Volar Locking Plates (VLP) have revolutionised the treatment of distal radius fractures allowing the anatomic reduction and stable fixation of the more comminuted and unstable of fractures. The benefits of this in terms of range of movement (ROM), pain and earlier return to work and daily activities is documented. However we were interested in was what improvements in wrist function patients made from 6 to 12 months after injury?

Distal radius fractures have an incidence rate of 17.5% among all fractures. Their treatment in case of comminution, commonly managed by volar locking plates, is still challenging. Variable-angle screw technology could counteract these challenges. Additionally, combined volar and dorsal plate fixation is valuable for treatment of complex fractures at the distal radius. Currently, biomechanical investigation of the competency of supplemental dorsal plating is scant. The aim of this study was to investigate the biomechanical competency of double-plated distal radius fractures in comparison to volar locking plate fixation. Complex intra-articular distal radius fractures AO/OTA 23-C 2.1 and C 3.1 were created by means of osteotomies, simulating dorsal defect with comminution of the lunate facet in 30 artificial radii, assigned to 3 study groups with 10 specimens in each. The styloid process of each radius was separated from the shaft and the other articular fragments. In group 1, the lunate facet was divided to 3 equally-sized fragments. In contrast, the lunate in group 2 was split in a smaller dorsal and a larger volar fragment, whereas in group 3 was divided in 2 equal fragments. Following fracture reduction, each specimen was first instrumented with a volar locking plate and non-destructive quasi-static biomechanical testing under axial loading was performed in specimen's inclination of 40° flexion, 40° extension and 0° neutral position. Mediolateral radiographs were taken under 100 N loads in flexion and extension, as well as under 150 N loads in neutral position. Subsequently, all biomechanical tests were repeated after supplemental dorsal locking plate fixation of all specimens. Based on machine and radiographic data, stiffness and angular displacement between the shaft and lunate facet were determined. Stiffness in neutral position (N/mm) without/with dorsal plating was on average 164.3/166, 158.5/222.5 and 181.5/207.6 in groups 1–3. It increased significantly after supplementary dorsal plating in groups 2 and 3. Predominantly, from biomechanical perspective supplemental dorsal locked plating increases fixation stability of unstable distal radius fractures after volar locked plating. However, its effect depends on the fracture pattern at the distal radius

There has been a substantial increase in the surgical treatment of unstable chest wall injuries recently. While a variety of fixation methods exist, most surgeons have used plate and screw fixation. Rib-specific locking plate systems are available, however evidence supporting their use over less-expensive, conventional plate systems (such as pelvic reconstruction plates) is lacking. We sought to address this by comparing outcomes between locking plates and non-locking plates in a cohort of patients from a prior randomized trial who received surgical stabilization of their unstable chest wall injury. We used data from the surgical group of a previous multi-centred, prospective, randomized controlled trial comparing surgical fixation of acute, unstable chest wall injuries to non-operative management. In this substudy, our primary outcome was hardware-related complications and re-operation. Secondary outcomes included ventilator free days (VFDs) in the first 28 days following injury, length of ICU and hospital stay, and general health outcomes (SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores). Categorical variables are reported as frequency counts and percentages and the two groups were compared using Fisher's Exact test. Continuous data are reported as median and interquartile range and the two groups were compared using the Wilcoxon rank-sum test. From the original cohort of 207 patients, 108 had been treated surgically and had data available on the type of plate construct used. Fifty-nine patients (55%) had received fixation with non-locking plates (primarily 3.5 or 2.7 mm pelvic reconstruction plates) and 49 (45%) had received fixation with locking plates (primarily rib-specific locking plates). The two groups were similar in regard to baseline and injury characteristics. In the non-locking group, 15% of patients (9/59) had evidence of hardware loosening versus 4% (2/49 patients) in the locking group (p = 0.1). The rate of re-operation for hardware complications was 3% in the non-locking group versus 0% in the locking group (p = 0.5). No patients in either group required revision fixation for loss of reduction or nonunion. There were no differences between the groups with regard to VFDs (26.3 [19.6 – 28] vs. 27.3 [18.3 – 28], p = 0.83), length of ICU stay (6.5 [2.0 – 13.1] vs 4.1 [0 – 11], p = 0.12), length of hospital stay (17 [10 – 32] vs. 17 [10 – 24], p = 0.94) or SF-36 PCS (40.9 [33.6 – 51.0] vs 43.4 [34.1 – 49.6], p = 0.93) or MCS scores (47.8 [36.9 – 57.9] vs 46.9 [40.5 – 57.4], p = 0.95). We found no statistically significant differences in outcomes between patients who received surgical stabilization of their unstable chest wall injury when comparing non-locking plates versus locking plates. However, the rate of hardware loosening was nearly 4 times higher in the non-locking plate group and trended towards statistical significance, although re-operation related to this was less frequent. This finding is not surprising, given the inherent challenges of rib fixation including thin bones, comminution, potential osteopenia and a post-operative environment of constant motion. We believe that the increased cost of locking plate fixation in this setting is likely justifiable given these findings

Introduction. Locking plates can provide greater stability than conventional plates; however, reports revealed that fractures had a high incidence of failure without medial column support; the mechanical support of medial column could play a significant role in humeral fractures. Recent studies have demonstrated the importance of intramedullary strut in proximal humeral fracture fixation, the relationship to mechanical stability and supporting position of the strut remain unclear. The purpose of this study was to evaluate the influence of position of the intramedullary strut on the stability of proximal humeral fractures using a locking plate. Materials and methods. Ten humeral sawbone (Synbone) and locked plates (Synthes, cloverleaf plate), with and without augmented intramedullary strut (five in each group) for proximal humerus fractures, were tested using material testing machine to validate the finite element model. A 10 mm osteotomy was performed at surgical neck and a strut graft (10 cm in length) was inserted into the fracture region to lift the head superiorly. Each specimen was statically tested at a rate of 5 mm/min until failure. To build the finite element (FE) model, 64-slices CT images were converted to create a 3D solid model. The material properties of screws and plates were modeled as isotropic and linear elastic, with an elastic modulus of 110 GPa, (Poisson's ratio, n=0.3). The Young's moduli of cortical and cancellous bones were 17 GPa and 500 MPa (n=0.4), respectively. Three alter shifting toward far cortex by 1, 2, and 3 mm in humeral canal were installed in the simulating model. Results and discussion. The test result showed stiffness for only locked plate was 149.2±21.3 N/mm; and the plating combined with an intramedullary strut was 336.5±50.4 N/mm. On average, the stiffness was increased by 2.2 times in the augmented fixation relative to the only locking plate fixation. The finite element analytical results showed stiffness of 162 N/mm for fixation without strut, and 372 N/mm for those with strut augmentation. The stiffness between experiment and FE analysis agreed in 8.6% for the only locking plate case; and agreed in 10.5% for the case fixed with intramedullary strut. FE analysis showed the stability of construct increased 7%, 11% and 20% as the strut shift by 1, 2, and 3 mm, respectively. Gardner (2007) reported the importance of mechanical support at the medial region for maintenance of reduction when proximal humerus fracture treated with locking plates. Conclusion. The intramedullary strut may provide superior stability than the only locking plate fixation. The FE model provides a useful implement to find the optimal configuration of plate fixation. Acknowledgements. All authors thank the funding support from National Science Council (NSC 102-2628-B-650-001) and E-Da Hospital (EDPJ1020027)

It is very difficult to perform total knee arthroplasty (TKA) for severe varus bowing deformity of femur. We performed simultaneous combined femoral supra-condyle valgus osteotomy and TKA for the case had bilateral varus knees with bowing deformity of femurs. Case presentation. A 62-year-old woman consulted our clinic with bilateral knee pain and walking distability. She was diagnosed rickets and had bilateral severe varus bowing deformity of femurs from an infant. Her height was 133 cm and body weight was 51 kg. Bilateral femur demonstrated severe bowing and her knee joint demonstrated varus deformity with medial joint line tenderness, no local heat, and no joint effusion. Bilateral knee ROM was 90 degrees with motion crepitus. Bilateral lower leg demonstrated mild internal rotation deformity. Bilateral JOA knee score was 40 Roentgenogram demonstrated knee osteoarthritis with incomplete development of femoral condyle. Mechanical FTA angles were 206 degree on the right and 201 on the left. She was received right simultaneous femoral supra-condyle valgus osteotomy with TKA was performed at age 63. Key points of surgical techniques were to use the intramedullary guide for valgus osteotomy as temporary reduction and fixation then performed mono-cortical locking plate fixation. Several mono cortical screws were exchanged to bi-cortical screws after implantation of the femoral component with long stem. Cast fixation performed during two weeks and full weight bearing permitted at 7 weeks after surgery. Her JOA score was slightly improved 50 due to other knee problems at 9 months after surgery, her right mechanical FTA was decreased to 173, and she received left simultaneous femoral supra-condyle valgus osteotomy with TKA as the same technique at April of this year. She has been receiving rehabilitation at now. Conclusions. Most causes of varus knee deformity are defect or deformity of medial tibial condyle and TKA for theses cases are not difficult to use tibial augment devices. However the cases like our presentation need supra-femoral condyle osteotomy before TKA. It was easy and useful to use intramedullary guide for valgus osteotomy as temporary reduction and fixation then performed mono-cortical locking plate fixation before TKA

We present a case series of patients who underwent 3 or 4 part proximal humerus fracture fixation using an intra-osseous suture technique. 18 patients are included in the study with follow up data obtained ranging from 1 to 4 years. Oxford Shoulder Scores (OSS) and range of movement measurements were taken for all patients. The mean OSS for the group was 50/60 with a mean forward flexion of 140°, abduction of 132°, external rotation of 48° and internal rotation to the level 10. th. thoracic vertebra. Three patients developed adhesive capsulitis, 2 requiring subsequent arthroscopic release. This data compares favourably to outcomes reported in the literature with hemiarthroplasty or locking plate fixation. An activity based costing analysis estimated that the treatment costs for proximal humerus fractures was approximately £2,055 when performing a soft tissue reconstruction, £3,114 when using a locking plate and £4,679 when performing a hemiarthroplasty. This demonstrates a significant financial saving when using intra-osseous fixation compared to other fixation techniques. We advocate the use of the intra-osseous suture fixation technique for certain 3 and 4 part fractures. It gives good functional outcomes, significant cost savings and potentially makes revision procedures easier when compared to other fixation techniques

Introduction. Although total knee replacement became a widespread procedure for the purpose of knee reconstruction, osteotomies around the knee were regularly performed. Total knee arthroplasty should be performed for advanced arthritis of the knee. With the advent of biplanar open wedge high tibial osteotomy (HTO) combined with locking plate fixation, HTO has been expanded and its surgical outcome has been improved in recent years. However, post-operative joint-line obliquity has been raised as a concern with this procedure, which may affect the outcome especially in the knees with severe varus deformity. Hence the purpose of this study is to analyze the compression and shear stresses in the knee cartilage with joint line obliquity after HTO. Methods. Using a three-dimensional computer aided design software, the digital knee model with soft tissues was developed. The geometrical bone data used in this study were derived from commercially available human bone digital anatomy media (3972 and 3976, Pacific Research Laboratories, Inc., WA, USA). The three-dimensional knee model was transferred to finite element model. Material properties of the soft tissues and bones were derived from previous studies. The loading condition was adjusted to the load during a single-leg stance of the gait cycle, which resulted in an axial compressive load of 1200 N. Two different conditions were subjected to the analysis: normal alignment and joint-line obliquity after HTO. For the normal alignment, a static force of 1200 N was applied along the mechanical axis. For the joint-line obliquity models, a single force of 1200 N was applied rotating force directions in the frontal plane from the normal direction by 2.5º, 5º, 7.5º, and 10º, respectively. Results. The maximum values of the axial stresses in the cartilages for the normal condition showed almost same values in medial and lateral compartments. In the joint-line obliquity models, the maximum axial stress values in the medial compartment did not exhibit substantial change up to the level of 7.5º obliquity, while a rise in maximum stress value was observed for the model with 10º obliquity. The shear stress showed a different tendency. In the joint-line obliquity models, a steep rise of laterally directed shear stress in the medial compartment was observed for models with obliquity of 5º or more. Discussion. The shear stress in the medial cartilage increased to almost twice as high as the normal knee level for the joint- line obliquity model with an inclination of 5º. The maximum shear stress values increased in accordance with the obliquity angle. The elevated stress could be deleterious to the cartilage. In such large amount of correction by tibial osteotomy leads to unfavorable mechanical environment in the knee. For those severe situations, double-level osteotomy, which retains anatomical knee joint line by simultaneous femoral and tibial osteotomies, should be considered to correct the joint-line obliquity

Fractures of the anteromedial facet (AO/OTA 21-B1.1, O'Driscoll Type 2, subtype 3) are associated with varus posteromedial rotational instability of the ulnohumeral joint and early post-traumatic arthritis. The purpose of this study was to examine the stability of plate (locking and non-locking) vs screw constructs in the fixation of anteromedial coronoid facet fractures in a sawbone model. An anteromedial coronoid facet fracture (AO/OTA 21-B1.1) was simulated in 24 synthetic ulna bones. They were then assigned into 3 fracture fixation groups: non-locking plate fixation, locking plate fixation, and dual cortical screw fixation. An AO 2.0 mm screw and plate system was used for the plate fixation groups and 2.0 mm cortical screws were used for the screw-only group. Following fixation, each construct was potted in bismuth alloy and secured to a servohydraulic load frame. Each construct was cycled in tension and then in compression at 0.5Hz. For both cycling modalities, an incremental loading pattern was used starting at 40 N and increased by 20 N every 200 cycles up to 200N. Fracture fragment displacement was recorded with an optical tracking system. Following cyclic loading each construct was loaded to failure (displacement >2 mm) at 10mm/min. Tension cycling – All constructs in the plated groups (locking and non-locking constructs) survived the cyclic tension loading protocol (to 200N) with maximum fragment displacement of 12.60um and 14.50um respectively. There was no statistical difference between the plated constructs at any load level. No screw-only fixed construct survived the tension protocol with mean force at failure of 110N (range 60–180N). Compression Testing – All constructs in the plated groups (locking and non-locking constructs) survived the cyclic compression loading protocol (to 200N), while all but one of the screw-only fixation constructs survived. Fracture fragment displacement was significantly greater in the screw-only repair group across all loading levels when compared to the plated constructs. There was no statistically significant difference in fragment motion between the locking and non-locking groups. Failure Testing – The maximum load at failure in the screw-only group (281.9 N) was significantly lower than locking and non-locking constructs (587.0 N and 515.5N respectively, p <0.05). There was no difference between the locking and non-locking group in mean load to failure or mean stiffness. Screw construct stiffness (337.2 N/mm) was lower than the locking and non-locking constructs (682.9 N/mm and 479.1 N/mm respectively) however this did not reach statistical significance (p=0.051). Fixation of anteromedial coronoid fractures is best achieved with a plating technique. Locking plates did not offer any advantage over conventional plates. Isolated screw fixation might not provide adequate stability for these fractures which could result in loss of reduction leading to post-traumatic arthrosis or instabilility

Statement of Purpose. To compare the functional outcome of Distal Tibial Metaphyseal fracture treated with Circular frame compared vs. Locking Plate. Methods and Results. Distal Tibial Metaphyseal fractures were retrospectively identified over an 18 month period. Each fracture was assessed individually using radiographs. All paediatric, compound, tibial plateau and intra-articular fractures were excluded from the study. Other methods of fixation including intramedullary nailing were also excluded. The remaining fractures were assigned to either the circular frame fixation or the locking plate intervention group. Outcomes were assessed using radiographs for union dates and microbiology results for evidence of infection. Patients were followed up by postal questionnaires, which included a modified American Orthopaedic Foot and Ankle Score (AOFAS), the Olerud and Molander Score (O&M) and a custom questionnaire. The custom questionnaire asked about co-morbidities, smoking status and work days lost following surgery. After exclusions, 30 patients (Frame=15, Plate=15), were sent out questionnaires via post. We received completed questionnaires from 21 patients (Frame=11, Plate=10) giving us a response rate of 70%. Results show no difference in infection rates, skin necrosis, non-union or re-operation rates. There was also no significant difference in patient AOFAS and O&M scores at follow up. Conclusion. There is no significant difference in complications and functional Outcomes between locking plate fixation and circular frames in the treatment of distal Tibial Metaphyseal fractures

Purpose of study:. Up to 30% of distal femur fractures treated with a locked plate have problems with union. Distal femur locked plates have become a very popular means of internal fixation because of their ability to provide stable distal peri-articular fixation. In spite of this enthusiasm however several studies have reported significant problems with healing. In the distal femur it is recognized that locked plate fixation may be too rigid if used in certain configurations preventing the essential micro movement required for biological healing. Implant failure may arise from rigid configurations that cause excessive hardware stress concentrations. In an attempt to address these problems longer plates and an increased working length have been proposed to reduce construct rigidity. The purpose of our study is to investigate whether an increased working length translates into improved healing. Description of method:. We undertook a retrospective review of 92 consecutive cases performed at our institution from 2007–2010. Case notes and X-rays were reviewed. Working length, plate to fracture zone ratios and working length to fracture zone ratios were calculated. Union was assessed radiographically and clinically. Covariates of smoking, age, sex and fracture severity were included. Outcomes considered were union or established non-union. Delayed union was defined as union after 20 weeks. Summary of results:. Median time to union was 16.9 weeks. 11 delayed unions (23.4%, 95%CI(10.8–36.0%)), 3 non-unions (6.4% 95%CI(0.0–13.6%)) and no implant failures were recorded. Our data are consistent with the previously reported proportion of distal femur fractures treated with a locked plate that have problems with union. Although trends were present, no significant associations between impaired healing and exposure variables were found. Conclusion:. While biomechanical studies have demonstrated increased flexibility of longer plates with an increased working length, clinically this did not translate into significantly improved fracture healing in our study

Introduction. Getting the distal locking screw lengths right in volar locking plate fixation of distal radius is crucial. Long screws can lead to extensor tendon ruptures whereas short screws can lead to failure of fixation, especially if there is dorsal comminution of the fracture. The aim of our study was to determine the distal radius anatomy in relation to sagittal lengths and distance between dorsal bone edge and extensor tendons based on MRI scan. Method. One hundred consecutive MRI scans of wrist were reviewed by two of the authors on two occasions. All MRI scans were performed for different wrist pathologies except distal radius fractures or tumours. An axial image, two cuts proximal to the last visible articular surface, was selected. Sagittal length at 5 different widths, maximum volar width, radial overhang over distal radio-ulnar joint and the distance between dorsal bone edge and extensor tendons were measured. Results. A total of 120 MRI scans were included of which 74 were women and 46 were men. Mean volar width was 32mm and longest sagittal length was 22 mm (at Lister's tubercle). Length radial to Lister's tubercle was the shortest (17mm) and ulnar sides were 21mm and 29mm. Male measurements were mean 3mm longer than females. Mean radial overhang over DRUJ was 4mm. Distance from bone to tendons was within 2mm of dorsal radius edge. Conclusion. The study provides a reference guide to average screw lengths at different widths of distal radius in males and females. EPL tendon is closest to bone although all the extensor tendons are within 2mm of bone edge and carry a risk of injury from drill and screw placement. DRUJ is also at risk of injury if screws are placed within 4mm of ulnar edge of distal radius

Background. Osteotomies around the knee have been used to correct lower limb mal-alignment for over 50 years. The procedure is technically demanding and carries specific risks of neurovascular injury, incorrect planning and execution, and insufficient fixation. In recent years, with the advent of locking plates, fixation techniques have improved significantly but the correct planning and execution of the operation remains difficult. Despite the availability of CT and MRI 3D imaging, surgical planning is still traditionally performed on 2D plain X-rays [1]. Especially with multi-planar deformities, this technique is prone to error. The aim of this clinical pilot study is to evaluate the feasibility of virtual pre-operative three-dimensional planning and correct execution of osteotomies around the knee with the aid of patient specific surgical guides and locking plates. Patients and methods. Eight consecutive patients, presenting with significant malalignment of the lower limb were included in the study. Pre-operative CT scans of the affected limb and the normal contra-lateral side were obtained and 3D models of the patient's anatomy were created, using dedicated software (Mimics® 3-matic®, Materialise, Leuven Belgium) [2]. These models were used to evaluate the required surgical correction. The healthy contralateral limb was mirrored and geometrically matched to the distal femur or proximal tibia of the healthy side. A virtual opening wedge correction of the affected bone was used to match the geometry of the healthy contralateral bone. Standard lower limb axes measurements confirmed correction of the alignment [3]. Based on the virtual plan, surgical guides were designed to perform the planar osteotomy and achieve the planned wedge opening and hinge axis orientation (see figure 1). Apart from guiding the osteotomy, the patient specific surgical guide also guided drilling of the planned screw holes. Post-operative assessment of the correction was obtained through planar X-rays, CT-scan and full leg standing X-ray. Results. One three-planar, three bi-planar and four single-plane osteotomies were performed. All guides could be used during surgery and served accurate guidance of the osteotomy plane and screwholes. The guides matched the bone very well in all cases without remaining toggle. The maximum deviation between the planned pre-operative wedge angle and the executed post-operative wedge angle was 1° in the coronal, sagittal and horizontal plane. The desired mechanical femorotibial axis on full-leg standing X-rays was achieved in 6 patients. Two patients were undercorrected by 1° and 2° respectively. No significant peri-operative complications occurred. Conclusion. 3D planning and guided correction of multi-planar deformity of femur or tibia is a feasible and accurate novel technique