Association For Osteosynthesis Research Articles

The role of 3-dimensional printed models in the management of the distal radius fractures.

This study aimed to compare inter- and intra-observer agreement between radiographs with 2-dimensional and 3-dimensional computed tomography scans with and without 3-dimensional printed models in the evaluation of the distal radius fracture of Association for Osteo synth esis/ Ortho paedi c Trauma Association type C classification. Fifteen consecutive cases with X-Rays, 2-dimensional and 3-dimensional computed tomography reconstructions views, and 3-dimensional printed models were selected. Three-dimensional printed models of the distal radius fractures were created using 2-dimensional computed tomography scan files in Digital Imaging and Communication in Medicine format, processed with the 3-dimensional Slicer software, and segmented, creating a 3-dimensional printed model in Standard Triangle Language format. Threedimensional models were printed using fused deposition modeling (FDM) type 3D printer Zortrax M200Plus using polylactic acid material on a scale of 1 : 1. Twenty observers were invited into the study. Intra- and inter-observer reliability was analyzed using Fleiss' kappa statistics. Overall kappa values for both groups in interobserver agreement range from 0.113 to 0.283 and in intra-observer agreement from 0.25 to 0.545. Generally, inter-observer agreement increased with additional 3-dimensional printed models from slight to fair, and intra-observer agreement increased from fair to moderate. Surgeons' opinions about 3-dimensional printed models with Likert scale-type questions show positive overall results ranging from 8.3± 2.1 to 8.6 ± 1.4. This study has shown that the inter- and intra-observer agreement with the addition of a 3-dimensional printed model for the evaluation of the distal radius fractures of Association For Osteo synth esis/ Ortho pedic Trauma Association C type for classification, fractures morphology, and preoperative planning tends to increase; however, improvements for an inter-observer agreement remain fair. Level III Diagnostic Study.

Mid-Term results in adult humeral fractures with titanium elastic nail fixation versus plate and screw fixation and locking intramedullary nailing

Aims: To compare plate-screw fixation, intramedullary nailing (IMN), and titanium elastic nailing (TEN) as a new fixation method with respect to nonunion, complication rates, and functional outcomes in the repair of adult humeral shaft fractures. Methods: A total of 38 adult patients who were treated due to humeral shaft fracture at our clinic and were followed for minimum six months between January 2012 and January 2015 were retrospectively analyzed. Age, sex, fracture etiology an length of hospitalization were recorded. Fractures were classified according to the Association for Osteosynthesis(AO) classification. Nonunion rates as assessed by X-ray during visits, angulation, shoulder, elbow and hand disability scores were evaluated using the DASH, Mayo Elbow and UCLA Shoulder scoring, and Stewart Hundley criteria. Results: There was no significant epidemiological difference between the groups. The length of hospitalization was lower in the TEN group. There was no significant difference in nonunion rates and functional scores according to the type of treatment. Angulation rate was slightly higher in the TEN group. The effect of angulation on functional score showed no influence on the functional status. The three treatment types mostly achieved excellent and good outcomes. Conclusion: Our study results suggest that TEN seems to be a good alternative treatment in eligible patients with humeral shaft fractures considering complications of other treatments. However, we believe that further, large-scale, randomized-controlled, prospective studies with longer follow-up duration are required to confirm these findings and to establish a definite conclusion. Level of Evidence: Therapeutic Level III.

Functional Outcome of Distal Humerus Fractures Treated With Open Reduction and Internal Fixation With Bicolumnar Plating in a Tertiary Care Setting.

Introduction Fractures of the distal humerus in the adult comprise approximately one-third of all humeral fractures. Over the past 20 years, nonoperative treatment for these fractures has been substituted by anatomic reduction and internal fixation based on the Association for Osteosynthesis (AO)/Association for the Study of Internal Fixation (ASIF) philosophy of plate fixation which resulted in early mobilization and superior performance. Pre-contoured, anatomically designed locking plates are anticipated to offer sufficient stability, permit early elbow range of motion, and safeguard the soft tissue.In comparison to any other joint, the elbow's good anatomical alignment, perfect stability, and early mobilization principles are of utmost significance. Methodology A hospital-based consecutive case series of distal humerus fracture patients managed surgically with bicolumnar plating at R.L. Jalappa Hospital Centre, from June 2021 to June 2022 was chosen. Patients were clinically assessed by measuring the range of motion of the elbow with a goniometer. A six-week post-operative review was the first one. Routine checkups were scheduled every four weeks up until there was evidence of fracture consolidation radiologically. Clinically Mayo Elbow Performance score (MEPS) was analyzed at the end of six-month follow-up and tabulated. Institutional Ethical committee permission was taken prior to the study. Results In the study, 47% of cases had an Excellent MEPSfollowed by 33% of patients having a good MEPS and 13% having a Fair MEPS rating. Only 7% of patients had poor MEPS. Among the patients, 33.3% had 90 MEPS followed by 16.6% cases had 85 MEPS. Only 2 patients had55 MEPSin the study. The fracture pattern configuration based on AO classification in our study was C2>C1>C3>A2.3=A3.3. Conclusion Due to an increase in road traffic accidents, complicated distal humeral fractures are becoming more common among younger people. In terms of stability and arc of motion, excellent to good functional outcomes were attained in around 80% of the study group.Because of the extremely stable build system produced by parallel plating, there have been no reported instances of implant failure or non-union.

Influence of Radiographic Bone Quality on the Type of Proximal Humerus Fracture.

The risk of proximal humerus fractures increases with age and deterioration of bone quality over time, and the treatment of these injuries may be clinically challenging.The aim of this study was to analyse the relationship between local bone quality and the morphology of proximal humerus fractures. We conducted a retrospective study of 187 patients diagnosed with proximal humerus fractures. X-ray images of all patients were analysed, and on this basis, bone quality was assessed, using the Deltoid Tuberosity Index (DTI), average cortical bone thickness (CBTavg) and the Tingart measurement. The type of fracture was classified according to Neer's and Association for Osteosynthesis (AO) classifications. Moreover, the caput-collum-diaphyseal (CCD) angle was measured and the relationships between valgus or varus fractures and the DTI, CBTAVG and Tingart parameters were investigated in all patients. Using the Neer classification, the most common fracture type was type 3, found in 90 patients (48.1%). A total of 51 patients (27.3%) sustained an AO B1 fracture. Significantly lower mean DTI values were noted in patients with a Neer 4 fracture compared to those with Neer 3 (p = 0.02) and Neer 2 fractures (p = 0.03). Moreover, significantly higher mean DTI (p <0.00) and CBTAVG (p <0.025) values were noted in the group of patients with valgus fractures (CCD> 140º). 1. In the group of patients diagnosed with a four-part fracture according to Neer, bone quality assessed using the Deltoid Tuberosity Index was significantly worse than in two- and three-part fractures. 2. Significantly higher bone quality, assessed on the basis of the DTI and CBTAVG indices, was observed among patients with valgus fractures compared to those with varus fractures.

Management of fracture both bone of forearm with dynamic compression plating and its outcomes

Introduction: Forearm fractures are one of the most common injuries encountered by an orthopaedic surgeon. Before AO (Association for Osteosynthesis), they were treated with cast immobilization and also other fixation techniques which were described such as intramedullary k-wire, intramedullary nail, external fixator etc. Though still relevant today, however they have been demonstrated to be successful only in selected cases, with high rate of non-union, malunion and with ill effects on the functions of the forearm. The most effective method of producing rigid internal fixation by the use of compression plates was developed by AO School in Switzerland. Objective: The aim of this study is to assess the results of fixation of fractures of shaft of both bone of forearm with dynamic compression plating (DCP) and its advantages and its complications Setting: This study was conducted at the orthopedics department of a teaching hospital in India. Design: This was 2 years prospective, longitudinal, hospital based, observational study, and its outcomes. Participants: The study was done in 30 patients (22 males and 8 females) with fracture both bone of the forearm, who were treated with open reduction and internal fixation with dynamic compression plate and screws at Mahatma Gandhi Memorial Hospital (attached to Kakatiya Medical College, Warangal), between January 2017 to January 2019. Results: Anderson’s criterion was employed to categorize the functional results. Good or full range of mobility of elbow and wrist joints, with excellent and satisfactory results was present in 28 patients (94%), 1 patient (3%) having restriction of elbow motion and pronation and supination and 1 patient (3%) with non-union of ulna, who recovered with bone grafting. Conclusion: Based on our experience and results, we conclude that with anatomic open reduction and rigid internal fixation with dynamic compression plate is a good fixation procedure for displaced diaphyseal fractures of both bone of the forearm. Adherence to strict asepsis, AO principles, proper post-operative rehabilitation and patient education are more important to obtain excellent results.

Retrograde nailing versus locked plating for distal femur fractures

Purpose Two major therapeutic principles can be employed for the treatment of distal femoral fractures: Retrograde Intramedullary Nail (RIN) or locked plating (LP). Both operative stabilizing systems follow the principle of biological osteosynthesis. Intramedullary nailing protects the soft tissue envelope owing to its minimally invasive approach and closed reduction techniques better than distal femoral LP. The purpose of this study was to evaluate and compare outcome of distal femur fracture stabilization using RIN or LP techniques. Patients and methods In a prospective study from 2014 to 2015, we analyzed 30 patients with distal femur fracture who had been treated by RIN (15 patients) or LP (15 patients). The patients had a mean age of 49 years (20–85 years). Mechanism of injury was high-energy impact in 66.7% and low-energy injury in 33.3%. Fractures were classified according to Association for Osteosynthesis (AO) classification: there were 17 type A fractures and 13 type C1 fractures. Functional and radiological outcomes were assessed. Results Clinical and radiographic evaluation according to the functional score of Sanders and colleagues demonstrated that, in RIN group, one (6.6%) case was excellent, nine (60%) cases were good, and four (26.8%) cases were fair, whereas in locked compression plates (LCP) group; eight (53.2%) cases were good, four (26.8%) cases were fair, and three (20%) cases were poor. In RIN group, the average time of fracture union was 19.5 weeks, with a range of 12–28 weeks. Of 15 cases, 14 (93.4%) cases progressed to union, and one (6.6%) case had delayed union and need dynamization. In LCP group, average time was 27.65 weeks, with a range of 12–32 weeks. Of 15 cases, 12 (80%) cases progressed to union, one (6.6%) case had nonunion, and two (13.4%) cases had delayed union. Conclusion Both femoral retrograde interlocking nail and LCP of distal femur appear to have statistically insignificant differences regarding knee motion, pain, resuming function, and rate of need of second surgery. However, retrograde nail is preferable to LP in terms of operative time, blood loss, image intensifier exposure time, early appearance of callus, weight bearing, and shorter time required for full union.

Triangular Fixation Technique for Bicolumn Restoration in Treatment of Distal Humerus Intercondylar Fracture.

BackgroundDistal humerus intercondylar fractures are intra-articular and comminuted fractures involving soft tissue injury. As distal humerus is triangle-shaped, parallel plating coupled with articular fixation would be suitable for bicolumn restoration in treatment of distal humerus intercondylar fracture.MethodsThis study included 38 patients (15 males and 23 females) who underwent olecranon osteotomy, open reduction and internal fixation with the triangle-shaped cannulated screw and parallel locking plates (triangular fixation technique). Functional results were assessed with the visual analog scale (VAS) scores, Mayo elbow performance (MEP) scores and Disabilities of the Arm, Shoulder and Hand (DASH) questionnaires. Anteroposterior and lateral elbow radiographs were assessed for reduction, alignment, fracture union, posttraumatic arthrosis, and heterotopic ossification, and computed tomography (CT) scans were used to obtain more accurate measurements of articular discrepancy.ResultsAll fractures healed primarily with no loss of reduction. The mean VAS, MEP, and DASH scores of the affected elbow were not significantly different from those of the unaffected elbow (p = 0.140, p = 0.090, and p = 0.262, respectively). The mean degree of flexion was significantly lower in the affected elbow than in the unaffected elbow, but was still considered as functional (p = 0.001, > 100° in 33 of 38 patients). Two cases of articular step-offs (> 2 mm) were seen on follow-up CT scans, but not significantly higher in the affected elbow than in the unaffected elbow (p = 0.657). Binary logistic regression analysis revealed that only Association for Osteosynthesis (AO) type C3 fractures correlated with good/excellent functional outcome (p = 0.012). Complications occurred in 12 of the 38 patients, and the overall reoperation rate for complications was 10.5% (4 of 38 patients).ConclusionsTriangular fixation technique for bicolumn restoration was an effective and reliable method in treatment of distal humerus intercondylar fracture. This technique maintained articular congruency and restored both medial and lateral columns, resulting in good elbow function.

Condylar orientation plating in comminuted intraarticular fractures of adult distal humerus.

Background:The condyles of the distal humerus have characteristic orientation in reference to the diaphysis. Anatomical reduction of the articular surface in intraarticular fractures of adult distal humerus does not always restore preinjury functional status. The purpose of this study was to determine the outcome of treating these fractures with technique of condylar orientation precontoured plating. The principle of the technique is to primarily restore the anatomical orientation of the reconstructed distal humeral condyle with the diaphysis of the humerus apart from anatomical reduction of fracture.Materials and Methods:Seventy one consecutive patients with comminuted intraarticular adult distal humerus fractures were treated with the condylar orientation plates, which were specifically designed between 1999 and 2009. 43 fractures were Association for osteosynthesis (AO) type C3, 24 were C2 and 4 were C1. Six were open cases and two were of nonunion distal end humerus. On medial and posterolateral side of the distal humerus, precontoured Sherman plates were applied. Patients were followed up for a mean of 3 years. They were assessed clinically (using mayo elbow performance score [MEPS]) and radio-graphically.Results:Sixty (84.5%) patients regained MEPS of 90 or more that is an excellent result (range of movement and functional status). One patient had nonunion with implant failure, and two patients developed heterotopic ossification. The mean MEPS was 95. Average extension and flexion was 15° and 133°. The result was graded as excellent in 60, good in 7, fair in 3 and poor in 1. At the time of most recent followup, 63 elbows were painless, and eight had mild pain.Conclusion:Excellent pain free range of motion with a high rate of union can be achieved in comminuted intraarticular distal humerus fractures in adults with the use of condylar orientation precontoured plating technique. Condylar orientation is very important with perfect articular congruity in elbow motion.

Do we have an ideal classification system for thoracolumbar and subaxial cervical spine injuries: what is the expert’s perspective?

Online questionnaire survey. To obtain the opinion of experts on whether the currently available classification systems for thoracolumbar and subaxial cervical spine injuries meet their expectations with regard to the desired objectives of a good classification system and practical implementability. An online survey was conducted during August-September 2013 using a specially designed questionnaire. Members of Spine Trauma Study Group of International Spinal Cord Society and other spinal injury experts were approached, and responses were analyzed. Forty-two spine experts responded. Majority (87.50%, n=35) were involved with education and research. For subaxial cervical spine injuries, Allen Ferguson classification was more commonly used (37.50%, n=15) and thought to be practically implementable in day-to-day practice (30.77%). For thoracolumbar injuries, while Thoracolumbar Injury Classification and Severity Score (TLICS) was more commonly used (47.50%, n=19), the response of experts for practical implementability in day-to-day practice was more evenly distributed among TLICS, AO (Association for Osteosynthesis) and Dennis classifications (30.77, 23.08 and 25.64%, respectively). Experts felt that the classification systems did not serve all the desired objectives. The reliability for residents was especially a concern. We may still be far from an ideal classification system. Many experts continue to prefer or would consider shifting back to traditional and simpler systems. There is a need for developing classification systems that would be better implementable practically in day-to-day clinical practice, better guide treatment, be more reliable, incorporate other modifiers influencing treatment and be more comprehensive in that order of priority.

Enhancement of fracture healing by electrical stimulation in the comminuted intraarticular fracture of distal radius

Effectiveness of an alternating electric current (AC) stimulation in prevention of bone deformity for comminuted intraarticular fracture of distal radius were verified by comparing postoperative results treated with a wrist-bridging external fixator combined with or without an AC stimulator (EF and NEF, respectively), and a palmar locking plate (LP). This study evaluated 92 cases (mean age 67.9 ± 11.4 years) of type C2 and 60 cases (mean age 69.7 ± 9.5 years) of type C3 distal radius fractures, as classified by the Association for Osteosynthesis. In total, 55 and 24 cases were treated with EF and NEF, respectively; and 73 cases were treated with LP. Callus appeared 27.5 ± 4.6 days postoperatively and the external skeletal fixation period was significantly shorter in the EF group than in the NEF group. The decrease in radial length was significantly lower in the EF group when compared to the LP group. There were no significant differences among the groups for the other radiographic and functional parameters. AC stimulation combined to the external fixation may be a promising method to prevent postoperative deformity in the severely comminuted intraarticular fractures by accelerating callus maturation and facilitating new bone bridging across the gap of fracture site.

Surgical management of edentulous/atrophic mandibular fracture: a report of two cases

J Korean Assoc Oral Maxillofac Surg 2012;38:50-4) According to Luhr's classification, a fracture in the mandible with a width of less than 15-20 mm is considered to be an atrophic mandibular fracture and its incidence is very rare. Because of the reduced cross-sectional area and smaller contact area of the fractured ends as well as the poorly vascularized bony structure and delayed bone healing, an atrophic mandibular fracture is a great challenge for oral and maxillofacial surgeons. Surgeons tend to perform closed reduction, because open reduction is considered a non-life-saving surgery among elderly patients. Thus, most of them have limited experience in surgical management. According to recent reports, open reduction yields a good result, and the Association for Osteosynthesis (AO) group has recommended open reduction. This is a case report of our two experiences of open reduction and rigid fixation of atrophic mandibular fractures by the AO principle. Articles were also reviewed here.

Das komplexe Beckentrauma des älteren Patienten

The definition of complex pelvic trauma has allowed a selection of those pelvic fracture patients with the highest mortality rate. The term complex pelvic trauma is used as a definition for pelvic fractures which are associated with serious soft tissue lesions in the pelvic region. These may include visceral and neurovascular, as well as extensive skin and muscle injuries. Haemodynamic instability particularly related to vascular injuries raises the mortality dramatically. Traumatic hemipelvectomy, which represents the worst case of a complex pelvic trauma, is associated with mortality rates of up to 60%. The pelvic study groups 1-3 of the German trauma association (DGU) and the Association for Osteosynthesis (AO) provide the worldwide largest database on pelvic injuries (group 1, 1991-1993: 1,722 patients from 10 hospitals; group 2, 1998-2002: 2,569 patients from 22 hospitals; and group 3, 2005-2007: 2,704 patients from 23 hospitals). Using this database this article reviews epidemiological data, therapy concepts, associated injuries as well as the incidence and mortality rates related to complex pelvic trauma over a 16-year time period. Special attention has been paid to complex trauma in the elderly (patients >60 years of age). An additional aim of this article is to analyze the correlation between different treatment modalities and the mortality rate of complex pelvic trauma and to investigate whether changes in the treatment of complex pelvic trauma have improved the outcome of these injuries. Taken together an increase in measures for an initial mechanical stabilization of the pelvic ring, such as the use of the pelvic C clamp, the external fixator or primary osteosynthesis was found over the 16-year observation period. In addition to stabilization of the pelvic ring, pelvic tamponade for mechanical haemostasis has been proven to be one of the most effective measures to control haemorrhaging. These treatment regimes did not differ between young patients and patients >60 years of age. Regarding the outcome of these treatment strategies only slight decreases in the mortality rate were found (pelvic study group 1: 21%; pelvic study group 2: 22%; pelvic study group 3: 18%). In all pelvic study groups the mortality rate in patients >60 years of age was found to be significantly higher than in individuals <60 years of age (pelvic study group 1: 57% versus 29.6%, pelvic study group 2: 33% versus 22.6%, pelvic study group 3: 41% versus 10.4%, p <0.05, respectively).

Comparative Reliability of 3 Thoracolumbar Fracture Classification Systems

Prospective study of 3 spine surgeons, 3 spine fellows, 3 nonspine orthopedists, and 12 orthopedic residents classifying 97 thoracolumbar fractures using the Denis, Association for Osteosynthesis (AO), and Thoracolumbar Injury Severity Score (TLISS) systems and reclassifying them 3 months later. To compare the reliability of the Denis, AO, and TLISS classification systems and evaluate the skills necessary for their use. The Denis and AO systems are the traditional methods of classification of thoracolumbar fractures. The purpose of this study was to evaluate a novel classification system, the TLISS and compare its reliability among observers as compared with the Denis and AO classifications. Ninety-seven sequential fractures from 1 surgeon's practice at a level 1 trauma center were collected. Twenty-one orthopedic physicians from two area level 1 trauma centers then completed the evaluation of the all fractures. Evaluator experience included staff, spine fellows, and residents. The interobserver and intraobserver reliability were determined. In the TLISS, subgroups of evaluators, showed variation in reliability as expected with the highest reliability occurring in the senior resident group and attending spine surgeon group. The lowest reliabilities were in the nonspine attending orthopedists and junior residents. In each group, the neurologic status was consistently the category with the highest interobserver and intraobserver reliability. In the Denis and AO classifications, the highest reliabilities were again in the senior residents and spine attendings. The lowest were again in the nonspine attendings and junior residents. As a management tool, the TLISS seems to be an acceptably reliable system when compared with the Denis and AO systems. There is a base level of knowledge and familiarity necessary for the application of the system at reliable levels.

Results of Dorsal or Volar Plate Fixation of AO Type C3 Distal Radius Fractures: A Retrospective Study

The aim of this study was to define the outcome after dorsal or volar plating of Association for Osteosynthesis (AO) type C3 distal radius fractures based on the fracture morphology. Twenty-nine patients with AO type C3 distal radius fractures were surgically managed between 1996 and 2005. Group 1 (n = 15) had volar plating. Group 2 (n = 14) had dorsal plating. Outcomes were evaluated at an average of 22 months after surgery. Statistical analysis was performed using the Wilcoxon test and chi-square test. No significant differences were seen for the scores of Gartland and Werley, Castaing, Stewart I and II, Green and O'Brien, and Disability of the Arm, Shoulder and Hand between the 2 groups. The visual and verbal pain analog scales did not show significant differences between the 2 groups. Radiology analysis showed significant difference in comparison with the contralateral side in terms of dorsopalmar inclination (3 degrees +/- 3) and distal radioulnar joint angle (98 degrees +/- 8) for the patients in group 1, whereas there were no significant differences in group 2. The development of radiographic post-traumatic arthritis was significant in both groups. Significant functional differences were seen for flexion (45 degrees +/- 15) and hand span (20 cm +/- 2) in group 1 as well as for extension (37 degrees +/- 19), flexion (42 degrees +/- 12), and radial deviation (16 degrees +/- 10) in group 2. We found more complications after dorsal plate osteosynthesis than after volar plate osteosynthesis. This study shows satisfactory functional and subjective outcome results in both groups. Group 1 had non-significant better functional results than group 2, whereas both groups showed good to very good radiology results.

Considerations on the time of surgery of femoral fractures

As shown by a study elaborated in 1980 by the A.O. (Working Association for Osteosynthesis) which was based on the data of 1127 patients, the number of general complications occuring during the primary treatment of fractures of the femur had increased by 13%. However, this study also comprised a great number of polytraumatically injured persons possessing other indications for surgery than patients with monosseous fractures of the femur shaft. So all monosseous fractures of the shaft were compiled with the aid of the A.O. computer in Bern, and 1257 cases were received. It is clearly demonstrated by evaluating these cases that a primary treatment of fractures of the femur has a significantly better effect than a delayed treatment. The number of cardiac complications increases with the time interval passing between injury and treatment. The same effect was not statistically proved for pulmonary complications; on the contrary some pulmonary complications occured during primary treatment in young patients, i.e. in a group of patients where this is expected least of all. For the future, the circulatory parameters of these patients must be estimated with special accuracy. Fatalities only occurred in the group of the oldest patients; the number of deaths increased significantly with the time interval after the injury. The differences between the present study and the preceding. A.O. study of 1980 are explained by the relatively great number of polytraumatically injured persons with fractures of the femur included in the first study. However, no satisfactory explanation does exist for the deaths occurred in 1972 at our own hospital, mentioned at the beginning of this report.

Die Behandlung und Ergebnisse der Malleolarfrakturen

The authors compared the therapy results of 100 conservatively treated malleolar fractures and 100 malleolar fractures operated upon with the therapy results of the malleolar fractures registered at the documentation centre of the A. O. (working association for osteosynthesis) in Bern. The comparison shows that after surgical treatment, the therapy periods are scarcely shorter than after conservative treatment, the therapy results, however, are significantly better. There is a smaller rate of complications and subjective troubles after surgical treatment. The results of clinical and X-ray check-up examinations were essentially better after surgical treatment than after conservative treatment. The ability of patients concerning their professional and private activities was less disturbed after surgical treatment.