Midshaft clavicle fractures can be classified into simple or complex/comminuted. The hardest fracture to treat is the severely comminuted and displaced fracture. We retrospectively compared 286 consecutive operatively treated simple (2 and 3 part) fractures with the more complex comminuted (>=4 part) midshaft clavicle fractures, looking at outcome, complication rate and union rate.

Between 2008 and 2010 the senior author operated on 286 displaced midshaft clavicle fractures using a plate and screws. In this cohort there were 173 simple (2 and 3 part) fractures and 99 complex (>=4 part) fractures. The operation was performed through a limited incision technique and was standardized. All fractures were fixed with at least 3 screws on either side of the comminution. All patients were up until radiological and clinical union. A standardized questionnaire was used to assess patient satisfaction, return to work, sport and outcome at each postoperative visit. All complications were documented.

All fractures eventually went onto union. There were 242 males and 44 females with the average age being 33. The complex fractures had a larger scar, took longer to return to normal motion, work and sport, and took on average 10 weeks to unite compared to 6 weeks in the simple fractures. The infection rate in the simple fractures was 1% and in the complex fractures was 2%. The big difference was the incidence of non union in the complex fractures of 10% compared to 1%; the other main difference was postoperative shoulder stiffness of 3% at 3 months in the complex fractures compared to 1 % in the simple fractures. Plate elevation/irritation was also more prevalent in the complex fractures of 10% compared to 3%.

This study clearly shows there is a higher complication rate in complex fractures. Particular attention must be placed on surgical technique and anatomical reduction of these difficult fractures followed closely by postoperative rehabilitation. Future studies of clavicle fractures should specify the type of fracture being treated to give a better understanding of the potential outcome.

Purpose

There is increasing evidence that primary fixation of displaced mid-shaft fractures of the clavicle results in superior short-term outcomes when compared to traditional non-operative methods. However, the results from published studies are limited to relatively short-term (one year or less) follow-up. Accurate data of longer follow-up is important for a number of reasons, including patient prognostication, counseling and care, the design of future trials, and the economic analysis of treatment. The purpose of this paper was to examine the results of the two year follow up of patients enrolled in a previously published randomized clinical trial of operative versus non-operative treatment of displaced fractures of the clavicle.

Distal radius fractures are the most common osteoporotic fractures among women. The treatment of these fractures has been shifting from a traditional non-operative approach to surgery, using volar locking plate (VLP) technology. Surgery, however, is not without risk, complications including failure to restore an anatomic reduction, fracture re-displacement, and tendon rupture. The VLP implant is also marked by bone loss due to stress-shielding related to its high stiffness relative to adjacent bone. Recently, a novel internal, composite-based implant, with a stiffness less than the VLP, was designed to eradicate the shortcomings associated with the VLP implant. It is unclear, however, what effect this less-stiff implant will have upon adjacent bone density distributions long-term. The objective of this study was to evaluate the long-term effects of the two implants (the novel surgical implant and the gold-standard VLP) by using subject-specific finite element (FE) models integrated with an adaptive bone formation/resorption algorithm. Specimen: One fresh-frozen human forearm specimen (female, age = 84 years old) was imaged using CT and was used to create a subject-specific FE model of the radius. Finite element modeling: In order to simulate a clinically relevant (unstable) fracture of the distal radius, a wedge of bone was removed from the model, which was approximately 10 mm wide and centered 20 mm proximal to the tip of the radial styloid. Bone remodeling algorithm: A strain-energy density (SED) based bone remodeling theory was used to account for bone remodeling. With this approach, bone density decreased linearly when SED per bone density was less than 67.5 µJ/g and increased when it was more than 232.5 µJ/g. When it was in the lazy zone (67.5 to 232.5 µJ/g), no changes in density occurred. Boundary conditions: A 180 N quasi-static force representing the scaphoid, and a 120 N quasi-static force representing the lunate was applied to the radius. The midshaft of the radius was constrained. FE outcomes: To examine the effects of stress shielding associated with each implant, the long-term changes of bone density within proximal transverse cross-sections of radius were inspected. The regional density analysis focused on three transverse cross-sections. The transverse cross-sections were positioned proximal to the subchondral plate, and were distanced 50 (cross-section A), 57 (cross-section B), and 64 mm (cross-section C) from the subchondral endplate. For both implants in all three cross-sections, cortical bone was reserved completely at the volar side. On the dorsal side, the cortical bone was completely resorbed in the VLP model. In all cross-sections, the averaged resultant density was higher for the “novel implant”. The difference ranged from 33% (cross-section A) to 36% (cross-section C) in favor of the “novel implant”. On average, the density values of the novel implant were 34% higher in transverse cross-sections (A, B, and C). This study showed that the novel implant offered higher density distributions compared to the VLP, which suggests that the novel implant may be superior to the VLP in terms of avoiding stress shielding

Aim. Silver is known for its excellent antimicrobial activity, including activity against multiresistant strains. The aim of the current study was to analyze the biocompatibility and potential influence on the fracture healing process a silver-coating technology for locking plates compared to silver-free locking plates in a rabbit model. Methods. The implants used in this study were 7-hole titanium locking plates, and plasma electrolytic oxidation (PEO) silver coated equivalents. A total of 24 rabbits were used in this study (12 coated, 12 non-coated). An osteotomy of the midshaft of the humerus was created with an oscillating saw and the humerus stabilized with the 7 hole locking plates with a total of 6 screws. X-rays were taken on day 0, week 2, 4, 6, 8, and 10 for continuous radiographical evaluation of the fracture healing. All animals were euthanized after 10 weeks and further assessment was performed using X-rays, micro-CT, non-destructive four-point bending biomechanical testing and histology. Furthermore, silver concentration was measured in the kidney, liver, spleen and brain. Results. X-rays showed normal undisturbed healing of the osteotomy in all animals without any differences between the two groups over the entire X-ray analysis over 10 weeks (Figure 1). Callus formation was observed up to week 4 to 5 followed by callus remodeling after 6 weeks indicating physiological fracture healing pattern in both the silver and in the silver free group. Micro CT analysis revealed overall tissue (callus and cortical bone) volume as well as tissue density to be comparable between the two groups. Mechanical testing showed comparable stiffness with an average stiffness relative to contralateral bones of 75.7 ± 16.1% in the silver free control group compared to 69.7 ± 18.5% (p-value: 0.46). Histology showed no remarkable difference in the analysis of the healed osteotomy gap or in the surrounding soft tissue area. Silver content was found to be close to baseline values without differences between the two groups. Conclusions. This study shows that the presented antimicrobial silver surface modification for locking plates has a good biocompatibility without any negative influence on the fracture healing processes compared to the silver free control group. This allows for further clinical investigation of this silver technology for locking plates in fracture patients with an elevated infection risk, e.g. in patients with open fractures. For any figures or tables, please contact the authors directly

Purpose. On January 12th, 2010 a magnitude 7.0 earthquake struck the downtown area of Port au Prince, the capital of the poorest country in the western world. Nearly a quarter of a million people were killed and a million other were injured. Our goal was to provide follow up and acute care to injured Haitain patients. Method. During an eight day period in June of 2010 a group of three physicians from Memorial University were part of a humanitarian mission to this country in conjunction with the University of Maryland and the humanitarian group Catholic Relief Services (CRS). Attempting to provide orthopedic care six months after such a disaster presented numerous challenges in this part of the world. Security and travel were always a concern due to the rising number of foreign kidnappings that plague the capital city. The heat and humidity made the simplest of tasks exhausting and uncomfortable. Living conditions, although above average for Haiti, consisted of no heated water, diseased mosquitoes, and sleeping of concrete floors. CRS provided us with the means to deal with all of these challenges. Results. Care was provided at Hospital St. Francis de Sales which was devastated during the earthquake. Two hundred bodies remained buried in the rubble and less than 20% of the original structure remained standing and functional. Wards consisted of donated military style tents with minimal protection from the elements. Communication with the short staffed nurses and abundant patients required the use of translators or a familiarity with French or Creole. Attaining x-rays required outside transport of patients and blood work was only done in an emergency situation. Surgical cases took place in a surgical theatre with two OR tables operating simultaneously. A nurse anesthetist provided care for all surgical patients with only one operational anesthetic machine. Lack of basic supplies on a day to day basis and frequent and ill timed power outages ensured even the smallest of cases presented their own challenges. Greater than 25 orthopedic cases were completed during our mission. These were wide in scope including the complications of earthquake trauma, fresh trauma, hip fractures, and tumor removals. Five Moores hemiarthroplasties were performed as this was the only prosthesis available. ORIF of fracture nonunions included a midshaft humerus, a both bones forearm, several midshaft tibias, and an infected humeral supracondylar fracture. Cases were completed with incomplete equipment sets and without a scrub nurse. Conclusion. Providing orthopedic care in less developed areas of the world present numerous challenges. Utilizing humanitarian organizations that are well organized and integrated into the culture are essential. Orthopedic surgeons must be willing to rely less on technology and more on basic principles and hard work to provide safe and beneficial care where it is truly needed

Introduction. Clavicle fractures accounting for 3–5% of all adult fractures are usually treated non-operatively. There is an increasing trend towards their surgical fixation. Objective. The aim of our study was to investigate the outcome following titanium elastic stable intramedullary nailing (ESIN) for midshaft non-comminuted clavicle fractures with >20mm shortening/displacement. Methods. 38 patients, which met inclusion criteria, were reviewed retrospectively. There were 32 males and 6 females. The mean age was 27.6 years. The patients were assessed for clinical/radiological union and by Oxford Shoulder and QuickDASH scores. 71% patients required open reduction. Results. 100% union was achieved at average of 11.3 weeks. The average follow-up was 12 months. The average Oxford Shoulder and QuickDASH scores were 45.6 and 6.7 respectively. 47% patients had nail removal. One patient had lateral nail protrusion while other required its medial trimming. Conclusion. In our hands, ESIN is safe and minimally invasive with good patient satisfaction, cosmetic appearance and overall outcome

Introduction and Purpose of Study. Osteogenesis imperfecta (OI) is a bone metabolic disorder that results in multiple fractures and deformities in children. The management of these patients should be in highly specialised units were multi-disciplinary management is mandatory. The aims of this study were twofold: 1. To determine the incidence and pattern of fractures in this population. 2. To determine the type, outcomes and complications of surgical treatment in the same population. Methods. A retrospective audit of patients treated for OI at a tertiary academic Hospital, from January 2002 to December 2011 was done. Results. Fifty three patients with OI were seen in the period under review. The patients came from six South African provinces including two other African countries. The male to female ratio was 1:1. The majority of patients were classified as type III and type IV, 19 (36%) and 14 (26%) respectively. Twelve patients (23%) had a first degree relative with OI. All patients received bisphosphonate therapy intravenously except two who were on oral medication. Seventeen patients (33%) had associated kyphoscoliosis – none were treated surgically. The most common long bone fractures were of the midshaft femur (61 fractures) and tibia (35 fractures). Seventeen patients (32%) received intramedullary rodding of either femur or tibia. Surgery had to be repeated due to rod migration in nine long bones (29%). The most common complication of surgery was rod migration and peri-implant fracture. Conclusion. Long bone fractures of the femur and tibia were most common cause of morbidity. Intramedullary rodding is a safe and effective means of long bone fracture management in patients with OI

When fixing a mid or distal periprosthetic femoral fracture with an existing hip replacement, creation of a stress-riser is a significant concern. Our aim was to identify the degree of overlap required to minimise the risk of future fracture between plate and stem. Each fixation scenario was tested using 4th generation composite femoral Sawbones®. Each sawbone was implanted with a collarless polished cemented stem with polymethyl methacrylate bone cement and cement restrictor. 4.5mm broad Peri-loc™ plates were positioned at positions ½, 1 and 2 shaft diameters (SD) proximal and distal to the tip of the femoral stem. Uni-axial strain gauges (medial and lateral longitudinal gauges, anterior and posterior torsional gauges) measured microstrain at tip of the femoral stem with a standard load of 500N in axial, 3-point lateral and composite torsion/posterior loading using an Instron machine. With axial loading fixation with 2SD proximal resulted in the least amount of strain, in both tension & compression, at the tip of the femoral stem. Fixation with 4 unicortical screws was significantly better than 2 alternating unicortical screws (mean microstrain difference 3.9 to 15.3, p<0.0001). With lateral 3-point loading fixation with 2SD proximal overlap and 2 alternating unicortical screws resulted in the least amount of strain, in both tension and compression, at the tip of the femoral stem (p<0.0001). With torsion & posterior displacement 2SD proximal fixation resulted in the least amount of rotational strain. There was no significant difference between 4 unicortical screws compared to 2 alternating unicortical screws (p>0.05 in 3 of 4 gauges). Fixation of midshaft or distal femoral fractures with a well-fixed total hip arthroplasty should have at least 2 shaft diameters of proximal overlap with a 4.5mm broad plate. It is not clear if 4 unicortical screws or 2 alternating screws are optimal

Aims

Double-level lengthening, bone transport, and bifocal compression-distraction are commonly undertaken using Ilizarov or other fixators. We performed double-level fixator-assisted nailing, mainly for the correction of deformity and lengthening in the same segment, using a straight intramedullary nail to reduce the time in a fixator.

Currently, there is no animal model in which to evaluate the underlying physiological processes leading to the heterotopic ossification (HO) which forms in most combat-related and blast wounds. We sought to reproduce the ossification that forms under these circumstances in a rat by emulating patterns of injury seen in patients with severe injuries resulting from blasts. We investigated whether exposure to blast overpressure increased the prevalence of HO after transfemoral amputation performed within the zone of injury. We exposed rats to a blast overpressure alone (BOP-CTL), crush injury and femoral fracture followed by amputation through the zone of injury (AMP-CTL) or a combination of these (BOP-AMP). The presence of HO was evaluated using radiographs, micro-CT and histology. HO developed in none of nine BOP-CTL, six of nine AMP-CTL, and in all 20 BOP-AMP rats. Exposure to blast overpressure increased the prevalence of HO.

This model may thus be used to elucidate cellular and molecular pathways of HO, the effect of varying intensities of blast overpressure, and to evaluate new means of prophylaxis and treatment of heterotopic ossification.

Cite this article: Bone Joint J 2015;97-B:572–6

Objectives

There remains conflicting evidence regarding cortical bone strength following bisphosphonate therapy. As part of a study to assess the effects of bisphosphonate treatment on the healing of rat tibial fractures, the mechanical properties and radiological density of the uninjured contralateral tibia was assessed.