Arbeitsgemeinschaft Fur Osteosynthesefragen Research Articles

Management of Radius and / Or Ulna Fracture by Screw Intramedullary Nail in Skeletally Mature Patients

The standard nailing of both bone forearm fractures of the radius and ulna poses a possible complication of nail migration androtational instability, despite being one of the best reduction techniques. This study has strived to evaluate how effectively screw elasticintramedullary nail is useful in the therapy for mature diaphyseal fractures of both bone forearms. The issues faced with conventional nailingtechniques for managing forearm fractures have also been discussed. A prospective evaluation of twenty-one cases with forearm fractures (radiusand ulna or isolated fracture of the single bone) was done. Out of the twenty-one cases studied, eighteen patients had undergone closedreduction, and three cases required mini-open reduction. The fracture was categorized as claimed by Arbeitsgemeinschaft furOsteosynthesefragen (AO) Foundation/Orthopedic Trauma Association(OTA). The results were evaluated according to Anderson criteria, inwhich 13 cases had excellent results, 4 had good results, 3 had an unsatisfactory result, and 1 was reported as failure. Also, there was 1 case ofsynostosis and 1 case of delayed union in radius. We concluded that the intramedullary screw nail for forearm fractures in adults could be used asa good internal fixation therapy giving excellent functional and radiological results. This technique is easy to learn, and the implant used is alsocost-effective, thus, providing a good fixation of the fracture. The most accepted technique for forearm fracture, as per current recommendationand AO, are open reductions and internal fixation with plating, but our study is exclusive since it helped to overcome the failure of conventionalnailing of both forearm bones with the potential complication of nail migration and rotational instability in spite the best reduction.

Evaluating Resource Utilization with Free or Pedicled Perforator Flaps in Distal Leg Reconstruction.

The decision between local and free tissue coverage for distal lower leg defects has long been dictated by the location and size of defects. Recent reports of distal defects treated successfully with pedicled perforator flaps demonstrate equivalent clinical outcomes; however, the complication rate can be high. The goal of this study was to evaluate the cost equivalence of free versus pedicled perforator flap to assist decision-making and guide clinical care. The institutional database was searched for patients with acute injury over the distal lower extremity requiring free or pedicled perforator flap. Demographic, clinical, and total resource cost was gathered. Patients were matched to Gustilo-Anderson or Arbeitsgemeinschaft fur Osteosynthesefragen classification as well as size of defect and outcomes, and cost compared. We have included 108 free flaps and 22 pedicled perforator flaps in the study. There was no difference in complication rate between groups. Free flaps had significantly more reoperations, required longer operative time, and had longer intensive care unit (ICU) care with higher cost of surgery and overall cost than pedicled flaps. When controlling for size of defect, surgical cost remained significantly different between groups (p = 0.013), but overall cost did not. Multivariable regression analysis indicated flap type to be the primary driver of cost of surgery, while body mass index elevated the total cost. Pedicled perforator flap coverage for small to medium-sized defects (< 70 cm2) is a viable and cost-effective option for distal lower leg soft tissue reconstruction after acute traumatic injury with similar clinical outcomes and shorter operative duration and ICU stay.

In Reply: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Evaluation and Treatment of Patients With Thoracolumbar Spine Trauma: Radiological Evaluation.

To the Editor: We would like to thank the editor for giving us the opportunity to reply to the letter and comments by Dr Aly.1 Radiological evaluation of thoracolumbar fractures is important for fracture classification and deciding the treatment plan. However, there is no consensus on the imaging protocol followed for the evaluation of these fractures. The primary objective of our systematic review was to determine whether the use of MRI to determine ligamentous integrity, in addition to x-rays and computerized tomography (CT), predicted the need for surgical intervention.2 Two of 2278 studies met the inclusion criteria. Winklhofer et al,3 in their retrospective study of 100 patients with thoracolumbar fractures, found that the Arbeitsgemeinschaft fur Osteosynthesefragen classification changed in 31% and the thoracolumbar injury classification and severity classification changed in 33% of patients after MRI review. With the addition of MRI, the Thoracolumbar Injury Classification and Severity score changed from <5 (indication for conservative treatment) to ≥5 (indication for surgery) in 24% of patients.3 Pizones et al4 conducted a prospective study of 30 patients and found that MRI changed the diagnosis in 40% of patients, fracture classification in 24% of fractures, and treatment plan in 16% of patients. However, both these studies provided only level III evidence and included a heterogeneous patient population. Aly et al,5 in their retrospective review of 244 patients with thoracolumbar fractures, included patients with intact neurological status only and diagnosed posterior ligamentous complex (PLC) injury by ≥2 CT findings (instead of one) and black stripe on MRI (instead of high-signal intensity). They used a more robust methodology compared with the previous 2 studies and found that MRI changed the fracture classification by 10% and Thoracolumbar AOSpine Injury Score (TLAOSIS)–based treatment by 20%. They explained the lower rate of fracture reclassification (10% vs 30% reported previously) by differences in sample size, patient population, and CT/MRI criteria for PLC injury. They also provided detailed fracture reclassification rates after MRI for each fracture subtype and TLAOSIS category which may help guide when to get an MRI in patients with thoracolumbar fracture with no neurological deficit. The study by Aly et al1 is commendable because it adds to the current literature on the topic and also addresses some of the drawbacks of the previous studies. However, there are certain limitations of this study such as retrospective, single-institution design, and lack of external validation. We believe that prospective multicenter studies are required to establish these findings. In addition, radiological studies that focus on the characteristics of PLC injury to differentiate between self-healing injuries and injuries that require surgery would be valuable.

Sternal Fractures in Blunt Chest Trauma: Retrospective Analysis of 330 Cases.

To analyse the range of injuries associated with sternal fracture (SF) and their clinical features and outcomes. Observational study. Department of Emergency Medicine, Faculty of Medicine, Selcuk University, Konya, Turkey, from July 2010 to July 2020. Sternal fractures were considered in 330 patients with blunt trauma during the study period. They were categorised according to the Johnson and Branfoot classification and the Arbeitsgemeinschaft fur Osteosynthesefragen / Orthopaedic Trauma Association classification. Demographic data were collected, including age, gender, mechanism of injury, associated injuries, and the length of hospital stay. During the 10-year study period, a total of 4024 thoracic trauma patients were admitted to the emergency department. Of these, 330 (8.2%) had a sternal fracture. The median age of the patients was 41 (8-90) years, and 72.7% were male. Isolated sternal fractures occurred in 93 patients (28.2%). An additional thoracic injury was observed in 74 patients (22.4%) included in the study, and an accompanying extrathoracic injury was observed in 34 patients (10.3%). In 129 patients (39.1%), both thoracic and extrathoracic pathologies were detected, in addition to SF. The mortality rate among patients with isolated sternal fracture was 1.1%; the mortality rate among patients with sternal fracture accompanied by additional pathologies was 6.6%. Sternal fractures are frequently associated with other injuries. Although isolated sternal fracture has a good prognosis, careful evaluation and clinical observation are essential for additional injuries. Emergency medicine, Sternal fracture, Chest trauma.

Precisely Closed Reduction of Nasal Bone Fracture Assisted With Plain Film Measurements Under the Picture Archiving and Communication System.

To prevent aesthetic and functional deformities, precisely closed reduction is crucial in the management of nasal fractures. Plain film radiography (PF), ultrasonography (USG), and computed tomography can help confirm the diagnosis and classification of fractures and assist in performing closed reduction. However, no study in the literature reports on precisely closed reduction assisted with PF measurements under the picture archiving and communication system (PACS). We retrospectively evaluated 153 patients with nasal bone fracture between January 2013 and December 2017. Surgeons conducted precisely closed reduction assisted with PF measurement of the distance between the fracture site and nasal tip under PACS on 34 patients (group A). Another group on 119 patients were reduced under surgeon's experience (group B). No significant differences in age, gender, Arbeitsgemeinschaft fur Osteosynthesefragen (AO) classification, and reduction outcome were observed between group A and group B (P > .05). The operative time of the group A was significantly lower (12.50 ± 4.64 minutes) compared to group B (23.78 ± 11.20 minutes; P < .001). After adjusted age, gender, and AO classification, patients in group A scored 10.46 minutes less on the operative time than those in group B (P < .001). In addition, the severity of nasal bone fracture (AO classification, β = 3.37, P = .002) was positive associated with the operative time. In this study, closed reduction in nasal bone fracture assisted with PF measurements under PACS was performed precisely, thereby effectively decreasing operative time and the occurrence of complications. This procedure requires neither the use of new instruments or C-arm nor USG or navigation experience. Moreover, reduction can be easily performed using this method, and it requires short operative time, helps achieve great reduction, less radiation exposures, and is cost-effective.

Advantages of preoperative planning using computed tomography scan for treatment of malleolar ankle fractures.

Malleolar ankle fractures have been classified using plain radiographs, and there is no consensus regarding the role of computed tomography (CT) scans in preoperative planning. We analyzed critical aspects, such as limits of standard radiographs, types of injury, classification methods and cost/benefit evaluations. CT scans allow a 3D analysis of the fracture to be obtained and consequently assess the indication for surgical procedure, surgical access and the type of fixation devices required. This exam is useful for detecting lesions that may go unnoticed on radiographs and will help surgeons to clarify the pathoanatomy of ankle fractures. According to Arbeitsgemeinschaft fur Osteosynthesefragen/ Orthopaedic Trauma Association (AO/OTA) classification, CT scan is recommended in medial malleolar fractures with vertical rim, type 44B fractures with posterior malleolar involvement and all type 44C fractures (according to AO/OTA). Also Tillaux-Chaput fractures (43-B1 according to AO/OTA), malleolar fractures in the presence of distal tibial fractures (43 according to AO/OTA) and distal tibia fractures in adolescents should be studied with CT scans.

Comparison of five percutaneous pinning methods for unstable extra-articular distal radius fractures: A mechanical study using sawbones.

Objectives This study aims to mechanically compare five different extra-focal bi-cortical pin configurations (using two and three pins) employed for fixation of a simulated unstable extra-articular distal radius fracture with dorsal comminution using a sawbone model.Materials and methods This in vitro mechanical study was conducted between June 2019 and July 2019. A standard fracture model (Arbeitsgemeinschaft für Osteosynthesefragen [AO] type 23-A3.3) was created using a fourth generation composite artificial radius bone. Five groups with two- and three-pin configurations were tested under axial, volar, and dorsal loading with a universal test device. Mean stiffness values were compared statistically.Results Comparison of stiffness values from axial and volar loading tests between groups in paired comparison showed no statistically significant difference (p=0.194 and p=0.086, respectively). Dorsal loading tests showed statistically significant difference between the groups in pairwise comparison (p=0.002). Three-pin groups (Groups 3, 4, and 5) had higher stiffness values compared to two-pin groups (Groups 1 and 2) in dorsal loading tests (p=0.001). Three-pin configuration test groups with two divergent or convergent pins from the radial styloid performed better compared to both two-pin groups (p=0.01, p=0.002) in dorsal loading tests.Conclusion Our data demonstrated that the three-pin configuration with two divergent or convergent Kirschner wires from the styloid and a third wire from the dorsal/ulnar cortex had higher stiffness values compared to two-pin configurations in dorsal loading tests. When indicated, we suggest the use of a three-pin construct. Particularly in cases with a risk of volar angulation, we recommend a three-pin configuration with two divergent or convergent bi-cortical Kirschner wires.

Subaxial Cervical Spine Injuries: WFNS Spine Committee Recommendations.

To formulate specific guidelines for the recommendation of subaxial cervical spine injuries concerning classification, management, posttraumatic locked facets and vertebral artery injury. Computerized literature was searched on PubMed and google scholar database from 2009 to 2020. For classification, keywords “Sub Axial Cervical Spine Classification,” resulting in 22 articles related to subaxial cervical spine injury classification system (SLICS) system and 11 articles related to AO (Arbeitsgemeinschaft für Osteosynthesefragen, German for “Association for the Study of Internal Fixation”) Spine system. The literature search yielded 210 and 78 articles on “management of subaxial cervical spine injuries” and the role of “SLICS” and “AO Spine” respectively. Keywords “management of traumatic facet locks” were searched and closed reduction, traction, approaches and techniques were studied. “Vertebral artery injury and cervical fracture” exhibited 2,328 references from the last 15 years. The objective was to identify the appropriate diagnostic tests and optimal treatment. Up-to-date information was reviewed, and statements were produced to reach a consensus in 2 separate consensus meetings of World Federation of Neurosurgical Societies (WFNS) Spine Committee. The statements were voted and reached a positive or negative consensus using Delphi method. Based on the most relevant literature, panelists in Moscow consensus meeting conducted in May 2019 drafted the statements, and after a preliminary voting session, the consensus was identified on various statements. Another meeting was conducted at Peshawar in November 2019, where in addition to previous statements, few other statements were discussed and voted. Specific recommendations were then formulated guiding classification, management, locked facets and vertebral artery injuries. This review summarizes the WFNS Spine Committee recommendations on subaxial cervical spine injuries.

Can the complications of distal locking be prevented with a new nail that offers a novel locking technique in the treatment of humeral shaft fractures?

Objectives This study aims to investigate whether complications related to distal locking can be prevented with InSafeLOCK® nail in the treatment of humeral shaft fractures.Patients and methods Hospital records of 31 patients (15 males, 16 females; mean age 54.4±10.1 years; range, 20 to 86 years) treated with InSafeLOCK® nail for humeral shaft fractures were investigated retrospectively between February 2016 and January 2019. AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification was used to determine the type of fracture. During the implementation, the elapsed time for distal locking was investigated. Complications encountered during both implementation and postoperative follow-up were investigated.Results Fourteen of the fractures were type A, 12 were type B, and five were type C. The mean follow-up time was 18.2 (range, 6 to 30.5) months. The mean duration for distal locking was 2.1 (range, 1.2 to 3.1) minutes. In one (3.2%) patient, cortical penetration occurred at the anterior cortex of the humerus at distal to the nail. In one patient, nail breakage occurred at the distal part of the nail. In one patient, rotational instability occurred due to screw loosening.ConclusionInSafeLOCK® humeral nail is safe when applied with the recommended technique. It can easily be applied without damaging the veins, nerves or other soft tissues around the elbow due to the internal distal locking feature; furthermore, there is no need to use fluoroscopy or targeting guide. Thus, it is possible to avoid complications that may occur during and after distal locking in conventional intramedullary nail implementations.

A new proximal femoral nail antirotation design: Is it effective in preventing varus collapse and cut-out?

Objectives This study aims to compare the mechanical features of the existing proximal femoral nail antirotation (PFNA) system and the new PFNA system that we designed using three-dimensional (3D) finite element analysis.Materials and methods This experimental study was conducted between 2019 and 2020. We constructed two femur models with Arbeitsgemeinschaft für Osteosynthesefragen (AO) type A1 fractures using 3D computed tomography scans. The new and standard PFNA designs were inserted into the femur models and subsequently transferred to the program. We investigated the distribution of stress on the tip of the lag screw, the calcar region, lag screw-nail junction, and the additional screw inserted through the greater trochanter (only present in the new PFNA design) using 3D finite element analysis.Results When the von Mises stress distributions in our models were examined, the maximum stress at the lag screw-nail junction was 18 mpa in the new design PFNA, while it was 20 mpa in the classic PFNA model. The maximum stress at the junction of the additional screw that had greater trochanter inlet with the nail was found as 42.5 mpa. The maximum stress on the calcar region was found to be 10 mpa at the new design PFNA, while it was 13 mpa with 30% increase in the classic PFNA. The stress on the tip of the lag screw was found to be 49 mpa in the classic PFNA design, while in the new design PFNA it was found as 28 mpa with a decrease of more than 40%.ConclusionAs per our findings, the new PFNA design leads to reduced stress on the lag screw-nail junction, the calcar region, and the tip of the lag screw.

Surgical treatment of multifragmentary segmental femur shaft fractures with ORIF and bone graft versus MIPO: a prospective control-group study.

Aim Multifragmentary segmental femoral shaft fracture is a high energy injury frequently associated with life-threatening conditions. The aim of this study was to compare the use of bio metallic open reduction internal fixation (ORIF) (plate with allograft bone strut) with minimally invasive plate osteosynthesis (MIPO) fixation for the treatment of multi-segmental femoral shaft fracture in terms of outcomes, bone healing and complications. Methods Forty patients with segmental femoral shaft fractures were included and divided into two groups: 20 patients treated with ORIF+, 20 with MIPO. All fractures were classified according to AO (Arbeitsgemeinschaft für Osteosynthesefragen) and Winquist and Hansen Classification. Evaluation criteria were: duration of follow up and surgery, Non-Union Scoring System, Pain Visual Analogic Scale (VAS), objective quality of life and hip function, subjective quality of life and knee function, quality of life the Short Form-12 Survey Questionnaires (SF-12), bone healing and femoral alignment (radiographs), Radiographic Union Score for Hip (RUSH). Results Better results of ORIF in terms of complication rate, RUSH, VAS, regression between RUSH and VAS, average correlation clinical-radiographic results and patients' outcomes (Cohen k) were obtained, and similar results for the length of follow up, surgery duration, perioperative blood transfusion, wound healing. No statistical difference for Harris Hip Score (HHS), Knee Society Score (KSS), quality of life (SF-12). Conclusions The ORIF and bone strut allograft technique had better results compared to the MIPO technique with regards to complication rate, RUSH, VAS, regression between RUSH and VAS, and average correlation clinical-radiographic results and patients' outcomes (Cohen k) in the surgical treatment of multifragmentary segmental femoral shaft fractures.

A Possible Protective Effect of the 'Cam Deformity' on Femoral Neck Fracture: The Relationship between Hip Morphology and the Types of Hip Fracture.

We retrospectively evaluated the cases of 169 hip fracture patients, their previous fractures, and the contralateral hip joint's morphology. A history of contralateral hip fracture was present in 23 patients (Contra group). The other patients had a unilateral hip fracture: a trochanteric fracture (Troch group, n=73) or a femoral neck fracture (Neck group, n=73). In the Troch and Neck groups, we used anteroposterior and cross-table axialview radiographs of the contralateral hip to evaluate the proximal femur's anatomy. In the Contra group, the concordance rate between the first and second types of hip fracture was 65.2%, and the second hip fracture's morphology indicated that the trochanteric fracture had a cam deformity in terms of the femoral head-neck ratio. The average alpha angle and femoral head-neck offset in the Troch group were significantly larger than those in the Neck group. In the Neck group, pistol-grip deformities of Arbeitsgemeinschaft für Osteosynthesefragen types B1 (subcapital), B2 (transcervical), and B3 (displaced) were observed in 42.1%, 75%, and 6% of cases, respectively. There was a smaller alpha angle and a larger femoral head-neck offset in the contralateral hip of femoral neck fractures; thus, the "cam deformity" may protect against femoral neck fractures.

Efficacy of non-bridging external fixation in treating distal radius fractures.

ObjectiveTo investigate the efficacy of non‐bridging external fixation in treating distal radius fractures (DRF) and its effect on wrist joint function.MethodsThe medical records of 207 patients who were treated for DRF between May 2008 and April 2017 in our hospital (age, 18.0–70.0 years; 99 males and 108 females) were retrospectively analyzed. All patients had evident wrist trauma and the diagnosis of DRF was confirmed by imaging tests. A total of 101 patients received bridging external fixation (control group), whereas another 106 received non‐bridging external fixation (study group). At 12 weeks after the procedure, the treatment effect was measured using the Dienst scoring system (rating scale: ≤3 points, excellent; 4–7 points, good; 8–11 points, fair; >12 points, poor), and the wrist joint function was evaluated by Gartland and Werley classification (rating scale: 0–2 points, excellent; 3–8 points, good; 9–20 points, fair; >21 points, poor); meanwhile, the radial length, radial inclination, and palmar tilt were examined by X‐ray. Follow‐up visits were conducted once every 2 weeks for 6 months, and the incidences of complications in the two groups within 6 months after operation were recorded, including incision infection, Kirschner wire loosening, delayed fracture healing, and arthritis.ResultsThere were no differences in the sex ratio, mean age, mean injury period, Arbeitsgemeinschaft fur osteosynthesefragen classification, and cause of fracture between the two groups (all P > 0.05). In terms of the treatment effects, the study group had a higher percentage of excellent results (P < 0.001) and lower percentages of fair and poor results (P = 0.002, P = 0.001) than the control group 12 weeks after treatment, while both groups had similar percentages of good results (P = 0.109). In terms of the score of the wrist joint function, the study group had a higher proportion of excellent result than the control group 12 weeks after treatment (P = 0.029), whereas no intergroup differences in the proportion of good, fair, and poor results were observed (all P > 0.05). After follow‐up for 6 months, the incidences of incision infection, Kirschner wire loosening, delayed fracture healing, and arthritis, as well as the total complication rate were found to be similar between the two groups (all P > 0.05).ConclusionsUsing non‐bridging external fixation for treating DRF allows some level of wrist movement during the early stage of fixation, effectively maintains the radial length, radial inclination, and palmar tilt, and achieves better outcomes than bridging external fixation.

Two Point Fixation in ZMC Fracture–A Case Report

Tripod fractures constitute of zygomatic bone and its four articulations viz; frontal bone, maxillary bone, sphenoid bone and temporal bone. Whenever a Tripod fracture happens,one or more of these articulations are interrupted. Personal altercations, Assaults, Road traffic accidents are the common causes leading to fracture of the zygomatic bone.The zygomatico-maxillary complex is one of the principle buttress of the face and helps in transmitting the occlusal forces to the skull base. Anatomic disfigurement caused by zygomatic fracture warrants intervention tore establish facial symmetry. It is most predictably restored to pre morbid condition by ORIF and AO (Arbeitsgemeinschaft fur Osteosynthesefragen) miniplate osteosynthesis has proven to be an invaluable aid when used in severe cranio-maxillo-facial trauma.

Is intramedullary screw fixation biomechanically superior to locking plate fixation and/or tension band wiring in transverse olecranon fractures? A cadaveric biomechanical comparison study

ObjectivesTo compare clinically important mechanical properties of three techniques used to fix transverse olecranon fractures (Arbeitsgemeinschaft fur Osteosynthesefragen and Orthopaedic Trauma Association class 2U1B1): (1) intramedullary (IM) screw, (2) locking plate, and (3) tension band wire in a realistic loading protocol using a cadaveric model. MethodsFresh frozen cadaveric transverse olecranon fracture models were fixed with an IM screw (n = 6), a locking plate (n = 6), or a tension band (n = 6). Compression after fixation was recorded using a pressure sensor in the fracture before samples were loaded through the triceps tendon for 500 cycles of 0–500 N, assessing implant survival. The primary outcome measure was compression force before loading. The secondary outcome was frequency of implant failure defined as breakage of the implant itself or fracture gapping >5 mm. Binary outcomes were compared with χ2, and continuous variables were compared with unadjusted analysis of variance and a multivariable regression model adjusting for age, sex, dual-energy X-ray absorptiometry T-score, and testing order. ResultsNo statistically significant difference was shown in fracture compression between IM screw (mean, 162 N; 95% confidence interval [CI], 27–297 N), locking plate (mean, 125 N; 95% CI, −9–260 N), and tension band (mean, 163 N; 95% CI, 29–298 N) in unadjusted (p = 0.89) and adjusted (p = 0.82) analyses. A 100% implant failure rate was observed with tension band compared with 0% implant failure with IM screw or locking plate (p < 0.01). ConclusionWe found no statistically significant differences in compression across the fracture site among techniques. We did find a higher risk of implant failure with tension band compared with IM screw and locking plate during cyclic loading in cadaveric bone.

Tibial diaphyseal fractures in children: indications and limitations of the treatment with monolateral and hybrid external fixator.

Aim To report our indications and limitations about the use of external fixation in children. Methods It was retrospectively reviewed all tibial fractures treated with monolateral and hybrid external fixator, at our three Centres. It was included 32 fractures which did not show an acceptable reduction after an attempt under anaesthesia. The exclusion criteria were: open fractures, children with previous fractures of the lower limbs, with skeletal congenital diseases, fractures involving the physis and with neurovascular involvement. All fractures were classified according to the AO (Arbeitsgemeinschaft für Osteosynthesefragen) classification. An outcome was evaluated according to the time needed to obtain radiographic bone healing, the range of motion (ROM) of the ankle, the asymmetry of the lower limbs, the malunion, and complications. Results The average time of consolidation was 10.66 weeks (6-17 weeks). There were no cases of deep infection, but only seven cases of superficial pin infections. No patients reported loss of ROM of the knee or ankle. We had zero cases of residual angle greater than 5°, and in all cases the difference in length between the limbs was <1 cm. Conclusion The external fixation is a viable technique in the treatment of tibial fractures in children. Therefore, the external fixation, both monolateral and hybrid, should be considered a viable treatment for this type of fracture.

Treatment outcomes of distal tibia fractures among adult patients at Moi Teaching and Referral Hospital, Eldoret, Kenya

Background: The treatment of distal tibia fractures remains challenging since they are prone to higher rates of complications. Treatment options are expanding and although their indications, advantages and disadvantages have been discussed in literature, controversy still exists over the clinical efficacy and cost-effectiveness of each option. This has led to different orthopaedic surgeons employing different operative treatment options based on their experience, preference and patient characteristics. Objective: This study sought to describe the patients’ characteristics and treatment of distal tibia fractures at MTRH and compare the outcome results of the various treatment options. Design: A prospective observational study design was used. Adult patients with distal tibia fractures admitted during the study period were included through consecutive sampling. Methods: A total of 76 patients were followed up. Data including injury aetiology, fracture types and classification, treatment and complications were collected. Functional outcome was assessed using Olerud and Molander Ankle Score (OMAS) at 6 months after treatment. Data was collected between October 2015 and March 2017 using a structured questionnaire and analyzed using STATA version 13 at 95% confidence level. Chi square test was used to determine the significance of associations between categorical variables. Results: The median age was 40.0 (30.0, 52.0) years, with a male-to-female ratio of 1.7:1. Most common causes of injury were RTA in 37 patients and falls in 29 patients. There were 48 closed and 28 open injuries. According to Arbeitsgemeinschaftfur Osteosynthesefragen (AO)/ Orthopaedic Trauma Association (OTA) classification, there were 40 (52.6%) type A, 28 (36.8%) type B and 8 (10.6%) type C fractures. Twenty-five (32.9%) patients were treated non-operatively, 28 (36.8%) patients underwent internal fixation with plating and 23 (30.3%) patients were treated using external fixation method. Non-operative treatment was mostly used for closed injuries (80%) whereas majority of open fractures (82%) were treated operatively ( P =0.033). Complications occurred in 48 (57.8%) patients, including 30 (62.5%) wound infections, 21 (43.7%) malunions and 3 (6%) chronic osteomyelitis. Infections were significantly higher among external fixation treated patients ( P =0.002). At final follow up the functional outcome using OMAS was excellent in 11(14.5%) patients, good in 28 (36.8%), fair in 17 (22.4%) and poor in 20 (26.3%) patients. OMAS scores were significantly high in patients treated with plating and low in patients with comminuted fractures, complications and open injuries ( P <0.001). Conclusion: Distal tibia fractures mostly occurred in young males. Road traffic accidents and falls were the commonest causes. Treatment by plate fixation resulted in significantly higher functional outcome scores and lower rate of complications compared to non-operative treatment. Recommendation: Distal tibia fractures should be treated operatively by plate fixation to improve treatment outcomes. Keywords: Distal tibia fracture, OMAS, Treatment outcome

A study on surgical management of extra articular distal femur fractures by retrograde intramedullary interlocking nail in adults

The distal femur fractures are complex injuries, and it can be challenging to manage. These fractures often are unstable, comminuted and tend to occur in elderly or multiply injured patients. Because of the proximity of these fractures to the knee joint, regaining full knee motion and function may be difficult. 1 If the fracture of the hip square measure excluded, 31% of femoral fractures involve the distal portion. Distal femur fractures by definition require distal 9 cm of the femur [2]. Extra-articular fractures of the distal femur are serious injuries that frequently result in varying degrees of permanent disability. The degree of functional loss is often the result of articular cartilage and bone damage, softtissue injury or a combination thereof [3].Several published studies in the 1960s reported better results with non- surgical than surgical management of distal femur fractures [10, 11]. But now, the most predictable results are presently attained with surgical interventions, and it is now recognized that operative fixation with ability to obtain an anatomical reduction of the joint surface, restoring axial alignment and beginning early range of motion present clear advantage over closed means of treatment [12-16] In 1970, the AO (Arbeitsgemeinschaft fur Osteosynthesefragen) reported

Tratamiento de defectos masivos de tibia. Técnica de transporte óseo con fijador AO

Introduction: Bone transport is the slow transportation of the bone fragment along a bone defect, providing distraction osteogenesis.Objective: To describe the surgical technique of bone transport using the AO external fi xator and to present the result of this procedure in tibial diafi sis defects of more than 4 cm long, which were the result of severe open fractures or infected no unions.Material and Methods: This is a retrospective, descriptive study of 14 patients treated in several centers in Montevideo from April 2011 to April 2015.Results: The average age of the patients was 32 years (15-32), the average bone loss 6,7 cm (4-11), the distraction speed 0,58 mm/day, the mean distraction period 92 days (35-172) and the mean time external fi xation was 194 days. The mean follow up was 13 months (6-27). All patients needed an additional surgical procedure in the docking site. Bone healing was accomplished in 9 patients and there were 2 no unions. There were 2 further patients who abandoned the treatment and another patient who requested amputation. At the latest follow up there was no recurrence of infection.Conclusion: Bone transport using AO external fi xator, is a valid alternative for the treatment of segmental bone loss of the diafi sis of the tibia with or without infection*Arbeitsgemeinschaft fur Osteosynthesefragen

Posterior Instrumentation for Unstable Thoracolumbar Fractures

Background: About 90 percent of all spinal injuries involve the thoracolumbar region. Unstable fractures need surgical treatment to achieve a painless, balanced and stable spine preserving or recovering neurological function, highest degree of spinal motion and to allow early patient mobilization.Objective: This study was carried out to evaluate radiological outcome of posterior instrumentation in thoracolumbar fractures.Methodology: A total of 110 patients with thoracolumbar fracture were included in the study, which was carried out at Kathmandu Medical College Teaching Hospital from December 2011 to December 2016. Unstable Arbeitsgemeinschaft fur Osteosynthesefragen type A and type B fractures were treated with short segment instrumentation and type C with long segment instrumentation. Radiological evaluation of postoperative correction of kyphotic angle and vertebral height was measured and was compared with immediate postoperative correction and loss of correction in two years final follow up.Results: Mean postoperative correction of vertebral kyphotic angle was 25° and loss of correction in final follow up was 5°. Mean postoperative vertebral height correction was 24% and its loss in final follow up was 2%. There was no significant difference in loss of correction of vertebral kyphosis and vertebral height in short segment and long segment fi xation in final follow up.Conclusion: Long segment posterior instrumentation results in good reduction and its maintenance for Arbeitsgemeinschaft fur Osteosynthesefragen type C thoracolumbar fractures whereas similar results can be achieved with short segment posterior instrumentation in type A and type B fractures. Journal of Kathmandu Medical College,Vol. 6, No. 4, Issue 22, Oct.-Dec., 2017, Page: 150-155