AO Type B3 Research Articles

Comparative Biomechanical Study of Fragment-Specific Plates and Headless Screws for Radial Styloid and Lunate Facet Fixation in Distal Radius Fracture Evaluated in a Synthetic Composite

To evaluate the compressive stiffness (ability to resist compression under an applied load) of fragment-specific plate and headless screw fixation for radial styloid and volar lunate facet fractures in a synthetic composite distal radius. A simulated radial styloid fracture (AO type B1.1) and simulated volar lunate facet fracture (AO type B3.3) were created in synthetic composite distal radii and fixed with a fragment-specific plate (FSP) using a radial styloid or lunate facet plate or with two- or three-headless screws (2HS, 3HS), creating 6 fixation models: B1.1/FSP, B1.1/2HS, B1.1/3HS, B3.3/FSP, B3.3/2HS, and B3.3/3HS. Compressive stiffness of fixation constructs under initial static load, cyclic load, and final static load was investigated. Nonaxial loadings, including shearing and rotation, were not evaluated. Regarding AO type B1.1, the mean stiffness of the B1.1/FSP construct was not significantly different from the intact radius, and the mean stiffness was greatest in the B1.1/3HS and lowest in the B1.1/2HS construct. For AO type B3.3, the mean stiffness of the B3.3/3HS construct was not significantly different from the intact radius, and the mean stiffness of the B3.3/FSP and B3.3/2HS construct was greatest and lowest, respectively. Minimal differences in stiffness between initial and final static loads confirmed that there was no evidence of failure implant under cyclic compressive loads. Fragment-specific plates and two- or three-headless screw fixation maintained mechanical stability through compressive cyclic loading for radial styloid and volar lunate facet fractures. The FSPs and three-headless screws fixations provided superior stiffness over the two-headless screws fixation. There was no articular fracture failure in all fixation constructs with initial static compression, cyclic loading, and final compression. Fragment-specific plates and headless screws can both be considered as adequate fixation for radial styloid and volar lunate facet fractures.

Patient-specific bone material modelling can improve the predicted biomechanical outcomes of sacral fracture fixation techniques: A comparative finite element study

ObjectiveTo evaluate and compare the biomechanical efficacy of six iliosacral screw fixation techniques for treating unilateral AO Type B2 (Denis Type II) sacral fractures using literature-based and QCT-based bone material properties in finite element (FE) models. MethodsTwo FE models of the intact pelvis were constructed: the literature-based model (LBM) with bone material properties taken from the literature, and the patient-specific model (PSM) with QCT-derived bone material properties. Unilateral transforaminal sacral fracture was modelled to assess different fixation techniques: iliosacral screw (ISS) at the first sacral vertebra (S1) (ISS1), ISS at the second sacral vertebra (S2) (ISS2), ISS at S1 and S2 (ISS12), transverse iliosacral screws (TISS) at S1 (TISS1), TISS at S2 (TISS2), and TISS at S1 and S2 (TISS12). A 600 N vertical load with both acetabula fixed was applied. Vertical stiffness (VS), relative interfragmentary displacement (RID), and the von Mises stress values in the screws and fracture interface were analysed. ResultsThe lowest and highest normalised VS was given by ISS1 and TISS12 techniques for LBM and PSM, with 137 % and 149 %, and 375 % and 472 %, respectively. In comparison with the LBM, the patient-specific bone modelling increased the maximum screw stress values by 19.3, 16.3, 27.8, 2.3, 24.4 and 7.8 % for ISS1, ISS2, ISS12, TISS1, TISS2 and TISS12, respectively. The maximum RID values were between 0.10 mm and 0.47 mm for all fixation techniques in both models. The maximum von Mises stress results on the fracture interface show a substantial difference between the two models, as PSM (mean ± SD of 15.76 ± 8.26 MPa) gave lower stress values for all fixation techniques than LBM (mean ± SD of 28.95 ± 6.91 MPa). ConclusionThe differences in stress distribution underline the importance of considering locally defined bone material properties when investigating internal mechanical parameters. Based on the results, all techniques demonstrated clinically sufficient stability, with TISS12 being superior from a biomechanical standpoint. Both LBM and PSM models indicated a consistent trend in ranking the fixation techniques based on stability. However, long-term clinical trials are recommended to confirm the findings of the study.

FUNCTIONAL EVALUATION OF VOLAR BARTON FRACTURES MANAGED WITH ANATOMICAL PLATING AT A TERTIARY CARE CENTER IN NEPAL: A RETROSPECTIVE REVIEW OF RECORDS.

Introduction Distal end radius fractures have been extensively studied in literature and yet many aspects of management remain controversial. Volar Barton fractures have been treated surgically with volar locking plates. Very few dedicated studies have been conducted in Nepal. The aim of this study was to describe the functional outcomes of Volar Barton fractures managed with open reduction and internal xation (ORIF) and Volar plating at a high volume tertiary care centre in Nepal. This retrospective Methodology review of patients was conducted after approval of the institutional ethics committee. A review of records of patients operate in the last 24 months was be performed. Patients aged 18 to 65 years who had been operated for Volar Barton fractures (AO type B3) within 3 weeks of injury with ORIF and Volar plating with a minimum of 12 months follow up were included in the study. Data regarding demographics, side of injury, functional outcomes using the Patient rated wrist evaluation (PRWE), Modied Mayo Wrist score and Radiological parameters. Statistical analysis of the data was done. Proportion, percentage, mean, standard deviation was calculated. A total of 180 records of patients who underwent ORIF Results and plating between 1st April 2021 to 31st March 2021 were identied. Of these 50 patients met the inclusion criteria and were included in the analysis. The mean age of the patients was 36.4 ± 1.4 years (18- 62 years). All fractures united with a mean union time of 5.7 ± 3.2 weeks. On radiographic assessment at 12 months the Volar tilt was 5.23 ± 2.41®, mean radial height was 9.23 ± 2.2®. Radial inclination was 22.9 ± 5.0®. The mean articular step was 0.3 ± 0.5 mm. Functional outcomes using the PRWE at 12 months was 3.5 ± 1.3. The Modied Mayo score was 82.12 ± 7.3. Conclusion Volar plating provides good functional and radiological outcomes in our study population. It has good union rates and a relatively low complication rate.

Comparison of the Outcomes between AO Type B2 Thoracolumbar Fracture with and without Disc Injury after Posterior Surgery.

ObjectiveThe type AO B2 thoracolumbar fracture is a kind of flexion‐distraction injury and the effect of disc injury on treatment results of patients with B2 fracture remains unclear. The objective of the current study was to compare and analyze the outcomes in AO Type B2 thoracolumbar fracture patients with and without disc injuries in terms of the Cobb angle of kyphosis, the incidence of complication, and the rate of implant failure.MethodsThis is a retrospective study. Of the 486 patients with thoracolumbar fractures who underwent posterior fixation, 38 patients with AO type B2 injuries were included. All the patients were divided into two groups according to changes in the adjoining discs. Disc injury group A included 17 patients and no disc injury group included 21 patients. Clinical and radiologic parameters were evaluated before surgery, after surgery, and at follow‐up. Clinical outcomes included visual analogue scale (VAS) scores, incidence of complications, and incidence of implant failure. Radiologic assessment was accomplished with the Cobb angle (CA), local kyphosis (LK), percentage of anterior vertebral height (AVBH%), intervertebral disc height, and intervertebral disc angle. Fisher's precision probability tests were employed and chi square test were used to compare categorical variables. Paired sample t tests and independent‐sample t tests were used to compare continuous data.ResultsDisc injury mainly involved the cranial disc (15/19, 78.9%). The mean follow‐up period for the patients was 30.2 ± 20.1 months. No neurologic deterioration was reported in the patients at the last follow‐up. Radiological outcomes at the last follow‐up showed significant differences in the CA (18.59° ± 13.74° vs 8.16° ± 9.99°, P = 0.008), LK (12.74° ± 8.00° vs 6.55° ± 4.89°, P = 0.006), and %AVBH (77.16% vs 90.83%, P = 0.01) between the two groups.Implant failure occurred after posterior fixation in five patients with disc injury who did not undergo interbody fusion during the initial surgery. Additionally, in the subgroup analysis, interbody fusion in the implant failure group were significantly different than in the no implant failure group (0% vs 75%, P = 0.009).ConclusionsAO B2 fracture patients with disc injury have higher risk of complications, especially implant failure after posterior surgery. Interbody fusion should be considered in AO type B2 fracture patients with disc injury.

Minimally Invasive versus Conventional Open Surgery for Fixation of Spinal Fracture in Ankylosed Spine.

Introduction:This was a retrospective study aimed to investigate the perioperative outcomes of long construct minimally invasive spinal stabilisation (MISt) using percutaneous pedicle screws (PPS) versus conventional open spinal surgery in the treatment of spinal fracture in ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH).Material and Methods:Twenty-one patients with AS and DISH who were surgically treated between 2009 and 2017 were recruited. Outcomes of interest included operative time, intra-operative blood loss, complications, duration of hospital stay and fracture union rate.Results:Mean age was 69.2 ± 9.9 years. Seven patients had AS and 14 patients had DISH. 17 patients sustained AO type B3 fracture and 4 patients had type B1 fracture. Spinal trauma among these patients mostly involved thoracic spine (61.9%), followed by lumbar (28.6%) and cervical spine (9.5%). MISt using PPS was performed in 14 patients (66.7%) whereas open surgery in 7 patients (33.3%). Mean number of instrumentation level was 7.9 ± 1.6. Mean operative time in MISt and open group was 179.3 ± 42.3 minutes and 253.6 ± 98.7 minutes, respectively (p=0.028). Mean intra-operative blood loss in MISt and open group was 185.7 ± 86.4ml and 885.7 ± 338.8ml, respectively (p<0.001). Complications and union rate were comparable between both groups.Conclusion:MISt using PPS lowers the operative time and reduces intra-operative blood loss in vertebral fractures in ankylosed disorders. However, it does not reduce the perioperative complication rate due to the premorbid status of the patients. There was no significant difference in the union rate between MISt and open surgery.

Patients with ankylosing spondylitis suffering from AO Type B3 traumatic thoracolumbar fractures are associated with increased frailty and morbidity when compared with patients with diffuse idiopathic skeletal hyperostosis

AO Type B3 hyperextension thoracolumbar fractures are the commonest fracture subtype in ankylosing spinal disorders. Although often considered together in spinal fractures, ankylosing spondylitis (AS) and diffuse idiopathic skeletal hyperostosis (DISH) are distinct spondyloarthropathies with different pathophysiology. Few studies have compared the two entities in the setting of traumatic thoracolumbar fractures. The authors compare demographic metrics, injury profile, clinical and radiographical outcomes between patients with AS and DISH in patients suffering from AO Type B3 traumatic thoracolumbar fractures. From January 2008 to December 2018, a retrospective analysis of consecutive surgically-managed patients with AO Type B3 fractures was performed. Demographic metrics, co-morbidity [Charlson-comorbidity index, modified frailty index (mFI), etc.], injury profile (level of injury, mechanism of injury, etc.), clinical (postoperative complication, etc.) and radiographical variables were collected. Differences between patients with AS and DISH were compared. Fourteen patients were identified. All patients had AS (n=6) or DISH (n=8). The mean age was 72.8±10.2 years and 78.6% of patients were neurologically intact at presentation. Medical and/or surgical complications occurred in 10 of 14 (71.4%) patients. As compared to patients with DISH, patients with AS were more likely to have low falls as the injury mechanism [odds ratio (OR): 35.0, P=0.026], have higher mFI (OR: 30.6, P=0.015), and experience a higher number of postoperative complications per patient (AS: 1.8/patient vs. DISH: 0.5/patient, P=0.024). In the setting of AO Type B3 fractures, patients with AS are more frail and have higher in-hospital morbidity compared to patients with DISH. Despite both pathologies being ankylosing in nature, further studies are required to fully understand the clinical differences between the two entities to enable clinicians to apply a more targeted and nuanced approach in managing fractures in ankylosing spinal disorders.

Tape suture for stabilization of incomplete posterior pelvic ring fractures\u2014biomechanical analysis of a new minimally invasive treatment for incomplete lateral compression pelvic ring fractures

BackgroundIncomplete lateral compression fractures (including AO Type B2.1) are among the most common pelvic ring injuries. Although the treatment of choice remains controversial, sacroiliac (SI) screws are commonly used for the operative treatment of incomplete lateral compression fractures of the pelvic ring. However, the disadvantages of SI screws include the risk of nerve root or blood vessel injury. Recently, tape sutures have been found useful as stabilizing material for the treatment of injuries of the syndesmosis, the rotator cuff and knee ligaments. In this current study, we aimed to test the biomechanical feasibility of tape sutures to stabilize the pelvis in the setting of AO Type B2.1 injury.MethodsSix human cadaveric pelvises underwent cyclic loading to compare the biomechanical stability of different osteosynthesis methods in a B2.1 fracture model. The methods tested in this experiment were a FiberTape® suture and the currently established SI screw. A 3D ultrasound tracking system was used to measure fracture fragment motion. Linear regression was used to model displacement and stiffness at the posterior and anterior pelvic ring.ResultsAt the posterior fracture site, the FiberTape® demonstrated similar displacement (2.2 ± 0.8 mm) and stiffness (52.2 ± 18.0 N/mm) compared to the sacroiliac screw (displacement 2.1 ± 0.6 mm, P > 0.999; stiffness 50.8 ± 13.0 N/mm, P > 0.999).Considering the anterior fracture site, the FiberTape® again demonstrated similar displacement (3.8 ± 1.3 mm) and stiffness (29.5 ± 9.0 N/mm) compared to the sacroiliac screw (displacement 2.9 ± 0.8 mm, P = 0.2196; stiffness 37.5 ± 11.5 N/mm, P = 0.0711).ConclusionThe newly presented osteosynthesis, the FiberTape®, shows promising results for the stabilization of the posterior pelvic ring in AO Type B2.1 lateral compression fractures compared to a sacroiliac screw osteosynthesis based on its minimal-invasiveness and the statistically similar biomechanical properties.

Evaluation of volar locking plate fixation for management of intra-articular fractures of distal end of radius

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; With the increase in high velocity trauma, the incidence of intra-articular fractures of distal end of radius, particularly in adults- the working class of society is increasing. Normal functioning of wrist is of paramount importance for all activities of daily living and working. The present study was undertaken to evaluate the results of using volar locking plate for fixation of intra-articular fractures of distal end radius, with emphasis on return to pre-injury employment assessment.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; It is a combined prospective and retrospective study from January 2013 to June 2016. Twenty patients of intra-articular fractures of distal end of radius (AO type B2 and B3) were treated with volar locking plate through volar approach. The patients were regularly followed up for one year. The assessment of pain, range of motion, activity and grip strength were scored by Green and O’Brien’s system.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; According to scoring system of Green and O’Brien the patients were assessed at 1 year follow up. 17 patients (85%) showed excellent results (scores 90-100). 2 patients (10%) showed good result (scores 80-89) while 1 patient (5%) had fair outcome (score 65-79). No patient had poor result (score less than 65). 19 patients (95%) returned to their pre-injury employment at 1 year.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Open reduction and internal fixation with volar locking plate is reliable and excellent methods of management of intra-articular fracture of distal end of radius especially shear type of injury (AO type B2 and B3) in adults. &lt;/p&gt;

Efficacy of modified 270°spinal canal decompression combined with one-stage pedicle screw fixation and vertebral reconstruction for severe thoracolumbar fractures

Objective To investigate the efficacy of modified 270°spinal canal decompression combined with one-stage pedicle screw fixation and vertebral reconstruction for severe thoracolumbar fractures. Methods A retrospective case-control study was made on 44 cases of severe thoracolumbar fractures treated from January 2009 to June 2014. There were 34 males and 10 females, with age range of 20-68 years (mean, 37.9 years). The injured vertebrae included T11/12 in one case, T12-L1 in 10, L1/2 in 21, L2/3 in nine and L3/4 in three. Injury type was all AO type B2. According to the American Spinal Injury Association (ASIA), neurological deficit was Grade A in three cases, Grade B in five, Grade C in 22, and Grade D in 14. Load sharing score (LSC) was 7-9 points (mean, 8.1 points), while the thoracolumbar injury classification and severity score (TLICS) was 7-9 points (mean, 8.2 points). According to the difference of surgical procedures, all cases were divided into traditional group (21 cases) and improved group (23 cases). The patients in traditional group were treated by 270° spinal canal decompression combined with one-stage pedicle screw fixation and vertebral reconstruction, and those in improved group were treated by modified 270°spinal canal decompression combined with one-stage pedicle screw fixation and vertebral reconstruction. Between-group differences were compared with regard to operation time, intraoperative blood loss, postoperative drainage, allogeneic blood transfusion, pain visual analogue scale (VAS) at postoperative 72 hours, Cobb angle, anterior vertebral height, spinal canal compromise, Denis score, work state, neurological function, bone graft fusion and complications. Results Duration of follow-up was (32.4±15.8)months (range, 12-60 months). No wound infection or deterioration of neurological function was found after operation. Operation time was (2.4±0.5)hours in traditional group, less than (2.8±0.6)hours in improved group (P 0.05). VAS was (3.2±0.9)points in traditional group and (3.3±0.9)points in improved group at postoperative 72 hours (P>0.05). Cobb angle, anterior vertebral height and spinal canal compromise in both groups obtained well recovery and maintained after operation (P 0.05). At the last follow-up, ASIA Grade A was noted in three cases, Grade C in two, Grade D in 23, and Grade E in 16. Bone union was achieved in all cases, with no implant loosening or breakage observed. Thirteen cases in traditional group were found with residual bone fragments in the spinal canal after surgery, and two of them received revision surgery. Conclusions Either modified or traditional 270° spinal canal decompression combined with one-stage pedicle screw fixation and vertebral reconstruction can attain satisfactory clinical results in treatment of severe thoracolumbar fractures. However, the modified 270°spinal canal decompression can achieve more thorough decompression without reducing stability of the spine. Key words: Spinal fractures; Thoracic vertebrae; Lumbar vertebrae; Fracture fixation, internal

Intra articular distal radius fractures and volar plate fixation: a prospective study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Despite being one of the most common fractures encountered in patients, intra-articular distal radius fractures still pose therapeutic challenge to Orthopaedic surgeons. With the advent of locking plates, the fixation of these fractures has been made better, specifically by fixed angle volar locking plate. This study investigates the efficacy of these plates using volar approach, functional and clinical outcome, in addition to the radiological alignment.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Thirty patients with closed distal radius fractures, with AO TYPE B3, B4, AND C fracture pattern, operated with distal radius plate fixation using volar approach, were included in the study during the period of August 2014 to August 2016. With a minimum follow up of six months, radiological outcome was analysed and functional outcome recorded (Gartland and Werley’s demerit scoring system).&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; With a mean age of 42 years and follow up of six months, the range of movement of the wrist was very satisfactory, and the mean grip strength was 80% of the opposite wrist. Radiological parameters were well‑maintained, and functional parameters by Gartland and Werley showed a significant improvement in most of the patients during the follow‑up period. The complication rate was less and insignificant.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Primary volar plate fixation of intraarticular distal radius fracture provides a stable construct that helps in early mobilization, thereby better functional outcomes and minimizes chances of delayed/malunion.&lt;/p&gt;

NON-UNIONS AFTER FIXATION OF HUMERAL FRACTURES USING HACKETHAL'S BUNDLE NAILING TECHNIQUE.

ABSTRACTObjective:The aim of the study was to identify factors contributing to the development of non-union after fixation of diaphyseal humeral fractures using Hackethal's intramedullary nailing technique. Methods:In the time period from 2001 to 2010 156 patients with diaphyseal humeral fractures were treated surgically using Hackethal's technique. Six of them (3.8%) developed non-union. This group included three women and two men aged 63-69 years and one woman aged 37 years. The following parameters of the patients were recorded: age, gender, comorbidities, substance abuse, mechanism of injury, fracture type and location according to the AO/ASIF classification, and the operative technique. Results:A non-union developed in six patients treated with Hackethal´s method (3.8%). Five of six non-unions (83%) were observed in patients in their sixties. In the subgroup of sexagenarians, non-union developed in 20.8% of surgically treated patients, as compared to 3.8 % in entire group. In the union group, fractures have been caused by high energy trauma in 52% of patients. In patients who developed non-union, high energy trauma caused 67% of fractures. With correct surgical technique the development of a non-union was observed in 0.7% of patients, with incorrect technique in 35.7% (p<0.001). Conclusion:Treatment of diaphyseal humeral fractures with Hackethal's intramedullary elastic bundle nailing resulted in an overall high union rate. Factors contributing to the development of non-union were extension of this method to AO type B3 and C fractures and technical imperfection during implantation. Level of Evidence III, Prospective, Case-Control Study.

Transmanubrial Approach for Fracture of Lower Cervical Spine (C7) in Elderly Patients: A Case Report

Background: Fractures of the cervical spine are a frequent injury in the elderly with potentially devastating consequences. In most cases surgical therapy is required, in hyperextension fractures most often with anterior cervical fusion. Methods: We report a case of an 88-year old patient with a fracture of C7 (AO-type B3) who underwent anterior cervical fusion with manubrium sterni osteotomy for application of the caudal screws. Results: The insertion-angle of the caudal screws could be optimized; a dorsal instrumentation could be spared. Conclusion: We want to describe a technique that potentially simplifies addressing the vertebral bodies of the cervicothoracic junction for anterior cervical fusion in patients with difficult anatomical conditions and allows a safe and stable insertion of the caudal screws. Level of evidence: Level V (case report).

Spinal Epidural Hematoma after Thoracolumbar Posterior Fusion Surgery without Decompression for Thoracic Vertebral Fracture.

We present a rare case of spinal epidural hematoma (SEH) after thoracolumbar posterior fusion without decompression surgery for a thoracic vertebral fracture. A 42-year-old man was hospitalized for a thoracic vertebral fracture caused by being sandwiched against his back on broken concrete block. Computed tomography revealed a T12 dislocation fracture of AO type B2, multiple bilateral rib fractures, and a right hemopneumothorax. Four days after the injury, in order to promote early orthostasis and to improve respiratory status, we performed thoracolumbar posterior fusion surgery without decompression; the patient had back pain but no neurological deficits. Three hours after surgery, he complained of acute pain and severe weakness of his bilateral lower extremities; with allodynia below the level of his umbilicus, postoperative SEH was diagnosed. We performed immediate revision surgery. After removal of the hematoma, his symptoms improved gradually, and he was discharged ambulatory one month after revision surgery. Through experience of this case, we should strongly consider the possibility of preexisting SEH before surgery, even in patients with no neurological deficits. We should also consider perioperative coagulopathy in patients with multiple trauma, as in this case.

Factors predicting the development of early osteoarthritis following lateral tibial plateau fractures: mid-term clinical and radiographic outcomes of 73 operatively treated patients.

The indications for operative treatment of lateral tibial plateau fractures are still controversial. The objective of this study was to determine whether residual articular surface depression and valgus malalignment of plated lateral tibial plateau fractures at medium-term follow-up affect the clinical and radiographic outcomes. A chart review of patients with operatively treated (AO type B3.1) tibial plateau fractures that were admitted to our level I trauma center between 2002 and 2008 was performed. Out of 123 patients, 73 were available to participate in a clinical and radiographic follow-up examination. The mean follow-up time was 54 months. Patients were clinically assessed and completed the Lysholm knee score and Western Ontario and McMaster Universities Osteoarthritis Index. Maximal articular surface depression, radiological mechanical axis, and degree of posttraumatic osteoarthritis were evaluated from standing radiographs. Patients with valgus malalignment of 5° or greater at follow-up developed more advanced osteoarthritis (Kellgren-Lawrence grade 3-4) than patients with a normal mechanical axis (p = 0.006). Similarly, patients with articular depression greater than 2 mm at follow-up also developed more advanced osteoarthritis compared to patients with a depression of 2 mm or less (p = 0.001). The degree of valgus malalignment or articular depression had no effect on the Western Ontario and McMaster Universities Osteoarthritis Index or Lysholm scores. The postoperative articular congruity and normal mechanical axis of the lower leg after plate fixation in lateral tibial plateau fractures seem to have a role in prevention of posttraumatic osteoarthritis but does not appear to predict clinical outcome at medium-term follow-up. The role of initial dislocation and associated cartilage damage in the development of osteoarthritis following these fractures is still unknown.

Primary total elbow arthroplasty in complex fractures of the distal humerus.

To evaluate short- to medium term outcome of total elbow arthroplasty (TEA) in complex fractures of the distal humerus. A consecutive series of 24 complex distal humerus fractures operated with TEA in the period 2006-2012 was evaluated with the Mayo Elbow Performance score (MEPS), plain radiographs, complications and overall satisfaction. The indications for surgery were 1: AO type B3 or C3 or Sheffield type 3 fracture and age above 65 or 2: fracture and severe rheumatoid arthritis. Mean follow-up time was 21 mo. Twenty patients were followed up. Four patients, of which 3 had died, were lost to follow up. According to the AO classification there were 17 C3, 1 B2 and 2 A2 fractures. Mean follow-up was 21 months (range 4-54). Mean MEPS was 94 (range 65-100). Mean flexion was 114 degrees (range 80-140). According to MEPS there were 15 excellent, 4 good and 1 fair result. Patient satisfaction: 8 excellent, 10 good, 2 fair and 1 poor. There were two revisions due to infection treated successfully with revision and three months of antibiotics. In two patients the locking split had loosened. One was referred to re-insertion and one chose yearly controls. Two patients had persistent dysaesthesia of their 5th finger, but were able to discriminate between sharp and blunt. Our study suggests that TEA in complex fractures of the distal humerus in elderly patients can result in acceptable short- to medium term outcome.

Volar plate fixation of distal radius fractures

We aimed to evaluate the results of volar locking and unlocking plate fixation of adult distal radius fractures. Thirty-four patients (14 female, 20 male, mean age: 48.5 +/- 17.9 years) who were treated for distal radius fractures were investigated retrospectively. The fractures were distributed as follows: 17.6% AO type B3, 11.8% AO type C2 and 70.6% AO type C3. The patients were evaluated clinically (Gartland and Werley score, visual analog scale (VAS), Disabilities of the Arm, Shoulder and Hand (DASH) score) and radiographically (Stewart score). The mean follow-up of patients was 24 +/- 16.3 months. According to the Gartland-Werley score, the results were excellent in 24.9%, good in 55.9%, moderate in 11.8% and poor in 2.9% of the patients. The mean VAS score was 0.5 +/- 1.1, and the mean DASH score was 26.1. According to the Stewart criteria, 44.1% of the patients were rated as excellent, 52.9% as good and 2.9% as moderate. Two patients had complex regional pain syndrome, one patient carpal tunnel syndrome and one patient tenosynovitis. Volar plate fixation is a good and effective treatment for distal radius fractures. The plate should be inserted properly and physiotherapy should not be ignored.

Use of Noninvasive Interactive Neurostimulation to Improve Short-Term Recovery in Patients with Surgically Repaired Bimalleolar Ankle Fractures: A Prospective, Randomized Clinical Trial

We undertook a trial with 60 patients who had undergone operative reduction and internal fixation of bimalleolar, AO type B2 ankle fractures with comminution. Patients were randomized into 2 groups, one of which received postoperative treatment using a noninvasive interactive neurostimulation device (InterX ®) and the other with a sham device. The trial was designed to test the hypothesis that incorporation of noninvasive interactive neurostimulation into the rehabilitation protocol would result in reduced pain, increased range of motion, reduced edema, and reduced consumption of pain medication, in comparison with the sham therapy group. Outcome measurements included the patient's subjective assessment of level of pain, range of motion, and the extent of edema in the involved ankle, and the use of ketorolac for postoperative control of pain. The results showed significantly better results in the patients receiving treatment with active neurostimulation (repeated measures analysis of variance, P < .001).

Lateral fixation of AO type-B2 ankle fractures: the Acutrak plus compression screw technique

The Acutrak plus compression screw (APCS) (Acumed Inc., Beaverton, OR, USA) is an intramedullary implant which can achieve stable fixation with minimum soft tissue dissection. The characteristics of the APCS include fully-threaded length, headless, cannulated, and variable thread pitch. Twenty-three patients with AO type-B2 ankle fractures treated with lateral fixation by an APCS were retrospectively reviewed. Evaluation of postoperative roentgenograms for adequacy of reduction revealed a good reduction in 22 of 23 (95.7%) patients. The average wound incision was 4.1 cm. The operative time was 25.3 minutes. All the ankle fractures showed radiographic evidence of healing within four months. At the final follow-up, the ankle scores of the patients were evaluated for functional outcomes. Good to excellent results were obtained in 21 (91.3%) patients. No patient complained of symptomatic hardware. In conclusion, lateral fixation of AO type-B2 ankle fractures by APCS offers several advantages including stable fixation, a small surgical wound, less dissection of soft tissue, no palpable hardware, and easy application with a short operating time.

Lateral fixation of open AO type-B2 ankle fractures: the Knowles pin versus plate

Forty-seven patients with open lateral malleolar (AO type-B2) fractures treated with copious irrigation and radical debridement, reduction, and immediate fixation by Knowles pins or lateral plates were retrospectively reviewed with an average follow-up period of 29 months. The 47 patients were divided into two groups, based on the method of treatment. The Knowles pin group included 25 patients. The plate group included 22 patients. There was no difference between the Knowles pinning and lateral plating with respect to the rate of good reduction (96% vs. 95.5%, p = 1). Both of the groups were similar in good and excellent results (92% vs. 86.4%, p = 0.65). However, Knowles pinning had significantly shorter operation time, smaller wound size, less symptomatic hardware, and lower complication rate than lateral plating (all p values <0.04). In conclusion, lateral fixation of open AO type-B2 ankle fractures by the Knowles pin is recommended due to its efficacy, simplicity, and low complication rate.

Osteosynthese am proximalen Humerus mittels winkelstabiler Platte oder Doppelplatte: eine vergleichende biomechanische Untersuchung / Angle-fixed plate fixation or double-plate osteosynthesis in fractures of the proximal humerus: a biomechanical study

Internal fixation of fractures of the proximal humerus needs a high stability of fixation to avoid secondary loss of fixation. This is especially important in osteoporotic bone. In an experimental study, the biomechanical properties of the angle-fixed Philos plate (internal fixator) and a double-plate osteosynthesis using two one-third tubular plates were assessed. The fracture model was an unstable three-part fracture (AO type B2). Eight pairs of human cadaveric humeri were submitted to axial load and torque. In the first part of the study, it was assessed to which degree the original stiffness of the humeri could be restored after the osteotomy by the osteosynthesis procedure. Subsequently, subsidence during 200 cycles of axial loading and torque was analysed. During axial loading, the Philos plate was significantly stiffer and showed less irreversible deformation. Two double-plate fixations, but none of the Philos plate osteosynthesis, failed. During torsion, there were no significant differences between the two implants. From the biomechanical point of view, the angle-fixed Philos plate represents the implant of choice for the surgical fixation of highly unstable three-part fractures of the proximal humerus, as the internal fixator system is characterised by superior biomechanical properties.