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.

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.

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.

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.

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: 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.

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.