Locking Plate Fixation Research Articles

Dorsal Cortical Screw Penetration in Volar Distal Radius Plating: Comparison of 3 Fluoroscopic Views.

The skyline or dorsal tangential view (DTV) and the carpal shoot-through (CST) have been developed to enhance the intraoperative examination of the distal radius's dorsal cortex during open reduction and internal fixation with volar plates. This study aimed to assess the lateral view (LV), DTV, and CST's effectiveness in showcasing screws that penetrate the dorsal cortex. Eighty patients, comprised of 42 women and 38 men with an average age of 53 years, underwent volar locking plate fixation for displaced distal radius fractures. The procedures incorporated the use of intraoperative LV, DTV, and CST views. Every view was meticulously examined to record the presence of screws that breached the dorsal cortex of the fractured region. Only 2 screws were found to protrude the dorsal cortex in the LV, demonstrating 100% specificity and 18.8% sensitivity. On the DTV, 9 screws were detected with the same specificity but increased sensitivity (75%). On the CST, all 12 screws were identified, making for 100% specificity and sensitivity. Of 501 distal screws, 13 (2.54%) penetrated the dorsal cortex, with an average length of 1.34 mm (range, 0.5-2 mm). These screws were subsequently replaced with shorter screws in 12 of 80 patients. The findings show that the CST and DTV are more precise and accurate than LV in identifying dorsal screw protrusion during distal radius volar plating. To minimize the likelihood of subsequent complications, it is highly advisable to implement these views in all procedures.

Outcome of Locking Plate Fixation Adjunctive to Intramedullary Rodding in Osteogenesis Imperfecta Patients.

An intramedullary rodding is the preferred fixation method in limb stabilization of OI patients. However, the intramedullary rod may not provide adequate fixation and rotational stability, especially in adolescents and adults. The incorporation of adjunctive plate fixation alongside intramedullary rodding has been introduced to enhance this stability, although its complications remain insufficiently understood. The goal of this study was to explore the outcomes of adjunctive plating in conjunction with intramedullary rodding for limb stabilization in OI patients, emphasizing the complications related to the plates during the healing phase and following plate removal. This retrospective study examined 74 limb segments from 45 patients with OI who underwent intramedullary rodding and adjunctive plating from 2008 to 2022. Criteria for inclusion comprised surgical treatment followed by a minimum of 2 years of follow-up or complication before that time point. The need for adjunctive plating arose from inadequate fixation, rotational instability, and persistent cortical gaps with intramedullary rodding alone. Medical records and follow-up radiographs were reviewed to assess the healing of the target lesion and any complications. The study encompassed 30 males and 15 females, ranging in age from 4 to 38 years, with 51 femoral and 23 tibial segments receiving treatment. Union was successfully achieved in 63 cases (85.3%), with an average union time of 14.4 months. Plates were subsequently removed in 62 cases after an average duration of 18.0 months. Before union, 11 revision surgeries were performed in 4 peri-implant fractures, 1 screw pull-out, and 6 failure of union. One sustained peri-implant fracture after the union. Following the removal of plates, complications included 10 refractures at screw sites, 3 progressive angulations at the previously targeted lesions, and 1 osteomyelitis. Kaplan-Meier analysis revealed that half of the refractures occurred within 1.8 years postplate removal. The overall complication showed borderline significance (P=0.056) among age groups. All the plate-related complications occurred at the diaphyseal, unicortical screws. Plate fixation, when used as an adjunct to intramedullary rodding, effectively stabilizes limbs in OI patients when intramedullary rods alone are inadequate. Nevertheless, given the significant risks associated with plate-related complications, adjunctive plating should be employed selectively only in instances where the union is unlikely to be achieved with intramedullary rodding alone. Level IV-case series.

Does endoscopic carpal tunnel release during distal radial fracture fixation improve outcomes? A randomized controlled trial.

This study investigated the functional outcome of prophylactic carpal tunnel release during distal radial fracture fixation. A total of 60 patients undergoing anterior locking plate fixation for a distal radial fracture were randomized into two groups: one having prophylactic endoscopic carpal tunnel release and the other serving as a control. Functional outcomes were assessed using the Patient-Reported Wrist Evaluation, Quick Disabilities of the Arm, Shoulder, and Hand, EuroQol 5-Dimension 5-Level questionnaire, Boston Carpal Tunnel Questionnaire, Pain Numerical Rating Scale, grip strength and finger-to-palm distance over a 12-month period. The study found no significant differences in overall functional outcomes or complications between the groups.Level of evidence: I.

Action observation intervention using three-dimensional movies improves the usability of hands with distal radius fractures in daily life-A nonrandomized controlled trial in women.

Prolonged immobilization of joints after distal radius fracture (DRF) causes cerebral disuse-dependent plasticity (DDP) and deterioration of upper extremity function. Action observation therapy (AOT) can improve DDP. This nonrandomized controlled trial (UMIN 000039973) tested the hypothesis that AOT improves hand-use difficulties during activities of daily living in patients with DRF. Right-handed women with volar locking plate fixation for DRF were divided into AOT and Non-AOT groups for a 12-week intervention. The primary outcome was difficulty in using the fractured hand, assessed with the Japanese version of the Patient-related Wrist Evaluation (PRWE). The secondary outcomes were range of motion (ROM) of the injured side and gap between measured ROM and patient-estimated ROM. The survey was administered immediately post operation and at postoperative weeks 4, 8, and 12. The AOT group used a head-mounted display and three-dimensional video during ROM exercises. The Non-AOT group used active ROM exercises alone. A generalized linear model (GLM) was used to confirm interactions and main effects by group and time period, and multiple comparisons were performed. Thirty-five patients were assigned to the AOT group (n = 18, median age, 74 years) or the Non-AOT group (n = 17, median age, 70 years). In the GLM, PRWE Total, PRWE Specific, and PRWE Usual scores revealed interactions between groups and periods. The post-hoc test revealed that the PRWE Specific scores (z = 3.43, p = 0.02) and PRWE Usual scores (z = 7.53, p<0.01) were significantly lower in the AOT group than in the Non-AOT group at 4 weeks postoperatively, whereas PRWE Total scores (z = 3.29, p = 0.04) were lower at 8 weeks postoperatively. These results suggested that AOT can improve hand-use difficulties in right-handed women after DRF surgery. AOT positively affects the motor imagery of patients with DRF and can reverse the patient's perceived difficulty in using the fractured hand during rehabilitation.

Ilizarov versus ORIF for Open AO Type-C Pilon Fractures

Objective: This study aimed to evaluate the clinical effectiveness of ORIF versus Ilizarov for the management of Type C closed pilon fractures of the distal tibia at 12 months follow up. Methods: This retrospective cross sectional study was conducted at Jinnah Postgraduate Medical Center (JPMC) between 29th May 2015 and 27th November 2019 that included patients 18 years and older diagnosed with open AO type C pilon fractures. The primary outcome was the patient-reported Disability Rating Index (DRI) months. While the secondary outcomes were quality of life assessment using the patient satisfaction form (SF-12) and AOFAS-Ankle Hindfoot Score. Radiographs were assessed for fracture healing, time to healing, and malalignment. Results: Fifteen patients underwent ORIF, while 26 patients were treated with Ilizarov, there was no statistically significant difference in DRI scores at 12 months between the two groups. In terms of clinical outcomes, both groups had comparable results throughout the follow-up period. The number of unplanned surgical procedures was not statistically significant (p=0.73), 26.92% (n=7) in the Ilizarov as compared to 33.33% (n=5) in the ORIF group. Conclusion: Among patients with an acute, displaced, intra-articular fracture of the distal tibia, neither external fixation nor locking plate fixation resulted in superior disability status at 12 months. Patient factors may need to be considered in deciding the optimal approach. doi: https://doi.org/10.12669/pjms.40.10.8941 How to cite this: Shaikh SA, Tanveer MO, Tahir M, Ahmed N. Ilizarov versus ORIF for Open AO Type-C Pilon Fractures. Pak J Med Sci. 2024;40(10):2213-2218. doi: https://doi.org/10.12669/pjms.40.10.8941 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Ultrasonographic Evaluation of Flexor Pollicis Longus Tendon Location in Various Functional Hand Positions.

Background: Flexor pollicis longus (FPL) tendon injury is a significant complication following distal radius fractures treated with volar locking plate fixation. We were unable to find any studies investigating the FPL tendon in relation to the distal radius in various functional hand positions. The aim of this study is to comprehensively evaluate FPL tendon location in essential functional hand positions commonly encountered in daily life, including pulp pinch, key pinch, chuck grip, power grip, cylindrical grasp and spherical grasp. Methods: We assess the position of the FPL tendon and finger flexor tendons concerning the radius in various functional hand positions. Sixty-two wrists in 31 healthy volunteers were examined using transverse ultrasonography at the watershed area of the radius in six different functional hand positions, including pulp pinch, key pinch, chuck grip, power grip, cylindrical grasp and spherical grasp. Results: The shortest distance between the FPL tendon and radius was observed in the key pinch position with a mean of 3.37mm, while the cylindrical grasp position showed the farthest distance with a mean of 4.21mm. Conclusions: The location of the FPL tendon and finger flexor tendons varies across different functional hand positions. Our study shows that these tendons are closest to the radius when the hand is in the key pinch position. Level of Evidence: Level IV (Diagnostic).

Three- or four-part proximal humeral fractures in middle-aged and active elderly group of patients: a narrative review of treatment options.

Proximal humerus fractures (PHFs) occur in all age groups but more in elderly population with variety of treatment options. The choice of treatment of PHFs is rather controversial in the middle-aged and active elderly population. This review article highlights the current literature on the efficacy of treatment options for PHFs in middle-aged and active elderly patients which could help surgeons in decision making in clinical practice. PubMed and Scopus databases from January 1953 to February 2024 were searched and screened for studies, including systematic reviews, on the treatment of PHFs in middle-aged and elderly that served for narrative review of rationale behind such design. Patients with minimally displaced fractures should be treated nonoperatively. Internal fixation with intramedullary nailing is a viable option in cases of two-part surgical neck fractures, those with diaphyseal involvement and no significant displacement of the tuberosities, or pathologic fractures. Those elderly patients with displaced three- or four-part PHFs fractures with intact rotator cuff muscles should be treated with locking plate fixation if anatomical reduction of fracture fragments including tuberosity is possible, as the results after union despite avascular necrosis are favorable. Moreover, patients with failed fixation treated with salvage reverse shoulder arthroplasty (RSA) have similar outcomes to RSA for acute PHFs. Hemiarthroplasty should be reserved for select group of young active patients with unconstructable fracture, intact rotator cuff, and good tuberosity bone stock. RSA should be offered as first option for elderly patients with poor bone stock, rotator cuff insufficiency, fracture dislocations, head-split fractures, and severely displaced 3- and 4-part PHFs. The treatment of choice in middle-aged and active elderly patients with three- or four-part PHFs depends on several factors such as fracture pattern, bone quality, possibility of anatomical reduction, status of rotator cuff, and patient expectations. The success of treatment is based on patient selection while setting correct patient expectations.

Medial Tibial Condylar Valgus Osteotomy improve clinical outcomes and effectively corrects significant Tibial varus deformities without compromising joint line obliquity or patellar heigh

BackgroundTibial condylar valgus osteotomy (TCVO), or Chiba osteotomy, is a recognized procedure for treating advanced knee osteoarthritis in middle-aged individuals. Although its effectiveness is established, limited literature exists on its outcomes for specific conditions such as post-traumatic deformities, Blount disease (BD), and Pagoda-like proximal tibia varus deformities. HypothesisWe hypothesized that TCVO could improve both clinical and radiographic outcomes in patients with severe varus deformities, correcting lower-limb variances while preserving joint line obliquity (JLO) and patellar height in substantial varus deformities. Patients and methodsThis study included 33 patients who underwent TCVO, with etiologies including post-traumatic (26 patients, 78.8%), Blount disease (4 patients, 12.1%), and Pagoda deformities (3 patients, 9.1%). The average age was 32.5 years (standard deviation = 12.8 years). Techniques for deformity correction varied, including Patient Specific Instrumentation (PSI) for 10 patients (30.3%) and locking plate fixation for 13 patients (39.4%). We assessed several radiological parameters such as hip-knee-ankle angle (HKA), medial proximal tibial angle (MPTA), joint line convergence angle (JLCA), Caton-Deschamps index (CDI), and proximal posterior tibial angle (PPTA). Patient-reported outcomes, including the Knee injury and Osteoarthritis Outcome Score (KOOS) and simple knee value (SKV), were recorded both pre-operatively and two years post-operatively. ResultsStatistically significant improvements were observed in clinical scores and alignment changes two years post-operatively, including increases in HKA (from 166.1 to 178.4, p < .0001) and MPTA (from 72.4 to 85.1, p < .0001), and a decrease in JLO (from 9.8 to 3.2, p < .0001). No significant changes were noted in JLCA, PPTA, and CDI, with the patellar height remaining stable post-operatively. The achieved corrections closely matched the pre-operative plans. ConclusionTCVO offers significant improvements in radiological and clinical parameters for patients with substantial tibial varus deformities, effectively maintaining JLO and patellar height. Optimal outcomes from TCVO are dependent on careful patient selection and precise execution of surgical techniques. Level of evidenceIII.

Biomechanical Evaluation of Suture Augmentation of Dorsal Locking Plate Fixation in Transverse Patella Fractures.

Adjunctive suture augmentation of patellar plate fixation has yet to be investigated. Our biomechanical study sought to evaluate whether suture augmentation improves dorsal patellar locking plate fixation. Our hypothesis was that suture augmentation would improve fixation of this construct. A transverse patella fracture in six matched cadaveric pairs was stabilized using a patellar locking plate with or without suture augmentation. Specimens were tested at 60° knee flexion with load placed through quadriceps. Cyclic loading followed by load to failure was done. Stiffness, deformation at peak, and nonrecoverable deformation were calculated. During cyclic loading, suture augmentation demonstrated a higher average stiffness throughout all loads. At the final cycle, deformation was markedly higher without suture augmentation. Average load to failure was higher with suture augmentation. Maximum load to failure occurred at 2500 N in both groups. Suture augmentation in a transverse patellar fracture model improved dorsal plate fixation, leading to less fracture displacement at the final load. Although suture augmentation demonstrated higher stiffness and lower deformation, these trends were not statistically significant. In both groups, plate fixation sustained very high loads, which reflects the fixation strength of the dorsal locking plate and screw construct in this fracture model.

Treatment of distal femur aseptic nonunion after lateral locking plate fixation: results of medial custom made plating and free fibula flap transfer using CAD-CAM technology

BackgroundAim of the present paper is to report the preliminary results of CAD-CAM (Computer-Aided Design - Computer-Aided Manufacturing) technology application to distal femur nonunion treatment with free fibula flap, custom made medial plating and maintenance of a stable lateral locking plate. MethodsTwo cases of distal femur nonunion that occurred after lateral locking plating were treated and prospectively followed-up. Surgical planning followed the same preoperative protocol adopted for mandibular CAD-CAM reconstruction. Wide cutting sections were planned to obtain radical debridement. The tailored custom-made plate, a 3D rendering of bone defect and the cutting guides were produced and sterilized. Surgical intervention was conducted by steps (medial approach, bone resection, recipient vessels isolation, fibula harvesting and cutting, plate-fibula construct assembly, microvascular anastomosis, final fixation). ResultsThe mean follow-up was 13 (12-15) months. Bone union was achieved in both cases at mean 3.1 months. Full weight bearing without referred pain or discomfort was reached in both cases at mean 8,5 months (range 7 – 10). No complications occurred. ConclusionsCAD-CAM technology proved to be useful and reliable in custom made medial plating combined with free fibula transfer for the treatment of distal femur nonunion after lateral locking plating. Trial registrationnone.

Impact of augmentation strategy variations on the mechanical characteristics of patients with osteoporotic proximal humerus fractures with medial column instability.

Low bone density and lack of medial support are the two most important factors affecting the stability of locking plate fixation for osteoporotic proximal humeral fractures (PHFs). This study aimed to compare the biomechanical characteristics of PHILOS locking plates combined with calcar screws, bone cement, fibular allografts, and medial locking plate support strategies for treating osteoporotic PHFs with medial column instability. A three-part osteoporotic PHF (AO 11-B3.2) model with metaphyseal loss was generated using 40 synthetic humeri and fixed via four distinct medial support strategies. All models were mechanically tested to quantify the mechanical characteristics. Subsequently, finite element models were created for each biomechanical test case. The stress distribution and displacement of the four different fixation structures were analyzed using finite element analysis. The results demonstrated that the PHILOS locking plate combined with the medial locking plate, exhibited the greatest stability when subjected to axial, shear, and torsional loading. Furthermore, the PHILOS locking plate combined with bone cement showed structural stability similar to that of the PHILOS locking plate combined with fibular allograft but with lower stress levels on the fracture surface. In conclusion, the PLP-MLP fixation structure showed superior biomechanical properties under axial, shear, and torsional loading compared to other medial support methods. Repairing the medial support when treating osteoporotic PHFs with medial column instability can enhance the mechanical stability of the fracture end in both the short and long term.

Lag screw versus locking plate fixation for traumatic displaced medial malleolar fractures: a systematic review and meta-analysis

BackgroundLag screw fixation (LSF) or locking plate fixation (LPF) are both recommended for the treatment of medial malleolar fractures (MMFs). However, no standard has been established for attaining optimal surgical treatment or functional recovery. We hypothesized that LPF for MMFs would result in superior outcomes compared to LSF. To test this hypothesis, we conducted a systematic review and meta-analysis of the clinical outcomes of LSF and LPF in the treatment of MMF. Patients and methodsWe searched for studies published prior to November 2023 across the PubMed, Embase, Cochrane Library, and ClinicalTrials.gov databases. Standardization of individual effect sizes was conducted; subsequently, pooled effect sizes were derived by employing random-effects models. ResultsFive retrospective studies involving 394 patients were reviewed. American Orthopedic Foot and Ankle Society (AOFAS) scores were significantly higher among patients who received LPF (mean difference [MD]: 2.21; 95% confidence interval [CI]: 0.37–4.04; p = 0.02) than among those who received LSF. Pain scores were significantly lower among patients who received LPF (MD: −0.35; 95% CI: −0.64 to −0.05; p = 0.02) than among those who received LSF. No significant differences in delayed union was observed between the groups (Relative risk [RR]: 1.43; 95% CI, 0.37–4.04; p = 0.42). Fixation failure was slightly higher in patients who received LSF than in those who received LPF (RR: 3.11; 95% CI, 0.88–11.01; p = 0.08). DiscussionCompared with LSF, LPF yields superior functional outcomes, superior patient comfort, and comparative complication rates. LPF is also better able to prevent rotation and apply compressive forces across fracture sites, which can facilitate the management of different types of MMF. Additional randomized controlled trials with larger sample sizes are warranted. Level of evidenceIII.

How Does the Position of the Wedge Influence the Tibial Slope After High Tibial Osteotomy?

Open-wedge high tibial osteotomy often results in an increase in the tibial slope. Factors responsible for this increase are not clearly defined. The purpose of this study is to assess the influence of the position of the wedge on the changes of the tibial slope. This monocentric retrospective study included 87 patients with symptomatic isolated medial osteoarthritis of the knee. All patients were operated with open-wedge high tibial osteotomy with locked plate fixation. Tibial slope was measured on lateral x-ray of the tibia referring to posterior tibial cortex. The position of the wedge was estimated by measuring the distance between the posterior tibial cortex and the posterior lower part of the wedge. Measurements were performed by the same observer using Carestream® software. Data were analyzed with the SPSS 20 statistical software. Mean tibial slope was 6,03° preoperatively and 5,98° postoperatively with a non-significant decrease of 0,05°. Mean distance between the wedge and the posterior tibial cortex was 9,02mm, there was a significant correlation between this distance and the change in tibial slope (p&lt;0,001) (R=0,73). However, there was no significant correlation between preoperative varus, degree of correction, age or BMI and changes in tibial slope. So, we recommend, during open-wedge high tibial osteotomy, to place the wedge in the posterior part of the osteotomy to avoid an increase in tibial slope and ensure better knee function.

Locking Plate Fixation with Calcium Phosphate Bone Cement Augmentation for Elderly Proximal Humerus Fractures-A Single-Center Experience and Literature Review.

Proximal humerus fractures (PHFs) are among the most common upper-extremity fractures, with a rising incidence linked to the growing elderly population. Treatment options include non-surgical and surgical methods, but the best approach for geriatric PHFs remains debated. Patient selection for treatment must consider clinical and functional outcomes and the potential complications of surgery. Osteoporosis, a key factor in elderly PHFs, meaning those in patients over 65 years old, often results from low-energy trauma and necessitates treatments that enhance bone healing. Bone cement, such as calcium phosphate, is widely used to improve fracture stability and healing. However, the benefits of surgical fixation with bone cement augmentation (BCA) for elderly PHF patients remain controversial. Hence, in this article, we searched databases including MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and Web of Science to analyze the evidence on locking plate fixation (LPF) with BCA for proximal humeral fractures. We aim to provide readers with updates concerning the above issues.

Intraoperative Complications in Medial Opening Wedge High Tibial Osteotomy.

Medial opening wedge high tibial osteotomy has been established for treatment of medial symptomatic knee arthrosis with varus malalignment in young and elderly but active patients. To obtain satisfactory results, it is essential for surgeons performing osteotomy to identify, prevent, and treat potential intraoperative adverse events. Lateral hinge fracture (LHF) is the most common intraoperative complication while popliteus artery injury is rare but limb-threatening. Computed tomography is the benchmark to detect LHF, the risk of which increased markedly with the opening gap larger than 11 mm. Setting the lateral hinge in a safe zone is the most important preventive measure. Medial long locking plate fixation may allow patients even with unstable hinge fractures to start early full weight bearing. Additional fixation of LHF is optional, and bone void filling is not routinely used. For protection of popliteus artery injury, flexing the knee joint is unreliable. It is paramount to place a protective retractor just behind the posterior tibial cortex toward the proximal tibiofibular joint before osteotomy, particularly in case of aberrant artery. A repertoire of surgical pearls is described in detail in this review to identify, prevent, and manage those intraoperative complications.

Application of improved carpal shoot through view in volar plate internal fixation of distal radius fractures

To explore the application of improved carpal shoot through view (ICSTV) method in the treatment of distal radius fractures with volar plate internal fixation. The clinical data of 67 patients with distal radius fractures who met the selection criteria between January 2020 and January 2023 was retrospectively analyzed. There were 30 males and 37 females with an average age of 53.6 years (range, 18-75 years). According to the AO/Orthopaedic Trauma Association (AO/OTA) classification, there were 25 cases of type B and 42 cases of type C. The time from injury to operation ranged from 2 to 6 days, with an average of 3.8 days. During the operation, bilateral cortical drilling was performed, and the length of the implanted screw was 1-2 mm shorter than that measured by the depth ruler. Standard anteroposterior and lateral (AAL) fluoroscopy and ICSTV fluoroscopy were performed after volar anatomic locking plate fixation, respectively. If the dorsal cortex of the distal radius was detected to be penetrated, the short screw was replaced and ICSTV fluoroscopy was performed again until no screw was penetrated. The detection rate of dorsal cortical screw penetration was compared between AAL fluoroscopy and ICSTV fluoroscopy. Postoperative CT scan was performed to confirm the presence or absence of dorsal cortical screw penetration. Intraoperative AAL fluoroscopy found 5 screws penetrating the dorsal cortex in 4 patients (6.0%), and ICSTV fluoroscopy found 19 screws penetrating the dorsal cortex in 15 patients (22.4%) including the above 4 patients, with a significant difference in the detection rate between the two fluoroscopy methods [ OR=0.267 (0.084, 0.845), P=0.018]; 15 patients were replaced with short screws during operation. At the same time, ICSTV fluoroscopy detected 2 screws penetrating into the distal radioulnar joint in 2 cases (3.0%), which could not be found in AAL fluoroscopy, and the direction of the screws was adjusted and replaced. All patients were reexamined by wrist CT within 3 days after operation, and no dorsal cortical screw penetration or screw penetration into the distal radioulnar joint was found. All the 67 patients were followed up 6-18 months, with an average of 11.3 months. Extensor tendon irritation occurred in 2 patients at 3 months after operation, and no extensor tendon rupture occurred in all patients during follow-up. All fractures healed well, and the healing time was 8-13 weeks, with an average of 10.8 weeks. There was no complication such as internal fixation loosening or fracture displacement. The Gartland-Werley score at last follow-up ranged from 0 to 15, with an average of 5.6. ICSTV fluoroscopy can effectively detect occult dorsal cortical screw penetration of the distal radius that can not be revealed by AAL fluoroscopy.

Factors that interfere with immediate return to activity following volar locking plate fixation for distal radius fractures.

In the present study, the clinical findings that interfere with the immediate return to activity following volar locking plate (VLP) fixation for distal radius fractures were investigated. A total of 95 patients who underwent VLP fixation for distal radius fracture between July, 2014 and January, 2022 were divided into a good group (good score and outcome; n=86; 22 males and 64 females; median age, 61 years) and a poor group (poor score and outcome; n=8; 8 females; median age, 63.6 years) according to the quartiles of the disabilities of the arm, shoulder and hand (Q-DASH) score, at 1 month following VLP fixation. The duration from injury to surgery, the direction of fracture dislocation and radiographic parameters [radial inclination (RI), volar tilt (VT) and ulnar variance (UV)] at the time of injury were examined. Radiographic parameters (RI, VT and UV), the range of motion of the wrist joint, grip strength ratio and visual analog scale (VAS) at 1 month following VLP fixation were also examined. These parameters were compared among both groups. Moreover, logistic regression analysis was performed to determine whether these factors were independently associated with a poor Q-DASH score at 1 month following VLP fixation. At the time of injury, fracture displacement was significantly higher in the poor group (VT, -23.8˚; UV, 4.2 mm) than the good group (VT, -6.5˚; P=0.02; UV, 1.3 mm; P=0.01). No differences in the other parameters were observed between the groups. At 1 month following VLP fixation, the grip strength ratio (17.2%) in the poor group was significantly lower than that in the good group (43.8%, P<0.001), while the VAS score (5.6) in the poor group was significantly higher than that in the good group (2.4, P<0.001). Logistic regression analysis revealed that VT and UV at injury (P<0.05), grip strength ratio (P<0.001) and pain (VAS score) (P<0.001) were all independently associated with a poor Q-DASH score. On the whole, the present study suggests that large amounts of fracture displacement, weakness of grip strength and post-operative pain can be factors interfering with the return to activity immediately following VLP fixation.

Far Cortical Locking Versus Standard Constructs for Locked Plate Fixation in the Treatment of Acute, Displaced Fractures of the Distal Femur

Background: Fixation of distal femoral fractures remains a challenge, and nonunions are common with standard constructs. Far cortical locking (FCL) constructs have been purported to lead to improved fracture-healing as compared with that achieved with traditional locking bridge plates. We sought to test this hypothesis in a comparative effectiveness clinical trial. Methods: This randomized trial was performed across 16 centers and included adult patients with an AO/OTA type 33A or 33C distal femoral fracture that was suitable for bridging fixation. We excluded patients with periprosthetic fractures. Participants were randomly assigned to either FCL fixation or standard locking plate fixation. The primary outcome was a hierarchical composite of radiographic and clinical fracture-healing at 3 months after fixation. We estimated between-group differences with use of the win ratio approach. Secondary outcomes included radiographic healing, clinical fracture-healing, complications, reoperations, and health-related quality of life (Short Form-36 Health Survey Version 2 [SF-36] Physical Component Summary and Mental Component Summary scores) at 3, 6, and 12 months after fixation. Results: We randomly assigned 193 patients to treatment with either FCL screws (96 patients) or standard screws (97 patients). The study population had a mean age of 63.4 years, consisted predominantly of women (68%), and was well-balanced between AO/OTA 33A and 33C fractures. Based on 4,355 pairwise comparisons, the calculated win ratio was 1.18 (95% confidence interval [CI], 0.77 to 1.79; p = 0.45), indicating that patients assigned to FCL screws had better outcomes in 51% of the comparisons. Radiographic healing did not differ significantly between the groups (odds ratio, 1.36; 95% CI, 0.69 to 2.72; p = 0.38), nor did Function IndeX for Trauma (FIX-IT) scores (p = 0.41). There were no significant differences between the groups in terms of SF-36 Physical Component Summary scores at 3 months or in the change in scores at 12 months after fixation. Conclusions: In this multicenter randomized trial of adult patients with an AO/OTA type 33A or 33C distal femoral fracture, similar clinical and radiographic healing outcomes were observed in the FCL and standard fixation groups. Level of Evidence: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Treatment of the Distal Forearm Fracture by Volar Dual Window Approach.

Distal forearm fractures were defined as distal radius fractures with concomitant distal ulna fractures, except ulna styloid fractures. Distal forearm fractures are common among geriatric populations, particularly those with osteoporosis. Conventionally, distal forearm fractures are reduced by a double incision approach; however, malreduction and instability of the distal radioulnar joint were not uncommon. We introduced a modified volar dual window approach to treat the distal forearm fracture and evaluate the functional outcomes and complications. From January 2020 to June 2023, 13 patients with distal forearm fractures underwent open reduction by the modified dual window approach with locking plate fixation. After surgery, splints were applied for two weeks, and the patients underwent postoperative hand therapy for three months. The mean Quick Disabilities of the Arm, Shoulder, and Hand scores, range of motions, grip strength, postoperative radiographic parameters, and complications data were collected. The mean follow-up period was 12.1 months, and the mean age was 52.3 years. Average wrist flexion was 67°, extension 69°, pronation 81°, and supination 79°. Grip strength was 28.3 ± 11.5 kg, which was 88% of the uninjured opposite side. The Visual Analog Scale score during activities was recorded as 0.5 ± 0.9. The mean Quick Disabilities of the Arm, Shoulder, and Hand score was 14 ± 11.5. The postoperative radiographic parameters were as follows: radial height: 10.8 ± 1.7 mm, radial inclination: 22.6 ± 3.7°, volar tilting: 4.0 ± 3.9°, and ulnar variance: -0.4 ± 1.4 mm. All the patients achieved bone union at the final follow-up. Two patients underwent ulnar implant removal due to irritation symptoms. Neither infection, nor neurovascular injury, nor malreduction developed in these patients. The modified volar dual window approach can achieve good wrist function and distal forearm fracture reduction without increasing neurovascular or wound healing complications. This method is an alternative approach for distal forearm fracture, especially in comminuted distal ulna fracture or distal radioulnar joint incongruity.

What Have We Learned in the Wrist Joint of Distal Radius Fracture through Wrist Arthroscopy?

Abstract Background Wrist arthroscopy is an efficient tool for the surgical treatment of distal radius fracture (DRF). It could show us the various conditions of the radiocarpal joint, its effectiveness seems to overwhelm that of fluoroscopy. Methods Since July 2005, we have performed wrist arthroscopy and plate presetting arthroscopic reduction technique (PART) for 141 extra-articular and 559 intra-articular DRFs and investigated various kinds of intra-articular conditions and advantages of wrist arthroscopy. Results The pathological conditions clarified and the advantages of PART in the surgical treatment of DRF are: (1) accurate reduction of intra-articular fragments is possible compared with fluoroscopic reduction, (2) intra-articular fragments (free body) undetected with radiograph and CT can be recognized, (3) screw protrusion into joint surface can be monitored, (4) intra-articular soft tissue injury associated with fracture can be evaluated and treated, and (5) debridement of joint hematoma can be performed. Severe complications such as tendon rupture, major neurovascular injury or compartment syndrome from arthroscopy were never encountered. Conclusions The volar locking plate fixation and simultaneous arthroscopic intervention is problematic because vertical traction must be applied and released during surgery. PART can overcome these difficulties and achieved good clinical results.