Locking Plate Osteosynthesis Research Articles

Outcomes Following Low-Profile Mesh Plate Osteosynthesis of Patella Fractures.

Treatment of patella fractures is fraught with complications and historically poor functional outcomes. A fixation method that allows for early mobilization and decreases symptomatic hardware rates will improve knee range of motion, postoperative functional status, and reoperation rates. The purpose of this study was to evaluate the functional outcomes after locked plate osteosynthesis of patella fractures at a Level 1 trauma center. A retrospective case series was conducted of patients who underwent open reduction internal fixation (ORIF) of a patella fracture using a locked mesh plating technique coupled with neutralization of forces on the distal pole of the patella. Twelve patients were evaluated at a mean follow-up of 19 months (range, 6-30) with physical exam, functional outcomes, and radiographs. There were 9 women and 3 men with an average age of 66.1 years (range, 53-75). Radiographic bony union was achieved in all patients by 3-month follow-up. Visual Analog Pain Score averaged 1.7 (median, 1.0; range, 0-8), the mean Knee Outcome Score - Activities of Daily Living Scale was 83.9 (median, 92.1; range, 45.7-100.0), the mean Short Form Musculoskeletal Function Assessment (SMFA) Function Index was 9.9 (median, 3.7; range, 0.7-41.2), and the mean SMFA Bother Index was 11.1 (median, 3.1; range, 0-62.5). The SF-36 Physical Component Score mean was 48.4 ± 8.5 and the SF-36 Mental Component Score mean was 54.1 ± 9.6. No complications developed and there were no reoperations for nonunion, infection, or symptomatic hardware. This study demonstrates that locked plate osteosynthesis for operative patella fractures can reliably achieve bony union with potentially superior functional outcomes as compared with traditional methods. Further studies are needed to evaluate plate fixation for patella fractures, but early results are promising.

Treatment of rotational malalignment of the lower leg

Rotational malalignment after intramedullary nailing of tibial shaft fractures is not uncommon. In-toeing and out-toeing conditions in children are often the reason for orthopedic and traumatological medical consultation. Evaluation of diagnostic modalities and therapeutic options for rotational malalignment in relationship to the patient's age. Surgical indications and efficacy of specific surgical techniques. Systematic literature search in the German Institute for Medical Documentation and Information (DIMDI) and MEDLINE and evaluation of the currently published articles. In adults computed tomography (CT) scanning is the gold standard for measuring the rotational alignment of the lower leg. To avoid exposure to ionizing radiation, magnetic resonance imaging (MRI) is currently the preferred modality in children and adolescents. The indications for corrective osteotomy are dependent on the functional complaints as well as the rotation angle measured by CT or MRI. Presently, there is no published study which demonstrates acorrelation between rotation of the lower leg and the development of arthrosis in the knee or ankle joint. When arotational osteotomy above the tibial tubercle is performed, correction of the rotation and the distance between the tibial tuberosity and the trochlear groove (TT-TG) and therefore patellofemoral imbalance can be effectively treated. Treatment of rotational malalignment after tibial shaft fractures is performed by diaphyseal osteotomy with intramedullary nail stabilization. In children, supramalleolar rotational osteotomy with subsequent locking plate osteosynthesis or stabilization using external fixation is performed for torsion correction. If there is asuspicion of rotational malalignment in the lower leg, aCT scan can be performed in adults and MRI in children and adolescents. Surgical indications for corrective osteotomy are dependent on functional complaints as well as the CT and MRI measurements. The CT and MRI reference values are only published according to the method of Waidelich et al. and Jend et al.

Anterolateral distal tibia locking plate osteosynthesis and their ability to capture OTAC3 pilon fragments

BackgroundIntra-articular Pilon fractures remain therapeutically challenging due to osteochondral fracturing and comminution, marginal impaction, and insult to the soft tissue envelope. The purpose of this study was to compare the efficacy of anterolateral distal tibial locking plates in capturing main fracture fragments in tibial plafond fractures. MethodsFrom May 2011 to Dec 2015, 169 OTA C-type pilon fractures met inclusion and exclusion criteria with computed tomographic (CT) scans performed prior to definitive fixation. For each patient, the fracture lines were mapped, digitized, and graphically superimposed to create a compilation of fracture lines. Based on these average measurements, three distal tibia sawbones had three different anterolateral plates applied. Axial CT scan images were used to determine the efficacy of screw purchase in main fracture fragments in pilon fractures. ResultsThe Smith & Nephew PERI-LOC plate secured the largest number of fracture lines (90.1%) but missed the Volkmann fragment with greatest frequency at 3.6%. The Synthes 2.7/3.5 mm VA-LCP captured 87.3% of the fracture lines while missing the Volkmann fragment 3.2% of the time. The Synthes 3.5 mm LCP captured 86.5% of the fracture lines but was the best at securing the Volkmann fragment (1.2% missed). All three implants were deficient in capturing the medial malleolar fragment. The PERI-LOC and 2.7/3.5 mm VA-LCP did not differ with respect to percentage of fragments captured (p = 0.721) but both outperformed the 3.5 mm LCP (p = 0.021 and p = 0.05, respectively). ConclusionsThis study was consistent with prior literature in defining three main fracture fragments: anterior, medial, and posterior. All three plates were deficient in capturing the medial malleolar fragment. The Smith and Nephew PERI-LOC plate secured the most number of fracture lines, while the Synthes 3.5 mm LCP was least likely to miss the Volkmann fragment and most likely to miss the medial malleolar fragment. No plate was found to be superior to the other in capturing all fracture lines of the OTAC3 pilon fragments. Level of evidenceThree.

Successful treatment of infected wound dehiscence after minimally invasive locking-plate osteosynthesis of tibial pilon and calcaneal fractures by plate preservation, surgical debridement and antibiotics

ObjectiveThe aim is to present a case series that illustrates possible benefits from combining minimally invasive plate osteosynthesis (MIPO), plastic surgery and antibiotic therapy, in order to treat and eradicate infection in patients with tibial pilon or calcaneal fractures. MethodsEleven consecutive patients with dehiscence of the surgical wound in outcomes MIPO using a Locking Compression Plate (LCP) for tibial pilon, or calcaneus fractures. The patients had developed a documented infection of the surgical wound. All patients were treated and followed-up by the multidisciplinary team with the orthopedic surgeon, the plastic surgeon and the infectious disease physician. All patients were followed by the plastic surgeon to treat the wound dehiscence, as well as by the orthopedic surgeon until fracture consolidation. The duration of the antibiotic therapy was from 4 to 6 months. After 6 weeks, the intravenous treatment was replaced by oral administration. The follow-up intervals were 15 days, 40 days, and 3 months. ResultsThe average time of wound closure was 109±60 days. The antibiotics used were chosen according to the antibiogram. The antibiotic therapy had a duration of 4–6 months, and after 6 weeks, the therapy switched to oral administration. At the 3-month follow-up, all patients had excellent outcomes and had returned to their normal activity of daily living. ConclusionThe patients in this study responded positively to a combination of MIPO, plastic surgery and antibiotic therapy, confirming that multidisplinary treatment in association with titanium devices are able to eradicate infection in short time.

Working length and proximal screw constructs in plate osteosynthesis of distal femur fractures

BackgroundThe study purpose is to evaluate the working length, proximal screw density, and diaphyseal fixation mode and the correlation to fracture union after locking plate osteosynthesis of distal femoral fractures using bridge-plating technique. MethodsA four-year retrospective review was performed to identify patients undergoing operative fixation of distal femur fractures with a distal femoral locking plate using bridge-plating technique for the metadiaphyseal region. Primary variables included fracture union, secondary surgery for union, plate working length, and diaphyseal screw technique and configuration. Multiple secondary variables including plate metallurgy and coronal plane fracture alignment were also collected. ResultsNinety-six patients with distal femur fractures with a mean age 60 years met inclusion criteria. None of the clinical parameters were statistically significant indicators of union. Likewise, none of the following surgical technique parameters were associated with fracture union: plate metallurgy, the mean working length, screw density and number of proximal screws and screw cortices. However, diaphyseal screw technique did show statistical significance. Hybrid technique had a statistically significant higher chance of union when compared to locking (p=0.02). All proximal locking screw constructs were 2.9 times more likely to lead to nonunion. ConclusionsPlating constructs with all locking screws used in the diaphysis when bridge-plating distal femur locking plates were 2.9 times more likely to incur a nonunion. However, other factors associated with more flexible fixation constructs such as increased working length, decreased proximal screw number, and decreased proximal screw density were not significantly associated with union in this study.

Management of resistant distal femur non-unions with allograft strut and autografts combined with osteosynthesis in a series of 22 patients

Introduction and purposeChallenges to the surgeon in managing cases of resistant non-union of the distal femur include poor bone stock, disuse osteopenia and joint contractures. Procedures varying from simple bone grafting to megaprosthesis revision have been described. We successfully managed such cases using our technique of combining cortical allograft struts to augment the defect in the femoral condyle coupled with autogenous iliac crest bone grafting and locking plate osteosynthesis. Materials and methodsBetween April 2012 and May 2014, 22 patients who presented with resistant nonunions of the distal femur following initial surgery were managed using this technique. Cortical allograft struts were taken from the tissue bank of our institution. All patients were followed up post operatively and their time to union was noted. Functional outcome was calculated using LEFS (Lower extremity functional score). The average follow up of all our patients was 24 months. ResultsAll patients went on to achieve complete bony union. The average union time was 6.2 months (5 to 8 months). One patient who was a diabetic had superficial infection post operatively which was treated successfully with IV antibiotics. Average knee flexion was 110 degrees (80 to 130 degrees). The mean LEFS score was 72 (59 to 79). ConclusionCombing a locking plate fixation with the bone grafting technique of using an allograft strut to support the metaphyseal medial bone defect and autografts gives a good union and a good functional outcome in the management of resistant non-unions of the distal femur by enhancing the biology and providing a good structural support to the distal femur.

Detection of primary screw perforation in locking plate osteosynthesis of proximal humerus fracture by intra-operative 3D fluoroscopy.

The purpose of this study was to identify the rate of primary screw perforations after osteosynthesis of proximal humerus fractures with intra-operative 3D fluoroscopy and to analyse the rate of secondary screw perforations as well as complications, outcome, and revision surgeries after a minimum of 12months. Thirty-three patients (20 female, 13 male, median age 67years, range 35-85years) with displaced proximal humerus fractures were included. After reduction and fixation, an intra-operative 3D fluoroscopy was performed to evaluate primary screw perforations (PS) and screws with "near perforation" (nPS). These screws were changed intra-operatively. Patients were followed-up for a minimum of 12months. Clinical and radiological parameters, such as secondary screw perforation, secondary loss of reduction, or functional outcome, were investigated. In six patients (18.2%), humeral head screws were changed due to primary PS (n=2) or nPS (n=4) after the intra-operative 3D fluoroscopy. Follow-up revealed an adapted constant score (%CMS) of 76.2% after a mean follow-up of 17.7months. Two secondary screw perforations were observed (6%). Loss of reduction was observed in eight patients (24.2%). The intra-operative 3D reveals a high rate of primary screw perforations or near perforations. Immediate change of these screws may lead to a lower rate of secondary screw perforations and, therefore, reduce post-operative complications.

Locking plate fixation of mid-shaft clavicle fractures: analysis of complications, reoperation rates and functional outcome

Introduction: Clavicle fractures account for about 5-10% of all fractures and most of these fractures are located in the middle third of clavicle. Traditionally, these fractures have been treated by conservative methods. In recent years, surgical fixation of these fractures is becoming a prefered method of treatment and locking plate fixation is a commonly used mode of osteosynthesis. However, the functional results and complications of locking plate fixation documented in the literature are not clear and often conflicting. So the aim of this study is to analyse the results of locking plate osteosynthesis of mid-shaft clavicle fractures. Objective: To study complications, reoperation rates and functional outcome of clavicle fractures treated with locking plate osteosynthesis. Methods: Sixty Seven cases of mid-shaft clavicle fractures who underwent locking plate fixation in our orthopaedic department from January 2013 to December 2016 were identified. Those patients who attended regular follow-up and had recorded Constant-Murley Scores (CMS) were included. Seven patients who did not attend regular follow-up or had incomplete records were excluded from analysis. The study group comprising 60 patients were analysed for complications and functional outcome by studying patient records and x-rays. Results: There was one case of failure of fixation with non-union and 8 patients had their plate removed for discomfort. Overall, there were 92 % excellent to good, 5% fair and 3% poor results. There were no cases of infection. Conclusion: The locking plate osteosynthesis gives good to excellent functional outcome in most of the patients. It helps with early mobilisation and prevents shoulder stiffness. The overall rate of implant failure and non-union after plate fixation is low. The necessity of removal of implant in significant number of patients should be kept in mind.

Do low profile implants provide reliable stability in fixing the sternal fractures as a "fourth vertebral column" in sternovertebral injuries?

Flexion and compression forces to the trunk can cause severe instability of the vertebral column and the anterior chest wall, mostly associated with an unstable fracture of the sternum. In combination, the worst case would be a complete disruption of the trunk. Some authors consider the sternum-rib-complex to be the fourth vertebral column. This study discusses the possibilities to treat instable trunk injuries with sternal fractures concomitant to vertebral spine fractures through anterior sternal plating employing a locked plate osteosynthesis in a low profile design instead of the use of bulky implants. 11 Patients suffering from at least one fracture of a vertebral body in combination with an unstable sternum fracture were stabilized through a locked plate osteosynthesis in low profile design at the sternum between November 2011 and October 2014. The vertebral spine injury was stabilized as well, if necessary. Patients were followed up with a look at the consolidation of the fractures and the question if any failure of the implants occurred. Anterior sternal plating was uneventful in all cases. All Sternal fractures showed sufficient consolidation. No failure of implants has been seen during follow up over two years.. A locked plate osteosynthesis of a sternal fracture in low profile design seem to be an appropriate option for stabilization of the sternum in combined sternovertebral injuries.

Comparative analysis of locking plate versus hook plate osteosynthesis of Neer type IIB lateral clavicle fractures.

Controversy exists on optimal operative treatment of vertically unstable Neer IIB lateral clavicle fractures. Aim of this study was to analyse and compare clinical and radiological results and complications of locking plate osteosynthesis (LPO) versus hook plate osteosynthesis (HPO) with acromioclavicular joint (ACJ) stabilization. The hypothesis was, that HPO would recreate coracoclavicular stability more effectively and potentially lead to a superior outcome. This retrospective, observational cohort study included 32 patients (19 HPO, 13 LPO) with a mean age of 44.1 ± 14.2years at surgery. The mean follow-up period was 54.2months (range 25.2-111.4months). Besides standard radiography, bilateral coracoclavicular distances were assessed by means of preoperative and follow-up stress radiographs after implant removal. Clinical outcome measures included the Constant score (CS), the Oxford shoulder score (OSS), the subjective shoulder value (SSV) and the Taft score (TS). Bone union occurred in all but one patient and proved to occur delayed in five patients (15.6%). Radiographical healing required a mean of 4.2 ± 4.0months irrespective of the type of osteosynthesis. At follow-up, mean coracoclavicular distance was increased by 34% (±36) without significant differences between both groups. HPO patients obtained a significantly lower TS (HPO: 9.5 ± 1.5 points, LPO: 11.1 ± 1.3 points; p = 0.005). Other mean score values did not differ (CS: 90.1 ± 7.4 points, OSS: 43.2 ± 9.2 points, SSV: 91.1 ± 14.7%). Sixteen patients (50.0%) experienced complications. Overall prevalence of complications was significantly higher in the HPO group (p = 0.014). Both HPO and LPO were equally effective in relation to restoration of vertical stability, overall functional outcome and fracture consolidation in treatment of Neer IIB fractures. Contrary to our hypothesis, HPO was not associated with superior recreation of the coracoclavicular distance. Considerable drawbacks of HPO were an inferior ACJ-specific outcome (Taft-Score) and a higher overall complication rate. Level of evidence IV.

The Operative Management of Flail Chest Injuries with Concomitant Sternal Fracture.

Background: Flail Chest Injuries (FCI) are one of the most severe thoracic injuries. Moreover, an additional sternal fracture (SF) even worsens the outcome, such as the duration of mechanical ventilation, therefore an surgical fixation of the fractures could be considered in certain cases to improve the weaning from the ventilator. This paper aims to emphasize on the management of different types of SF in FCI. Methods: All surgically treated cases (2012-2016) that showed the combination of FCI and SF have been evaluated for their clinical details, the morphology of the fractures and the technical aspects of the surgical procedure in a retrospective investigation. Results: All of the SF (n=15) had been fixed by locked plate osteosynthesis through a median approach in a supine position. Three main regions of the sternum showed the need for different fixation strategies: the upper manubrium, central and lower corpus sterni. Concomitant rib fractures were addressed either through the same approach or through additional limited incisions. Conclusions: Combinations of SF and FCI are high risc injuries with high demand on surgical skills. They can be properly fixed with a locking plate osteosynthesis through a combination of limited incisions employing different types of plates depending on the type of SF.

Hemiarthroplasty vs. locking plate osteosynthesis – what is the better solution for displaced proximal humerus fractures?

<b>Introduction</b>: Displaced proximal humerus fractures pose significant clinical problems. The aim of this study was to compare treatment results between open reduction and internal fixation (ORIF) and hemiarthroplasty (HA).<br /> <b>Material and methods</b>: The study was a retrospective assessment. Sixty-three patients (30 HA, 33 ORIF) met the inclusion criteria; mean age: 64.5 years. The Constant-Murley scale, DASH score and VAS surveys for pain and satisfaction were used to evaluate the results.<br /> <b>Results: </b> The HA group: the constant score was 44 points, and the DASH score was 57 points; 53% of patients had osteolysis of the greater tubercle; none of the patients had revision surgery. ORIF group: the constant score was59 points, and the DASH score was 38 points; 21% of patients had a vascular necrosis; revision surgery was performed in 18% of cases. A significant correlation between good functional outcomes and young age of patients was found in the ORIF group (p-value < 0.048). Patients who started physical therapy earlier achieved better results. DASH scores were better compared to ones from the objective Constant-Murley score. There was no difference in satisfaction between HA and ORIF groups (p-value < 0.1).<br /> <b>Conclusions</b>: The ORIF should be considered for patients < 60 years old, but gives increased risk of urgent revision, due to screw protrusion. The HA provides fewer complications, lower risk of revision and can be better for patients between 60 and 70 years old. When choosing the treatment method, we should avoid focusing only on fracture configuration, but should also consider patient-related factors, such as age and lifestyle.

Interlocking Nailing Versus Plating in Tibial Shaft Fractures in Adults: A Comparative Study.

Tibial diaphyseal fractures are the commonest long bone fractures in adults, most commonly managed by intramedullary interlocking nailing. However, several meta-analysis show that locking plate osteosynthesis is equally effective in managing tibial diaphyseal fractures and are associated with less number of complications. To compare the results of fixation of tibial fractures following plating and nailing in terms of union, patient satisfaction and complications. A hospital based non randomized clinical trial was performed from September 2013 to August 2016 where closed or open diaphyseal or metaphyseo- diaphyseal fractures of the tibia (closed or open Gustilo Anderson type 1 through 3B) were included. Simple sequential allocation was used for allotting the patients to two groups, one for interlocking nailing and other for plating. The patients were followed up for clinical, radiographic and functional results. Forty patients with 41 involved limbs completed follow up for one year. The duration of surgery and average blood loss during surgery was 75.45±3.03 minutes and 165.00±5.31 ml respectively in case of nailing and 85.05±2.54 minutes and184.29±5.33 ml respectively in case of plating and their difference was statistically significant. In our study union was achieved in less than 20 weeks in 29 (70.8%) of the patients and 25-30 weeks in nine (22%) cases. The average time of union in our study was 19.55±0.69 weeks in case of interlocking nailing and 20.38±1.39 weeks in case of plating and there was no statistically significant difference between the two. However, there is statistically significant difference in the functional score in between the two groups in terms of Lower Extremity Functional Score (LEFS). Delayed union in one case of nailing and two cases of plating, valgus malunion in one case of nailing and joint stiffness in two cases each of nailing and plating were the major complications observed. There was no difference between the two modalities in terms of fracture union. Complications were lesser but more serious in case of plating. Patient satisfaction was more with plating.

Geriatric complex proximal humeral fracture: intraoperative locking plate problems and proposed solutions

Background: Surgical treatment of complex proximal humeral fractures in the elderly is controversial. There are no clear criteria on whether to preserve the humeral head or replace it. The aim of this study was to evaluate the results of locking-plate internal fixation and to clarify the encountered intraoperative problems with their suggested solutions. Methods: The study included 34 patients older than 60 yr of age. Eighteen had three-part fractures and 16 had four-part fractures according to Neer’s classification. All patients had internal fixation with locking plates and according to the encountered problems additional procedures were added to obtain stable reduction and rigid fixation. The clinical evaluation depended on the objective Constant-Murley score (CMS) and the subjective Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire. Results: The mean follow up was 27.7±5.6 mo, and the mean age was 69.9±4.4 yr. The mean CMS was 70.9±14.8 points, and the mean DASH score was 28.2±17.8 points. Humeral head avascular necrosis occurred in three (8.8%) with significant reduction in CMS (P=0.001). Partial loss of initial reduction occurred in four patients (11.8%) with significant reduction in CMS (P=0.007). Secondary surgery was mandatory for six patients (17.6%). Conclusions: We believe that locking plate osteosynthesis with preservation of the humeral head is worth considering in elderly patients with complex injuries provided the surgeon and facility are prepared for any problems that may arise.

Mid-Term Results of Minimally Invasive Plate Osteosynthesis and Circular External Fixation in the Treatment of Complex Distal Tibia Fractures.

The treatment of pilon tibia fractures is challenging. Anatomical reduction of the joint surface is essential. Excessive soft-tissue dissection may interfere with the blood supply and can result in nonunion. We sought to compare the outcomes of distal tibia fractures treated with medial locking plates versus circular external fixators. We retrospectively evaluated 41 consecutive patients with closed pilon tibia fractures treated with either minimally invasive locking plate osteosynthesis (n = 21) or external fixation (EF) (n = 20). According to the Ruedi and Allgower classification, 23 fractures were type B and 18 were type C. Soft-tissue injury was evaluated according to the Oestern and Tscherne classification. Time to fracture union, complications, and functional outcomes were assessed annually for 3 years with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score. Mean ± SD values in the plate group were as follows: age, 42.4 ± 14 years; union time, 19.4 ± 2.89 weeks (range, 12-26 weeks); and AOFAS ankle scores, 86.4 ± 2.06, 79.5 ± 1.03, and 77.9 ± 0.80 at 1, 2, and 3 years, respectively. Four patients in the plate group needed secondary bone grafting during follow-up. In the EF group (mean ± SD age, 40.7 ± 12.3 years), all of the patients achieved union without secondary bone grafting at a mean ± SD of 22.1 ± 1.7 weeks (range, 18-24 weeks). In the EF group, mean ± SD AOFAS ankle scores were 86.6 ± 1.69, 82.1 ± 0.77, and 79.7 ± 1.06 at 1, 2, and 3 years, respectively. There were no major complications. However, there were soft-tissue infections over the medial malleolus in five patients in the plate group and grade 1-2 pin-tract infections in 13 patients and grade 3 pin-tract infections in one patient in the EF group. Post-traumatic arthritis was detected in eight plate group patients and seven EF group patients. Minimally invasive plating and circular EF methods have favorable union rates with fewer complications.

Role of locking dynamic hip screw in management of inter-trochanteric fractures of femur in elderly patients

Introduction: Dynamic Hip screw is the implant of choice for most inter-trochanteric fractures of the femur. But, its most common mode of failure is for the lag screw to cut out of the femoral head, the second is for the plate to be forced off the femur with the screws being pulled out of the osteoporotic bone. With the introduction of Locking plate osteosynthesis, in which fixed angle devices are used, which are not dependent on the holding power of screws alone, the bone-implant construct so formed is mechanically stable and fixation failure due to screw loosening in osteoporotic bone can be reduced. This study aims to evaluate DHS with a locking side-plate for fixation of inter-trochanteric fractures in elderly. Methods: Aim was to study the outcome of Locking Dynamic Hip Screw fixation in 25 patients admitted in GNDH with inter-trochanteric femur fractures in elderly age group. The clinical and radiological outcomes were evaluated with regular follow-up and the functional grading was done according to Harris Hip Score. Results: In our study, the mean time to radiological union was 13.96 weeks. There was one patient with deep infection, but no other significant complication in our study. None of the patients in our study had lag screw cut-out, varus collapse or side plate pull out or any other implant specific complications. The average modified harris hip score was calculated to be 82.12 %. Functionally, 16 % had excellent, 48% as good, 32% as fair and 4% had poor results. Discussion: The present study indicates that DHS with a locking side plate is a terrific treatment option for inter-trochanteric fractures in elderly, with no major complications for fracture union. To accomplish the goal of early mobilisation and reduced failures we need an implant which has an inherently stable construct independent of the bone quality and does minimal damage to the vascular supply of the bone and has a low complication rate. Locking DHS helps us achieve that goal.

Injuries of the Medial Clavicle: A Cohort Analysis in a Level-I-Trauma-Center. Concomitant Injuries. Management. Classification.

Introduction: Although shoulder girdle injuries are frequent, those of the medial clavicle are widely unexplored. An applied classification is less used just as a standard management. Methods: A retrospective analysis of medial clavicle injuries (MCI) during a 5-year-term in a Level-1-Trauma-Center. We analyzed amongst others concomitant injuries, therapy strategies and the classification following the AO standards. Results: 19 (2.5%) out of 759 clavicula injuries were medial ones (11 A, 6 B and 2 C-Type fractures) thereunder 27,8% were displaced and thus operatively treated Locked plate osteosynthesis was employed in unstable fractures and a reconstruction of the ligaments at the sternoclavicular joint (SCJ) in case of their disruption. 84,2% of the patients sustained relevant concomitant injuries. Numerous midshaft fractures were miscoded as medial fracture, which limited the study population. Conclusions: MCI resulted from high impact mechanisms of injury, often with relevant dislocation and concomitant injuries. Concerning medial injury's complexity, treatment should occur in specialized hospitals. Unstable fractures and injuries of the SCJ ligaments should be considered for operative treatment. Midshaft fractures should be clearly distinguished from the medial ones in ICD-10-coding. Further studies are required also regarding a subtyping of the AO classification for medial clavicle fractures including ligamental injuries.

Surgical Stabilization of Costoclavicular Injuries - A Combination of Flail Chest Injuries and a Clavicula Fracture.

Background: Flail chest injuries (FCI) are associated with a high morbidity and mortality rate. As a concomitant clavicle fracture in FCI even worsens the outcome, the question is how can those costoclavicular injuries (CCI) be managed surgically. Methods: 11 patients with CCI were surgically treated by a locked plate osteosynthesis of the Clavicle and the underlying ribs through limited surgical approaches under general anesthesia. Patients were followed up after 2, 6, 12, 26 and 52 weeks. Results: All patients showed severe chest wall deformity due to severely displaced fractures of the ribs and the clavicle. They were suffering from pain and restriction of respiratory movements. The chest wall could be restored to normal shape in all cases with uneventful bone healing and a high patient convenience. Fractures of the clavicle and the second rib were managed through an innovative clavipectoral approach, the others through standard approaches to the anterolateral and the posterolateral chest wall. Two patients complained about numbness around the lateral approach and lasting periscapular pain. Conclusions: Surgical stabilization might be the appropriate therapy in CCI with dislocated fractures since they would cause severe deformity and loss of function of the chest wall and the shoulder.

Complications during removal of conventional versus locked compression plates: is there a difference?

Osteosynthesis plate removal is one of the most commonly performed procedures in orthopaedic surgery. Due to technological advances and the quality of increasing osteosynthesis material, more and more locked plates have been implanted over the last 20years. The aim of this study was to determine whether the complication rate during plate removal differs between conventional and locked plates. In this retrospective cohort study, 620 patients were included and divided into two groups based on the type of plate (locked and conventional). Technical complications during implant removal included screw breakage, destroyed screw head, implant breakage, remaining implant material, refracture, bony or soft tissue overgrowth. The following plate-associated complications were identified: osteosynthesis plate not detachable, plate bent or broken, necessity of special tools or plate loosened. Three types of screw-related complications were observed: screw not detachable, screw broken or screw dislocated. Overall, complications related to the plate or screws were documented in 110 of the 620 cases. These complications occurred in 48 of the 382 cases involving conventional osteosynthesis (7.7% of all removals, 12.6% of all conventional removals) and in 62 of the 238 cases involving locked plate osteosynthesis (10.0% of all removals, 26.1% of all locked plate removals). The statistical analysis showed a significantly higher implant-related complication rate with locked plates compared to the conventional plates (p < 0.01). Hardware removal can be a complication-afflicted operation, especially cases involving locked-plate removal should only be performed if a strong indication is evident. Possible benefits of the procedure should be considered carefully, taking the cost-benefit ratio into account.

Impact of cement-augmented condylar screws in locking plate osteosynthesis for distal femoral fractures — A biomechanical analysis

IntroductionCompromised bone quality and the need for early mobilization continue to lead to implant failure in elderly patients with distal femoral fractures. The cement augmentation of screws might facilitate improving implant anchorage. The aim of this study was to analyse the impact of cement augmentation of the condylar screws on implant fixation in a human cadaveric bone model. Material and methodsTen pairs of osteoporotic femora (mean age: 90 years, range: 84–99 years) were used. A 2-cm gap osteotomy was created in the metaphyseal region to simulate an unstable AO/OTA 33-A3 fracture. All specimens were treated with a polyaxial locking plate. Specimens randomly assigned to the augmented group received an additional cement augmentation of the condylar screws using bone cement. A servohydraulic testing machine was used to perform incremental cyclic axial loading using a load-to-failure mode. ResultsAll specimens survived at least 800N of axial compressive force. The mean compressive forces leading to failure were 1620N (95% CI: 1382–1858N) in the non-augmented group and 2420N (95% CI: 2054–2786N) in the group with cement-augmented condylar screws (p=0.005).Deformation with cutting out of the condylar screws and condylar fracture were the most common reasons for failure in both groups. Whereas axial stiffness was comparable between both osteosyntheses (p=0.508), significant differences were observed for the plastic deformation of the constructs (p=0.014). ConclusionThe results of the present study showed that the cement augmentation of the condylar screws might be a promising technique for the fixation of distal femoral fractures in elderly patients with osteoporotic bones.