Comminuted Fracture Patterns Research Articles

Reply to comment on Cheng et al.: Comparison study of two surgical options for distal tibia fracture—minimally invasive plate osteosynthesis vs. open reduction and internal fixation

Dear Editor, We read the comments on our research article entitled “Comparison study of two surgical options for distal tibia fracture—minimally invasive plate osteosynthesis vs. open reduction and internal fixation” [1] in International Orthopaedics. Thank you for the constructive arguments from our colleagues. However, we could not totally agree with the conclusion, and discussions on several aspects below contribute to our viewpoints. To perform a well-matched pair comparison in clinical trial requires a considered prospective design; we acknowledge that factors such as age, gender and fracture pattern are as important as other factors influencing fracture healing, which include nutritional status, pre injury activity status, smoking status, osteoporosis and the presence of systemic diseases. However, we compared not only the healing results but also other variables such as operation time, blood loss, hospital stay and final Mazur score, etc., which actually may have little relation to those factors influencing fracture healing. Furthermore, the statistical results revealed no significant difference between groups. In our trial, four pairs of comminuted fractures were enrolled and in the ORIF group one case of osteomyelitis was confirmed, whereas this complication was not seen in any case in the MIPO group. But this could not be taken as evidence that the MIPO technique is better than ORIF, even though the faster union time in comminuted fracture should be appreciated. Conversely, the soft tissue complications must be attached to importance by surgeons due to its high incidence with the MIPO technique. Lau et al. [2] reported that despite delayed surgery being adopted, 15% of infection and 52% of severe soft tissue impingement rates were encountered in MIPO treatment of distal tibia. Combined with our understanding and experience, the MIPO technique can not ensure reduced chance of wound complication nor offer a more comfortable feeling than using the ordinary plate. As for those comminuted cases usually associated with high energy trauma, soft tissue status sometimes should be considered much more over the union rate. Collinge et al. also reported significant reoperation rate (35%) and prolonged time to union in patients treated by the MIPO technique in those with highly comminuted fracture patterns, bone loss or type II or III open fractures [3]. Sharma et al. were against our principle of fibular fixation only for fractures involving the syndesmosis, and they argued that many authors[4, 5] have reported that fibular fixation is a must for comminuted tibia fracture patterns. However, Gupta et al. [4] argued clearly in their discussion that ”It is not essential to fix fibular fractures in the presence of a simple fracture pattern of the tibia provided the fibular fracture is proximal to the syndesmosis. However, any fibular fracture at the level of or distal to the syndesmosis, with comminution of the distal tibia, requires stabilisation to maintain the lateral column of the ankle thereby preventing late collapse and secondary loss of reduction”, which is consistent with our viewpoint. We therefore think that Sharma misunderstood the opinion of Gupta about the issue of fibula fixation. In the research of Bonnevialle et al. [5], 126 cases of distal tibial fractures associated with fibular fractures were enrolled. The fibula lesions were not treated in 79 cases and the other 47 cases were fixed. The results showed 17 nonuion of tibia; however, among them seven were from the untreated fibula group (7/79) and ten from the fibula treated group (10/47). Those union failures were reviewed in relation to the fixation the fibular fracture by the author. Although the fixation of fibula can be somewhat helpful to reduce the tibial fracture, the potentially negative impact of fibular fixation in union of the tibia has been raised [6, 7]. And despite assistance of fibula fixation in tibia reduction, an experienced surgeon can manage to reduce even severely comminuted tibia fractures with only manipulation under an intraoperative image intensifier or by direct reconstruction. Whereas, dealing with fibula fracture usually involves extra cost and more operating time. Furthermore, laboratory comparison has proved that fixation of the tibia with LCP can provide adequate stability without fibula treatment [8]. Therefore we would recommend fibula fixation only if the syndesmosis is involved. In conclusion, we appreciate any suggestions and debate on the issue of MIPO treatment for distal tibia fracture. We hope in future that any unresolved issues can be more powerfully explored by further evidence. Regards, Dr. Wang Cheng Dr. Li Ying Dr. Wang Manyi

Comment on Cheng et al.: Comparison study of two surgical options for distal tibia fracture—minimally invasive plate osteosynthesis vs. open reduction and internal fixation

Dear Editor, We read with great interest the article by Cheng et al. on ‘Comparison study of two surgical options for distal tibia fracture—minimally invasive plate osteosynthesis vs. open reduction and internal fixation’ [1] in the online issue of International Orthopaedics. The authors have concluded in their study that the minimally invasive plate osteosynthesis (MIPO) technique is not distinctively superior to open reduction and internal fixation (ORIF) in the treatment of distal tibial fractures. However, there are several intriguing points that we think need to be discussed further and elaborated upon. To have a meaningful comparative analysis, the comparison groups should be matched for as many important variables as possible except for the variable to be measured, which in this case happens to be the surgical technique. However, the authors have used only three variables, viz. age, gender and fracture pattern. Several other factors that influence fracture healing and have not been compared include nutritional status, pre-injury activity status, smoking status, osteoporosis and the presence of systemic diseases. Also, the authors have not mentioned whether the quality of reduction and fixation was assessed and if so, whether it was comparable across the paired groups. The fracture patterns included in the study are quite variable, ranging from simple patterns (AO type A), wedge patterns (AO type B) and comminuted patterns (AO type C). We believe that it is unrealistic to club all three categories together for a comparative analysis. Some interesting facts emerge from subgroup analysis of the comminuted (AO type C) fracture patterns. Although the number of cases is small, one can still appreciate the fact that three of four comminuted (AO type C) fractures (patients 7, 8, 9 and 10) united faster with the use of the MIPO technique. One case of four (25%) AO type C fractures developed osteomyelitis, whereas this complication was not seen in any case in the MIPO group. The authors performed fibular fixation only for fractures involving the syndesmosis. However, many authors have reported that fibular fixation is a must for comminuted tibial fracture patterns. By restoring the lateral column, indirect reduction can be achieved and this also prevents fracture collapse [2, 3]. To conclude, we believe it would be wrong to jump to the assumption that the MIPO technique is not superior to ORIF for all distal tibial fractures. Distal tibial fractures are a diverse group, ranging from simple fracture patterns to complex patterns. MIPO, when used with the principles of bridge plating, apparently seems to be the superior of the two techniques for the subgroup of comminuted (AO/OTA type C) fracture patterns. Large, multi-centre randomised controlled trials are needed to confirm or refute this observation. Regards, Siddhartha Sharma Mohammad Farooq Butt

Comparison of Olecranon Plate Fixation in Osteoporotic Bone: Do Current Technologies and Designs Make a Difference?

The purpose of this study is to determine if recent innovations in olecranon plates have any advantages in stabilizing osteoporotic olecranon fractures. Five olecranon plates (Acumed, Synthes-SS, Synthes-Ti, US Implants/ITS, and Zimmer) were implanted to stabilize a simulated comminuted fracture pattern in 30 osteoporotic cadaveric elbows. Specimens were randomized by bone mineral density per dual-energy x-ray absorptiometry scan. Three-dimensional displacement analysis was conducted to assess fragment motion through physiological cyclic arcs of motion and failure loading, which was statistically compared using one-way analysis of variance and Tukey honestly significant difference post hoc comparisons with a critical significance level of α = 0.05. Bone mineral density ranged from 0.546 g/cm to 0.878 g/cm with an average of 0.666 g/cm. All implants limited displacement of the fragments to less than 3 mm until sudden, catastrophic failure as the bone of the proximal fragment pulled away from the implant. The maximum load sustained by all osteoporotic specimens ranged from 1.6 kg to 6.6 kg with an average of 4.4 kg. There was no statistical difference between the groups in terms of cycles survived and maximum loads sustained. Cyclic physiological loading of osteoporotic olecranon fracture fixation resulted in sudden, catastrophic failure of the bone-implant interface rather than in gradual implant loosening. Recent plate innovations such as locking plates and different screw designs and positions appear to offer no advantages in stabilizing osteoporotic olecranon fractures. Surgeons may be reassured that the current olecranon plates will probably adequately stabilize osteoporotic fractures for early motion in the early postoperative period, but not for heavy activities such as those that involve over 4 kg of resistance.

Minimally Invasive Plating of High-Energy Metaphyseal Distal Tibia Fractures

The purpose of this study is to evaluate clinical results and outcomes of a strict cohort of high-energy injuries of the metaphyseal distal tibia with minimal or no intraarticular involvement treated using the minimally invasive plating concept. Level II trauma center. Retrospective analysis of a consecutive case series with limb-specific and whole-person outcomes measures. Minimally invasive medial plating for high-energy metaphyseal fractures of the distal tibia with little or no intraarticular involvement. Clinical and radiographic results were assessed at a minimum of 1 year, and outcomes measures were applied at final follow-up at a minimum of 2 years. Limbs were assessed with the American Orthopaedic Foot and Ankle Surgeons (AOFAS) ankle-hindfoot instrument and the method of Olerud and Molander. Patient outcomes were evaluated with the Short Form-36 (SF-36) and the Musculoskeletal Functional Assessment (MFA). Twenty-six patients were followed until healed at an average of 36 months (12-56 months). Mean fracture healing time was 35 weeks (12-112 weeks) with acceptable alignment restored (angulation<or=5 degrees or shortening<or=1 cm) in all but 1 case. Two patients (7%) had loss of fixation and 9 (35%) underwent secondary surgeries to achieve union. Risk factors for healing problems included high grades of fracture comminution, bone loss, and high-grade open injuries (P<0.05). SF-36 outcomes scores in 21 patients at >2 years were comparable to normative data of patients with uninjured limbs, whereas MFA results showed functional deficits in 4 of 10 subsections. Minimally invasive medial plating will restore limb alignment and yield successful clinical outcomes for high-energy metaphyseal fractures of the distal tibia. Despite the significant reoperation rate and prolonged time to union, most patients can expect a predictable return of function. Strong consideration should be given to adjunctive measures in at-risk patients, including those with highly comminuted fracture patterns, bone loss, or Type II or III open fractures.

Complications Following Internal Fixation of Unstable Distal Radius Fracture With a Palmar Locking-Plate

The increasing number of fixed-angle plate systems used to treat distal radius fractures carries with it the problem of determining the optimal fixation for unstable fractures. Our goal was to analyze the clinical and radiological outcomes of patients with displaced, unstable distal radius fractures treated with a palmar fixed-angle plate. Prospective protocol; multicenter clinical study; retrospective analysis. Level 1 university trauma centers. Over a mean 15-month period (range, 12 to 27 months), 141 consecutive patients were treated for an unstable dorsally displaced distal radius fracture of which 114 or 81% were followed for 1 year or longer. Open reduction and palmar internal fixation with a fixed-angle plate (2.4 mm LCP Distal Radius Plates; Synthes, Salzburg, Austria). Indication for surgical treatment was the inability to obtain or maintain fracture or articular alignment after initial closed reduction. In a follow-up period, which had to be longer than 12 months, objective and subjective functional results (active range of motion; strength; Disabilities of the Arm, Shoulder, and Hand (DASH) score; visual analog scale (VAS); Green and O'Brien Score) and radiographic assessment (palmar tilt, radial inclination, ulnar variance, fracture union) were assessed. Potentials for complications were given special attention. In the 114 patients followed for a minimum of 12 months, there were 21 men and 93 women with a mean age of 57 years (17 to 79 years). Fractures were classified according to the AO/ASIF classification system as type A2 (n = 39), A3 (n = 16), C1 (n = 24), C2 (n = 30), or C3 (n = 5). The modified Green and O'Brien Score revealed 31 excellent, 54 good, 23 fair, and 6 poor results. Active wrist motion averaged 54 degrees extension (82% as compared with the uninjured side) and 46 degrees flexion (72% as compared with the uninjured side). The average pronation was 81 degrees (95% as compared with the uninjured side), and the average supination was 82 degrees (95% as compared with the uninjured side). Mean grip strength at final follow-up was 70% of the uninjured side. Low residual pain values in the wrist were demonstrated: 81 patients (71%) were pain free, 17 patients (15%) had mild pain, 10 patients (9%) had moderate pain, and 6 patients (5%) had severe pain. The DASH score averaged 13 points (range, 0 to 39 points). Fracture union was achieved in all patients. A mean loss of palmar tilt of 3.4 degrees (range, 0 to 8 degrees), radial inclination of 0.4 degrees (range 0 to 2 degrees), and of the ulnar variance of 1.2 mm (range, 0 to 6 mm) was measured. The overall complication rate was 27% (31/114). The most frequent problems were flexor and extensor tendon irritation (57% of the total number of complications), including 2 ruptures of the flexor pollicis longus tendon, 2 ruptures of the extensor pollicis longus tendon, 4 cases of extensor tendon tenosynovitis, and 9 cases of flexor tendon tenosynovitis. Carpal tunnel syndrome was observed in 3 patients, and complex regional pain syndrome occurred in 5 patients. In 2 cases, loosening of a single screw was seen. Delayed fracture union occurred in 3 patients, and intraoperative intraarticular screw displacement was recognized in 1 patient. Neither clinical outcome nor complication rate were dependent on fracture type (intraarticular versus extraarticular). Fixation of unstable dorsally displaced distal radius fractures with a fixed angle plate provides sufficient stability with minimal loss of reduction. Nevertheless, very distal palmar plate position can interfere with the flexor tendon system, too long screws can penetrate the extensor compartments, and distal screws in comminuted fracture patterns can cut through the subchondral bone and penetrate into the radiocarpal joint. Mindful of these problems, we consider that the complex fracture pattern of an unstable distal radius fracture cannot be treated by a single plate system and approach.

Comparison of Plate and Screw Fixation and Screw Fixation Alone in a Comminuted Talar Neck Fracture Model

Talar neck fracture fixation has been studied in noncomminuted fracture models, but no large clinical series of comminuted fracture patterns have been published and no biomechanical studies have compared plate fixation with screw fixation in comminuted talar neck fractures. Nine matched pairs of fresh frozen talar specimens were stripped of soft tissue and mounted in a cylindrical jig. The talar neck was fractured using a dorsally directed shear force at a rate of 200 mm/min, and dorsal comminution was simulated by removing a 2-mm section of bone from the distal fracture fragment. One specimen from each pair was fixed with either two solid 4.0-mm partially threaded cancellous screws posterior-to-anterior just lateral to the posterior process of the talus or with a four-hole 2.0-mm minifragment plate contoured to the lateral surface of the talar neck and secured with 2.7-mm screws. A 2.7-mm fully threaded cortical screw was placed medially using a lag technique. The specimens were then loaded to failure with a dorsally directed force at a rate of 200 mm/min. Failure was defined as the load producing 2 mm of displacement. A Student's t-test analysis was used with significance set at p < or = 0.05. Posterior-to-anterior screw fixation had a statistically significant higher load to failure than plate fixation (p < 0.05). Mean load to failure for the screw group was 120.7 +/- 68.5 N and 89.7 +/- 46.6 N for the plating group. Plate fixation may offer substantial advantages in the ability to control the anatomic alignment of comminuted talar neck fractures, but it does not provide any biomechanical advantage compared with axial screw fixation. Further, the fixation strength of both methods was an order of magnitude lower than those found in previous studies of noncomminuted fractures.

Biomechanical Comparison of Flexible Stainless Steel and Titanium Nails with External Fixation Using a Femur Fracture Model

There are several options available for surgical stabilization of pediatric femoral shaft fractures. The purpose of this study was to compare the stability afforded by Ender stainless steel nails, titanium elastic nails, and one-plane unilateral external fixators for the fixation using a synthetic adolescent midshaft femur fracture model. The anterior-posterior (sagittal plane) bending, lateral (coronal plane) bending, torsional, and axial stiffness values were calculated using 6 different fixation configurations. These included pairs of 3.5-mm-diameter Ender nails with and without distal locking, 3.5- and 4.0-mm-diameter titanium elastic nails as well as single- and double-stacked monolateral external fixators. Eight synthetic femur models, 4 each with simulated transverse and comminuted fracture patterns, were sequentially tested for stability afforded by the various fracture fixation configurations. External fixation exhibited significantly greater control of anterior-posterior angulation compared with all flexible-nailing systems. Although Ender nails were slightly superior to titanium nails in control of sagittal plane angulation, this was not statistically significant. Compared with the external fixation constructs, all 4 flexible nail constructs demonstrated higher torsional stability. For prevention of axial shortening, all fixation methods were similar for the transverse fracture pattern, whereas external fixation was superior to flexible nails in the comminuted fracture model. No significant benefit was demonstrated with double stacking of external fixators. These findings may help guide clinicians choose the optimal fixation method for treatment of pediatric femoral shaft fractures.

Submuscular Bridge Plating for Pediatric Femur Fractures

Operative stabilization is the treatment of choice for pediatric femur fractures in patients age ≥5 years to skeletal maturity. The method of stabilization is dependent on many factors, such as age, fracture location, fracture pattern, and surgeon preference. Stabilization can be more challenging for length unstable comminuted and long oblique fracture patterns because of concerns for femoral head avascular necrosis with rigid intramedullary nails and the potential difficulty of stabilizing these complex fractures with elastic intramedullary nails. Submuscular bridge plating restores length and alignment and rigidly stabilizes the unstable pediatric femur fracture. The technique is minimally invasive, “bridges” the fracture leaving the soft tissue intact, and avoids potential avascular necrosis. The technique is described here in detail.

Treatment of Complex Subtrochanteric Fracture with the Long Gamma AP Locking Nail: A Prospective Evaluation of 64 Cases

Complex subtrochanteric fractures are uncommon injuries and challenging to manage. We elucidate the role of the Long Gamma AP Locking Nail (LGAPN) in the management of such fractures in the acute stage. Between 1992 and 2002, 64 consecutive cases with nonpathologic complex subtrochanteric fractures managed with the LGAPN were enrolled in this study. Associated injuries were present in 16 cases. The average follow-up period was 68 months. Mean time to union was 14 weeks. There were two complications (one wound infection and one delayed union). The time to union and functional results were not statistically different between different ages (below 50 years old, or older than 50 years) and the number of distal locking screws used (one or two). Longer time to union is noted in patients with a longer operation time and a more comminuted fracture pattern by the AO classification. Closed reduction and internal fixation with the LGAPN were proven to be safe and effective in the treatment of complex traumatic subtrochanteric fractures in all age groups, and one distal locking screw is sufficient for distal fixation.

Biomechanical Analysis of Antegrade and Retrograde Flexible Intramedullary Nail Fixation of Pediatric Femoral Fractures Using a Synthetic Bone Model

Biomechanical testing was performed to evaluate the stability of simulated transverse and comminuted femoral fractures after retrograde and antegrade flexible titanium intramedullary nail fixation. Ten synthetic adolescent-sized femoral bone models were used. Five underwent retrograde fixation with two C-shaped nails inserted from medial and lateral entry portals. The other five underwent antegrade fixation using one C- and one S-shaped nail through lateral entry holes just inferior to the greater trochanter. Retrograde nail fixation demonstrated significantly less axial range of motion and greater torsional stiffness than antegrade fixation in both transverse and comminuted fracture patterns. However, there appeared to be a biomechanical trend of greater resistance to shortening for antegrade nails.

Biomechanical analysis of antegrade and retrograde flexible intramedullary nail fixation of pediatric femoral fractures using a synthetic bone model.

Biomechanical testing was performed to evaluate the stability of simulated transverse and comminuted femoral fractures after retrograde and antegrade flexible titanium intramedullary nail fixation. Ten synthetic adolescent-sized femoral bone models were used. Five underwent retrograde fixation with two C-shaped nails inserted from medial and lateral entry portals. The other five underwent antegrade fixation using one C- and one S-shaped nail through lateral entry holes just inferior to the greater trochanter. Retrograde nail fixation demonstrated significantly less axial range of motion and greater torsional stiffness than antegrade fixation in both transverse and comminuted fracture patterns. However, there appeared to be a biomechanical trend of greater resistance to shortening for antegrade nails.

Bicondylar tibial plateau fractures managed with the Sheffield Hybrid Fixator: Biomechanical study and operative technique

The two main challenges in the management of bicondylar tibial plateau fractures are: Firstly, the compromised skin and soft tissue envelope which invite a high rate of complications following attempted open reduction and dual plating. Secondly, poor bone quality and comminuted fracture patterns, which create difficulty in achieving stable fixation. Although dual plating is considered to be the best mechanical method of stabilizing these complex fractures, there remains concern regarding the high rate of complications associated with extensive soft tissue dissection, required for the insertion of these plates in an already compromised knee. The Sheffield Hybrid fixator (SHF) technique offers a solution to the two main problems of these difficult fractures by minimizing soft tissue dissection, since bone fragments are reduced and fixed percutaneously, and providing superior cancellous bone purchase with beam loading stabilization for comminuted fractures. Our biomechanical testing showed the SHF with four tensioned wires to be as strong as dual plating and able to provide adequate mechanical stability in the fixation of bicondylar tibial plateau fractures. This was confirmed clinically by a prospective review of the use of the SHF at our centre, for managing complex and high-energy tibial plateau fractures with a good final outcome and no cases of deep infection or septic arthritis.

Subunit Principles in Midface Fractures: The Importance of Sagittal Buttresses, Soft-Tissue Reductions, and Sequencing Treatment of Segmental Fractures

The patterns of midface fractures were related to postoperative computed tomography scans and clinical results to assess the value of ordering fracture assembly in success of treatment methods. A total of 550 midface fractures were studied for their midface components and the presence of fractures in the adjacent frontal bone or mandible. Preoperative and postoperative computed tomography scans were analyzed to generate recommendations regarding exposure and postoperative stability related to fracture pattern and treatment sequence, both within the midface alone and when combined with frontal bone and mandibular fractures. Large segment (Le Fort I, II, and III) fractures were seen in 68 patients (12 percent); more comminuted midface fracture combinations were seen in 93 patients (17 percent). Midface and mandibular fractures were seen in 166 patients (30 percent). Midface, mandible, and nasoethmoid fractures were seen in 38 patients (7 percent). Frontal bone and midface fractures were seen in 131 patients (24 percent). Split-palate fractures accompanied 8 percent of midface fractures. Frontal bone, midface, and mandibular fractures were seen in 54 patients (10 percent). The midface, because of weak bone structure and comminuted fracture pattern, must therefore be considered a dependent, less stable structure. Its injuries more commonly occur with fractures of the frontal bone or mandible (two-thirds of cases) and, more often than not (>60 percent), are comminuted. Comminuted and pan-facial (multiple area) fractures deserve individualized consideration regarding the length of intermaxillary immobilization. Examples of common errors are described from this patient experience.

Sagittal Fractures of the Palate: A New Method of Treatment

A new technique is described for stabilizing complex vertical fractures of the maxilla. Advantageous use of the comminuted fracture pattern of the maxillary buttresses allows the maxilla to be divided into two parts at the Le Fort I level. with intermaxillary fixation applied, stabilization is achieved by applying miniplate fixation to the nasal side of the hard palate. The maxilla is reduced to the previously stabilized anterior midfacial buttresses with plates and screws. Comminuted segments of defects in the anterior buttresses are replaced with contoured calvarial grafts. This method has the advantage of maintaining transverse palatal width in a rigid fashion without the need for further osteotomies. It has satisfactorily restored preinjury occlusal relationships in six patients, without the need for dental splints. In no instance has hardware extrusion occurred after fixation.

Sagittal fractures of the palate: A new method of treatment

A new technique is described for stabilizing complex vertical fractures of the maxilla. Advantageous use of the comminuted fracture pattern of the maxillary buttresses allows the maxilla to be divi...