Prominent Hardware Research Articles

Ultrasound Imaging Improves Identification of Prominent Hardware in the Surgical Treatment of Distal Radius Fractures: A Cadaveric and Prospective Clinical Study.

Background Volarly applied locking plates are one of several current treatment options for displaced fractures of the distal radius. Presently, surgeons use intraoperative depth gauges and fluoroscopy to select and confirm proper screw length. The contour of the dorsal cortex beneath the extensor compartments along with fracture comminution may limit the accuracy of screw length selection. Question/Purpose To evaluate the accuracy of ultrasound (US) and fluoroscopy in the detection of dorsally prominent screws placed during volar plating of experimentally created distal radius fractures and extend this prospectively into the clinical setting. Patients and Methods Distal radius fractures were experimentally induced in fresh cadaveric arms. The fractures were then internally fixated with volar locking plates utilizing fluoroscopic imaging. US imaging of the dorsal surface of the radius was then performed followed by dorsal dissection and direct caliper measurements to quantitate screw tips as recessed, flush, or protruding from the dorsal cortex. A small, prospective clinical study was also conducted to validate the clinical usefulness of using US to provide additional information regarding screw tip prominence. Results Our study demonstrated that US was able to detect dorsally prominent screw tips not visible on fluoroscopy. Cadaveric dissection showed a higher statistical correlation between US imaging and actual prominence than between fluoroscopy and actual prominence. Conclusions US examination after volar plate fixation of comminuted distal radius fractures may detect dorsal screw tip prominence when screw lengths are selected to engage the dorsal cortex. Level of Evidence IV.

Bilateral vascularized rib grafts to promote spinopelvic fixation in patients with sacral agenesis and spinopelvic dissociation: a new surgical technique

Background ContextSacral agenesis is a rare congenital disorder that may have spinopelvic instability due to sacroiliac joint malformation. Surgical indication in patients with sacral agenesis is to improve their sitting balance and protect the visceral organs. Achieving solid arthrodesis across this congenital malformation is challenging and prone to non-union. PurposeThe purpose of this study was to describe a novel surgical technique with vascularized ribs for management of sacral agenesis and complex spinopelvic dissociation. Study DesignRetrospective study. Patient SampleSix patients with sacral agenesis were reviewed and followed for a mean of 8.5 years after spinopelvic fusion augmented with vascularized rib graft spanning the lumbo-pelvic junction. Outcome MeasuresThe primary outcome measure was the presence or absence of a stable spinopelvic junction and fusion across the spine-vascular rib grafts-pelvis interface. The secondary outcome measures were maintenance of pelvic obliquity, lumbosacral kyphosis, and overall sagittal balance. MethodsThe surgical procedure consisted of two-stage surgeries performed 6–12 weeks apart. The first stage consisted of spinal instrumentation and correction of the deformity via a posterior approach and impaction of one of the vascularized ribs from the spine to the iliac crest. The second stage consisted of an anterior thoraco-lumbar approach for spinal fusion and the second vascularized rib spanning the spine to the iliac crest. ResultsAll six patients eventually achieved a solid spinal and spinopelvic fusion. All vascularized ribs increased in diameter over time. A high complication rate consisted mainly of spinal infections and prominent hardware requiring revision surgeries (a total of seven procedures in four patients). Two patients had decreased mobility secondary to spinopelvic surgery at last follow-up. ConclusionsSpinopelvic fusion can be successfully achieved with this novel surgical technique using vascularized rib grafts. This technique allows for biological long-term maintenance of the sagittal deformity correction. Fusion across the lumbosacral junction in patients with sacral agenesis may place them at risk of losing the ability to mobilize independently. Recent lower profile implants have prevented implant-related complications.

The Fibula Nail for the Management of Unstable Ankle Fractures

Surgery for unstable ankle fractures comes with risks of infection and painful, prominent hardware not infrequently requiring further surgery to remove plates and screws. The fibula nail offers the opportunity for lower profile hardware and minimally invasive surgical techniques. The technique for using the fibula nail is illustrated in detail; in addition, recent literature pertaining to the fibula nail is reviewed.

CORR Insights(®): Factors Associated with Reoperation after Fixation of Displaced Olecranon Fractures.

Where Are We Now? Olecranon fractures occur commonly, and account for approximately 10% of upper extremity fractures in adults [10, 13]. Most displaced olecranon fractures are treated with open reduction and internal fixation (ORIF). Tension band wiring remains the most commonly used method of internal fixation, although other methods of fixation are being used such as low-profile plating, intramedullary screw fixation, and locked intramedullary nailing [1, 2, 4, 7, 9]. But reoperations complicate the care of many (and in some series, most) patients treated with ORIF for olecranon fractures [3-5, 7, 12]. The factors resulting in these reoperations are not fully understood, and could be related to the fractures, the patients, or the implants used. Several reports [7, 9-11] identified different factors associated with reoperations including prominent hardware, arthrosis, infection, ulnar neuropathy, and older age. Efforts to reduce the frequency of these reoperations have focused on techniques to eliminate or reduce hardware prominence and wire migration such as the use of low profile plates and intramedullary implants [1, 2, 4-6, 8]; these efforts have met with only mixed success. Where Do We Need To Go? In our attempt to reduce reoperation rates after ORIF of olecranon fractures, we need to investigate all of the different factors associated with reoperation. In the current study, Claessen and colleagues confirmed the higher than usual rate of reoperation. The authors also confirmed that the type of implant did not affect the rate of reoperation. Wire or implant migration was the cause of reoperation in only 3% of the patients. After careful analysis of all factors studied, Claessen and colleagues concluded that personal factors were more influential in affecting the decision to reoperate than the fracture-related or implant-related factors. They also found that women and younger patients were more inclined to have a reoperation compared to men and older patients. The importance of this study lies in its ability to shed light on the personal factors as being more significant than the technical factors. That is a game-changer in our understanding of this important issue. This study also points to the importance of counseling patients—especially women and younger patients who have an increased likelihood of needing a second procedure for implant removal. In order to meet the challenge of reducing the rate of reoperation after ORIF of olecranon fractures, we still need followup studies that can investigate multiple elements of this very important topic. We need to investigate the use of other internal fixation devices that do not cause prominence, as all hardware currently used for this procedure result in some prominence. The promising good results regarding the use of multidirectional locking intramedullary nails, which could decrease the implant prominence, is encouraging [1, 2, 4]. Gehr and colleagues [4] demonstrated no implant removal after the use of a locked intramedullary nail in 73 patients at 1-year after surgery. But we need to scrutinize these implants carefully for clinical efficacy and cost-effectiveness. How Do We Get There? Although quite a few studies have evaluated patient- and fracture-related factors associated with reoperations after olecranon ORIF [3, 5, 8, 10, 12], we still need more papers, and more-focused analyses on this topic. Specifically, we need to further understand why younger patients and women would undergo more reoperations compared to other patients. Perhaps some other studies such as national registries or database studies may shed some light on those confounding variables. Sifting through all the variables in the decision making process may be challenging since the decision to use a certain type of hardware depends mainly on the fracture and the surgeon's comfort with the use of certain method of fixation. That being so, we should strive to better understand the various factors that influence reoperations after olecranon ORIF. By doing so, we can develop certain precautions or plans that could contribute to reducing the rate of reoperation in these types of injuries.

A survey of current practices and preferences for internal fixation of displaced olecranon fractures.

Olecranon fractures represent 10% of upper extremity fractures. There is a growing body of literature to support the use of plate fixation for displaced olecranon fractures. The purpose of this survey was to gauge Canadian surgeons' practices and preferences for internal fixation methods for displaced olecranon fractures. Using an online survey tool, we administered a cross-sectional survey to examine current practice for fixation of displaced olecranon fractures. We received 256 completed surveys for a response rate of 31% (95% confidence interval [CI] 30.5-37.5%). The preferred treatment was tension band wiring (78.5%, 95% CI 73-83%) for simple displaced olecranon fractures (Mayo IIA) and plating (81%, 95% CI 75.5-85%) for displaced comminuted olecranon fractures (Mayo IIB). Fracture morphology with a mean impact of 3.31 (95% CI 3.17-3.45) and comminution with a mean impact of 3.34 (95% CI 3.21-3.46) were the 2 factors influencing surgeons' choice of fixation method the most. The major deterrent to using tension band wiring for displaced comminuted fractures (Mayo IIB) was increased stability obtained with other methods described by 75% (95% CI 69-80%) of respondents. The major deterrent for using plating constructs for simple displaced fractures (Mayo IIA) was better outcomes with other methods. Hardware prominence was the most commonly perceived complication using either method of fixation: 77% (95% CI 71.4-81.7%) and 76.2% (95% CI 70.6-81.0%) for tension band wiring and plating, respectively. Divergence exists with current literature and surgeon preference for fixation of displaced olecranon fractures.

Distal interphalangeal joint arthrodesis with Herbert screw

Fifteen patients underwent arthrodesis of finger distal interphalangeal joint (DIP) and/or thumb interphalangeal joint (IP). Only Hebert screw intramedullary compression fixation was used. There was one faulty proximal thread placement with some pain, but the patient refused further surgery. Full union was achieved in 14 of the cases, with prominent hardware in one and intolerance to cold in two.

Clinical Comparison of Minifragment Plates Versus Conventional Semitubular Plates for Fixation of Distal Fibula Fractures.

Although operative stabilization of unstable distal fibula fractures is frequently performed and discussed, the ideal implant and technique for these injuries is still debated. The purpose of this study was to determine if minifragment plating of distal fibula fractures would clinically provide equivalent fixation and cost and minimize hardware prominence when compared with standard one-third tubular plating. A retrospective review was conducted on 44 patients who had undergone operative stabilization of a displaced fibula fracture. Inclusion required fibula fixation with either a traditional one-third semitubular plate or a 2.7-mm minifragment plate. Retrospective review of the patient demographics, injury and surgical variables, and radiographs was completed by two surgeons not involved with the patients' original care. The minifragment group demonstrated equivalency in maintenance of fracture reduction relative to standard tubular plating. Both groups were able to maintain the talocrural angle with less than 1° of change from initial postoperative to final postoperative radiographs. No significant differences were seen in postoperative hardware irritation between groups. Use of a minifragment plating system for displaced fibula fractures appears to be safe but comes with the significant potential added cost of the technology. Interestingly, no significant differences were seen in implant-related irritation or implant removal, but further investigation with a larger study population would help better determine these outcomes.

Comparative study of treatment of fracture shaft femur by intramedullary interlocking nails through piriform fossa entry and tip of the greater trochanter entry approach

Background: Several techniques and tools are available for achieving fracture reduction during antegrade intramedullary nailing of femur fractures. Aims: To compare results of femoral shaft fracture treatment with nailing through the greater trochanter to nailing through the piriformis fossa (PF). Materials and Methods: The present pilot project was conducted in a time span of 1-year. The patients admitted with femoral diaphyseal fractures were alternately selected for antegrade nailing through PF group and greater trochanter entry (GTE group) approach. Total number of patient in each group was 15 (n = 15). Results: Complications of nailing: PE group - 6.7% infection, 20% malunion, 20% delayed union, 20% restriction of hip range of motion (ROM), 6.7% restriction of knee ROM, 13.3% limb length discrepancy, 13.3% hardware prominence. GTE group - 13.3% malunion, 13.3% delayed union, 33.3% Restriction of hip ROM, 6.7% restriction of knee ROM, 20% limb length discrepancy, 26.7% hardware prominence. Radiological union time in PE was 12-15 weeks in 5 patients, 16-19 weeks in 8 patients, 20-23 weeks in 1 and >24 weeks in 1 patient. Radiological union time in GTE was 12-15 weeks in 4 patients, 16-19 weeks in 9 patients, 20-23 weeks in 2 patients. Need for dynamization was 20% in the PE group and 13.3% in GTE group. Thoresen's scoring system showed no significant difference between the two groups. Conclusion: Femoral nailing through the greater trochanter with specifically designed nails and with attention to specific techniques for such insertion should be considered a rational alternative to femoral nailing through the PF with the benefit of reduced requirement for fluoroscopy and decreased operative time.

Outcome of Minimaly Invasive Plate Osteosynthesis (MIPO) Technique with Locking Compression Plate in Distal Tibial Fracture Management

Background: Distal tibial fractures including tibial pilon present a challenge as to their best method of management due to subcutaneous location of larger portion of tibia, paucity of soft tissue coverage and precarious blood supply of distal leg. MIPO (Minimal invasive plating osteosynthesis) has evolved as a newer concept to treat distal tibial fractures with minimal articular comminution and minimal soft tissue damage. It works on Biological fixation principle which assists physiological process of bone healing wisely with minimal operative intervention. Method: A prospective study for the management of distal tibial fractures by MIPO technique by using pre-contoured metaphyseal LCP (locking compression plate) was done, in 20 patients, between January 2012 and October 2013. Fractures were classified as per AO system and patients were followed and scored according to TEENY and WISS clinical scoring criteria. Result: Among 20 patients operated, there were 15 males and 5 females with a mean age of 38.95yrs (range from20-67yrs). 17 patients sustained extra-articular fractures (type A), 02 partial-articular fractures (type-B) and 01 total-articular fracture (type-C). High energy trauma (road traffic accident) predominated causing 13 fractures. Average trauma surgery interval was 12 days (02-22days). Patients were followed minimum for 6 months (range 06-18 months). Superficial wound infections were seen in 02 cases, surgical wound breakdown with implant exposure in 01 case and prominent hardware in 01 case. 17 patients (85%) had excellent/good outcome and 03 cases with complications had fair (02 cases) to poor (01 case) outcome. Conclusion: MIPO is an effective and safe technique for the management of distal tibial fractures without intra-articular comminution and minimum soft tissue damage. It preserves bone biology by maintaining balance between devascularisation and mechanical perfection. Further studies with longer follow-up and large sample size are warranted.

Neuromuscular scoliosis and pelvic fixation in 2015: Where do we stand?

Neuromuscular scoliosis is a challenging problem to treat in a heterogeneous patient population. When the decision is made for surgery the surgeon must select a technique employed to correct the curve and achieve the goals of surgery, namely a straight spine over a level pelvis. Pre-operatively the surgeon must ask if pelvic fixation is worth the extra complications and infection risk it introduces to an already compromised host. Since the advent of posterior spinal fusion the technology used for instrumentation has changed drastically. However, many of the common problems seen with the unit rod decades ago we are still dealing with today with pedicle screw technology. Screw cut out, pseudoarthrosis, non-union, prominent hardware, wound complications, and infection are all possible complications when extending a spinal fusion construct to the pelvis in a neuromuscular scoliosis patient. Additionally, placing pelvic fixation in a neuromuscular patient results in extra blood loss, greater surgical time, more extensive dissection with creation of a deep dead space, and an incision that extends close to the rectum in patients who are commonly incontinent. Balancing the risk of placing pelvic fixation when the benefit, some may argue, is limited in non-ambulating patients is difficult when the literature is so mottled. Despite frequent advancements in technology issues with neuromuscular scoliosis remain the same and in the next 10 years we must do what we can to make safe neuromuscular spine surgery a reality.

Current techniques for management of transverse displaced olecranon fractures

displaced transverse fractures of the olecranon are the most common fractures occurring in the elbow in adults that requires operative intervention. a literature search was performed on PubMed, Web of Science, Science Direct/Scopus, Google Scholar and Google using the keywords 'olecranon', 'fracture', 'internal fixation' and 'tension band wiring', with no limit for time or restrictions to language. thirty-one clinical articles were selected: 20 retrospective studies, 9 prospective cohort studies, and 2 randomized control trials. The CMS ranged from 18 to 66 (mean 41.68): overall, the quality of the studies was poor, and no moderate or good quality studies were found. The mean follow-up was 46.7 months (range 1 to 350 months). Several complications occurred after surgery: prominent hardware, skin breakdown, wire migration and infections occurred frequently. Removal of the hardware was required in 472 patients, usually after complaints, but also removal was routinely undertaken. tension band wiring is still the most widely applied method to operatively manage olecranon fractures, with the transcortical method of using K-wires the most satisfactory. Plate fixation is a good alternative as complications are minimal. Other techniques using absorbable sutures are less investigated, but are promising, especially in children.

Does Proximal Metatarsal Osteotomy Need Internal Fixation? A Case Report

Internal fixation for proximal metatarsal osteotomies is generally not required, since many authors state that weight bearing may promote fusion of the metatarsal segments in the correct position. This study reports a case of a 54 years old woman affected by metatarsalgia who was treated surgically with a proximal metatarsal osteotomy. Radiographies showed a non-union of the metatarsal osteotomy and MRI, bone scintigraphy and blood tests excluded infection. Surgical treatment consisted in debridement of fibrous non-union, autologous bone grafting and plate and screw fixation. The plate was removed 12 months after the surgery because of soft tissue irritation and hardware prominence. At the last follow-up, the patient was pain free and resumed her daily activities. In general, proximal osteotomies are safe procedures for the treatment of metatarsalgia. Although fixation is a controversial topic, it should be reconsidered in order to avoid nonunion.

Outcomes Following Removal of Instrumentation After Posterior Spinal Fusion

Although there is good evidence to support the removal of instrumentation for infection following posterior spine fusion, there are few studies that report outcomes following removal for late operative site pain. The purpose of this study was 3-fold: (1) to determine whether removal of instrumentation following posterior spinal fusion resolves preoperative pain, (2) to determine whether indolent infection not detected before removal of instrumentation is related to late operative site pain, and (3) to determine whether curve progression differs when spinal hardware is removed for infection versus late operative site pain. A retrospective study of consecutive patients aged 10 to 21 years, who underwent removal of instrumentation after posterior spinal fusion over a 10-year-period was conducted. Patient demographics, preoperative and postoperative imaging results, laboratory studies, and operative findings were reviewed. All patients had a minimum 2-year follow-up. Statistical analysis was performed using 2-sample t test, bivariate analysis, and multivariate logistic regression models. Seventy-five patients were included. Indications for removal of spinal instrumentation were pain (57%), infection (28%), hardware failure (8%), and prominent hardware (7%). The mean time from index procedure to hardware removal was 2.8 years. The average loss of curve correction following complete hardware removal was 23.1 degrees. Patients who underwent removal of hardware because of infection had bigger changes in their curves than those without infection (mean, 33.8 degrees vs. 18.8 degrees). Of the 43 patients with pain, only 40% reported relief of their symptoms following removal of hardware. Sixteen of the 43 patients were found to have indolent infection confirmed by positive intraoperative culture results. Patients should be cautioned that hardware removal after posterior spinal fusion may not provide complete pain relief. Furthermore, there is risk for curve progression following removal of instrumentation, particularly in the setting of infection. Back pain may be an indicator of infection, and intraoperative cultures should be taken at the time of implant removal. Level IV; retrospective case series.

Management of heterotopic ossification and restricted forearm rotation after tension band wiring for olecranon fracture.

A 32-year-old lady presented to our clinic with persistent painful restriction of her dominant forearm movements for three months after tension band wiring of olecranon. She had full elbow flexion and extension; however, her forearm rotations were restricted and painful. Investigations revealed prominent tips of the wire, eroding the radial tuberosity with heterotopic ossification between the radius and ulna. As there was no synostosis, the patient had implant exit. During surgery, before implant removal, examination under anaesthesia revealed a mechanical block of the rotation beyond 30° on pronation and supination from neutral. However, after the removal of implant, the mechanical block eased off and with gentle manipulation, full pronation and supination were achieved. At the final follow-up at 6 months, the patient had full pain-free forearm rotation with regression of heterotopic ossification. Our case report highlights the importance of intra-operative assessment of wire tips at full supination and pronation, and in patients with restricted forearm rotation, CT scan may be needed to assess the position of the hardware is essential as it can progress to synostosis. In cases with prominent hardware, removal of the implant may suffice if performed before the development of synostosis

A clinical evaluation of alternative fixation techniques for medial malleolus fractures

BackgroundMedial malleolus fractures have traditionally been managed using partially threaded screws and/or Kirschner wire fixation. Using these conventional techniques, a non-union rate of as high as 20% has been reported. In addition too many patients complaining of prominent hardware as a source of pain post-fixation. This study was designed to assess the outcomes of medial malleolar fixation using a headless compression screw in terms of union rate, the need for hardware removal, and pain over the hardware site. SettingSaint Louis University and Mercy Medical Center, Level 1 Trauma Centers, St. Louis, MO. MethodsAfter IRB approval, we used billing records to identify all patients with ankle fractures involving the medial malleolus. Medical records and radiographs were reviewed to identify patients with medial malleolar fractures treated with headless compression screw fixation. Our inclusion criteria included follow-up until full weight bearing and a healed fracture. Follow-up clinical records and radiographs were reviewed to determine union, complication rate and perception of pain over the site of medial malleolus fixation. Sixty-four ankles were fixed via headless compression screws and 44 had adequate follow-up for additional evaluation. ResultsSeven patients had isolated medial malleolar fractures, 23 patients had bimalleolar fractures, and 14 patients had trimalleolar fractures. One patient (2%) required hardware removal due to cellulitis. One patient (2%) had a delayed union, which healed without additional intervention. Ten patients (23%) reported mild discomfort to palpation over the medial malleolus. The median follow-up was 35 weeks (range: 12–208 weeks). There were no screw removals for painful hardware and no cases of non-union. ConclusionsHeadless compression screws provide effective compression of medial malleolus fractures and result in good clinical outcomes. The headless compression screw is a beneficial alternative to the conventional methods of medial malleolus fixation.

Unilateral versus bilateral iliac screws for spinopelvic fixation: are two screws better than one?

Long-segment spinal instrumentation ending at the sacrum places substantial biomechanical stress on sacral screws. Iliac (pelvic) screws relieve some of this stress by supplementing the caudal fixation. It remains an open question whether there is any clinically significant difference in sacropelvic fixation with bilateral versus unilateral iliac screws. The primary purpose of this study was to compare clinical and radiographic complications in the use of bilateral versus unilateral iliac screw fixation. The authors retrospectively reviewed 102 consecutive spinal fixation cases that extended to the pelvis at a single institution (University of California, San Francisco) in the period from 2005 to 2012 performed by the senior authors. Charts were reviewed for the following complications: reoperation, L5-S1 pseudarthrosis, sacral insufficiency fracture, hardware prominence, iliac screw loosening, and infection. The t-test, Pearson chi-square test, and Fisher exact test were used to determine statistical significance. The mean follow-up was 31 months. Thirty cases were excluded: 12 for inadequate follow-up, 15 for lack of L5-S1 interbody fusion, and 3 for preoperative osteomyelitis. The mean age among the 72 remaining cases was 62 years (range 39-79 years). Forty-six patients underwent unilateral and 26 bilateral iliac screw fixation. Forty-one percent (n = 19) of the unilateral cases and 50% (n = 13) of the bilateral cases were treated with reoperation (p = 0.48). In addition, 13% (n = 6) of the unilateral and 19% (n = 5) of the bilateral cases developed L5-S1 pseudarthrosis (p = 0.51). There were no sacral insufficiency fractures. Thirteen percent (n = 6) of the unilateral and 7.7% (n = 2) of the bilateral cases developed postoperative infection (p = 0.70). In a retrospective single-institution study, single versus dual pelvic screws led to comparable rates of reoperation, iliac screw removal, postoperative infection, pseudarthrosis, and sacral insufficiency fractures. For spinopelvic fixation, placing bilateral (vs unilateral) pelvic screws produced no added clinical benefit in most cases.

Decreasing the occurrence of intraoperative technical errors through periodic simple show, tell and learn method

BackgroundTechnical errors (TE) that occur during surgery for treating fractures are considered as being preventable by good preoperative planning and surgeon education. This prospective study evaluated a new instructional method for improving surgical outcomes that involved assessing surgeons’ own recent performances. MethodsPostoperative radiographs from two groups of patients were assessed during consecutive 4-month periods. 350 operations were included in the Early Group and 411 operations in the Late Group. All the TE that occurred during the first period were reviewed and discussed among the residents and the consultant surgeons who had performed those operations. The same procedure was followed 4 months later. The TE were classified as minor, moderate and major. ResultsThe two groups included the same 41 surgeons. The most common TE were: insufficient reduction, varus and valgus malalignment and prominent hardware. The total number of errors dropped significantly, from 52 (14.7%) during the first period to 26 (6.3%) during the second period (p=0.0003). The TE score severity dropped from 81 to 38, respectively (p=0.0001). The most affected regions were, the humerus (p<000.1), midshaft femur (p=0.007), proximal femur (p=0.004) and radius (p=0.008). Most of the gains were made in the moderate category (p=0.0001). The consultants performed statistically better than the residents in the first period (12% vs. 20%, p=0.036), but almost similar to the residents in the second period (5.3% vs. 9%, p=0.164). A TE index was calculated by dividing the accumulated sum by the number of operations and it dropped in both groups from 0.2 and 0.3 to 0.09 and 0.09, respectively. ConclusionIntraoperative TE can be significantly reduced by periodic performance evaluations in a seminar setting during which groups of surgeons can review the TE that they and their colleagues had made during recent orthopaedic surgical procedures.Level of Evidence: Level II.

Results of parallel plate fixation of comminuted intra-articular distal humeral fractures

This study investigated the results of parallel plate fixation of comminuted distal humeral fractures in a consecutive series of patients. Parallel plate fixation was used in 47 patients (30 women), mean age 60 years (range 18-98 years), with Arbeitsgemeinschaft für Osteosynthesefragen (AO) type C distal humeral fractures during 2007 to 2011. Medical records and radiographs were retrospectively assessed. Thirty-five patients completed Disabilities of Arm, Shoulder and Hand (DASH) outcome measure and the RAND Medical Outcomes Study 36-Item Short Form (SF-36) Health Survey. Twenty-seven patients underwent clinical examination, Mayo Elbow Performance Score (MEPS) rating, and radiography after 3.9 years (range, 1.6-7.9 years) of follow-up. The mean flexion arc was lower on the affected side vs the unaffected elbow (123° vs 140°, P = .03). The mean MEPS was 88; the result was excellent in 14, good in 8, fair in 3, and poor in 2 patients. DASH results indicated slight impairment of upper extremity function compared with the reference value (26 vs 10, P = .001). RAND SF-36 scores indicated normal quality of life compared with reference values from the Finnish population. Forty-four fractures united uneventfully. One case each of nonunion and malunion occurred. One olecranon osteotomy failed to unite. There were 3 cases of infection. Prominent hardware was a common late problem, and plates often required removal. The complication rate was 7 of 47 (15%); 4 of these patients (9%) required reoperation. The hardware removal rate was 13 of 47 (28%). Parallel plate fixation is an effective method to treat comminuted distal humeral fractures. Good elbow function can be restored in most cases with minor impairments that do not worsen quality of life.

Adult proximal humerus locking plate for fixation of paediatric subtrochanteric fractures

The current study was done to evaluate the outcome of paediatric subtrochanteric fractures managed by adult proximal humerus locking plate (PHLP). This prospective study included eight children (three females and five males) with femoral subtrochanteric fractures who met the inclusion criteria and underwent open reduction and internal fixation of the fracture with ipsilateral long adult PHLP. The mean age of the patients at the time of surgery was 13 years (range 10-16 years), and the mean follow-up was 32 months (range 18-48 months). Outcome at final follow-up was assessed using the Harris hip score. At the time of final follow-up, all fractures united at an average of 8.75 weeks (range 6-14 weeks). The average final Harris hip score was 80.25 (range 67-90). The only complain was prominent hardware in the proximal thigh, near the trochanteric ridge, which was present in two of our patients, and one of them opted for implant removal at 10 months. Internal fixation of paediatric subtrochanteric fractures using the proximal humeral locking plate of the ipsilateral side appears to be a good treatment option for the age group of 10-16 years, though comparative studies with a larger sample size are required to further support this observation.

Unusually prominent hardware in patellar fracture- a case report

Unusually prominent hardware in patellar fracture- a case report