membrane; this seemed to inhibit the blood supply to the lesion. The thick membrane and avascular granulation in the false joint were excised and bone grafting carried out. Symptoms were dramatically improved immediately after operation and bony union was confirmed in the three surviving patients.

Three Cannulated Screws (3CS), Dynamic Hip Screw (DHS) with antirotation screw (DHS–Screw) or with a Blade (DHS–Blade) are the gold standards for fixation of unstable femoral neck fractures. Compared to 3CS, both DHS systems require larger skin incision with more extensive soft tissue dissection while providing the benefit of superior stability. The newly designed Femoral Neck System (FNS) for dynamic fixation combines the advantages of angular stability with a less invasive surgical technique. The aim of this study is to evaluate the biomechanical performance of FNS in comparison to established methods for fixation of the femoral neck in a human cadaveric model.

Twenty pairs of fresh–frozen human cadaveric femora were instrumented with either DHS–Screw, DHS–Blade, 3CS or FNS. A reduced unstable femoral neck fracture 70° Pauwels III, AO/OTA31–B2.3 was simulated with 30° distal and 15° posterior wedges. Cyclic axial loading was applied in 16° adduction, starting at 500N and with progressive peak force increase of 0.1N/cycle until construct failure. Relative interfragmentary movements were evaluated with motion tracking.

Highest axial stiffness was observed for FNS (748.9 ± 66.8 N/mm), followed by DHS–Screw (688.8 ± 44.2 N/mm), DHS–Blade (629.1 ± 31.4 N/mm) and 3CS (584.1 ± 47.2 N/mm) with no statistical significances between the implant constructs. Cycles until 15 mm leg shortening were comparable for DHS–Screw (20542 ± 2488), DHS–Blade (19161 ± 1264) and FNS (17372 ± 947), and significantly higher than 3CS (7293 ± 850), p<0.001. Similarly, cycles until 15 mm femoral neck shortening were comparable between DHS–Screw (20846 ± 2446), DHS–Blade (18974 ± 1344) and FNS (18171 ± 818), and significantly higher than 3CS (8039 ± 838), p<0.001.

From a biomechanical point of view, the Femoral Neck System is a valid alternative to treat unstable femoral neck fractures, representing the advantages of a minimal invasive angle–stable implant for dynamic fixation with comparable stability to the two DHS systems with blade or screw, and superior to Three Cannulated Screws.

1. A case of congenital bowing of the tibia is described in which pseudarthrosis developed and recurred after nine operations performed by the age of ten years.

2. Union was finally secured by a procedure based on deep impaction of the trimmed upper fragment into the reamed-out lower fragment. This was followed by a Boyd type of partial amputation of the foot with calcaneo-tibial arthrodesis.

3. The end-bearing stump four years later is entirely satisfactory and the simple prosthesis gives equality of leg lengths.

Introduction:

Open reduction and internal fixation of displaced intra-articular calcaneal fractures is susceptible to a high incidence of wound complications. Displaced fractures create abnormal contact characteristics at the subtalar joint, resulting in poor functional outcome and arthritis. We present the functional outcomes of 32 fractures (Sanders 2 and 3) at an average follow up of two years.

We present a novel method to derive the surface distance of an osteosynthesis plate w.r.t. the patient-specific surface of the distal femur based on 2D X-ray images. Our goal is to study from clinical data, how the plate-to-bone distance affects bone healing. The patient-specific 3D shape of the femur is, however, seldom recorded for cases of femoral osteosynthesis since this typically requires Computed Tomography (CT), which comes at high cost and radiation dose. Our method instead utilises two postoperative X-ray images to derive the femoral shape and thus can be applied on radiographs that are taken in clinical routine for follow-up. First, the implant geometry is used as a calibration object to relate the implant and the individual X-ray images spatially in a virtual X-ray setup. In a second step, the patient-specific femoral shape and pose are reconstructed in the virtual setup by fitting a deformable statistical shape and intensity model (SSIM) to the images. The relative positioning between femur and implant is then assessed in terms of displacement between the reconstructed 3D shape of the femur and the plate. A preliminary evaluation based on 4 cadaver datasets shows that the method derives the plate-to-bone distance with a mean absolute error of less than 1mm and a maximum error of 4.7 mm compared to ground truth from CT. We believe that the approach presented in this paper constitutes a meaningful tool to elucidate the effect of implant positioning on fracture healing.

Aims

The objective of this study was to investigate bone healing after internal fixation of displaced femoral neck fractures (FNFs) with the Dynamic Locking Blade Plate (DLBP) in a young patient population treated by various orthopaedic (trauma) surgeons.

Calcaneal fracture fixation over the past decade has been practised via an extensile lateral incision. This can be complicated by infection and wound breakdown.

We have developed a new technique for fixation of the calcaneal fractures – MACO. We utilise a 4 cm sub fibular incision to aid joint visualisation and fracture reduction. Fixation is via percutaneous screws.

We analysed our prospectively collected database. 26 fractures were fixed over an 18 month period at Glasgow Royal Infirmary by three consultant surgeons. 22 patients were male and half were smokers. Mean follow up was 5 months (range 1.5 – 18 months).

The mean age of our patients is 41 (range 25–68). The mean pre operative Bohler's angle was 16.7 degrees. Gissane's angle was similarly abnormal with a mean of 129 degrees.

The average duration of surgery was 73 minutes (range 45–100 minutes). Post operatively, Bohler's angle was improved. The mean was 29 degrees. There was no significant difference with Gissane's angle. The mean was 128 degrees.

There were no superficial wound infections. One patient was troubled by wound breakdown with subsequent deep infection. There was no need for metalwork removal in our series of patients. Two patients developed post traumatic osteoarthritis of the sub talar joint. Only one has required sub talar joint fusion.

We conclude that the novel technique which we describe is successful in restoring calcaneal anatomy with few complications. Further follow up is needed to determine the long term outcomes of such surgery.

Background: Ankle fractures in the elderly with osteoporotic bones are often difficult to manage. The argument of whether we should treat such fractures surgically, conservatively or even plan primary arthrodesis is always there. Also, there is risk of difficult or failed fixation.

Patients and Methods: The study was a retrospective evaluation of the management and follow up of 126 patients presented with ankle fracture between 2001 and 2007. All patients were above 60 years at the time of injury and were treated whether conservatively or surgically.

Results: About 77% of our patients underwent open reduction and internal fixation (ORIF). The remaining had closed manipulation under anaesthesia (MUA) done. Some patients had multiple co-morbidities including diabetes (around 10%). The results of fixation were satisfactory. Early complications included superficial wound infection (13% of patients-all infections settled after conservative management with antibiotics and dressings), one chest infection. No difference in diabetic patients. Late complications include development of osteoarthritis (2%) and metal work loosening (2%). There were no reported ankle deformities and satisfactory union of fracture was achieved in all patients. Amongst patients who underwent MUA, more than 20% developed post traumatic osteoarthritis of ankle and 18% had chronic ankle pain. Ankle deformity was reported in 2 patients.

Conclusion: Our results show that accurate reduction and internal fixation of ankle fracture in the elderly is beneficial and of lower complication rates compared to MUA alone. The osteosynthesis failure rate was very low and patient spent less time in plaster and started physiotherapy earlier.

The aim of the study was to assess the medium term outcome for complex proximal humeral fractures treated with the long proximal humeral internal locking system (PHILOS) plate fixation.

All patients who had long PHILOS plate fixation of proximal humerus fractures with metaphyseal or diaphyseal extension over a three year period at our institution were included in the study. Patients had their case notes and radiographs reviewed. Patients were also contacted to assess functional outcome using the Visual Analogue Scale (VAS) for pain, DASH, Oxford shoulder score (OSS) and Stanmore Percentage of Normal Shoulder Assessment (SPONSA).

Out of an initial cohort of 34 patients, 1 died, 2 patients had unrelated illnesses resulting in them being unable to complete the assessment and 6 were lost to follow-up, leaving 25 patients (74%) for review. All patients had proximal humeral fractures with metaphyseal or diaphyseal extension requiring long plate osteosynthesis. One patient had the procedure for non union following initial treatment with an intra medullary nail and the rest were acute injuries. The patients were followed up after a mean of 27 months (range 11–60). The length of plate used varied from 5 to 12 holes for the shaft region.

There was 1 wound infection. 3 patients had non unions which required bone grafting and revision internal fixation. At final follow-up, mean pain was 3.6 (95% Confidence Interval 2.5–4.8) with only 4 patients having residual pain greater than 5 on the VAS scale. Mean DASH score was 41.2 (95% CI 32.0–50.4), mean OSS was 29.1 (95% CI 24.3–33.9) and mean SPONSA was 63.9% (95% CI 50.8–77.2)

The long PHILOS plate appears to represent a good treatment option for complex proximal humerus fractures with favourable medium term results and few complications.

Introduction In a Finite Element Analysis we calculated that in order to obtain a dynamic plate osteosynthesis a long plate with few screws and if possible no lag screw must be applied. These principles were employed in most shaft fractures at our institution since January 1999. We present the preliminary results of tibial shaft fractures treated with dynamic plate osteosynthesis.

Methods Forty-seven consecutive patients treated from January 1999 until August 2001 were followed clinically and radiologically. Fractures of the distal third and mid-shaft not suitable for a nail such as anatomical bends or narrow intramedullary canal were fixed with a long plate (titanium LCDCP) and few screws. In eight cases no lag screws were used. Six fractures were open fractures. Two cases needed a local flap for coverage of the defect.

Results There were no deep infections. There was one delayed union necessitating re-osteosynthesis and cancellous bone graft after four months. All other fractures healed within six months. No axis deviation was noticed. Due to the dynamic osteosynthesis all cases without lag screws healed with visible callus formation. However, breakage of three screws was seen.

Conclusion Intramedullary nails have become the gold standard for most tibial shaft fractures. However, a significant risk of malunion is associated with nails and in some anatomical instances a nail is not feasible. Dynamic plate osteosynthesis allows good bone healing with callus formation and restores length, axis and rotation of the bone. We consider it a safe and biological method for the treatment of most tibial shaft fractures.

Aims: 1. To assess the results and the effectiveness in the treatment of the complete articular fractures of the distal radius (23-C of MY̌ller), treated surgically with external þxation or osteosynthesis. 2. To support or refuse (conþrm or deny) the hypothesis that the treatment with external þxation is more efþcient, and less expensive, than the treatment with plate osteosynthesis. 3. To evaluate the effectiveness of the classiþcation of the fractures of long bones in segment 23. Material and Method: We study 733 fractures recorded in the AOI Documentation Center, 474 of which were treated with external þxation, while 259 were treated with osteosyn-thesis with plate. We study the variables of Sheets A (þliation) and C (follow-up) statistically. Results: From Sheet A we found statistic signiþcance differences in the age between sexes, but not between both treatments, local associated injuries (þxation > plate), associated treatment and reduction (þxation < plate), a better stability for the þxation, higher proportion of senior surgeon, general anaesthesia, antibiotic treatment and associated therapies for the plate group. In post-operative functional treatment, the external þxation group was better than the osteosynthesis. From Sheet C (follow-up), the group treated with osteosynthesis was far better than external þxation group in all of the variables. Conclusions: 1- The classiþcation of fractures of long bones, follows a gradient of increasing gravity. 2- The setting of the bone fracture was far better in the group treated with plate osteosynthesis, than in the group treated with external þxation, regardless of the group of fracture. 3- The þnal result is remarkably better in the group of plate osteosynthesis. 4- The ORIF with osteosynthesis has favoured a more frequent use of the bone grafting. 5- The þnal total cost of the treatment is much higher in the external þxation group. 6- We will use the external þxation in open fractures (open G-II-III), or with fragments not synthesing for theit size.

We studied the treatment with osteosynthesis in the 23-C fractures. Material and methods: we reviewed 259 complete articular fractures of the distal radius, type 23-C treated with plate osteosynthesis during 10 years. All cases are documented with the AOI sheets. All cases were classiþed with the Classiþcation of long bones of M.E.MŸller. Results: in the 259 fractures, 137 are females and 122 males, the age are between 10 to 84 years, the age average are 48ñ59 years (60ñ52 in females group, and 35ñ19 in the males group).

105 (41%) cases are in the right wrist, and 154 (59%) cases in the left wrist, 32 (12%) are open fractures. Etiology: 9% work,36% Trafþc,11% Sports,27% Home, 17% Others. The 17% had pathological antecedents previously. 18ñ5% had local injuries associated and 24ñ3% had general injuries associated. The 85% were operated for a Senior surgeon, 53% with loco-regional anaesthesia; 50% were treated with antithrombotic prophilaxis, and 26% with antibiotic treatment. 40% of cases needed some additional implant and the 24% needed surgery for the collateral injuries. We had 2% of acute local complications and 1% of general acute complications. During the follow-up, the 10% had local late complications and 1% had general late complications.

At the end of the follow-up, in 92% of patients (234 cases) use the extremity better than 75%, and 89% were pain free. X-Ray evaluation: 2% were Distrophy, and in 33% of cases had some articular alteration. Four months post-operative the 59% were recovered. The þnal disability is < 25% in the 85% of cases. Final evaluation: 88% of cases are good or excellent.

Purpose: Bone quality in elderly patients always subject to osteoporosis can compromise the stability of osteosynthesis materials. The fixation can be reinforced by using acrylic cement, allowing early rehabilitation. The purpose of the present work was to investigate the quality of acrylic cement-reinforced osteosyntheses and to study the functional consequences of this method. We also analysed early or secondary complications and determined the mid- and long-term advantages and disadvantages for the patient’s quality of life and also for later interventions on the fracture site.

Material and methods: Forty female patients treated between 1990 and 2000 were studied retrospectively. These elderly women (mean age 86.2 years at fracture), had 44 fractures (38 femurs including two with double fractures; four humeri) which had been treated by acrylic cement reinforced ostheosynthesis. The physiological status of the patients before trauma was assessed with the Robinson score and the degree of osteoporosis with the Sinon index. The quality of the cementing was assessed using the Cameron technique. Minimum follow-up was six months, necessary for inclusion.

Results: The preoperative Robinson score was 18.8. The mean Singh index was four. Cementing was satisfactory for 29 fractures. Immediate weight bearing or complete use of the limb was possible early for 42 of the 44 fractures. Bone healing was achieved at a mean 2.8 months for 43 fractures. Mean follow-up was 9.8 months. Twelve patients died before the end of the first postoperative year. At last follow-up, there was one nonunion and five infections, including three bone infections. The Robinson score at last follow-up was 16 on the average. Subsequent interventions did not have to be modified or abandoned because of the acrylic cement reinforcement of the osteosynthesis.

Discussion: The results of this retrospective series are comparable with those obtained with other centromedullary nailing or primary or secondary bone grafting techniques used for the treatment of patients with severe osteoporosis.

Introduction: Various surgical techniques existed for the treatment of three and four part proximal humeral fractures with variable outcomes. The aim of this study is to present a technique using small materials, to preserve all the biologic principles of fracture fixation, in the treatment of these challenging injuries.

Material: We perform a study taking as inclusion criteria: 3 and 4 parts proximal, closed, humeral fractures, treated surgically by open reduction and a modular biological internal fixation.

Surgical technique: Through a standard deltopectoral approach the fragments reduced, taking care to preserve the periosteum and manipulate meticulously the soft tissues. All the fractures were fixed with a combined system of Kirschner wires inserted to the proximal fragments, connected by “bone clips” forming a modular construction and fixed to the main distal fragment by AO screws.

Results: 24 patients complied with the inclusion criteria and were followed up a mean of 18 months. All patients achieved a satisfactory result except a fracture-dislocation that developed AVN and was revised into a shoulder arthroplasty and two demented elderly patients with metalware failure that were also revised.

Conclusion: In this first series of non-selected cases the outcome of fracture consolidation is promising. Although this technique is in its embryonary phase of development and the functional results are currently been assessed, the radiological outcomes suggest that the technique described is a valid alternative to the treatment of these fractures if we indicate an osteosynthesis method that combines biology and stability.

Introduction: This study was designed to investigate the feasibility and advantages of minimally invasive plate osteosynthesis of tibia fractures.

Methods: In a prospective study, 24 cases of unstable tibial fractures were stabilized with a narrow LC-DCP (Limited Contact-Dynamic Compression Plate) inserted using minimally invasive percutaneous plate osteosyn-thesis technique. The technique consisted of 3 major steps: 1) reduction of fracture with or without distractor; 2) pre-contoured plate insertion percutaneously at the stab incision distant to fracture site; 3) plate fixation to the tibia percutaneously inserted screw. All the procedure was done under fluoroscopic guide. Between January 1998 and March 1999, we operated 16 proximal or distal periarticular fractures, 5 segmental fractures, and 3 mid-shaft fractures of adolescents that had still open physis. 18 fractures were closed, and 4 were open.

Results: 22 of 24 cases healed without second procedures such as bone graft or correction of angular deformity. There was no infection except 1 case of superficial infection that was healed with early removal of plate. There were 3 cases of screw breakage, but no procedure was required. At the follow-up, 2 patients were healed with > 5 degree varus alignment and > 10 degree internal rotation. All the patients had good knee or ankle function.

Conclusion: The authors feel confident that the minimally invasive technique for plate osteosynthesis of tibial fractures that would be inappropriate for intramedullary nailing will prove to a feasible and worthwhile method of stabilization, while avoiding the severe complications associated with the other methods.

Introduction: The treatment of fractures of the proximal humerus is still controversial. Conservative treatment may result in severe disability due to malunion and shoulder stiffness. Open reduction and rigid fixation requires extensive soft tissue exposure, which may result in a high incidence of avascular necrosis of the proximal humerus. Today, many authors are in the opinion that “minimal osteosynthesis” of such fractures is preferable to rigid fixation. It may be achieved by K.W. techniques, lag screws, rush pins, percutaneous pinning or percutaneous external fixation. This study reviews our experience with comminuted fractures of the proximal humerus treated by different minimal invasive techniques of fixation, using functional evaluation and radiological assessment.

Materials and methods: This study consists of 76 patients with comminuted fractures of the proximal humerus (33 M, 44 F, 18–89 year old, mean 52/5Y) with follow-up of 2–6 years (mean 3.5Y). They were treated by minimal invasive surgical techniques: 53 of them by closed reduction and percutaneous pinning and the remaining 23 by ORIF and minimal osteosynthesis. All patients were evaluated by Neer’s shoulder grading score and radiographs.

Results: Overall results were excellent and good in 85% of patients with 2, and 3 parts fractures of the proximal humerus, treated either by closed or open minimal osteosynthesis techniques, with some better results in less comminuted fractures.

9/13 (69%) of young patients with 4 part fractures treated by closed percutaneous minimal fixation had good functional results. In four other patients the clinical results were poor and two of them developed AVN of the humeral head. 5/8 (62.5%) of young patients with 4 part fractures treated by ORIF and minimal fixation had good functional results. In three other patients the clinical results were poor and one of them developed AVN of the humeral head.

Conclusions: Based on this study it seems that “minimal osteosynthesis” by K.W. techniques and by lag screws, by closed or open reduction, remains as the first optional treatment of complex fractures of the shoulder, even in young patients with a 4 part fracture.

Purpose: We report the operative technique and preliminary results for percutaneous osteosynthesis in the supine position with computed tomography guidance for acetabular fractures without joint displacement.

Material and methods: This prospective study conducted in a single unit included a consecutive non-randomised series of 55 patients who underwent surgery for an unstable pelvic injury between June 1996 and December 2000 under computed tomography guidance. In ten cases, the radiographic and computed tomographic analysis demonstrated a coronal fracture of one of the columns without joint displacement accessible for anteroposterior screw fixation. There were eight men and two women, mean age 35 years.

Surgery: the ten patients were operated on in the supine position, in the scanner room under the same aseptic conditions as in the operation room. The reference computed tomography slice was the Corse slice. The femoral vasculo-nervous bundle was identified. A threaded guide wire was inserted perpendicuallary to the fracture line, anteriorly to posteriorly (Cap Corse technique). A perforated screw with a 7.3 mm diameter was used to fix the fracture. Minimal post-surgical surveillance was 48 hours. Weight bearing was not authorised for six weeks to three months. Al patients were followed prospectively, and mean follow-up ws 16 months (12–36).

Results: Traction was lifted immediately after surgery in all cases. All the patients got up the day after surgery. Mean hospital stay was less than five days postoperatively in all cases. There were no complications (vascular, neurologic, infectious) and no secondary displacement. At last follow-up, he Postel Merle d’Aubigné score was 18 for eight patients, 16 for one and 14 for one. Two patients showed radiographic signs of degenerative hip disease.

Discussion: This percutaneous osteosynthesis method using computed tomographic guidance is reliable (100% well positioned screws) and avoids the need for traction in bed. Morbidity is low (no complications). Even though these eight patients did not present clinical and radiographic signs of osteoarthritis, this technique did not avoid the risk of degenerative hip disease in two patients.

Conclusion: An alternative to traction, percutaneous osteo-synthesis with computed tomographic guidance performed in the supine position for acetabular fractures is a cost-effective procedure.

We have treated 42 consecutive complex ununited fractures of the femoral shaft by wave-plate osteosynthesis at five different medical centres. There were 13 with previous infection, 12 with segmental cortical defects, and 3 were pathological fractures. In 39 cases there had been previous internal fixation and 21 patients had had more than one earlier operation.

Union was achieved in 41 patients at an average of six months, although three had required a second bone graft. Two patients had recurrence of infection and in one this resulted in the persistence of nonunion. There were no failures of the implant. All 41 patients with union are now fully weight-bearing, but four have a leg-length discrepancy, one has axial malalignment, and nine have residual stiffness of the knee. These results are surprisingly good, despite the complexity of the initial problem, and appear to confirm the biological and mechanical advantages of the wave plate over the conventional plate for such cases.

Unstable fractures of the distal tibia are being increasingly treated by open reduction and internal fixation using pre-contoured locking plates. Functional outcome following this type of fixation has not been reported previously.

The aim of this study was to functionally assess patients following MIPO fixation of distal tibial fractures.

Case notes of 26 patients treated at a single centre were reviewed. The fracture type, fixation technique, complications, time to union and subsequent treatment were documented. All patients returned for functional scoring using the validated American Academy of Orthopedic Surgeons (AAOS) foot and ankle core score.

Twenty-six consecutive patients were treated between 2002-2005. The majority were male, and 5 were open fractures. There were 13 AO type A, 4 type B and 9 type C fractures. Mean follow up was 20 months. Average time from injury to surgery was 2.5 days. All fractures were treated by a MIPO technique. A pre-contoured distal locking plate was used for the distal tibial reconstruction. Secondary surgical procedures e.g. 2nd look, delayed primary closure, or skin grafting were necessary in 3 cases. The fibula was plated in 60% of cases. Four patients developed wound infections requiring antibiotics, and all resolved. The commonest rehabilitation regime was 6 weeks non weight bearing in plaster. Mean time to union was 18 weeks. There were 3 cases of delayed union, requiring bone grafting. One patient required removal of the plate due to local irritation, and one required a broken screw to be removed. Mean range of movement was 10 degrees dorsiflexion, 30 plantarflexion. The mean normalised AAOS foot and ankle core score was 41 (SD +/− 8).

We conclude that MIPO fixation of distal tibial fractures is a safe and effective method of treatment. Functional outcome does not significantly differ from that of the general population.

Purpose of the study: Fractures of the metacarpals are common injuries generally observed in young males. Nailing, either with a centromedullary configuration or intermetacarpal construction is generally proposed. The nailing procedure nevertheless has its drawbacks: fracture instability, secondary displacement, pin migration, infection, requirement to remove material, injury to the cutaneous dorsal branch of the ulnar nerve, and most importantly, immobilisation for several weeks which is a major inconvenience for these young active patients. In this context, we wanted to compare two fixation systems: a locked plate versus centromedullary nailing.

Material and methods: This was a retrospective comparison of consecutive patients from September 2007 to December 2008. The series included 39 cervical fractures of the fifth metacarpal in 39 patients aged 31 years on average. The first 19 patients were treated with a locked plate (Médartis^®) (group A) and the 20 others with descending centromedullary nailing (group B). In group A, a dorsal approach respecting the dorsal cutaneous branch of the ulnar nerve was used. The technique consisted in insertion of distal locking screws enabling fracture reduction on the plate. No postoperative immobilisation was proposed and rapid mobilisation was encouraged. In group B, classical centromedullary nailing was performed with immobilisation with a short Thomine brace and syndactylisation of the last two fingers. Outcome was based on objective criteria (Jamar^® force, joint motion, duration of sick leave) and subjective assessment (DASH, VAS).

Results: Mean follow-up was 12 months in group A and 8 months in group B. Depending on the type of fracture, plates with different shapes and lengths were used in group A; a single pin was used in group B (16/10 or 20/10). Secondary displacement was more frequent in group B, but the results in recovered motion were better in group B. The only parameter better in group A was length of sick leave; four patients in group A underwent reoperation to remove the plate and for tenoarthrolysis. In all, the outcomes for cervical fractures of the fifth metatarsal were better in group B.

Discussion: Our preliminary results in group A show lesser complications and earlier return to work compared with better motion at last follow-up in group B. Centromedullary nailing remains the better treatment for cervical fractures of the fifth metatarsal. The extra cost of the plates does not appear to be warranted for the treatment of neck fractures of the fifth even though the patient can resume occupational activities earlier.

Purpose of the study: Computed tomography is recommended for the preoperative work-up of joint fractures as it allows an optimisation of the access as a function of the injury. During the operation, 2D radiographic or fluoroscopic controls are still widely used. After one year’s experience, we evaluated the potential pertinence of using 3D reconstructions intraoperatively with a mobile isocentric fluoroscope (iso-C-3D).

Material and methods: All operations for which the amplifier was used were collected prospectively. The type of fixation as well as the details of the installation and measures taken intraoperatively were noted.

Results: At one year, intraoperative 3D reconstructions were made during 48 operations in 47 patients: fracture of the calcaneum (n=13), thoracolumbar spin (n=12), acetabulum (n=11), tibial condyles (n=9), odontoid (n=2), pelvis (n=1). The installation was habitual for the calcaneum and odontoid fractures. For the other localizations, use of a carbon plateau table facilitated good quality imaging for spinal and tibial condyle fractures; a carbon orthopaedic table was useful for acetabulum and pelvis fractures. With the intraoperative 3D reconstruction the surgeon was able to check the freedom of the canal after reduction and fixation. For the calcaneum fractures, reduction of the thalamic fragment was revised in one patient; in another, an intra-articular screw was replaced. One intra-articular screw stabilizing the posterior wall was also changed during an acetabulum fixation.

Discussion: During our first year of use, 3D reconstruction intraoperatively has allowed us to avoid three early reoperations (for two calcaneums and one acetabulum). Classical 2D imaging of these two localizations is difficult to interpret because of the spherical form of the hip joint and, for the calcaneum, the difficulty in obtaining quality retrotibial images. Quality images requires specific installation, limiting interference with metallic supports.

Conclusion: The results we have obtained in our first year of use of the ISO-C-3D amplifier has led us to generalise its use for percutaneous fixation procedures involving the acetabulum and the calcaneum.

Introduction: Preoperative use of tomodensitometry is a common practice when assessing fractures with intraarticular involvement, helping to determine the most appropriate surgical approach according to the lesions observed. To date, during the surgical procedure itself, radiographical or fluoroscopic controls still largely rely on two dimensions X rays. We assessed the possible benefits of intraoperative tridimensional reconstructions using mobile isocentric fluoroscopy (iso-C-3D) after one year of use.

Material and Methods: All the procedures where intra-operative tridimensional fluoroscopy was used were assessed prospectively for one year. The type of osteosynthesis as well as specific modalities of installation and therapeutic measures driven from analysis of the images were analyzed.

Results: During the first year of use, intraoperative tridimensional reconstruction had been carried out in 48 procedures in 47 patients. The region involved was calcaneus 13 times, thoracolumbar spine 12 times, acetabulum 11 times, tibial condyles 9 times, axis 2 times and pelvis one time. Installation was the same than usually performed in the cases of calcaneus and axis osteosynthesis. For the other localisations, obtention of good quality images was facilitated through the use of a carbon table for spine and osteosynthesis of the tibial condyles, and through the use of a carbon traction table for acetabular or pelvic fractures. Intraoperative tridimensional reconstruction allowed to check for freedom of the vertebral canal after reduction and osteosynthesis of the spine. in the cases of fracture of the calcaneus, reduction of one thalamic fragment was improved in one case and one intraarticular screw could be changed in another case. In the case of acetabular surgery, one screw stabilizing the posterior wall was found intraarticular on tridimensional reconstruction and could be changed before closure.

Discussion: Intraoperative tridimensional reconstruction, during its first year of use, allowed to avoid 3 early reinterventions (for 2 calcaneus and one acetabulum). Accurate interpretation of standard plain X ray in these two localizations is difficult because of the spherical shape of the hip joint and because good quality imaging, especially the retrotibial view, is hardly obtained intraoperatively in fractures of the cacaneus. When using tridemensional reconstructions, acquisition of good quality images has to be anticipated during the installation of the patient, limiting any interfereces with metallic supports to a minimum.

Conclusion: the results obtained over the first year of use of intraoperative tridimensional reconstructions with the ISO-C-3D encouraged the authors to generalize its use when performing osteosynthesis of the acetabulum or calcaneus as well as percutaneus osteosynthesis of articular fractures.

Introduction: Throughout known medical literature the proximal humeral fracture is mentioned with an approximately 5% contribution to all fractures. The optimal operative strategy regarding proximal humeral fractures is still being discussed controversely. This study was conducted to show implant associated problems and their clinical relevance.

Materials and methods: Of a total 198 patients with proximal humeral fractures 166 patients, 98 females and 68 males at a mean age of 74,7 years were treated operatively from 2000 to 2004 in our clinic with an angle-stabile plate osteosynthesis and underwent a clinical and radiological follow-up. Retrospectively we characterised the fractures by using the most common classification of NEER and assessed the functional results with the CONSTANT score.

Results: The 166 evaluated patients with 8 cases of a type I fracture, 13 patients with type II fracture, 34 patients with type III fracture, 47 cases with type IV fracture, 42 patients with type V fracture and 22 cases with type VI were all operatively treated with an angle-stabile plate osteosynthesis. 142 patients underwent early assisted physical therapy. Of all assessed patients the average CONSTANT score was 79,7 points. Among the 8 patients with type I fracture the average CONSTANT score was 84,4 points, among the 13 patients with type II fracture it reached an average 87,4 points. The average score of the 34 patients with type III fracture was 78,8 points. The more complex fractures, according to NEER’s classification, reached average scores of 71,2 points among the 47 cases with type IV fractures, 69,8 points (42 patients, type V) and 61,6 points (22 patients, type VI). The presence of avascular necrosis of the humeral head in 18 cases resulted in a significantly worse functional outcome and therefore a lower average score of 48,1 points. For 36 patients the follow-up revealed intraarticular dislocation of the proximal locking screws which required operative revision in 15 cases.

Conclusion: Even in the complex proximal humeral fracture one can achieve good clinical results for the patients by using an angle-stabile plate osteosynthesis and therefore establishing a secure and rigid situation for an optimized consecutive physical therapy, especially in the elderly. To prevent from intraarticular screw placement the proximal locking screws should be chosen shorter, if possible, then initially measured.

Aims: internal fixation is not generally accepted as election treatment for displaced femoral neck fractures in patients older than 70. Results and risk factors are analysed in this later group of patients. Patients and Methods: 155 patients older than 70 with displaced femoral neck fractures were treated with closed reduction and parallel cannulated screws and prospectively followed for 2 years. Patients were allowed postoperative full weight bearing with aids. Quality of reduction and osteosynthesis were radiologically analysed. Results: 24 patients (15%) were lost. At the end of follow-up 52% of patients were asymptomatic, 13% had mild pain, 28% suffered a 2nd surgery (arthroplasty) and 7% were badly ill for aditional surgery. 57% presented uncomplicated consolidation, 28% non-union and 8% ischemic necrosis. Poor-quality reduction (p= 0.039) and poor-quality osteosynthesis (p=0.051) were significant risk factors for failure. A higher age (p=0.36), displacement (Eliason criteria) (p=0.26) and delay in surgery (p=0.53) were not significant risk factors. Conclusions: closed reduction and percutaneous fixation of displaced femoral neck fractures achieves good/fair results in only 65% of patients older than 70 years. Poor-quality reduction and osteosynthesis are risk factors for clinical and/or radiological failure.

Introduction: Primary fixation of displaced sub-capital fractures with low morbidity and low mortality offers an approach to a very common problem. The vast majority of patients receiving this form of treatment will not require further surgery. When confronting with the problem of primary arthroplasty which includes a higher morbidity and higher mortality, a higher infection rate and the possibility of prosthetic loosening especially in young patients, the choice seems clear.

Material and method: Between 1995 and 2000, a series of 21 patients (15f, 6m) were admitted for a displaced subcapital fracture (16 type Garden III, 5 type Garden IV) to our clinic. All the patients were operated 24 to 36 h after admission.

The mean age was 48y. The technique consists of:

Anatomic reduction (with a C-arm), which was the most crucial point of the technique.

Results: The mean follow-up was 34 m. We did not have any osteonecrosis of the head. No complications. The mobility of the hip was normal in all patients. There were two cases with delayed union and one case with non-union due to a distention at the site of the fracture after the reduction_

Conclusion: We believe that this technique, especially the combination of an anatomic reduction of the fracture and the use of a cancelocortical graft is a very prospective alternative to a prosthetic replacement in relatively young patients.

Aims: In spite of approved methods of osteosynthesis of proximal femoral fractures using modern implants stabilisation still may fail especially in unstable osteoporotic fractures which is a cause of revision surgeries and unsatisfactory functional results. The goal of our study was to determine predisposing factors of failure of either DHS or PFN osteosynthesis with respect to the degree of osteoporosis. At the same time we evaluated clinical results one year after surgery and evaluated occurrence of further osteoporotic fractures.

Methods: Within the framework of a research plan (2005–2009) patients with low energy fractures of trochanteric area with qCT proven osteoporosis have been randomised. Unstable intertrochanteric fractures were operated by either DHS or PFN osteosynthesis after adequate reduction. During surgery one bone sample was taken from the femoral head prior to insertion of head screw located at the tip of the screw and the second sample was taken from iliac crest. Samples from the femoral head were examined by histomorphometry. Relationship between histomorphometry and migration of osteosynthetic material was evaluated. After surgery patients were examined in osteology department including DEXA and received appropriate treatment of osteoporosis. Orthopaedic follow up was performed 6 weeks, 3, 6 and 12 months after surgery when patients were evaluated by Harris hip score. Results were evaluated statistically.

Results: From September 1. 2005 to August 31. 2006 55 patients with unstable intertrochanteric fractures had been randomised. DHS was used in 26 patients and PFN in 29 patients. The average age of the patients was 75,6 years. Only patients who were able to sign informed consent were elegible for randomisation. The average qCT T-score was −3,2 and the qCT Z-score was −1,1. In addition to osteoporosis osteomalacia was proven histologically in one patient. Secondary osteoporosis was proven in 15 per cent of all patients. 49 patients were examined 1 year after operation. Failure of osteosynthesis was observed in four cases (7,3 per cent, 2x DHS and 1x PFN cut out phenomenon, 1 case of PFN head screw migration). Migrating PFN screw was removed. There were no other revision surgeries. The average qCT T-score in patients with failure of osteosynthesis was −4,3, Z-score −2,1. The average HHS one year after surgery was 67,3.

Conclusions: In patients with proven osteoporosis in spite of correct surgical technique risk of osteosynthesis failure is increased. Optimized surgical techniques and implants may still improve surgical results in patients with severe osteoporosis (qCT T-score lower than −4).

Introduction: The aim of this study is to present a modification of the single tension band technique for the treatment of olecranon fractures, using a double tension band with smaller wires, preserving all the biological parameters for fracture fixation, in an effort to decrease related complications.

Material: Thirty-three patients with olecranon fractures treated with a double tension band fixation. Surgical Technique: Through a posterior approach the fracture is reduced keeping all principles for biologic fixation and stabilized with two parallel small K-wires inserted from the olecranon process and exit through the anterior cortex of the ulna. Then the extensor carpi ulnaris and flexor carpi ulnaris are partly elevated from the ulna and two 1.5-mm transverse drill holes are made through the ulna 3 and 4 cm distal to the fracture. Two 22-gauge wires are passed through the proximal and distal holes, bent into a figure of 8 over the dorsal ulna and simultaneously tightened. The proximal ends of the K-wires are bent and impacted into the olecranon process.

Eleven patients needed supplemental fixation with screws. All patients mobilized the first postop day.

Results: All the fractures consolidated. All patients but two regained full range of motion. No hardware failure was noted except one patient in whom one band was broken but without clinical relevance.

Conclusion: It seems that a double tension band fixation despite the smaller material utilized, provides a very stable construct, permitting early mobilization. Furthermore two bands tensioned independently provide greater compression forces at the fracture site and offer a back up in case that one band fails.

Unstable intertrochanteric fractures present a difficult problem with a high incidence of complications such as mechanical failure of the implants or cut-out. The use of bone cement (PMMA) has been suggested in the past but the application with hand to fill the existing voids has not given good results and also has high incidence of pseudarthrosis and infection.

A new technique is presented in which the PMMA is injected with syringe through the hole opened for the compression screws. The aim is to augment mechanical stability and also to replace the compressed spongiosa.

The study population of 105 patients with unstable intertrochanteric fractures was separated in 2 groups, hi group A (51 patients, 4 male/47 female, mean age 72.3) a conventional sliding nail was performed, while in group B (54 patients, 3 male/51 female, mean age 78.9) the new technique was applied. The two were similar regarding age and gender.

Post-operatively in group A 95% of the patients remain in bed for 1–2 weeks according to the surgeon opinion regarding the stability of osteosynthesis. 45% of them remain in a regime of bed to chair existence for 6 weeks. 72% return to its previous domicile and activity. In group B all patients were sat out the bed in the 1st day post-op and walked in the 2nd day post-op with partial weight bearing where that ability preexisted. 91% return to its previous domicile and activity.

In group A ll cases of cut-out were noted while in group B only 1 cut-out and also 2 cases, where we had screw failure, but fracture went on to union. All the difference are in favor in group B and statistical significant (p< 0,0 5). No infection was noted.

The suggested method appears to give a satisfactory solution to the problem of unstable intertrochanteric fractures, allowing fast and safe mobilization of the patient, reducing thus morbidity. Technically it is simple, easy to apply and does not require instrumentation while the extra cost is only that of a butch of PMMA.

In tibial plateau fracture, anatomical reduction of articular surface with stable fixation can restore the mechanical axis and allow early mobilization. Concomitant management of ligamentous and meniscal injury is essential for preservation of knee function. Open reduction and internal fixation has a significant complication rate.Percutaneous,fluoroscopically and arthroscopically assisted osteosynthesis with special fracture reduction and fixation technique can achieve the purpose of management of tibial plateau fracture, while limiting the soft tissue damage.

18 cases, including all J. Schatzker’s type of tibial plateau fracture, were operated with minimal access surgical technique. Male patients were predominant. The age ranged from 22 to 61 (mean 33.5). Detail pre-operatives planning with CT scan were performed in 16 patients. Fluoroscopy, arthroscopy and special fracture reduction and fixation technique were applied to all cases. All 18 cases could be reviewed. Follow up period ranged from 1 to 4 years (mean 2.3 yr.). Outcome was assessed by HSS Knee Score, standing radiograph and arthroscopy (2 cases).

According to HSS score, 14 patients were rated as excellent (100 to 85), 3 good (84 to 70), 1 fair (69 to 60) and none poor (< 60). Subjectively, 14 patients were satisfied with the treatment. 13 patients were working and participating in sport before injury. 15 took no analgesic, 2 took it once a week and 1 more often. In standing radiograph, only 2 patients showed minimal narrowing of joint space. There was no significant complication directly associated with the procedure.

Percutaneous, fluoroscopically and arthroscopically assisted osteosynthesis is a safe and effective minimal access surgical procedure. Precise pre-operative planning and special fracture reduction and fixation technique are all crucial for success. Short-term clinical outcome is encouraging.

To report the results of the intramedullary skeletal kinetic distractor (iskd) in patients with established leg length discrepancy following lower limb trauma.

12 patients with significant leg length discrepancy (> 20mm) following lower limb trauma were operated on using the iskd nail between september 2004 and december 2007. patients were followed up clinically and radiologically at minimum 18 months (mean: 27months range: 18–24 months).

8 femurs and 4 tibias were operated using the iskd nail. all patient in the series had successful completed treatements. the average leg length discrepancy was 38mm (91mm–21mm) and the average gained length was 37mm (76m–22mm). radiological union and bone consolidation were slow to occur. early weight bearing was permitted allowing earlier functional capacity. 6 patients required additional operations; 3 manipulation under anaesthesia for failed lengthening and 3 bone grafting for poor regenerate, 1 patient required more than one additional operation.

The iskd nail is an effective and reliable alternative technique for correcting leg length discrepancy in patients who have suffred lower limb trauma. it appears to mimic the results achieved with the use of a fine wire external fixator or a unilateral external fixator. the convenience of a fully implanted device is substantial. the complications are frequent but manageable with standard techniques.

The socio-economic conditions in many developing countries impede widespread general use of the assets of biomedical technology. In orthopedics this becomes evident from the large-scale, though illegal, reuse of osteosynthesis plates and screws. Scientific research into the issue of the safe reuse of osteosynthesis materials from a biological point of view has never been done. Therefore the aim of this study is to determine whether plates and screws after simple cleaning, applying means which are available in developing countries, are safe from a biological point of view. Cleaning methods evaluated include a toothbrush, water, detergent and bleach. X-ray photoelectron spectroscopy analysis of cleaned surfaces and water contact angle measurements indicate that application of these methods yield surface characteristics similar to those of new, sterilized plates. If desired, bleach can be applied without affecting the surface properties of the materials.

Subsequently, the reactivity of a mammalian monolayer in response to a used screw (ISO-10993-5) and endotoxin release (USP 27-NF 22) was evaluated, showing that all screws tested are non-cytotoxic with endotoxin release within the requirements of the FDA. This study shows that reuse is not necessarily unsafe from a biological point of view.

Background

Although minimally invasive plate osteosynthesis (MIPO) has become popular option for humeral shaft fractures, indirect reduction and its maintenance are technically challenging. The purpose of this study is to describe a reproducible technique utilizing an external fixator during MIPO and to assess its outcomes.

Introduction: The treatment of complex distal humeral shaft fractures is a challenge due to the fact that intramedullary nails do not present reliable results, while the ORIF with plates is associated with a higher morbidity. The purpose of this study is to exhibit the advantages of MIPO by anterior approach in distal humeral shaft fractures.

Material and methods: 6 fractures in 6 patients (with arm wrestling mechanism in 3 cases) were operated by indirect reduction and biological plating, avoiding the problems related to the neural vascular structures of the arm and especially to the radial nerve. According to AO classification, there were 1 fracture type 12A, 2 type 12B and 3 type 12C. The proximal approach of 3–5 cm was realized between the biceps (medially) and deltoid muscle (laterally). The distal approach of 3–5 cm was performed by subperiosteal dissection of the lateral supracondylar ridge of the humerus, with retraction of brachioradialis and long carpal extensor muscle, as well as the radial nerve, even though unseen. A DCP plate of 4,5 mm with 10–12 holes was molded and twisted medially to adapt to the anterior face of the humeral lateral column and diaphysis, thus avoiding occlusion of the coronoid or of the olecranon fossae. The plate was inserted from distal to proximal and fixed onto the shaft with at least 2 proximal and 2 distal screws, after reestablishing the humeral axis, length and rotation. After a short immobilization (1–2 weeks), the patient started rehabilitation.

Results: There were no vascular or nerve complications except a transient paresthesia for the radial nerve. All fractures healed within a mean time of 10 weeks after surgery, with good functional results regarding elbow mobility.

Discussions: The radial nerve may be endangered in the lateral column approach but even in such circumstances its identification is not required; the implant remains in the safe zone.

Conclusions: The authors are promoting the advantages of this technique regarding safety and feasibility as well as plate stability which allows a fast rehabilitation. Even if it is a demanding technique, MIPO seems to be the best option for distal third humeral fractures.

Last decade intramedullary nailing is the choice method for the treatment of lower extremity’s long bone fractures. This method matches much better the biomechanics of bones and therefore it leads to faster and better fracture porosis. The aim of our study is to record our experience of using intramedullary nailing and other methods of osteosynthesis for femur and tibia fractures and pseudarthrosis.

During the last 6 years we treated 264 with long bone fractures. One hundred ninety two of them are available at least for 2 years postoperatively. Patients with major health problems or tumors were excluded. From this group of patients 116 were men and 76 women with mean age 42 years (16 up to 75). They had 107 tibial fractures, 81 femoral fractures, 12 tibial pseudarthrosis and 3 femoral pseudarthrosis. We used reamed or undreamed intramedullary nails for 64 tibial and 52 femoral fractures and we used other methods (internal fixation with plates, external fixation) for 43 tibial and 29 femoral fractures. All the cases of pseudarthrosis were after surgical treatment and they were treated only with intramedullary nails. All the nails were dynamized depending on fracture type and the healing procedure. The follow up of our patients included clinical examination (pain, length, torsion etc) and x-rays at 1st, 3rd and 6th month postoperatively and after that every year.

Our data (clinical examination and x-rays) were enriched with objective estimation of patients physical condition at specific time intervals from the operation. We recorded also their one opinion about their health standard.

The analysis of our results shows that intramedullary nailing, and especially after reaming, provides more rigid and secure stabilization. It also leads to faster porosis. This method allows immediate mobilization of nearby joints and better rehabilitation. It has fewer complications and we found completely valuable for the pseudrathrosis cases. Regarding only patients general health condition and return in preinjury functional level and professional activities, intramedullary nailing becomes a statistically more useful method for treatment of long bone fractures of lower extremity.

Purpose: The surgical approach is an essential element for precise reduction and rigid fixation of fractures of the acetabulum. In cases where the anterior column is mainly involved and total hip arthroplasty (THA) is indicated, classical approaches do not allow double assess to the anterior column necessary for reduction and fixation and to the femoral canal for insertion of the prosthesis. Combining Heuter’s anterior approach and Letournel’s ilio-femoral approach provides access to the anterior column and to the often associated posterior hemi-transverse fracture, while allowing insertion of the total hip prosthesis.

Material and method: This combined approach was used for ten among 60 THA performed for fracture of the acetabulum. Seven were primary procedures and three were differed reconstruction procedures. Mean patient age was 60.6 years (range 50 – 85 years). Fracture types were: acetabular wall and anterior column (n=8), anterior column and posterior hemi-transverse (n=2). All fresh fractures exhibited major acetabular damage associated with fracture of the femoral neck. A hybrid THA was used for all cases after fixation of the fracture. The femoral heads were used as graft material for deficient anterior columns in two patients and as “piecemeal” grafts for the others.

Results: Mean follow-up was 36 months (range 24–35 months). At last follow-up all fractures had healed and all acetabular components exhibited solid fixation with no sign of migration. The mean outer diameter of the ace-tabular components inserted was 56 mm (52–64) using a 2 mm press-fit and one screw. The only complication was one postoperative anterior dislocation. Pain relief and function were satisfactory in all patients at last follow-up with a Postel Merle d’Aubigné score of 16 (13–18).

Discussion: This anterior surgical approach enables good access to the acetabular walls and anterior columns, allowing solid fixation and relatively easy THA. The Kocher-Langenbech approach is still better in case of posterior deficiency or when posterior fixation requires space for inserting an acetabular component. We reserve it for THA used to treat fresh fractures of the acetabulum with major damage to the acetabulum and/or the femoral head, with or without neck fracture in patients aged 55 years or more. For differed reconstruction, we also use this approach if the acetabular damage involves the anterior column.

Introduction

There is considerable uncertainty about the optimal treatment of displaced four-part fractures of the proximal humerus. Within the last decade locking plate technology has been considered a breakthrough in the treatment of these complex injuries.

This is an outcome study of the use of plate fixation for treatment of comminuted fractures of the distal third of tibia to determine prognostic factors such as age, sex, type of fractures, soft tissue injury and type of implant on healing.

Since 1999, a single surgeon (VP) has performed minimally invasive fixation in 18 patients for complex transitional fractures of the tibia. Follow up has been achieved by a combination of clinical and radiological assessment and notes review.

An overall excellent-good result was obtained in 17 of 18 patients. In one patient, the fixation was revised due to a 20 degree external rotation mal position. In two cases there was mild external rotation of 10 degrees. There were no infections.

The treatment of difficult juxta-articular fractures with a minimally invasive fixation is a useful management option. Peri-articular plates are easy to insert and give better results with respect to alignment correction.

Purpose: We report a retrospective analysis of 20 patients with complex fracture of the distal radius treated in an emergency setting with an external fixation and complementary osteosynthesis.

Material and methods: These 20 patients, mean age 43 years, fifteen men and five women were treated between January 1998 and November 2000. The dominant limb was involved in 16 cases. There were ten manual labourers and four patients who had regular sports activities. The surgical procedure included manual reduction then application of an external fixator (Orthofix). The second time was for insertion of an anterior plate in nine cases. For seven patients, pinning was associated with the plate. Only eleven patients were treated with external fixation and pinning alone. Mean hospitalisation was ten days. Active rehabilitation of the fingers included daily exercises. All external fixators had been removed on day 45.

Results: Mean follow-up was 22 months. Clinically, mean outcome was: palmar flexion 40°, dorsal flexion 36°, radial inclination 12°, ulnar inclination 15°, pronation 75°, supination 62°. Force was often less than 20% of the contra-lateral side. Radiologically, mean results were: on the AP view radial tilt 23°, radioulnar distance +1 mm, mean radial; and on the lateral view, radial tilt −1.4°. Bone healing was achieved on day 45. Two patients developed severe reflex dystrophy. There were no infectious or skin complications. Two patients developed a carpal tunnel syndrome. The plate was removed in two cases. Two patients developed palmar dysaethesia. Two patients had a complementary procedure on the distal radioulnar joint due to defective supination. Eleven patients resumed their occupational activities at a mean six months.

Discussion: The purpose of this analysis was to determine, retrospectively, the role of external fixation of the wrist associated with complementary osteosynthesis in patients with complex fractures of the distal radius. These extra- and intra-articular fractures are difficult to treat and require minute analysis. Outcome in our patients indicated that this analysis is often incomplete before treatment. We had four patients with a stair-step joint surface due to defective primary reduction. The radius was usually well reduced in the frontal plane but the sagittal plane was rarely corrected. The radioulnar distance evolved unfavourably in eight patients reaching > +2mm. Our poorest results were in cases with external fixation and pinning. The best results were obtained with combined treatment using a plate, pins and the external fixator.

Conclusion: We advocate a very careful and rigorous analysis of the fracture, in agreement with the SOFCOT 2000 symposium concerning complex fractures, and prefer a triple surgical procedure using a plate, pins and the external fixator.

Total hip arthroplasty is a challenging problem in case of high hip dislocation. In order to reduce the hip, a femoral shortening osteotomy is necessary to prevent damage to the neurovascular structures. In this study we present the mid-term results of a simple technique of simultaneous derotating and shortening osteotomy of the femur without the necessity of additional osteosynthesis.

In this retrospective study we included 28 patients with high hip dislocation. In these patients 30 consecutive cementless primary total hip arthroplasties with femoral shortening osteotomy were performed. 20 cases were previously operated. All patients were clinically and radiologically followed up after a mean of 4.5 years (range 2 – 5.7 years). Time point of consolidation was determined on consecutive radiographs for each patient.

The average operative time was 116 minutes (range 65 to 150 minutes). There were no intraoperative complications. Postoperatively no femur fractures, no pseudarthroses and no pareses were observed. The mean consolidation time of the osteotomy was 4.4 months. At the time of follow-up, one aseptic loosening had been verified. In this case a very small stem (size 03) had been used. The mean Merle d’Aubigne score for the unrevised hips improved from 8.2 points preoperatively to 15.1 points at follow-up.

In conclusion the presented technique allowed an easy and fast implantation of total hip arthroplasty in patients with high hip dislocation. The Zweymueller stem design with its rectangular cross-section seems responsible for the sufficient stability of the osteotomy resulting in a short consolidation time. Any additional osteosynthesis is obsolete. This leads to additional advantages including a short duration of surgery and a low complication rate. The good clinical results are attributable to the fact, that by shortening the femur, the physiological hip joint biomechanics could be approximated. The mid-term results of the described technique are very promising.

In fractures of proximal humerus, stable fixation of osteoporotic bone fragments poses a significant problem, and wide surgical approach causes damage to blood supply of the humeral head, and to synovial bursae of the shoulder and tendons. These problems cause further permanent unfavourable changes in the shoulder. The least invasive surgical treatment is the percutaneous multi-plane fixation with a bundle of Kirschner wires monitored with fluoroscopy. Stability of these fixations and fixations by tension band, screws and Rush pins were examined in anatomical specimens of porcine humeri and in clinical evaluation. Experimental research concerned the primary stabilisation of various types of Kirschner wires inserted to the proximal part of a porcine humerus, later pulled out using a tensile testing machine, and fixations of 2-part fractures of a porcine proximal humerus fixed with Kirschner wires (various types), tension band, screws and Rush pins. The fixed bones were next torn apart with the same tensile testing machine to examine the strength of the junction. One type of Kirschner wires was designed by us. This type provided the maximum initial strength in the bone and maximum fixation strength, and was next used in surgical treatment of 21 proximal humerus fractures estimated as 2- and 3-part fractures in Neer classification. Follow-up covered a period from 18 months to 10 years. Results were estimated with Neer criteria. Reference comparison group was 50 patients, treated with different methods. Most of the very good and good results (86%) were obtained by fixation with the Kirschner wires of our design. These wires were threaded all over the part which entered the bone.

Purpose: To investigate whether osteosynthesis with biodegradable plates and screws of an unstable part of the zygomatic arch in pigs could provide sufficient fixation for normal bone healing in the area.

Material and Methods: Six healthy pigs were operated under general anesthesia. Two osteotomy lines were created in the right zygomatic arches of the animals leaving the central part of the arch free. This part then was fixated with 2,0 mm Lactosorb® (Walter Lorenz Surgical, Inc., Jacksonville, FL,USA) plates and screws. The left zygomatic arches of the animals were osteotomized in the same fashion but were left without fixation, serving as controls.

Animals were sacrificed at 4,6,8 and 10 weeks. Specimens were evaluated macroscopically, radiographically and histopathologically.

Results: The histopathologic analysis showed that 4 of 6 fixated specimens from the experimental site demonstrated lack of callus formation and bone continuity.

Conclusion: These results indicate that biodegradable osteosynthesis in load bearing areas of the middle third of the facial skeleton provides most likely no sufficient fixation for callus formation and bone healing.

Purpose: The purpose of this study was to analyse mechanical failures involving dismonted osteosynthesis materials implanted to fix pertrochanteric or subtrochanteric fractures with a dynamic hip screw (DHS), a Gamma nail, or a plate nail system (STACA).

Material and methods: Our cohort included 16 patients among a series of 350 patients who had been treated with 240 DHS, 80 Staca nailplates, and 30 Gamma nails between 1996 and 1999. We used the Ender classification for the x-ray analysis and the Cuny criteria which describe the most common causes of dismounted material.

Results: According to the defined criteria, 70/350 osteosynthesis assemblies (20%) were considered insufficient on the immediate postoperative x-rays and eventually dismounted in 16 patients. Two of these patients had major osteopaenia according to the Singh criteria and ten underwent revision because of poor clinical tolerance. These patients had six DHS (3 “swinging” cervical nails, two dismounted plates, and one screw protruding into the joint space). A protruding screw was the problem for the eight Staca nail-plates. Two Gamma nails had a “swinging” screw. These cases of dismounted material were predominantly observed in patients with Ender grade 5, 7 and 8 pertrochanteric fractures.

Discussion: Our analysis of these cases revealed several important factors: 1) the quality of the fracture reduction with restitution of the medial pillar of the per-trochanteric mass; 2) central anchoring in the femoral head essential for stable fixation; 3) superior stability of the DHS in grade 1 and 6 fractures due to the greater projected surface improving hold in cancellous bone. Inversely, for subtrochanteric fractures (grade 7 and 8), centromedulary shaft anchoring with a Gamma nail reduces mechanical stress in varus and thus the risk of “swinging” screws. Finally, the monoblock construct of the Staca nail-plate, which does not have the dynamic potential of the DHS and the Gamma nail, raises a risk of protrusion, particularly in case of “internal rotation” fractures with major metaphyseal comminution (grades 4 and 5). This latter type of fixation is however very effective for simple pertrochanteric fractures with minimal comminution (grades 1 to 3).

Conclusion: Material dismounting results from a series of factors related both to the material used and to the operative technique. We thus reserve the Staca nail-plate for grade 1 to 3 fractures in the Ender classification, the DHS for grades 1 to 6 and the nail-screw fixation for subtrochanteric (grade 7 and 8) fractures.

Introduction: Over the last 10 years minimally invasive plate osteosynthesis (MIPO) has gained more and more popularity over the conventional open surgical approach (ORIF). Numerous clinical case collection studies reported the MIPO technique as a good, alternative method. While MIPO offers some advantages over ORIF, it also has significant drawbacks, such as more demanding surgical technique and increased radiation exposure. In an attempt to compare these approaches, a previous animal study 1 did not show any significant differences in fracture healing outcome. Using a new developed, standardised severe trauma model on the sheep femur 2, this study examines the effects of the surgical approaches on fracture healing.

Methods: 24 sheep (Merino wethers, mean age 5.6years, mean weight 39.1kg) underwent the trauma model 2 with a severe soft tissue damage and a multifragmentary, distal femur fracture as well as initial stabilisation with an external fixator. After five days of soft tissue recovery, the animals were definitively operated with an internal fixator (LCP) randomised either by a minimally invasive or open approach. The sheep were sacrificed after 4 and 8 weeks (two groups), mechanical testing performed and statistically analysed with ANOVA test.

Results: After 4 weeks, torsional rigidity is significantly higher in the MIPO group (30.1r10.6(SD)%) of fractured to intact bones, p< 0.05) compared to ORIF group (9.8r12.4(SD)%), while ultimate torque also shows increased values for MIPO technique (p=0.11). After 8 weeks, the differences in mechanical properties levelled out, but still higher values for the MIPO group (p=0.36/p=0.26).

Conclusion: In the early stage of fracture healing, minimally invasive plate osteosynthesis shows advanced healing pattern compared to open fixation technique. This advantage seems to level out over time.

Purpose

To promote rapid bone healing, an adequate stable fixation implant with a percutaneous reduction instrument should be used for Vancouver type B1 or C fractures. The objective of this study was to describe radiographic and clinical outcomes of patients with periprosthetic fracture (PPF) around a stable femoral stem, treated with a distal femoral locking plate alone or with a cerclage cable.