Buttress Plate Research Articles

Direct Anterior Bone Block Grafting for Coronoid Bone Loss and Dysplasia

Background: Critical coronoid bone loss (CCBL) can be the key factor of elbow instability, making bony reconstruction essential. Coronoid bone grafting (CBG) is challenging, with a paucity of descriptions in the literature. We present direct anterior CBG in a patient with instability, CCBL (>40%), lateral ulnar collateral ligament (LUCL) insufficiency, and ligamentous laxity who underwent LUCL reconstruction in the same setting. Indications: Isolated ligament reconstruction has a high failure rate in cases with CCBL and therefore requires additional bone grafting. The diagnosis of CCBL is made with lateral radiographs and further quantified by computed tomography imaging. Instability can be best assessed objectively during arthroscopy with a switching stick. CBG performed with an anterior approach facilitates direct access with advantages for plate and screw positioning and access to the proximal radio-ulnar joint. Technique Description: First, LUCL reconstruction was performed. After harvesting of the graft from the iliac crest, the coronoid was exposed with a direct anterior approach. The incision starts centrally medial to the biceps tendon (BT) in the flexion crease extending distally (9 cm). Ligation of multiple vessels (leash of Henry) is required. The deep dissection is continued between the bicipital aponeurosis and BT. Blunt and flat Langenbeck-type retractors are used with care, laterally (BT/radial nerve) and medially (aponeurosis/median nerve). The brachialis muscle is exposed and longitudinally split in line with its fibers, gaining access to the capsule. Harmful retraction on either side of the split has to be avoided. The capsule is incised as a Z-plasty, the coronoid exposed from the joint in the distal direction prior to freshening up the graft bed. The graft is held in place with a wire joystick, sculpted, and temporarily fixed. Joint congruency, stability, and a range of motion (ROM) are checked prior to definitive fixation with a 2.4-mm buttress plate and screws. Results: The coronoid process height was successfully reconstructed from <60% to 100% with durable elbow stability (>1 year), free ROM, and high patient satisfaction. Conclusion: CBG can be standardized and facilitated with a direct anterior approach as a key element for successful elbow stabilization in the setting of CCBL. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Special contoured pelvic brim reconstruction titanium plate combined with trans-plate buttress screws (quadrilateral screws) for acetabular fractures with quadrilateral plate involvement through the anterior ilioinguinal approach.

Managing complicated acetabular fractures involving the quadrilateral plate (QLP) can be challenging for surgeons, especially when complicated by comminution and osteoporosis. Traditional implants do not provide sufficient fixed strength or a proper match. The new-type pre-contoured infrapectineal buttress plates may have drawbacks, such as inaccurate fitting on the medial surface of QLP and an inability to apply reversed compression force to resist medial displacement of femoral head. Therefore, the primary purpose of this study is to introduce a novel technique that utilizes a special contoured pelvic brim reconstruction titanium plate combined with quadrilateral screws to reduce and stabilize acetabular fractures involving the QLP through the ilioinguinal approach. Additionally, the secondary purpose is to evaluate both clinical effectiveness and radiological outcomes of this technique for QLP fractures. We conducted a retrospective analysis of prospectively collected data from 48 patients (31 males and 17 females) who suffered from acute displaced fractures of the QLP and were treated between January 2012 and December 2019 using a special contoured plate combined with quadrilateral screws. The patients' mean age was 47.56 ± 11.31 years (range: 19-73 years). Fracture patterns included 20 both-column fractures, 12 anterior column and posterior hemitransverse fractures, eight T-type fractures, five transverse fractures and three anterior column fractures with the QLP affected, all of which had femoral head protrusion. Immediate postoperative reduction quality was evaluated according to Matta's criteria. Final clinical functions were assessed during follow-up using the modified Merle d'Aubigné and Harris Hip scores (HHS). The patients were followed up for an average of 48.36 ± 12.94 months (ranging from 24 to 84 months). The mean operative time was 246.08 ± 54.30 min (ranging from 178 to 397 min), and the average blood loss was 715.16 ± 263.84 ml (ranging from 400 to 2000ml). The radiological grading at postoperative stage showed anatomical reduction in 30 patients (62.50%), satisfactory reduction in 14 patients (29.17%), and poor reduction in four patients (8.33%). At the final follow-up, no re-protrusion of the femoral head was observed. In terms of functional outcome, the mean modified Merle d'Aubigné-Postel score was excellent in 26 patients (54.17%), good in 17 patients (35.42%), fair in four patients (8.33%), and poor in one patient (2.08%). The HHS was excellent in 23 patients (47.92%), good in 20 patients (41.67%), fair in four patients (8.33%), and poor in one patient (2.08%). The average HHS was 87.38 ± 7.86 (ranging from 52 to 98). Postoperative complications included lateral femoral cutaneous nerve injury in two patients, delayed wound healing and subsequent development of an inguinal hernia in one patient. Late complications were observed in two patients, with one case of heterotopic ossification and another case of post-traumatic osteoarthritis underwent hip arthroplasty within two years after surgery. Our results indicate that employing the contoured plate specifically designed for QLP injuries, in conjunction with quadrilateral screws through the ilioinguinal approach, can lead to positive outcomes in the treatment of displaced acetabular fractures involving the QLP. This straightforward and efficient technique offers a viable option for surgeons who are managing complex acetabular fractures.

Comparison of American orthopedic foot and ankle society score between anterior to posterior lag screws versus posterior buttress plating for posterior malleolus fixation in tri-malleolar ankle fracture

Background: Posterior malleolar fractures are frequent, occurring in up to 44% of all ankle fractures. Surgical management typically involves anterior to posterior (AP) lag screws or posterior buttress plates. This study aimed to compare the AOFAS (American orthopedic foot and ankle society) score between AP lag screw and posterior buttress plating for posterior malleolus fixation in tri-malleolar ankle fracture. Methods: This quasi-experimental study was conducted at the department of orthopedics and traumatology, Chittagong medical college hospital, Chattogram, Bangladesh, from November 2020 to October 2021. It involved 28 patients with ankle fractures, equally divided into two groups. Group A received AP lag screw fixation, and group B underwent posterior buttress plating. Data analysis was performed using MS office tools and SPSS version 23.0. Results: The posterior plating group demonstrated superior postoperative AOFAS scores compared with the AP screw group with statistically significant differences (88 versus 81, p=0.008). Significant differences were noted in the AOFAS pain score (p=0.045) and function score (p=0.019) at the final follow-up between the two groups. Conclusions: Patients with tri-malleolar ankle fractures in whom the posterior malleolus is treated with posterior buttress plating show superior postoperative AOFAS scores at follow-up compared to those treated with AP screws.

Clinical outcomes of capitellar fractures with posterior comminution treated with Herbert screws combined with metacarpal locking plates

BackgroundThe treatment of Dubberley type B capitellar fractures, which are frequently complicated, is widely debated. This study aimed to investigate the prognostic factors and clinical outcomes of Dubberley type B capitellar fractures treated with Herbert screws combined with posterior buttress plates.MethodsSeven men and nine women (aged 30–68 years) with Dubberley type B capitellar fractures were operated on with Herbert screws combined with posterior buttress plates. The patients were classified into Dubberley types IB (seven), IIB (four), and IIIB (five). Complications and bone union were observed, and functional outcomes were evaluated by the Mayo Elbow Performance Index (MEPI).ResultsAll patients were followed up for a mean period of 23.5 months (12–30 months). All fractures healed in 8–14 weeks (mean, 10.5 weeks). No cases of non-union, elbow instability, or avascular necrosis occurred. Degenerative arthritis occurred in 7 (44%) and heterotopic ossification in 11 (69%) patients. The median MEPI score was 92.5 (interquartile range, 85–100) points, with 11 reporting excellent, 3 good, and 2 fair outcomes. The MEPI scores of type IIIB fractures were significantly lower than those of types IB and IIB fractures, while the MEPI scores of type IB and IIB fractures did not differ significantly.ConclusionsDubberley type IIIB capitellar fractures with multiple articular fragments have a poorer prognosis than type IB and IIB fractures. However, Herbert screw fixation combined with posterior metacarpal locking plates is feasible, providing satisfactory recovery of elbow joint function.

Volar buttress plate fixation: An effective and reliable option for Bennett's fractures.

This study aimed to demonstrate the volar plate fixation technique for fixing Bennett's fractures due to its buttress effect. The retrospective study included 10 patients (8 males, 2 females; mean age: 35.9±11.56 years; range, 17 to 51 years) who were treated using the volar plate fixation technique between January 2018 and August 2022. The postoperative functional scores of the patients were evaluated using the Q-DASH (Quick Disabilities of the Arm, Shoulder, and Hand) score, and their pain status was evaluated with the Visual Analog Scale (VAS). We also assessed fracture union and development of complications. We assessed opposition according to Kapandji grade and abduction of the thumb. The mean follow-up time was 16.6±2.91 (range, 12 to 21) months. The technique was performed on the right extremity in eight patients and on the left extremity in two patients. All patients were right-hand dominant. The VAS score was 1 in two cases and 0 in the other cases. The mean Q-DASH score was 1.36±2.44. The mean pinch strength was 6.4±0.89 kg, and the mean grasp strength was 18.8±3.52 kg on the injured side. The mean Kapandji grade of opposition was 9.3±0.82, while the mean abduction degree was 37.4±2.01. Based on the early results of this technique, we conclude that volar plate fixation for Bennett's fractures is reliable and allows for early motion, providing anatomical and stable joint reduction, and it does not have implant complications such as hardware irritation. However, fixation of small fragments may be particularly challenging.

Biomechanics and finite element analysis of a novel plate designed for posterolateral tibial plateau fractures via the anterolateral approach

Surgical management of posterolateral tibial plateau (PLTP) fractures is challenging. One reason for this challenge is the lack of suitable internal fixation devices. Our aim was to introduce a novel plate via the anterolateral approach for managing PLTP fractures. The biomechanical testing and finite element analysis (FEA) were performed. PLTP fracture models were created using synthetic tibias (n = 10 within each group). These models were randomly assigned to three groups (groups A-C) and fixed with the lateral locking plate, the posterior buttress plate, and the novel plate, respectively. The vertical displacement of the posterolateral fragments was evaluated using biomechanical testing and FEA under axial loads of 250 N, 500 N, and 750 N. We also evaluated the stress distribution and maximum stress of each fracture model using FEA. Biomechanically, under the same loads of 250 N, 500 N, or 750 N, the vertical displacement was significantly different among the three fixation groups (p ≤ 0.001). FEA data indicated that the maximum displacement from group A to C was 3.58 mm, 3.23 mm, and 2.78 mm at 750 N, respectively. The maximum stress from group A to C was 220.88 MPa, 194.63 MPa, and 156.77 MPa in implants, and 62.02 MPa, 77.71 MPa, and 54.15 MPa in bones at 750 N, respectively. The general trends at 250 N and 500 N were consistent with those at 750 N. Based on our biomechanical and FEA results, the novel plate could be a good option for treating PLTP fractures. The novel plate showed stable and reliable features, indicating its suitability for further clinical application.

Treatment of Ideberg type Ⅱ scapular glenoid fracture with compression screw combined with Buttress plate through direct axillary approach

To investigate the effectiveness of compression screw combined with Buttress plate through direct axillary approach for Ideberg typeⅡ scapular glenoid fractures. A retrospective analysis was conducted on 11 patients with Ideberg type Ⅱ scapular glenoid fractures treated with compression screws combined with Buttress plate fixation through the direct axillary approach between January 2014 and June 2022. There were 7 males and 4 females, aged from 34 to 75 years, with an average of 56.0 years. The causes of injury included 4 cases of falling from height injury, 4 cases of heavy object injury, and 3 cases of traffic accident injury. The time from injury to operation was 2-5 days, with an average of 3.8 days. The operation time, intraoperative blood loss, hospital stay, complications, and fracture healing time were recorded. The Constant-Murley score, American Society of Shoulder and Elbow Surgeons (ASES) score, and shoulder joint flexion, abduction, external rotation (neutral position), and internal rotation (neutral position) range of motion were used to evaluate shoulder joint pain and function. The operation time was 45-105 minutes, with an average of 79.0 minutes; the intraoperative blood loss was 80-200 mL, with an average of 99.2 mL; the hospital stay was 3-8 days, with an average of 5.8 days. One patient had poor wound healing after operation, and the wound healed after strengthening dressing change; the rest wounds had primary healing, and no axillary nerve paralysis occurred. Except for 1 patient lost follow-up, the remaining 10 patients were followed up 10-54 months, with an average of 26.4 months. The postoperative X-ray film examination showed that the fractures healed well within 8-15 weeks, with an average of 11.0 weeks. There was no complication such as fracture displacement, internal fixator failure or fracture during follow-up. At last follow-up, the patient's shoulder joint flexion, abduction, external rotation (neutral position), and internal rotation (neutral position) range of motion, Constant-Murley score, and ASES score significantly improved when compared with those before operation ( P<0.05). Compression screw combined with Buttress plate through direct axillary approach is an effective way to treat Ideberg typeⅡ scapular glenoid fracture, with advantages of small trauma, concealed incision, and good effectiveness.

Syndesmosis dislocation and ankle ligament stress in the posterior malleolus fracture fixated – “in vitro analysis”

PurposeThe objectives of this study were to compare syndesmosis dislocation and ankle ligament stress after the fixation of the posterior malleolus fracture (PMF) with four different techniques by Finite Element Analysis (FEM). MethodsFour internal fixation techniques used for fixation of PMF were assessed by FEM: posterior one-third tubular 3.5 mm buttress plate (PP) with one screw (PP 1 screw), PP with two screws (PP 2 screws), two cannulated 3.5 mm lag screws in the anteroposterior (AP) direction (AP lag screws), and two posteroanterior (PA) cannulated 3.5 mm lag screws (PA lag screws). PMF with 30% fragment size was simulated through computational processing reconstructed from computed tomography (CT). The simulated loads of 700 N and 1200 N were applied to the proximal tibial end. The FEM evaluated the syndesmosis dislocation (mm) and stress values of the posterior tibiofibular ligament (PTFL) (in Kpa) and deltoid ligament (in Kpa) in the four mentioned subgroups. ResultsWe found that with a load of 700 N, syndesmosis dislocation varied from 6.5 to 7.9 mm, being the lowest and greatest for PA lag screw and PP 1 screw, respectively. In all groups was observed a greater dislocation in the syndesmosis at 1200 N of load. We observed that the stress values on the PTFL were lower for AP lag screws and PP 2 screws with 700 N and 1200 N, respectively. For both loads, PP 1 screw presented the greatest stress. Regarding the stress in the deltoid ligament, the AP lag screws presented the lowest stress for 700 N and PP 1 screw for 1200 N. For all fixation techniques, the syndesmosis displacement and ligament stresses were higher when 1200 N were imposed. ConclusionThis study demonstrated that PMF fixed with lag screws presents greater stability in the distal tibiofibular syndesmosis and higher joint loadings promoted greater displacement and ligaments stress, regardless of the fixation technique. Besides, lower stress in the syndesmosis is accompanied by a greater load on the deltoid ligament.

Biomechanical comparison of fixation methods on third-generation femoral composite bone models in Pauwels type 3 femoral neck fractures: Contribution of the medial buttress plate to fixation.

To compare the use of cannulated screws in an inverted triangular configuration, medial buttress plates, and the combination of these 2 fixation methods in the treatment of Pauwels type 3 femoral neck fractures. Twenty-eight anatomical composite third-generation femoral bone models were divided into 4 groups. The control group (group 1) was formed with 7 third-generation intact bone models. The fracture model was created with a 70° cutting block to fit 21 Pauwels type 3 fracture configurations. Seven models were fixed with an isolated 3.5 mm one-third semi-tubular medial buttress plate (group 2), 7 were fixed in an inverted triangular configuration with 6.5 mm cannulated screws (group 3), and 7 were fixed using a combination of 6.5 mm cannulated screws and a medial buttress plate (group 4). Cyclic loading was applied using axial forces ranging from 60 N to 600 N and moments ranging from 0.7 Nm to 7.0 Nm for 500 cycles. Once the cyclic loading stage was completed, the loads were removed from the system, and the quasi-static loading stage was employed to determine the stiffness and failure forces of the system under both axial and torsional forces. Quasi-static tests were performed with an axial speed of 1.8 mm/min and a torsional speed of 4.5°/min. The biomechanical properties of all groups were examined in terms of axial stiffness, torsional stiffness, and maximum axial force parameters. The stiffness values of groups 1, 2, 3, and 4 were 303 ± 35.8 N/mm, 159.6 ± 25 N/mm, 232 ± 35.9 N/mm, and 366.9 ± 58 N/mm, respectively, under axial forces (P < .01); 2172.7 ± 252.1 Nmm/°, 1225.3 ± 238.6 Nmm/°, 2123 ± 359.4 Nmm/°, and 2721.85 ± 304 Nmm/°, respectively, under torsional moments (P < .01); and 2072.1 ± 256.1 N, 1379.9 ± 290.6 N, 2099.1 ± 454.2 N, and 2648.4 ± 364.6 N, respectively, under the maximum force (P < .01). This study showed that in the fixation of Pauwels type 3 fractures formed on third-generation bone models, the utilization of half-thread cannulated screws in an inverted triangle configuration, along with a medial buttress plate, provided stronger fixation compared to the remaining implant groups and the control group. According to the evaluation of the parameters, the isolated application of a medial buttress plate had poorer biomechanical properties than other fixation methods.

Wedgeless V-Shaped Osteotomy of the Distal Medial Femur with Locking Plate Fixation for Correction of Genu Valgum in Adolescents and Young Adults.

Genu valgum is a common disorder affecting adolescents and young adults. Treatment of this disorder requires restoration of normal mechanical axis alignment and joint orientation, for which it is important to assess whether the deformity arises from the distal femur, knee joint, or proximal tibia. Most commonly, the deformity originates from the distal femur, and various osteotomies of the distal femur have been described1-6. The presently described wedgeless V-shaped osteotomy7,8 is a good option among the various alternative procedures listed below. The anesthetized patient is placed in the supine position on a radiolucent operating table. A bolster is placed beneath the knee to relax the posterior structures. A medial longitudinal skin incision is made that extends from the level of the medial joint line to 5 cm proximal to the adductor tubercle. The vastus medialis is identified and elevated anteriorly by detaching it from its distal and posterior aspects. The leash of vessels underneath the vastus medialis is identified, and the apex of the V-shaped osteotomy is kept just proximal to it. The anterior arm of the V is kept longer than the posterior one, both of them are kept perpendicular to each other, and the apex of the V is made to point distally. The osteotomy is performed on the medial cortex with use of an oscillating saw or multiple drill holes that are then connected using a thin osteotome. Care is taken not to utilize a saw or drill on the lateral cortex. A gentle valgus thrust is applied to break the lateral cortex without periosteal disruption. The apex of the V osteotomy on the proximal fragment is trimmed, and the deformity is corrected with varus force. The osteotomy site is stabilized with use of an anatomically contoured distal medial femoral locking plate or a medial proximal tibial L-shaped buttress plate (of the contralateral side). The implant position is verified under a C-arm image intensifier. The wound is closed in layers over a suction drain in a standard manner. Various types of corrective osteotomies of the distal femur have been described in the literature, including the lateral opening wedge, medial closing wedge, dome, and spike osteotomies1-6. All of these procedures have certain limitations and shortcomings. The wedgeless V-shaped osteotomy is another described procedure that is inherently stable7,8. It is a safe procedure and yields good clinical outcomes8,9. The posterior arm of the V-shaped osteotomy is kept smaller than the anterior arm. The proximal cortical bone is allowed to dig into the cancellous bone of the wider distal metaphysis during deformity correction. Trimming the apex of proximal bone end after making the osteotomy facilitates the process. In a study of 46 patients with a mean age of 16.9 years (range, 15 years to 23 years), Gupta et al.8 reported that the mean radiographic tibiofemoral angle improved from 22.2° (range, 16° to 29°) preoperatively to 5.1° (range, 0° to 10°) postoperatively (p < 0.001). Similarly, the mean lateral distal femoral angle improved from 79.2° preoperatively to 89.1° postoperatively (p < 0.001) and the mean mechanical axis deviation improved from 19.6 mm preoperatively to 3.7 mm postoperatively (p < 0.001). A total of 44 of 46 cases had an excellent functional outcome, with the other 2 having good outcomes. None of the patients in the study had an unsatisfactory outcome. It is important to keep the whole lower limb accessible to the image intensifier intraoperatively.Identification of the leash of vessels underneath the vastus medialis is important to decide the level of the osteotomy.It is important to preserve the periosteal sleeve on the lateral aspect of the femur. CORA = center of rotation of angulationECG = electrocardiogramLDFA = lateral distal femoral angleMAD = mechanical axis deviationMPTA = medial proximal tibial angle.

Dual-Plate Fixation for Proximal Humerus Fractures With Unstable Medial Column in Patients With Osteoporosis.

To compare radiological and clinical outcomes between lateral locking plate (LLP) and dual-plate fixation (LLP and additional medial buttress plate) for proximal humerus fractures with medial column comminution and varus deformity in patients with osteoporosis. Retrospective. Academic medical center. Overall, 52 patients were enrolled. Of these, 26 patients underwent dual-plate fixation. The control group (LLP) was matched to the dual-plate group for age, sex, injured side, and fracture type. Patients in the dual-plate group were treated with LLP and medial buttress plate, whereas patients in the LLP group were treated with only an LLP. Demographic factors, operative time, and level of hemoglobin of the 2 groups obtained from medical records. Changes in the neck-shaft angle and the development of postoperative complications were recorded. Clinical outcomes were measured based on the visual analog scale; American Shoulder and Elbow Surgeons; Disabilities of the Arm, Shoulder, and Hand; and Constant-Murley scores. The operation time and hemoglobin loss did not differ significantly between the groups. Radiographic evaluation showed a significantly lower change in neck-shaft angle in the dual-=plate group than in the LLP group. The dual-plate group also showed better Disabilities of the Arm, Shoulder, and Hand; American Shoulder and Elbow Surgeons; and Constant-Murley scores than the LLP group. Fixation using additional medial buttress plate with LLP may be considered for treating proximal humerus fractures in patients with an unstable medial column, varus deformity, and osteoporosis. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Preliminary Experience of Carbon Fiber Buttress Plating: A Case Series

Preliminary Experience of Carbon Fiber Buttress Plating: A Case Series

Comparison of clinical outcomes between posterolateral approach and modified Hardinge approach in salvage total hip arthroplasty after medial buttress plate failure for femoral neck fractures.

The purpose of this study was to investigate the clinical outcomes of salvage total hip arthroplasty (THA) after medial buttress plate surgery for femoral neck fractures via the modified Hardinge approach (MHA) and posterolateral approach (PLA) through a retrospective analysis. From October 2016 to October 2020, a total of 41 patients with failed femoral neck fractures treated with cannulated screws and medial buttress plates underwent unilateral salvage THA, and a retrospective study was conducted. According to the surgical approach, patients were divided into PLA group and MHA group. Clinical and radiological data were evaluated. The primary outcome indicators were the Pain Visual Analog Scale (VAS) and Hip Harris Score (HHS). Secondary outcome indicators include hemoglobin (HGB), hematocrit (HCT), creatine kinase (CK), creatine kinase-MB (CK-MB), etc. The occurrence of postoperative complications was also recorded. There were no differences in demographic or clinical characteristics before surgery. There were no differences in postoperative HGB, HCT, CK-MB and radiological parameters. The surgical approach had no effect on the hospitalization period. The PLA group had earlier ambulation time, and the serum level of CK was also low. Analysis of the HHS and VAS showed that on postoperative day 3, the PLA group had superior scores. The incidence of complications did not significantly differ between groups. The posterolateral approach for salvage THA provides better functional recovery with less muscle damage in the early postoperative period.

Biomechanical Analysis of Combined Medial Calcar and Lateral Locked Plating Versus Isolated Lateral Locked Plating of Proximal Humerus Fractures.

Medial calcar buttress plating combined with lateral locked plating is biomechanically tested against isolated lateral locked plating in synthetic humeri models for the treatment of proximal humerus fractures. Proximal humerus fractures (OTA/AO type 11-A2.1) were manufactured in 10 pairs of Sawbones humeri models (Sawbones, Pacific Research Laboratories, Vashon Island, WA). Specimen were randomly assigned and instrumented with either medial calcar buttress plating combined with lateral locked plating (CP) or isolated lateral locked plating (LP). Nondestructive torsional and axial load tests were performed to evaluate construct stiffness. Large-cycle axial tests were conducted followed by destructive ramp-to-failure tests. Cyclic stiffness was compared in both nondestructive and ultimate failure loads. Failure displacement was recorded and compared between groups. The addition of medial calcar buttress plating to lateral locked plating constructs significantly increased the axial ( P < 0.01) and torsional ( P < 0.01) stiffness of the construct compared with isolated lateral locked plating by 95.56% and 37.46%, respectively. All models demonstrated greater axial stiffness ( P < 0.01) after 5000 cycles of axial compression, not dependent on the fixation method. During destructive testing, the CP construct withstood 45.35% larger load ( P < 0.01) and congruently exhibited 58% less humeral head displacement ( P = 0.02) before failure when compared with the LP construct. This study demonstrates the biomechanical superiority of medial calcar buttress plating when combined with lateral locked plating as compared with isolated lateral locked plating of OTA/AO type 11-A2.1 proximal humerus in synthetic humeri models.

Technique Tip: Using a Targeting Guide to Place Flexible Syndesmosis Fixation, in Ankle Fractures With a Dual Plate Construct

Syndesmosis disruption alone or accompanying an ankle fracture is a frequent injury addressed by the foot and ankle surgeon. Reduction and fixation are usually performed with the use of implants as a tight rope and/or screw(s). When treating complex articular injuries requiring multiple buttress plates, the ability to enhance fixation with syndesmotic implants can be difficult in the presence of other hardware. We propose a technique using an anterior cruciate ligament targeting drill guide to precisely place syndesmotic fixation across both plates to achieve the ideal construct for stability. In this case, we used flexible fixation for the syndesmosis. Level of Evidence: Diagnostic level V; expert opinion.

A biomechanical comparison of three fixation methods for unstable femoral neck fractures with medial calcar defect

BackgroundUnstable femoral neck fractures with medial calcar defects are difficult to manage. The optimal fixation methods for these fractures have been a subject of ongoing debate among orthopedic surgeons. In this study, three different fixation techniques for vertical, medial defected femoral neck fractures were compared.MethodsIn this study, a biomechanical analysis was conducted to compare three fixation methods: cannulated screws (Group 1), cannulated screws combined with a medial buttress plate (Group 2), and intramedullary nails (Group 3). Synthetic composite bone models representing vertical collum femoris fractures with medial calcar defects were used. Each group consisted of seven specimens, and, to maintain consistency, a single surgeon performed the surgical procedure. Biomechanical testing involved subjecting the specimens to axial loading until failure, and the load to failure, stiffness, and displacement values were recorded. Normality was tested using the Shapiro–Wilk test. One-way ANOVA and Tukey’s HSD post hoc test were used for comparisons.ResultsThe difference in the load to failure values was statistically significant among the groups, with Group 2 exhibiting the highest load to failure value, followed by Group 3 and Group 1. Stiffness values were significantly higher in Group 2 than in the other groups. Displacement values were not significantly different between the groups. Fracture and displacement patterns at the point of failure varied across the groups.ConclusionThe results of this study indicate that fixation with a medial buttress plate in combination with cannulated screws provides additional biomechanical stability for vertical femoral neck fractures with medial calcar defects. Intramedullary nail fixation also demonstrated durable stability in these fractures. These findings can be used to better understand current management strategies for these challenging fractures to promote the identification of better evidence-based recommendations.

Technical trick: buttress plate fixation of comminuted capitellum fractures with combined suture repair of the lateral ulnar collateral ligament

Technical trick: buttress plate fixation of comminuted capitellum fractures with combined suture repair of the lateral ulnar collateral ligament

Biomechanical analysis of tibial plateau posterolateral fracture fragment fixation and introduction of a lateral tibia plateau hook plate system

BackgroundFixing the posterolateral fragments of tibial plateau fractures has been challenging owing to potential neurovascular injuries and fibular head blocks. Several surgical approaches and fixation techniques have been reported, with distinct limitations. We propose a novel lateral tibia plateau hook plate system and compare its biomechanical stability with other fixation methods. MethodsTwenty-four synthetic tibia models were simulated to present posterolateral tibial plateau fractures. These models were randomly assigned to three groups. Group A models were fixed with the lateral tibia plateau hook plate system, Group B with variable-angle anterolateral locking compression plates, and Group C with direct posterior buttress plates. The models’ biomechanical stability was evaluated using static (gradually increased axial compressive loads) and fatigue (cyclically loaded from 100 to 600 N for 2000 cycles each) tests. ResultsGroups A and C models exhibited comparable axial stiffness, subsidence load, failure load, and displacement in the static test. Group A model exhibited higher subsidence and failure loads than Group B model. Groups A and C models exhibited comparable displacement at 100 N cyclic loading in the fatigue test. Group C model was more stable at higher loads. Group C model endured the highest subsidence cycle numbers, followed by Groups A and B models. ConclusionsThe lateral tibia plateau hook plate system provided similar static biomechanical stability as the direct posterior buttress plates and comparable dynamic stability under limited axial loading. This system is a potential posterolateral treatment choice owing to its convenience and safety, in treating tibia plateau fractures.

The double-plate fixation technique prevents varus collapse in AO type C3 supra-intercondylar fracture of the distal femur

IntroductionVarus collapse followed by osteosynthesis for distal femoral fractures with conventional implants has been well documented but is seldom mentioned in fractures managed with locking plates. The purpose of this study was to assess the incidence of varus collapse after treating complex supra-intercondylar fractures of the distal femur (AO type C3) using a Single Plate (SP) or Double Plate (DP) fixation technique.Materials and methodsWe retrospectively reviewed 357 patients with distal femoral fractures who were treated at our hospital between 2006 and 2017. After excluding cases of infection, malignancy, periprosthetic fracture, revision surgery, pediatric fracture, and extra-articular fracture, 54 patients were included in the study. All demographic data and radiological and clinical outcomes were reviewed and analyzed.ResultsThere were 54 patients enrolled into this study with age from 15 to 85 years old (mean 41.6, SD = 19.9), and 32 of them were open fractures (59%). The patients were further divided into either an SP (n = 15) or a DP group (n = 39). Demographics, including age, sex, injury severity score, and open fracture type, were all compatible between the two groups. The overall nonunion rate was 25.9% (n = 14; 6 from the SP and 8 from the DP group; p = 0.175). The varus collapse rate was 9.3% (n = 5; 4 from the SP and 1 from the DP group (p = 0.018).ConclusionsThe varus collapse rate after osteosynthesis with a single lateral locking plate could be as high as 26.7% in AO type C3 fractures of the distal femur, which would be decreased to 2.6% by adding a medial buttress plate. Surgeons should consider DP fixation to avoid varus collapse in severely comminuted complete intra-articular fractures of the distal femur.

Effect of buttress plate in Herscovici type D vertical medial malleolar fractures and peripheral fractures: a retrospective comparative cohort study

BackgroundThe purpose of current retrospective study was to review the surgical methods and to evaluate the clinical efficacy of supporting plate for the treatment of vertical medial malleolus fractures on the basis of stable fixation of ipsilateral fibula.MethodsThis retrospective study included a total of 191 patients with vertical medial malleolus fractures. Patients enrolled were divided into simple vertical medial malleolus fractures and complex types of fractures. General demographic information and surgical information, including age, sex, surgical procedure and postoperative complications, were collected. The functional prognosis of patients was evaluated by American Orthopedic Foot and Ankle Society Ankle-Hindfoot Score (AOFAS) and Visual Analog Scale (VAS).ResultAmong patients with simple vertical fractures, the respective incidence of internal fixation failure in screw group, buttress plate group, and screw combined buttress plate fixation group (combined fixation group) was 10/61 (16.4%),1/54 (7.4%) and 1 (1.9%), and the difference was statistically significant (P = 0.024). The incidence of abnormal fracture growth and healing in screw group, buttress plate group and combined fixation group was, respectively, 13/61 (21.3%), 6/54 (12.5%) and 2 (3.85%), with statistically significant difference (P = 0.019). In the patients with complex types of fractures, after 2 years of postoperative follow-up, the AOFAS score and VAS score of the following subgroups had good results: 91.18 ± 6.05 and 2.18 ± 1.08 in patients with joint surface collapse, and 92.50 ± 4.80 and 2.50 ± 1.29 in patients with tibial fractures, with 100% excellent and good rate.ConclusionFor simple and complex vertical medial malleolus fractures, buttress plate showed excellent fixation. Despite poor wound healing and extensive soft tissue dissection with this approach, buttress plate may provide a novel insight into medial malleolar fractures, especially for extremely unstable medial malleolar fractures.