Medial Buttress Research Articles

Classifications in Brief: The Russell-Taylor Classification of Subtrochanteric Hip Fracture.

Classifications in Brief: The Russell-Taylor Classification of Subtrochanteric Hip Fracture.

Unstable Fracture Neck of Femur in Young Adults: Management with Cannulated Cancellous Screws Augmented with Medial Buttress Plate

ABSTRACT Objective This study is to evaluate the clinical and radiological outcome of unstable fracture neck of the femur in young adults treated with three cannulated cancellous screws augmented with medial buttress plate. Materials and methods Fifteen patients of less than 60 years were operated from January 2017 to March 2018. Reduction was achieved by closed or open means to Garden's alignment index grade I. Internal fixation was done with three cannulated cancellous screws through mini lateral incision, and medial buttress plating was done through modified Smith–Peterson approach. All patients were mobilized from the immediate postoperative period and allowed toe-touch weight-bearing as tolerated. All patients were followed at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months postoperatively. Results Fracture united in 14 of 15 patients. Reduction loss and backing out of cancellous screws occurred in one patient. No cases of avascular necrosis was identified at a mean follow-up of 13.7 months. No significant femoral neck shortening was observed in all united fractures. Conclusion Anatomical reduction by closed or open method; stable fixation with three cannulated cancellous screws augmented with medial buttress plate, increases fracture union rate compared to the historical series using closed reduction and cancellous screw fixation alone. Open reduction and medial antiglide plate fixation do not appear to increase morbidity. How to cite this article Singaravadivelu V, Kartheesan G, Vignesh S. Unstable Fracture Neck of Femur in Young Adults: Management with Cannulated Cancellous Screws Augmented with Medial Buttress Plate. J Orth Joint Surg 2019;1(1):1–4.

Medial buttress plate augmentation of cannulated screw fixation in vertically unstable femoral neck fractures: Surgical technique and preliminary results

ObjectiveTo evaluate the outcome and complications of unstable Pauwels type 3 femoral neck fractures treated with a combination fixation of three cannulated screws and a medial buttress plate. Patients and methodsFrom October 2015 to June 2016, 28 patients under 60 years of age with Pauwels type 3 femoral neck fracture were treated with open reduction and internal fixation using a direct anterior approach. Fracture consisted of three cannulated screws augmented with a medial buttress plate. All reductions achieved Garden’s alignment index grade one. Touch down weight bearing was permitted post-operatively for 6 weeks, and subsequently advanced to full weight bearing. One patient was lost to follow-up, which the remaining 27 patients were followed at 1 week, 6 weeks, 3 months, 6 months and 12 months post-operatively. ResultUnion without femoral neck shortening was achieved in 89% of cases. Implant failure was seen in 3 cases and was associated femoral neck shortening. Reduction loss with backing out of the cannulated screws occurred in these cases, and in one case there was also plate and screw breakage. There were no cases of avascular necrosis identified at a mean follow-up was 13.6 months ConclusionAt short time follow-up, treatment of Pauwels type 3 femoral neck fractures using cannulated screws combined with medial buttress plate improves the fracture union rate compared to historical series using cannulated screws alone. The method of medial buttress plate augmentation does not appear to increase any implant related complications, including avascular necrosis.

Biomechanical assessment of newly-designed proximal femoral medial buttress plate for treatment of reverse oblique femoral intertrochanteric fracture

To evaluate the biomechanical properties of proximal femoral medial buttress plate (PFMBP) for fixing the reverse oblique intertrochanteric fractures by comparing with proximal femoral locking compression plate (PFLCP) and proximal femoral nail antirotation (PFNA). Eighteen synthetic femoral bone models (Synbone) were divided into 3 groups (group PFLCP, group PFNA, and group PFMBP), 6 models in each group; an AO 31-A3.1 reverse oblique femoral intertrochanteric fracture was made based on the same criterion. After being fixed and embeded, the axial load testing, torsion testing, and axial load-to-failure testing were performed on each model. The axial displacement of different loads, torque of different torsion angles, and failure load of each model were recorded, and the stiffness of axial load and torsion were calculated. The axial stiffness in groups PFLCP, PFNA, and PFMBP were (109.42±30.14), (119.13±29.14), and (162.05±22.05) N/mm respectively, showing significant differences between groups ( P<0.05). There were significant differences in torque between different torsion angles in the same group, as well as in the torque between groups at the same torsional angle ( P<0.05). The torsion stiffness in groups PFLCP, PFNA, and PFMBP were (1.45±0.44), (1.10±0.13), and (1.36±0.32) N·mm/deg respectively; there were significant differences when compared groups PFLCP and PFMBP with group PFNA ( P<0.05), but no significant difference was found between group PFLCP and group PFMBP ( P>0.05). The failure loads of groups PFLCP, PFNA, and PFMBP were (1 408.88± 0.17), (1 696.56±0.52), and (2 154.65±0.10) N respectively, showing significant differences between groups ( P<0.05). The newly-designed PFMBP is better than PFNA and PFLCP in axial load stiffness and torsion stiffness for fixing reverse oblique intertrochanteric fracture by biomechanical test, indicating that reconstruction of medial stability is a key element for unstable intertrochanteric fracture.

Results of biological restoration of varus impacted proximal humeral fracture and stabilization with locked plate and calcar screws

Background: Varus impacted proximal humeral fractures (B2.2) is a unique type of fracture with multiple sequelae and unpredictable outcome. There is a high incidence of varus collapse and loss of fixation associated with this type of fracture especially in patients with loss of medial calcar. This created the idea of reconstructing the medial calcar during internal fixation to avoid recurring deformity and malunion. The aim of this study was to evaluate the results of fixation of varus impacted proximal humeral fracture using locking plate fixation with a calcar screw and without the use of bone grafting or opening of the joint capsule for reconstruction of the medial buttress. Methods: A series of 39 operative procedures of varus proximal humeral fractures were fixed with locking plate and calcar screws. Clinical and radiographic outcomes were collected and evaluated. Results: At 2-year follow-up, the mean Constant score was 83.9±6.4 (range 68-92), with four patients lost for different reasons. At final follow-up, the head-shaft angle was 130.3±8 degrees (range 111-143 degrees), the change in the angle because of subsidence ranged between 0 to 20 degrees (4.4±5.3 degrees). The complications included two superficial wound infections, one developed greater tuberosity nonunion, and nine had subsidence of the head with minor change of the head-shaft angle at follow-up. Six patients had a change of 5 to 10 degrees, while three patients had a 10 to 20-degree change. Conclusions: Medial calcar comminution can be treated successfully by the use of locking plate fixation with calcar screws with no additional grafting. Long-term follow-up is required to ensure the persistence of good results.

The outcome of unstable proximal femoral fracture treated with reverse LISS plates

BackgroundThe Russel-Taylor type 2B fractures compromised the trochanteric region and medial buttress of proximal femur. This fracture pattern limits the choice of implants and raises the risk of adverse outcomes. We aimed to (i) determine the outcome of Russel-Taylor type 2B fractures treated using reverse less invasive stabilization system plates (LISS-DF) and to (ii) learn what factors affected outcomes after osteosynthesis with reverse LISS plates. DesignA retrospective study SettingThe study was conducted at a Level III trauma center in Taiwan. MethodsTwenty-five consecutive patients presenting with a Russel-Taylor type 2B fracture were enrolled. All cases were treated with reverse LISS plates. A Modified Radiographic Union Scale for Femur (RUSF), Radiographic parameters, functional scores, and complications were assessed. ResultsUnion occurred in 21 cases at an average of 18.8 weeks. The average immediate postoperative neck-shaft angle was 130° (range: 122–135°) compared with 139° (range: 135–141°, p=0.05) on the contralateral side. Two cases had complications of proximal screws cutting out and two cases had broken implants. Finally, all 4 cases required repeated surgeries (16%). Malunion occurred in 4 patients and early mechanical failure (proximal screws cut out) occurred in 2. There was a significant difference in the purchase index of the proximal screws between cases with redisplacement and those without (26.4mm and 98.6mm, p=0.01). ConclusionsThe use of reverse LISS plate appeared to be an alternative procedure for the specific pattern in the present study. We recommend using this reverse locking plate to treat unstable proximal femoral fractures with meticulous techniques of placing plates. Adequate purchase of the proximal locking screws might decrease the risks of complications.

Rate of Malunion Following Bi-plane Chevron Medial Malleolar Osteotomy

Access to the medial half of the talus can be challenging even with an osteotomy. Although several techniques are presented in the literature, critical evaluation of fixation, union, and alignment is lacking. The chevron medial malleolar osteotomy provides advantages of perpendicular instrumentation access and wide exposure to the medial talus. Postoperative displacement resulting in malunion, and possibly provoking ankle osteoarthritis, is a known complication. The present study describes our experience with the osteotomy. A consecutive series cohort of 50 bi-plane chevron osteotomies performed from 2004 to 2013 were evaluated. Forty-six were secured using 2 lag screws, and 4 were secured using 2 lag screws and a medial buttress plate. Radiographic studies performed at 2, 6, and 12 weeks and at final follow-up were analyzed for postoperative displacement, malunion, non-union, and hardware-related complications. At initial postoperative follow-up, 47 of 50 had adequate radiographs for review, and 18 of 47 (38.3%) showed some displacement when compared to the initial osteotomy fixation position. By final follow-up, 15 of 50 (30.0%) had measurable incongruence. Hardware removal was performed in 13 (26.0%) cases at an average of 2.4 years postoperation. Bi-plane medial malleolar chevron osteotomy fixed with 2 lag screws showed a 30.0% malunion rate with an average of 2 mm of incongruence on final follow-up radiographs, which is higher than what has been reported in the literature. In our practice, we now use a buttress plate and more recently have eliminated postoperative osteotomy displacement. Level IV, retrospective case series.

Optimizing Stability in Femoral Neck Fracture Fixation.

Optimizing stability of femoral neck fracture fixation is important in obtaining a successful outcome. The mechanical problems and strategies for achieving optimal stability differ depending on patients' age and degree of osteoporosis. Femoral neck fractures in younger adults usually result from high-energy trauma and have a vertical fracture pattern. Strategies for optimizing fixation stability in this group include placing additional screws at right angles to the fracture plane and medial buttress plate augmentation. In elderly patients, screw position relative to the intact cortical femoral neck bone is of critical importance. Additional strategies for optimizing fixation stability in this group include the concept of length stable fixation, use of adjunctive calcium phosphate cement, and use of novel fixed angle fixation implants.

Coronoid Fractures.

Fractures of the coronoid process of the ulna are usually part of a more complex injury. The type of coronoid fracture corresponds with a specific pattern of injury with known pitfalls and recommended treatments. Tip fractures usually correspond with dislocation of the elbow and fracture of the radial head (the so-called terrible triad of the elbow because it is prone to redislocation, subluxation, and arthrosis) and are best repaired with a suture passed through drill holes along with repair or replacement of the fractured radial head and reattachment of the lateral collateral ligament to the lateral epicondyle. Anteromedial fractures are usually part of a subluxation injury and are best addressed with a medial buttress plate and reattachment of the lateral collateral ligament. Large basilar coronoid fractures are usually part of an olecranon fracture-dislocation and are usually repaired with 1 or 2 plates and screws. Tenuous fixation is protected with temporary external fixation or cross-pinning of the joint because healing of the coronoid with concentric elbow alignment is critical. Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Proximal Femoral Shortening after Operation with Compression Hip Screws for Intertrochanteric Fracture in Patients under the Age of 60 Years.

PurposeWe aimed to quantify proximal femoral shortening after operation with compression hip screws for intertrochanteric fracture in patients under the age of 60 years.Materials and MethodsWe followed 37 consecutive patients with intertrochanteric fractures treated with compression hip screws from March 2005 to February 2014. We designated the aspect of the fracture, a defect of the postero-medial wall, a defect of the lateral wall, and the degree of reduction as four potentially important factors we assumed would strongly affect proximal femoral shortening. We quantified proximal femoral shortening and compared the effects of above factors. We divided femoral shortening into two plane vectors; femoral offset in the horizontal plane and leg length discrepancy in the vertical plane. We measured shortening separately during two periods: during operation and after weight bearing (called dynamic compression).ResultsAfter bone union, the average femoral offset shortening was 5.45 mm. Patient groups with anatomic reduction and intact postero-medial wall showed lower femoral offset shortening than the respective opposite groups. As to functional score using modified Harris hip score, low femoral offset shortening group showed more 2.35 scores than high groups. None of the factors significantly affected leg length shortening.ConclusionWe found that a stable medial buttress is involved in lower femoral offset shortening. Thus, surgeons need to attempt to recover the defect of the medial wall and to reduce anatomically when operating intertrochanteric fractures with compression hip screws.

Application of a medial buttress plate may prevent many treatment failures seen after fixation of vertical femoral neck fractures in young adults

Femoral neck fractures in young adults with normal bone are mostly vertically oriented and may have variable amounts of comminution, which result from shearing forces during high-energy trauma. These factors play a role in the high rate of complications after this injury, including nonunion, malunion, failure of fixation, and avascular necrosis. These problems often occur together and inter-relate, for example, nonunion or malunion frequently result from fixation failure and varus collapse of the femoral head after reconstruction. The orthopaedic surgeon’s goals of obtaining and maintaining anatomic reduction until bony union have been addressed by a number of surgical approaches and fixation constructs, however, complications are still common and no consensus exists on how these problematic fractures may be best treated. For optimal treatment of vertical femoral neck fractures, anatomic reduction must be achieved and fixation must be able to resist the high shear forces across the fracture with hip motion, weight-bearing, and muscle tone. Buttress plate fixation is a common method for stabilizing fractures that require resistance to shear forces and stands as one of the basic principles of fracture care. This technique has not been widely applied to this injury pattern. We propose that the concepts of modern fracture care should be applied together for vertical femoral neck fractures in young adults. Specifically, we propose that anatomic reduction and fixation of vertically oriented femoral neck fractures with the addition of a medial buttress plate to resist shearing forces will improve on the historically high rate of complications after these difficult injuries.

Biomechanical analysis of distal femoral fracture fixation: dynamic condylar screw versus locked compression plate

Background This human cadaveric study introduces a laboratory model to establish and compare the fixation stability of the distal femoral locking plate (DFLP) and dynamic condylar screw (DCS) in distal femoral fracture fixation.Materials and methods The study was conducted on 16 fresh cadaveric femoral specimens, 8 implanted with the DCS and the other 8 with the DFLP. The construct was made unstable by removing a standard-sized medial wedge with a 1-cm base (gap osteotomy) beginning 6 cm proximal to the lateral joint line in the distal metaphyseal region with loss of the medial buttress. Each specimen underwent axial and torsional stiffness testing along with cyclic axial loading to failure. The mean DEXA value for the DFLP group was 0.82 g/cm2 and in the DCS group was 0.79 g/cm2.Results Axial stiffness in the DFLP group was significantly higher than in the DCS group, but no significant difference was found in torsional stiffness between the groups. A significant difference was found in the load-to-failure results between the groups. Plastic and total deformation was significantly higher in constructs in the DCS group than in those in the DFLP group. Total energy absorbed before construct failure was also significantly higher in the DFLP group than in the DCS group.Conclusions The DFLP construct proved stronger than the DCS in both axial stiffness and cyclic loading, but similar in torsional stiffness in biomechanical testing in a simulated A3 distal femoral fracture.

Risk of injury to the axillary nerve during antegrade proximal humeral blade nail fixation – An anatomical study

IntroductionThe antegrade intramedullary Locking Blade Nail (Marquardt, Germany) is a device aimed at improving purchase in the humeral head and reducing varus displacement by providing medial buttress support and triangular stability within the humeral head. The aim of this study is to measure the relationship of the proximal fixation screws to the axillary nerve. Methods13 whole cadavers underwent insertion of an antegrade proximal humeral blade nail via a deltoid split approach to both shoulders. The anatomic proximity of the anterior branch of the axillary nerve to the screws was measured following soft tissue dissection and inspection of the nerve. ResultsThe mean distance of the nerve from the anterolateral acromion was 62mm (range 45–81mm). The nerve lay closest to the distal blade fixation screw 4.9mm (range 0–19mm). In three cases the nerve lay directly underneath the washer and in all three cases there was macroscopic evidence of damage to the nerve. In 5 cases the nerve travelled obliquely in a cranial direction to lie 1.8mm (range 0–3mm) from the distal blade fixation screw, in 2 of these cases the nerve lay beneath the washer. ConclusionThe anterior branch of the axillary nerve is placed at risk during insertion of the locking screws despite use of protection sleeves and trocars. We advocate that when using antegrade intramedullary nails that incorporate an inferomedial calcar screw an extended anterolateral acromial approach is undertaken.

Treatment of Proximal Humeral Nonunions With a Locked Plate and an Intramedullary Strut Autograft

Proximal humeral fractures are common and account for 5% of all fractures. As a result of the poor results of conventional plate fixation, a multitude of other operative techniques have been described for the treatment of displaced fractures. The use of locking plates has distinct mechanical advantages over other modes of fixation but does not always adequately hold the head fracture that relies on a medial buttress to prevent its collapse into varus. Nonunions of proximal humeral fractures are not uncommon and represent a significant challenge to the treating surgeon. We describe a technique to treat a proximal humeral nonunion that combines the use of a locked plate with an iliac crest corticocancellous bone peg to augment the mechanical strength of the calcar region and autogenous cancellous bone graft in an attempt to enhance union rates.

Biomechanical comparison of dynamic condylar screw and locking compression plate fixation in unstable distal femoral fractures: An in vitro study

Background:Distal femur fractures are difficult to manage and the selection of implant for internal fixation remains controversial. The objective of this study is to establish the relative strength of fixation of a distal femoral locking plate (DFLP) compared with the dynamic condylar screw (DCS) in the distal femur fractures.Materials and Methods:Study was conducted on 16 freshly harvested cadaveric distal femoral specimens, eight implanted with DCS and other eight with DFLP. The construct was made unstable by removing a standard sized medial wedge of 1 cm base (gap-osteotomy) beginning 6 cm proximal to the lateral joint line in distal metaphyseal region with the loss of medial buttress. Fatigue test was conducted under load control mode at the frequency of I Hz. Specimens were subjected to cyclic loading of 2 kN, under observation for 50,000 cycles or until failure/cutout, which ever occurred earlier.Results:In DFLP group, there was no implant failure and the average number of cycles sustained was 50,000. Six out of eight specimens completed 50,000 cycles and two failed in DCS group. The average number of cycles sustained by DCS was 46150. Though the bone quality as assessed by dual energy X-ray absorptiometry DEXA was comparable in both DFLP and DCS group (P = 0.06), none failed in DFLP group and subsidence was 1.02 ± 0.34 mm (range: 0.60-1.32 mm), which was significantly 43% lower (P = 0.006) than subsidence in DCS group (1.82 ± 0.58; range: 1.20-3.08 mm). The average stiffness of DCS group was 52.8 ± 4.2 N/mm, which was significantly lower than average stiffness of locked condylar plate group (71.2 ± 5.1 N/mm) (P = 0.02).Conclusions:DFLP fixation of the distal femur fractures resulted in stronger construct than the DCS fixation in both cyclic loading and ultimate strength in biomechanical testing of a simulated A3 distal femur fracture.

Biomechanical analysis of four kinds of internal fixations for subtrochanteric fractures

Objective To compare the biomechanical properties of four kinds of internal fixations (PFN,DHS,DCS and PFLP) for different types of subtrochanteric fractures.Methods Thirty-two antiseptic femurs were randomly divided into four groups.After internal fixations implanted respectively,Seinsheimer type Ⅰ,type Ⅲ A with medial fragment restoration,type Ⅲ A with medial fragment discard and type Ⅳ subtrochanteric fracture models were sequentially produced.Each fracture model was tested under vertical load,torsional load and vertical damage load.The strain distributions on both medial and lateral side of subtrochanteric region were recorded and the compression stiffness and torsional stiffness of bone-implant composite were calculated.Finally,the loads of failure were recorded.Results The stiffness ratio of PFN in each fracture model and load of failure were the highest among the four groups,but the torsional stiffness ratio was the lowest.Tension strain ratios of DHS and DCS on lateral side became higher compress strain ratio with medial fragment restored.Stiffness ratio of DHS was lower than PFLP in each fracture model,torsional stiffness ratio was the highest in fracture model Ⅱ to Ⅴ,and the load of failure was only lower than PFN.The stiffness ratio and load of failure of DCS were both the lowest,torsional stiffness ratio was similar to PFLP's in fracture model Ⅱ toY.The stiffness ratio of PFLP was only lower than PFN's in each fracture model,but the load of failure was lower than DHS's.Conclusion Four kinds of internal fixations could achieve better stabilities for type Ⅰ subtrochanteric fractures.PFN and PFLP could achieve reliable stabilities for type ⅢlA subtrochanteric fractures.And,if the medial buttress was restored,we could consider of using the DCS.For type Ⅳ subtrochanteric fractures,only PFN could provide stable fixation.However,when bone fragments are large at comminuted part,PFLP could be chosen to fix them after anatomical reduction. Key words: Hip Fractures; Internal Fixators; Biomechanics

Transoral Endoscopic Assisted ORIF of Orbital Rim Fractures

Objectives: 1) Evaluate the feasibility of a purely transoral approach to infraorbital rim fractures using endoscopic assistance. 2) Analyze the patient outcomes of cosmesis and the success rate of reduction and fixation. Methods: A retrospective review was conducted in 16 midface facial fracture patients that presented to a level one trauma center in 2011-2012 involving orbital rim fractures that did not require orbital floor exploration. All patients had open reduction internal fixation (ORIF) of midface facial fractures (medial and lateral buttress, and orbital rim) through a transoral approach utilizing endoscopic assistance. The zygomatic-frontal (ZF) suture line fractures were repaired through a superior blepharoplasty incision. Orbital rim ORIF was accomplished with modified curved and ladder plates from stock midface vendor plating systems. The plates were fabricated to be positioned laterally on the orbital rim and then course inferiorly to the inferior orbital nerve (ION) and medially fixated to the medial buttress bridging the orbital rim fracture. Results: All patients had acceptable reduction and fixation of orbital rim fractures with cosmetically acceptable results. There was no plate extrusion or infection or worsening of ION parasthesias, with six patients having immediate post-operative improvement in their ION parathesia. No post-operative enophthalmos or diplopia was noted and no revision surgery was needed. Conclusions: A transoral endoscopic approach for carefully selected midface fractures involving the orbital rim is feasible with acceptable results. Future work is needed to develop a prefabricated plate that can be stocked in mid-face plating systems.

Comparitive Analysis Of Intramedullary Versus Extramedullary Fixation In Subtrochanteric Fractures

Prospective study of 40 cases of subtrochanteric fracture treated either extramedullary fixation intramedullary fixation in Sri Ramachandra medical center April 2011to June 2013. Inclusion criteria are all traumatic subtrochanteric fractures, exclution criterias are all open fractures paediatric fractures, pathologic fractures. We had 20 extramedullary and 20 intramedullary fixations we used schatzker and Lambert scoring system, mean follow up for 2 years. The most important factor to prevent the failure of fixation may be due to inadequate initial reduction. The most important factor to prevent the failure of fixation is anatomical reduction of fracture and restoration of medial buttress. In our comparative analysis of intramedullary versus extramedullary fixation of subtrochanteric fractures. Intramedullary devices give superior results than extramedullary devices. But the most important factor to prevent the failure of fixation is Anatomical reduction of fracture at time of surgery.

Comminuted quadrilateral plate fracture fixation through the iliofemoral approach

Comminuted quadrilateral plate fracture with medial displacement is a technically difficult fracture to treat. Minimal bone stock, proximity to the hip joint with limited surgical access, and difficulty in obtaining a stable fixation at this area, contribute to the surgical challenge of open reduction and internal fixation. Fixation of a medial buttress plate in an infrapectineal fashion is a well-described technique to address such fractures. However, this plate alone may be inadequate to buttress all the fragments in a grossly comminuted quadrilateral plate fracture. An additional spring plate is often placed underneath the infrapectineal plate to hold the fracture fragments. Conventionally, these spring plates are fixed to the ilium superiorly while the other end buttresses the quadrilateral plate when placed underneath the infrapectineal reconstruction plate. The standard ilioinguinal approach and modified Stoppa approach have been described for the surgical access to the quadrilateral plate. Both the approaches have some limitations in addressing quadrilateral plate fracture. The ilioinguinal approach requires extensive dissection and mobilisation of inguinal neurovascular bundle. The modified Stoppa approach does not permit visualisation of the entire anterior column and the hip joint. The authors, in this article, describe the fixation of the comminuted quadrilateral plate fracture through the iliofemoral approach combined with a medial ilioinguinal window. The technique involves fixation of a spring plate (Allis T-plate) at right angle to the infrapectineal buttress plate (90°–90° plate construct). The vertical limb of the T-plate is fixed to the iliopectineal eminence whereas the horizontal limb buttresses the quadrilateral plate Hence, this technique addresses fractures of both the iliopectineal eminence and the quadrilateral plate. Other than that, the iliofemoral approach permits direct visualisation of the entire anterior column and the hip joint without the necessity to dissect the ilioinguinal neurovascular structures.

Pseudarthrosis of the surgical neck of humerus treated by buttressing with a medial cortico-cancellous graft

Background:Pseudarthrosis of surgical neck of humerus is uncommon condition. Different methods of improving the stability of fixation have been described, including impaling the shaft into the head, placing a tension suture through the rotator cuff, or using an intramedullary cortical graft. We report our results of cortico-cancellous strut graft medially to counter the varus force, in conjunction with a fixed-angle implant on the lateral side.Materials and Methods:We used this technique in seven cases of pseudarthrosis of surgical neck of the humerus. There were four women and three men, ranging in age from 22 to 65 years. All were treated with a tricortical medial buttress bone graft and fixed-angle fixation device on the lateral side. A locking proximal humerus plate (Synthes) was used in six cases, and a bent reconstruction plate (Synthes) was applied in one case. The one in which reconstruction plate was applied was operated before the advent of locking plates. The limb was immobilized in 30° of abduction over a cushion for 6 weeks, followed by a sling for another 6 weeks.Results:The followup varied from 18 to 96 months. All our cases healed within mean 5.1 months (range 4–6 months). There was one case of avascular necrosis. All cases had useful function of shoulder.Conclusion:The medial buttressing by strut graft with external fixation by laterally placed fixed angle plate is successful to achieve fracture union in pseudarthrosis of surgical neck of humerus.