Intra-articular Displacement Research Articles

A study of Kapandji intrafocal pinning for the treatment of unstable extra articular distal radius fractures

Intrafocal pinning of distal radius fracture is indicated in unstable distal radius fractures without significant intra-articular displacement. It is a simple and effective, minimally invasive method of fixation for achievement of alignment and stability of unstable fractures. The study was conducted between November 2013 and October 2016. Patients attending the emergency and outpatient departments with history of trauma followed by pain and swelling of wrist, were evaluated clinically & radiologically. Patients with distal radius fracture who met the criteria were enrolled in the study. The operation was performed either under regional anaesthesia or intra venous anaesthesia. Reduction was carried out under image intensifier guidance and intrafocal pinning was undertaken with 2 Kirschner wires as described by Kapandji. Above elbow slab was applied for 3 weeks. Kirschner wires were removed at 6th week. Follow ups were done with radiological and functional evaluation on 1st week, 3rd week, 6th week, 12th week and 6 month. Of the 30 cases enrolled in our study, the age ranged from 40 to 72 years and the mean age of the patients was 54.77 years. The female/male ratio was 5:1 and the majority (83%) of patient sustained injury due to trivial trauma. All fractures united by 6 weeks. In the final follow up at 6th month, assessment of range of motion showed almost full range of motion. Functional evaluation was carried out with Gartland & Werleys Demerit point system (modified by Sarmiento et al). According to the score, 9 patients had excellent, 19 had well and 2 had fair results. None of the patient had poor results. Kapandji intrafocal pinning provides a stable fixation and good functional outcome in extraarticular distal radius fractures with few complications only.

A Rare Case of Intra-Articular Displacement of EndoButton Following Anterior Cruciate Ligament Reconstruction

The EndoButton is a commonly used device for femoral fixation of anterior cruciate ligament grafts. Complications from its usage remain rare. Incorrect femoral tunnel placement may increase the risk of intra-articular displacement of the EndoButton. We present a case of anterior femoral tunnel placement resulting in intra-articular displacement of the EndoButton after failure. A 24-year-old man presented to us after failure of anterior cruciate ligament reconstruction performed 3 years prior. Radiographs revealed an intra-articular displacement of the EndoButton. Intraoperatively, it was noted that the femoral tunnel exit was within the suprapatellar pouch, with the displaced EndoButton lodged between the posterior aspect of the lateral tibial plateau and the capsule. Intra-articular displacement of the EndoButton is a rare complication and has only been reported twice in the literature. Anterior placement of the femoral tunnel may predispose patients to this complication and it is recommended to check the EndoButton position intraoperatively to avoid such a complication, especially for the unexperienced surgeon.

Finite Element Analysis of Sacroiliac Joint Fixation under Compression Loads.

Sacroiliac joint (SIJ) is a known chronic pain-generator. The last resort of treatment is the arthrodesis. Different implants allow fixation of the joint, but to date there is no tool to analyze their influence on the SIJ biomechanics under physiological loads. The objective was to develop a computational model to biomechanically analyze different parameters of the stable SIJ fixation instrumentation. A comprehensive finite element model (FEM) of the pelvis was built with detailed SIJ representation. Bone and sacroiliac joint ligament material properties were calibrated against experimentally acquired load-displacement data of the SIJ. Model evaluation was performed with experimental load-displacement measurements of instrumented cadaveric SIJ. Then six fixation scenarios with one or two implants on one side with two different trajectories (proximal, distal) were simulated and assessed with the FEM under vertical compression loads. The simulated S1 endplate displacement reduction achieved with the fixation devices was within 3% of the experimentally measured data. Under compression loads, the uninstrumented sacrum exhibited mainly a rotation motion (nutation) of 1.38° and 2.80° respectively at 600 N and 1000 N, with a combined relative translation (0.3 mm). The instrumentation with one screw reduced the local displacement within the SIJ by up to 62.5% for the proximal trajectory vs. 15.6% for the distal trajectory. Adding a second implant had no significant additional effect. A comprehensive finite element model was developed to assess the biomechanics of SIJ fixation. SIJ devices enable to reduce the motion, mainly rotational, between the sacrum and ilium. Positioning the implant farther from the SIJ instantaneous rotation center was an important factor to reduce the intra-articular displacement. Knowledge provided by this biomechanical study enables improvement of SIJ fixation through optimal implant trajectory.

Clinical Faceoff: Controversies in the Management of Distal Radius Fractures.

D istal radius fractures are among the most common fractures of the upper extremity, and account for approximately 20% of all fractures seen within the emergency room. The distal radius comprises of three articular surfaces, namely the scaphoid facet, lunate facet, and sigmoid notch. Treatment goals are centered on restoration of articular congruity, and where appropriate, early ROM with minimal complications to permit early functional recovery. Numerous fracture classifications exist which aim to define the fracture and guide treatment [1] (Fig. 1). Despite the frequency of these injuries, controversy exists about how best to manage them. The American Academy of Orthopaedic Surgeons practice guidelines on treatment of distal radius fractures recommend operative fixation for radial shortening greater than 3 mm, dorsal tilt greater than 10 from neutral, or intraarticular displacement greater than 2 mm [4]. To explore the controversies that are abound in terms of how to manage these injuries, it is my distinct pleasure to introduce two experts in the field of hand surgery. Ghazi Rayan MD is a Professor of Orthopaedic Surgery at University Oklahoma College of Medicine. Martin Boyer MD is the Jerome T. Loeb Professor of Orthopaedic Surgery at Washington University Medical School, St. Louis.

Osteosynthesis of Distal Humeral Metaepiphyseal Fractures Via Posterior Approach with Olecranon Preservation

Eighteen patients with distal humeral metaepiphyseal fractures were operated on during the period from 2010 to 2013. Mean age of patients made up 43.1±8.4 (22-72) years, term after injury - 4.6±1.9 (2-11) days. According to AO classification C1 fractures were diagnosed in 13, C2 - in 3, C3 - in 2 patients. In all patients distal humeral metaepiphyseal osteosynthesis with two plates placed at 90° to each other was performed. Surgical intervention was performed without olecranon osteotomy and triceps tendon was kept intact. In 12 (66.7%) cases longitudinal dissection of the triceps in its middle third was performed. Residual intraarticular displacement averaged 0.2±0.03 mm. Long term results were assessed in 10 patients at an average 12 months after operation. Mean score by subjective and objective scales made up 4.3±0.3 and 4.2±0.3 points, respectively. Main advantages of the applied osteosynthesis technique were preservation of forearm extensor muscles integrity; absence of additional fixatives in olecranon zone; absence of the necessity to perform additional intervention to remove fixatives from the olecranon.

Osteosynthesis of Distal Humeral Metaepiphyseal Fractures Via Posterior Approach with Olecranon Preservation

Eighteen patients with distal humeral metaepiphyseal fractures were operated on during the period from 2010 to 2013. Mean age of patients made up 43.1±8.4 (22-72) years, term after injury - 4.6±1.9 (2-11) days. According to AO classification C1 fractures were diagnosed in 13, C2 - in 3, C3 - in 2 patients. In all patients distal humeral metaepiphyseal osteosynthesis with two plates placed at 90° to each other was performed. Surgical intervention was performed without olecranon osteotomy and triceps tendon was kept intact. In 12 (66.7%) cases longitudinal dissection of the triceps in its middle third was performed. Residual intraarticular displacement averaged 0.2±0.03 mm. Long term results were assessed in 10 patients at an average 12 months after operation. Mean score by subjective and objective scales made up 4.3±0.3 and 4.2±0.3 points, respectively. Main advantages of the applied osteosynthesis technique were preservation of forearm extensor muscles integrity; absence of additional fixatives in olecranon zone; absence of the necessity to perform additional intervention to remove fixatives from the olecranon.

Traitement prothétique des fractures du radius distal irréparables du sujet âgé autonome. Résultats préliminaires, étude prospective de 10 cas

Introduction The purpose of this paper was to define irreparable acute DRF in autonomous elderly patients and to review the current results of a prospective study using a resurfacing implant to treat these injuries. Methods A total of 10 wrists in 10 women were prospectively included. The average age was 75 years (range 64–87). General health status was normal in 3 patients and there were co-morbidities in seven. However, all patients were autonomous at home. Functional needs were high in 3, intermediate in 7. All but one DRF were articular “C” type. Displacement was volar in 4 patients and dorsal in 6 patients. Circumferential comminution was present in all cases. The average intra-articular displacement severity score (Intra-DSS) was 11.5/12. Impaction and cartilage defect were present in all cases. All patients sustained total wrist arthroplasty through a single dorsal approach. An ulnar head resection was combined in 8/10 cases. Post-operative immobilization was 3 weeks followed by a splint for 3 weeks. Follow-up consisted of clinical and radiographic evaluation at 6 weeks, 2, 6, 12 months. A wrist clinical score was used as well as the Quick-Dash and PRWE. Results Reflex sympathetic dystrophy was present in 2 patients. In the 5 patients with more than 3 months of follow-up and no RSD, the average VAS pain was 1.6. Average ranges of active motion were: pronation 65°, supination 66°, wrist extension 28°, and flexion 21°. The average grip strength was 38% of the contralateral side. The average wrist score was 57 pts. Discussion Implant surgery at the acute stage for complex fractures in the elderly is an old validated concept for hip, shoulder and elbow. This concept recently emerged for DRF as well. Indeed, some DRF in the elderly are beyond any osteosynthesis fixation. Autonomous elderly patients are good candidates to prosthetic surgery. Our preliminary results confirm that there may be a room for prosthetic replacement of the distal radius at the acute stage in selected elderly patients. Further controlled prospective studies are necessary to validate this concept.

Traitement prothétique des fractures du radius distal irréparables du sujet âgé autonome. Résultats préliminaires, étude prospective de 10 cas

The purpose of this paper was to define irreparable acute DRF in autonomous elderly patients and to review the current results of a prospective study using a resurfacing implant to treat these injuries. A total of 10 wrists in 10 women were prospectively included. The average age was 75 years (range 64–87). General health status was normal in 3 patients and there were co-morbidities in seven. However, all patients were autonomous at home. Functional needs were high in 3, intermediate in 7. All but one DRF were articular o C O type. Displacement was volar in 4 patients and dorsal in 6 patients. Circumferential comminution was present in all cases. The average intra-articular displacement severity score (Intra-DSS) was 11,5–12. Impaction and cartilage defect were present in all cases. All patients sustained total wrist arthroplasty through a single dorsal approach. An ulnar head resection was combined in 8–10 cases. Postoperative immobilization was 3 weeks followed by a splint for 3 weeks. Follow-up consisted of clinical and radiographic evaluation at 6 weeks, 2, 6, 12 months. A wrist clinical score was used as well as the Quick DASH and PRWE. Reflex sympathetic dystrophy was present in 2 patients. In the 5 patients with more than 3 months of follow-up and no RSD, the average VAS pain was 1,6. Average ranges of active motion were – pronation 65°, supination 66°, wrist extension 28°, flexion 21°. The average grip strength was 38% of the contralateral side. The average wrist score was 57 pts. Implant surgery at the acute stage for complex fractures in the elderly is an old validated concept for hip, shoulder and elbow. This concept recently emerged for DRF as well. Indeed some DRF in the elderly are beyond any osteosynthesis fixation. Autonomous elderly patients are good candidates to prosthetic surgery. Our preliminary results confirm that there may be a room for prosthetic replacement of the distal radius at the acute stage in selected elderly patients. Further controlled prospective studies are necessary to validate this concept.

Radiographic Interpretation of Distal Radius Fractures: Visual Estimations versus Digital Measuring Techniques

Distal radius fractures are a common injury. In the emergency room, trainees regularly assess these fractures using visual estimation. Our hypothesis is that assessment of radiographic parameters has sufficient accuracy for rendering treatment consistent with formal measurements. This study compared visual measurements made by 25 orthopaedic residents and attending physicians to formal measurements made by a single fellowship trained musculoskeletal radiologist in a series of patients with distal radius fractures. A search was performed utilizing the ICD-9 code for distal radius fracture in all patients presenting to a single institution emergency department. Participants used visual estimation to rate 25 radiographs. Parameters estimated included radial inclination, radial height, volar tilt, and the presence of intra-articular displacement. Analysis using Lin concordance coefficients, Bland Altman plots, and the Kappa statistic evaluated the agreement between visual estimation and formal measurements. The proportion of raters whose estimates would have resulted in a course of treatment that conflicted with the formal reading quantified the potential impact of visual estimation on treatment. Concordance coefficients were poor for radial inclination (ρc = 0.13), radial height (ρc = 0.24), and volar tilt (ρc = 0.46). The Kappa statistic for intra-articular displacement was 0.4. Analysis performed according to level of training did not result in substantial improvements in these statistics. Treatment based on visual estimates conflicted with formal readings 34% of the time for radial inclination, 38% of the time for radial height, 27% of the time for volar tilt, and 31% of the time for intra-articular displacement. Visual estimation is not an adequate form of measurement for evaluation of patients with distal radius fractures. Physicians should be mindful of these results when developing treatment plans based solely upon visual estimation.

Intra-articular scapular fractures: Outcomes after internal fixation

BackgroundAlthough operative treatment may offer an appropriate management option for displaced glenoid fractures, there is sparse research assessing post-operative functional outcomes. This study assessed functional outcomes of patients after undergoing open reduction and internal fixation of displaced glenoid fractures. MethodsFifteen patients were treated with open reduction and internal fixation for displaced intra-articular fractures between 2005 and 2010. The indication for operative fixation was intra-articular displacement >4 mm. Post-operative functional outcomes were assessed via retrospective chart review. Evaluation included review of pre-operative imaging for fracture type, review of post-operative plain radiographs for fracture healing, Disabilities of the Arm Shoulder and Hand (DASH) and American Shoulder and Elbow Surgeon Assessment (ASES) scores at last follow-up. ResultsAt a mean follow-up of 49 months (24–87 months) all patients had radiographic healing. The mean DASH score was 10 (range 0.83–29.17). Mean ASES score was 90 (range 41.7–100). No patients had evidence of hardware failure or infection. ConclusionsOpen reduction and internal fixation of displaced intra-articular glenoid fractures results in stable fixation and is associated with good functional outcome. Level of evidenceLevel IV. Case series.

Intra-articular distal radius fractures involving the distal radioulnar joint (DRUJ): three dimensional computed tomography-based classification

PurposeThe purpose of this study was to analyze fracture patterns and the magnitude of displacement in the distal radioulnar joint (DRUJ), by three-dimensional (3D) computed tomography (CT), for distal radius fractures with intra-articular displacement of the radiocarpal joint. MethodsWe reconstructed 3D images for 72 consecutive patients with displaced intra-articular distal radius fracture on the basis of fine-cut axial CT data. The fracture patterns involving the DRUJ were classified on the basis of the location and direction of fracture lines, and the extent of fracture comminution. We measured the maximum spatial distance of the gap and the step between the fragments in each 3D image, and the magnitudes of displacement between the groups were compared by analysis of variance followed by post-hoc analysis by use of Tukey’s test. ResultsSixty wrists had a fracture involving the DRUJ. We classified the 60 wrists into 3 types of fracture pattern. Type 1 was a transverse fracture with minimum displacement. Type 2, in which fracture lines extended into the distal margin of the sigmoid notch, was the most common longitudinal fracture. Type 3 was a fracture with multiple fragments. The step and gap in Type 3 was significantly larger than that in the other types. ConclusionsEighty-three percent of intra-articular distal radius fractures had DRUJ involvement, and 28% of the wrists had multiple fragments. For Type 3 fractures with dorsal or proximal comminution displacement was significantly larger than for simple Type 1 and 2 fractures. Surgical intervention for the DRUJ fragment may be beneficial when there is remarkable intra-articular displacement.

Management of high-energy bicondylar tibial plateau fractures by minimal internal fixation and the ilizarov frame: the knee function

Management of comminuted bicondylar tibial plateau fractures remains a challenge to orthopedic surgeons. Studies of long-term outcomes of treatment of the tibial plateau have included a mixture of fracture types, including low-energy split and split-depressed fractures. Thus, the middle- to long-term results of management of high-energy fractures are still lacking. The aim of this study was to evaluate the knee function and development of arthrosis after a minimum of 3 years in high-energy tibial plateau fractures treated by the Ilizarov external fixator. This is a retrospective study performed at an academically supervised level III, trauma center, in which percutaneous and/or limited open internal fixation and an Ilizarov frame were applied for displaced bicondylar high-energy tibial plateau fractures (Schatzker types V and VI, and Orthopedic Trauma Association types C1, C2, and C3). There were 55 patients in this study and they were followed for a minimum of 3 years. Completion of the Iowa knee score, and the Short Form-36 (SF-36) General Health Survey, was a must. After healing, none of the studied patients needed a secondary reconstructive procedure. The knee motion ranged between 15° of extension and 155° of flexion, with an average of 88 % of the total arc of the contralateral knee. The average Iowa knee score was 94 points (range, 65 to 100 points), at the final follow-up visit. Twenty-eight patients rated their outcome as excellent; 17, as good; and 10, as fair. All the studied patients returned to their previous original works. Thirty-five of them were performing strenuous labor. At the final follow-up visit, there were arthrosis grade 1 in the X-rays of 25 patient, grade 2 in 10, grade 3 in 2, and no evidence of arthrosis was found in 18 X-rays (grade 0). Compared with the radiographic appearance 3 years after surgery, there was no evidence of progression of arthrosis in 42 patients, while arthrosis progressed for one grade in 13 patients. The SF-36 subscale scores were similar to those of age-matched controls. Patients suffering from high-energy bicondylar tibial plateau fractures could be safely treated by minimal internal fixation and Ilizarov external fixation. This procedure has good prognosis for satisfactory knee function for up to 16 years of follow-up. The intra-articular displacement should be reduced properly, and only very minimal displacements are accepted. This leads to a better knee function and low arthrosis rate.

Minimally invasive percutaneous plate osteosynthesis for distal tibial fractures

Introduction Minimally invasive plate osteosynthesis (MIPO) is a relatively new surgical technique for the management of distal tibial fractures. Conventional open technique is unfavourable to the fracture biology because of excessive soft tissue stripping and can be associated with significant devastating complications. Objective The aim of this study was to determine the effectiveness of the MIPO technique for distal tibial fractures Methods Between 2004 and 2010 twenty-nine consecutive patients had distal tibial fractures treated with MIPO by the senior author. An anteromedial plate (Synthes®) was used for all patients. Case notes and radiographs of all patients were reviewed and data, including demographics, fracture classification, complications and fracture healing were recorded on a database. Results 29 Patients with a median age of 46 (range 25–82) were reviewed. 12 were female and 17 were male. Mean follow-up was 6.24 months. Using the AO classification there were 16 type A, 1 type B and 12 were type C fractures. Ruedi-Allgower classification showed 6 Group I fractures, 5 Group II fractures and 2 Group III fractures. There were no open fractures. 5 patients had temporary external fixation prior to MIPO. 28 patients had associated fibular fractures of which 6 required open reduction and internal fixation (through a separate surgical incision). There were no postoperative wound complications. No malunion or intraarticular displacement was noted radiographically. Two patients had delayed union but went on to heal without secondary procedures. There was 1 case of non-union. Two patients subsequently had their plates removed due to prominence of the metal work. Conclusion We conclude that the MIPO technique is safe and effective treatment for the management of distal tibial fractures. Complications associated with MIPO are infrequent and manageable.

Fracture Dislocation of the Glenoid Fossa With Open Physis: A Case Report

Scapular fractures are uncommon injuries that account for 1% of all fractures. Ten percent of these lesions involve the glenoid fossa and intraarticular displacement is rare, not exceeding 10% of the cases. The classification of intraarticular glenoid fractures was described by Ideberg on the basis of his findings in 100 patients with this type of injury. His classification, however, does not include a dislocation of the glenoid fossa without displacement of the humeral head. We report the case of a fracture dislocation of the glenoid fossa without displacement of the humeral head in a patient with open physis. Our surgical approach and results after 6 years of follow-up. Six years postoperatively the patient has minimal occasional discomfort and a full range of motion and strength, even in external rotation. Shoulder stability is also normal. Her Constant score is 97. The fracture is actually healed clinically and radiographically with no evidence of post traumatic articular degenerative disease or avascular changes. The fracture/dislocation of the glenoid fossa is an uncommon injury that can be effectively treated by open reduction and internal fixation. A posterior surgical approach was useful to achieve anatomic reduction and strong fixation in this case presentation.

Treatment of Distal Radius Fractures

The clinical practice guideline is based on a systematic review of published studies on the treatment of distal radius fractures in adults. None of the 29 recommendations made by the work group was graded as strong; most are graded as inconclusive or consensus; seven are graded as weak. The remaining five moderate-strength recommendations include surgical fixation, rather than cast fixation, for fractures with postreduction radial shortening >3 mm, dorsal tilt >10 degrees , or intra-articular displacement or step-off >2 mm; use of rigid immobilization rather than removable splints for nonsurgical treatment; making a postreduction true lateral radiograph of the carpus to assess dorsal radial ulnar joint alignment; beginning early wrist motion following stable fixation; and recommending adjuvant treatment with vitamin C to prevent disproportionate pain.

Displacement/Screw Cutout After Open Reduction and Locked Plate Fixation of Humeral Fractures

Fixation of proximal humeral fractures is challenging. Locking plate technology offers mechanical advantages for treating unstable fractures in weak bone. In this study, we assessed the radiographic and clinical results of a single surgeon's experience treating proximal humeral fractures with a locked proximal humeral plate. Fifty-three adult patients with a displaced proximal humeral fracture were treated with a proximal humeral locking plate over a forty-five-month period. A standard postoperative rehabilitation regimen was followed. Radiographs were made at two weeks, six weeks, three months, six months, and one year and were examined for fracture alignment, fracture displacement, hardware position, and healing. Postoperative outcomes were collected with questionnaires. Fifty-two (98%) of the fifty-three fractures healed by six months. Nineteen patients (36%) had radiographic signs of a complication, including screw cutout with intra-articular displacement in twelve (23%), substantial (>10 degrees ) varus displacement in thirteen (25%), and osteonecrosis in two (4%). These radiographic signs of a complication occurred in twelve (57%) of twenty-one patients older than sixty years of age and in seven (22%) of thirty-two patients under sixty years of age (p = 0.0015). Screw cutout occurred in nine (43%) of the twenty-one patients older than sixty years. Patients with a complication had worse functional outcomes as measured with the Short Musculoskeletal Function Assessment (p < 0.05) and the Quick Disabilities of the Arm, Shoulder and Hand (p < 0.001) questionnaires. We were unable to demonstrate a relationship between fracture type and complications. Revision surgery was performed in seven (13%) of the fifty-three patients. There were no cases of infection, nerve injury, or hardware failure. The use of locking plates in the surgical treatment of proximal humeral fractures is associated with an unexpectedly high rate of screw cutout and revision surgery, especially in patients older than sixty years who have a three or four-part fracture. The indications for open reduction and internal fixation in these patients require continued analysis.

Beschwerden im Verlauf nach konservativ behandelten distalen Radiusfrakturen - Prädiktoren aus der initialen Röntgenaufnahme

Radius fractures are frequent in adults, and the long-term results of conservative treatment remain disappointing. This study examines predictors for the clinical outcome in the initial radiograph. This will help to identify patients who will benefit from surgical treatment. A cohort study including a standardized telephone interview (Cooney score) was used to identify all conservatively treated patients with a distal radius fracture over a five-year period. The additional selection criteria were: over 15 years old, initial X-ray available, patient reachable by phone for the follow-up interview. The following measurements were taken from the initial radiograph: radius-base angle, radial shortening, radiopalmar angle and intraarticular displacement. Correlations and a simple test to predict negative outcome were computed. Of the initially identified 2211 patients with distal radius fracture, 179 also fulfilled the other criteria. The patients were 56.2 years old on average (standard deviation SD = +/- 22.45 years) and 72 % were female. 60 % of the fractures were on the right side. The average follow-up was 4.3 years (SD +/- 1.66). The Cooney score results averaged 85 points (with 100 being the optimal and maximum score), indicating good or very good functional results in the long term follow-up for 61 % of patients. However, 31 % received a rating of fair or poor and therefore had an unfavorable outcome. With respect to the correlations, age and shortening of the radius (but not gender) had a significant influence on the functional result. Using an age of 75 years or above and a radial shortening of at least 4 mm to predict an unfavorable outcome, the sensitivity is only 16 %, but the positive predictive value is 73 % and the specificity is 96 %. In the analysis of the initial radiographs after distal radius fracture, age and radial shortening primarily correlate with functional results after four years after conservative treatment. Using the values age > or = 75 and radial shortening > or = 4 mm, it is possible to predict an unfavorable functional outcome with a positive predictive value of 73 %. This could aid in the indication of operative treatment.

Arthroscopic-Assisted Reduction and Percutaneous External Fixation of Lateral Condyle Fractures of the Humerus

Lateral condyle fractures in children are the second most common fracture about the elbow. Anatomic reduction of intra-articular displacement is considered a priority. Most experts agree that the treatment of choice of mildly displaced (>2 mm) lateral condyle fractures is open reduction–internal fixation or intraoperative arthrography followed by closed reduction and percutaneous pinning. In this report we described an alternative approach using closed arthroscopic-assisted reduction. Arthroscopy was performed by use of a 30°, 4.5-mm arthroscope through a proximal anteromedial portal with no pump, and a proximal anterolateral portal was created for instrumentation. The fracture line was easily visualized after blood, fibrin, and loose articular debris were irrigated from the joint. The fracture was manually manipulated and reduced by use of a periosteal elevator placed through the proximal anterolateral portal into the fracture and via rotation until there was no step in the articular cartilage. Two lateral Kirschner wires were placed percutaneously, which result in firm fixation of the fracture. We think that the advantages of arthroscopy are further superior to intraoperative arthrography because arthroscopy not only allows for better anatomic reduction and visualization with minimal surgical trauma and less radiation time but also provides a valid diagnostic and treatment alternative for associated injuries.

しょう骨関節内骨折の観血的治療経験

Operative therapy was performed on 11 intra-articular fractures of the calcaneus by means of extended lateral approach with calcaneal plate. Preoperatively, all cases were evaluated by Sanders classification. Clinical evaluation was performed by Maxfield score, and nine out of all 11 cases achieved excellent or good results.Pre-and postoperative changes in radiographic findings were studied. Improvement of the Bhler angle was not necessarily reflected in the clinical results, but on the other hand, improvement of the width index and intra-articular displacement was reflected. This method is considered to be an effective treatment for intra-articular calcaneal fractures.

Das LISS-System als neues minimal-invasives winkelstabiles Verfahren zur Versorgung periprothetischer Femurfrakturen

The Less Invasive Stabilization System (LISS) is a minimally invasive technique indicated for fixation of periprosthetic fractures. This new system allows percutaneous placement of cortical-shaft screws and fixation of the fracture with fixed-angle locked screws with minimal surgical exposure of the mostly osteoporotic bone and without disturbance of the existing total joint replacement. Immediate range-of-motion exercises are begun postoperatively. A retrospective clinical review of 5 patients (2 total hip arthroplasties, 3 total knee arthroplasties) was performed to describe indications, surgical technique, intra- and postoperative complications and patient follow-up. Indications are periprosthetic distal femur fractures, per- and supracondylar fractures. Contraindications are none, except existing medical comorbidities. Extraarticular fractures were treated via stab incisions over the lateral femoral condyle. Fractures with intraarticular displacement were fixed via an anterolateral parapatellar approach to the knee joint. After anatomic reduction of femoral condyles, articular fragments are fixed with Kirschner wires, followed by closed reduction aligning the articular fragments controlling length, axis and rotation. The LISS is introduced proximally under the M. vastus lateralis along the femur. It is fixed with self-drilling cortical shaft screws, locked fixed-angle screws both proximally and distally. Range-of-motion exercises are begun on the second day postoperatively. Time to full weight bearing averaged 6-8 weeks depending on clinical and radiological findings. Benefits of the LISS technique include the minimally invasive approach with increased primary stability using monocortical fixings thus eliminating the need for spongiosaplasty and blood transfusion. Disadvantages of the percutaneous placement of the LISS include malplacement on the femur, proximal screw pull-out and postoperative rotational and axial malalignment.