Osteosynthesis Of Fractures Research Articles

Inferior subluxation of humeral head after osteosynthesis for greater tuberosity fracture

BackgroundInferior subluxation of the humeral head is frequently observed immediately after surgery for proximal humerus fractures; however, the incidence and risk factors of inferior subluxation after osteosynthesis for isolated greater tuberosity fractures remain unsolved. Additionally, the postoperative course of inferior subluxation has not been elucidated. The purpose of the present study is to identify the predictors for the occurrence of postoperative inferior subluxation by multivariate analysis and investigate the postoperative shift of inferior subluxation and its effect on surgical outcomes.MethodsWe retrospectively identified 68 patients who underwent surgery for isolated greater tuberosity fractures. The dependent variable was the inferior subluxation at 1 week postoperatively. The explanatory variables were age, sex, affected side of the shoulder, body mass index, history of smoking, local osteoporosis, time period to surgery, axillary nerve injury, inferior subluxation before surgery, fracture dislocation, surgical approach, surgical method, operative time, amount of blood loss, and postoperative drainage. Baseline variables that were statistically significant in the univariate analyses were included in the logistic regression analysis. The patients were further categorized into two groups according to the presence of inferior shoulder subluxation exhibited 1 week postoperatively: patients with inferior subluxation (+ IS group) and patients without inferior subluxation (− IS group). We compared the incidence of postoperative complications between the two groups.ResultsOf 68 patients, 17 (25.0%) had inferior shoulder subluxation observed 1 week postoperatively. Multivariate analysis showed that long operative time was a risk factor for postoperative subluxation (odds ratio = 1.03; P = 0.030). In all cases, inferior subluxation disappeared within 3 months of surgery. No significant difference in complication rate was observed between the + IS and − IS groups.ConclusionsThe present study provides novel information regarding postoperative inferior subluxation of fractures of the greater tuberosity. Inferior subluxation occurred in 25% of patients immediately after surgery. Long operative time contributes to the onset of postoperative inferior subluxation; however, this was temporary in all cases and had no significant effect on the surgical outcomes.Level of Evidence: Level III.

Study of the Stress-Strain State of the "Bone–Fixation Plate" System in Conjunction With Cortical Tissue Mechanical Properties

Background. Bone osteosynthesis is considered one of the most efficient methods of treating fractures of long tubular bones. Deve­lopment of modern computer technology and specialized software makes it possible for a traumatologist to perform preliminary efficiency estimation of osteosynthesis using fixation plates of various designs. Results of such studies can significantly depend on calculation model parameters. In most papers related to the study of a stress-strain state of “bone–fixator” systems, bone tissue is considered as a homogeneous, isotropic, elastic medium. However, in fact it is heterogeneous and has an anisotropy of mechanical characteristics. Accordingly in a case of using a simplified isotropic model of bone tissue, when performing calculations, there is a possibility of obtaining inaccurate results. Objective. Estimation of influence of orthotropy of the bone tissue physical and mechanical properties on a stress-strain state of the “bone–fixator” system. Methods. The study is performed in the software environment based on the finite element method. Osteosynthesis of a low transverse fracture of a fibula using a smooth plate is selected as a computational case. Two computational models simplified in terms of geometry are constructed to solve the problem. These models are different only in properties of cortical bone tissue. Results. Analysis of a stress state in elements of models indicated that normal stresses reached the highest values, and tangential stresses are relatively small. In addition, the character of stress distribution turned out to be significantly inhomogeneous. However, stress state patterns are qualitatively similar for both computational models. A common feature of the maximum stresses both in the bone and in the plate turned out to be that all the maximum stresses are the result of their concentration. Conclusions. Consideration of orthotropy of elastic parameters of a bone led to significant quantitative changes in the indicators of a stress state. It is established that the minimum safety margins for both models turned out to be considered by the maximum tensile stresses acting in the vertical direction. A similar result in estimating bone strength also occurs in a case when only elastic orthotropy is considered, but the orthotropy of strength indicators is not considered. If the strength orthotropy is considered for the isotropic model of cortical bone, the pattern changes qualitatively. The normal tensile stress directed along the tangent to a circumference of bone cross-section is considered unsafe. Calculations results indicate a possibility of using an isotropic model of cortical tissue when performing comparative estimations in order to identify the most efficient, in terms of strength, fixation plate designs.

Establishing safe zones to avoid nerve injury in the posterior minimally invasive plate osteosynthesis for humerus fractures: a magnetic resonance imaging study

Safety zones to avoid nerve injury at proximal incision of posterior minimally invasive plate osteosynthesis for humerus fracture have been scarcely studied. The purpose of this study was to describe the location of axillary and radial nerves (RN) in magnetic resonance imaging to establish safety zones. Fifty-two magnetic resonance imaging studies of the entire humerus were reviewed. The mean age was 50.6±12.1 years, with 37 female patients. The distance of the axillary nerve (AN; distal portion, humeral midpoint) and RN (medial border, midpoint, and lateral border of the humerus) was measured in relation to the posterolateral acromion angle, acromioclavicular axis, and transepicondylar axis. Univariate analysis (Student's t test) and a multivariate analysis (linear regression) were performed. P values < .05 were considered significant. The AN location at the humerus was 54.9±6.4 mm (20.1% humeral length [HL]) in relation to posterolateral acromion angle and 63.2±6.1 mm (23.2% HL) in relation to acromioclavicular axis. The RN location was 100.2±17.1 mm (36.6% HL) at the humerus medial border, 118.0±21.5 mm (43.1% HL) at the humerus midpoint, and 146.0±24.4 mm (53.6% HL) at the humerus lateral border. In relation to transepicondylar axis, it was 175.4±15.6 mm (64.3% HL), 156.0±19.0 mm (57.2% HL), and 127.4±21.2 mm (46.7% HL), respectively. Nerves location was related to HL, independent of gender. The main finding of our study is that the location of the AN and RN in relation to the humerus is related to the HL and can be used to predictably define the safe zones to avoid nerve injury in the proximal incision of posterior minimally invasive plate osteosynthesis for humerus fractures.

Modified high-submandibular appraoch for open reduction and internal fixation of condylar fracture: case series report.

Recently a modified high-submandibular approach (HSMA) has been introduced for treatment of condylar fracture. This approach involves an incision line close to the mandibular angle and transmasseteric transection, leading to a low incidence of facial palsy and allowing good visualization of the condyle area, especially the condylar neck and subcondyle positions. This study reports several cases managed with this modified HSMA technique for treating condylar fractures. Six cases of condylar fractures treated with modified HSMA technique were reviewed. Three unilateral subcondylar fracture, 1 bilateral subcondylar fracture, 1 unilateral condylar neck fracture, 1 unlateral simultaneous condylar neck and subcondylar fracture cases were reviewed. All the cases were successfully treated without any major complication. Reduction, fixation, and osteosynthesis of condylar fractures via the modified HSMA technique enabled effective and stable treatment outcomes. Therefore, the described approach can be used especially for subcondylar and condylar neck fractures with minimal complications.

ЛЕЧЕНИЕ ГНОЙНЫХ ГОНИТОВ

Purulent gonitis that has arisen after knee replacement, osteosynthesis with fractures of the bones forming the knee joint, arthroscopy, and the introduction of medications is a serious complication, the treatment of which is a social and economic problem. The aim of our study was to evaluate the effectiveness of the choice of treatment tactics for patients with purulent gonitis according to their etiology, local changes in the joint as well as the type and resistance of the infection causative agent. The analysis of the treatment of 154 patients was carried out. In most cases, 97 patients (63%), gonitis was noted in the form of the periprosthetic joint infection (PJI). In 33 (21%) cases it was noted with postoperative osteoarthritis after osteosynthesis of intra-articular fractures of the bones forming the knee joint. After arthroscopy with knee joint ligament surgery — 10 (7%) cases, intra-articular injections of drugs into the knee joint — 14 (9%). The high effectiveness of sanitizing treatment was achieved in 146 (94,8%) cases. 93 (95,8%) of the patients had PJI, 32 (96,9%) had postoperative osteomyelitis, 9 (90%) had arthroscopy, and 12 (85,7%) had intra-articular drug injections. The tactics of treatment of purulent gonitis depends on the etiology and nature of the joint lesion, the resistance of the microorganism, and the comorbid condition of patients.

Mini-invasive approach vs. traditional open reduction for periprosthetic hip fracture osteosynthesis with the NCB® plate

BackgroundPostoperative hip periprosthetic fracture (PPF) is a frequent complication whose treatment does not achieve optimal results among eldery fragile patients. Locking compression plate (LCP) osteosynthesis is the gold standard treatment for Vancouver B1 and VC fractures and there is a growing consensus in doing the same with B2 fractures in patients with high comorbidity. Following that trend of being as non-aggressive as possible we investigated whether a mini-open (MO) approach would lead to better outcomes in LCP plate osteosynthesis of hip PFFs when compared to the traditional open approach. MethodsWe retrospectively evaluated a cohort of 43 VB1, VB2 or VC hip PPFs treated with non contact bridging (NCB®) plate osteosynthesis by two possible approaches. MO vs traditional open approach. The main objective was to assess whether MO approach decreases operative time, bleeding and local complications. The secondary objective was to demonstrate that this may have a positive effect on patient function. ResultsThe mean age was 79.6 years old and 74.5% patients had an ASA score of III or IV. The surgical time was 148.53 min (SD 33.2) in the open approach versus 107.42 min (SD 25.6) in the MO, which was 31 min shorter (p<0.001). Hemoglobin dropped 0.9 points less, on average (p. 0.005) and 0.82 fewer blood concentrates were required (p. 0.022) with MO approach. There were no differences among complications but there was a trend towards greater independence and better mobility in the MO approach group with a postoperative Barthel of 74.37 (sd. 13.21) compared to the 66.67 points (sd. 13.7) in the traditional approach group. ConclusionMO approach in osteosynthesis of hip PFFs decreases operative time and intraoperative bleeding so it must be considered in fragile patients with high comorbidity.

Comparison of the clinical and radiographic outcomes of plate fixation versus new-generation locked intramedullary nail in the management of adult forearm diaphyseal fractures.

This study aimed to compare functional and radiographical outcomes following intramedullary nailing (IMN) versus plate and screw osteosynthesis in managing patients with diaphyseal forearm fractures. Forty-six patients (27 male, 19 female) were included in this retrospective study. Of these, 25 were treated with plate osteosynthesis and 21 with IMN. The mean age was 32.4 (range, 19-67) years in the plate group and 28.8 (range, 18-64) years in the IMN group. The mean follow-up was 22.3 (range, 12-36) months in the IMN group and 24.8 (range, 12-48) months in the plate group. Functional outcomes were evaluated based on the forearm pronation/supination range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Grace-Eversmann scoring criteria. The median time to union was 13.6 weeks in the plate group and 10.9 weeks in the IMN group (p<0.05). Union was achieved in 24 of 25 patients in the plate group (96%) and all patients in the IMN group (100%). The mean operative time was 69.7 (range, 45-110) minutes in the IMN group and 88.2 (range, 50-130) minutes in the plate group. The mean fluoroscopy time was 2.7 seconds in the plate group and 21.3 seconds in the IMN group. The mean length of hospital stay was five (range, 3-9) days in the plate group and four (range, 3-10) days in the IMN group. The mean operative time was significantly shorter in the IMN group (p < 0.05), while the mean fluoroscopy time was longer in the IMN group (p < 0.05). There was no significant difference between the groups in forearm pronation and supination, grip strength, DASH score, and Grace-Eversmann scoring criteria. Locked IMNs seem a viable alternative to ORIF with plate osteosynthesis for adult diaphyseal forearm fractures with similar healing rates, functional scores, and shorter operative times. Level III, Therapeutic Study.

Screw placement in arthroscopically assisted osteosynthesis of radial head fractures using a reference k-wire in the radiocapitellar joint: a cadaveric study

PurposeThe optimal screw placement in arthroscopically assisted fixation of radial head fractures is still an issue and no guiding methods have been evaluated in the recent literature. The study hypothesis was that using a “reference k-wire” percutaneously inserted in and parallel to the radiocapitellar joint would enable to achieve a trajectory more parallel to the radial head articular surface as compared to a free-hand k-wire placement.MethodsArthroscopically assisted placement of a k-wire in the radial head was performed in seven fresh-frozen human cadaver specimens by three surgeons. Three different techniques were evaluated: freehand drilling (technique A), placement using a “reference” k-wire in the radiocapitellar joint as a reference without (technique B), and with the AO parallel k-wire guide (technique C). Radiographs from all procedures were obtained and the inclination angle “α” between the k-wire and the articular surface of the radial head was measured and compared among the techniques.ResultsAngles of 84 radiographs were obtained and showed a mean α angle of 30.1° ± 13° for technique A, 5.7° ± 4.5° for technique B, and 5.4° ± 3.7° for technique C. The angle α was significantly higher with technique A as compared to B (p < 0.0001) and C (p < 0.0001). There was no difference between methods B and C (n.s.). No difference was observed among the surgeons for all three methods (p = 0.66).ConclusionWith the use of an additional “reference” k-wire placed in the radiocapitellar joint, the guiding k-wire for screw drilling can be placed almost parallel to the radial head joint line with limited variability and a good reproducibility during arthroscopically assisted radial head fracture fixation.Clinical relevanceThe here-presented method of an additional, percutaneous introduced “reference” k-wire is easily applicable and helpful to achieve parallel screw placement during arthroscopically assisted radial head fracture fixation.Level of evidenceIV, biomechanical cadaver study

Dynamics of homocysteine level in patients with osteoporotic fracture

The research was carried out in order to investigate the blood serum level of homocysteine (HCY) which is involved in bone metabolism and has prognostic significance in the monitoring of the regenerative processes in osteoporosis and osteoporotic fractures. The study was carried out on patients 45-83 years old divided into 3 groups: group I – 14 patients with osteoporosis confirmed by densitometry or X-ray examination­, group II – 15 patients with non-osteoporosis fractures, group III – 25 patients with osteoporotic fractures. The control group consisted of practically healthy 14 people. In patients with various fractures osteosynthesis with Ilizarov apparatus or with metal plates was performed. After the operation, the patients were treated in an inpatient setting for a week, then sent for outpatient treatment and prescribed calcium and vitamin D supplements to accelerate the bone regeneration process. A blood sample was taken at 3 stages to monitor the dynamics of HCY level by Elisa test: on the 1st day before treatment, on the 10th day of treatment and 1 month after it. The results showed that on the 1st day before the treatment HCY concentration was statistically increased 2.7 times in group I, 5.6 times in group II, and 6.5 times in group III compared to the control group. In the month of recovery, a significant decrease in HCY level was observed in all treated groups but it still remained higher than in the control indicating the need to recommend additional therapeutic prescriptions. Keywords: level of homocysteine, osteoporosis, osteoporotic fractures

Clinical and radiological outcome of the locked plate osteosynthesis in distal metadiaphyseal tibial fracture according to the severity of comminution: Varus reduction would not be preferable with lower clinical outcomes.

The optimal treatment for distal tibial fractures remains a matter of debate. Nonetheless, plate osteosynthesis produces favorable results to intramedullary stabilization in aspects of alignment restoration. The aim of the study was to compare the radiologic and clinical outcomes of distal metadiaphyseal tibial fracture between a simple/wedge fracture (SWF) and a comminuted fracture (CF) using minimally invasive plate osteosynthesis (MIPO). This retrospective study analyzed patients with SWF or CF of the distal tibial metadiaphysis that was surgically treated with a locking compression plate. Postoperative radiographic assessments and the time to radiologic union were noted. Clinical assessments were evaluated using both the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and the foot function index (FFI). Postoperative complications were documented. Seventy-one cases were analyzed over a mean follow-up period of 20.9 months. Thirty-six patients had SWF and 35 patients presented with CF. The mean time to radiologic union, amounts of postoperative coronal angulation, and incidence of malunion showed no statistical differences. Fibular fixation was more applied in the CF group (P < 0.001). Moreover, the clinical scores revealed no differences. Nonetheless, in the valgus union group, the AOFAS ankle-hindfoot score was 90.9 compared to 84.1 in the varus union group (P = 0.042) and the FFI was 9.2% compared to 20.2% in the varus union group (P = 0.017). Plate osteosynthesis for SWF or CF of the distal tibial metadiaphysis led to high union rates and good clinical outcomes. There was no significant difference in the radiologic and clinical results according to the presence of fracture comminution. Nonetheless, the valgus union group showed better clinical outcomes than the varus union group. Clinically, it would be preferred to avoid intraoperative varus reduction.

The Choice of Osteosynthesis for Distal Radius Fractures: A Matter of Taste, Fracture Instability, or Patient-Related Factors? A Retrospective Study of Functional Outcome in 346 Distal Radius Fractures Operated With Percutaneous Wires or Volar Plate Fixation.

Surgery with volar locking plate (VLP) for distal radius fractures (DRFs) has become dominant over percutaneous Kirschner wire (K-wire) (PKW) fixation. Not many studies have proved advantages of the VLP and the increasing dominance of the VLP is thus not derived from evidence of superiority but influenced by other factors. By retrospectively classifying 346 DRFs treated with either PKW or VLP fixation, according to the Buttazzoni classification system, we aimed to investigate the determining factors for choice of surgical method, and by review of the patients' medical records, the functional outcome, duration, and frequentness of the rehabilitation period were correlated to Buttazzoni type and surgical method. The odds ratio of having volar plate fixation was negatively correlated to age and positively correlated to a higher Buttazzoni type. We found no clinically significant differences in the functional outcome for different Buttazzoni type of fractures within the VLP and PKW groups, respectively, nor between the 2 methods of surgery for any Buttazzoni type of fracture. Younger patients and fractures with higher grade of instability were more likely to be treated with VLP than PKW; however, neither fracture instability nor surgical method had any impact on functional outcome.

Analytical, Stochastic and Experimental Solution of the Osteosynthesis of the Fifth Metatarsal by Headless Screw

This paper evaluates the various approaches to strength and stiffness analysis of fracture osteosynthesis using a headless Herbert screw. The problem has been extensively addressed using several scientific approaches, namely the analytical approach, stochastic approach, experimental approach, and (marginally) using the finite elements method. The problem is illustrated on the use of a prototype headless screw Ti: 4.0/1.4 × 30/7 (manufacturer: Medin, Czech Republic) and the surgical treatment of the fifth metatarsal fracture. Mathematical equations for the analytical calculation of the maximum stresses in the screw were established for tensile/compression loading. This problem is also interesting because of its static indetermination in tension and compression; for this reason, it was necessary to use the deformation condition, i.e., the relationship between screw extension and bone contraction. The stochastic (probabilistic) approach, i.e., application of the Monte Carlo method, takes advantage of the mathematical equations derived during the analytical solution by respecting of the natural variabilities and uncertainties. The analytical and stochastic approaches were validated by measurements on porcine bones and by the finite element method. The data measured experimentally were also processed and used for deriving an equation, appropriately approximating the data. The main part of the measurement was to determine the axial force generated during osteosynthesis with a headless screw. The obtained compressional force was used to determine the maximal stress in the screw and bone. Finally, the methods were compared. In this paper, comprehensive and original approaches based on the authors’ experience with multiple methods are presented. Obtained results are necessary for headless screw designers during optimalization of the implants and are also useful for surgeons developing new surgical techniques. This biomechanical problem was solved in cooperation with the engineering industry and physicians to improve the quality of care for patients with trauma in orthopedics and surgery.

Treatment of fractures of the main phalanx of the fingers in children

BACKGROUND: Fractures of the bones of the hand and wrist account for 25% of all fractures in children, whereas the phalanges are the most common localization of these injuries and account for 15%30% of all fractures of the upper limb. To fix fractures of the neck of the middle and main phalanx of the fingers, traumatologists resort to retrograde osteosynthesis with a spoke, which in all cases passes through the articular surface of the distal fragment, thereby blocking the joint adjacent to the fracture. This significantly complicated postoperative rehabilitation to restore movements.&#x0D; AIM: This study aimed to comparatively analyze the results of extra-articular osteosynthesis of fractures of the distal metaphysis of the main phalanx of childrens fingers.&#x0D; MATERIALS AND METHODS: A prospective cohort study included 52 children with fractures of the main phalanx of the fingers. The study cohort of children was divided into two groups. The main group included 29 children who underwent osteosynthesis of the distal fragment of the phalanx with spokes according to the authors method without passing them through the distal or proximal interphalangeal joint. The comparison group included 23 children who, during osteosynthesis, had spokes carried out retrogradely, through the articular surface of the distal phalanx fragment. The total volume of the restored active movements in the proximal interphalangeal joint was compared after 3, 6, and 12 weeks from the moment of surgery, including local signs of inflammation in the needle insertion site after 3 and 7 days from the moment of surgery.&#x0D; RESULTS: In the main group, signs of inflammation were found only in 10% of the cases, whereas in the comparison group, more serious signs were observed, such as the release of exudate along the spokes in two cases on day 3. The average values of the amplitude of movements at week 3 in the main group are more than two times higher than the average values of the comparison group, 12.06 and 5.56, respectively. The volume of movements in the main group was restored more than two times more efficiently, and in several patients, by week 12, it was restored to 100 of the total volume of active movements in the joint (p 0.05).&#x0D; CONCLUSIONS: The authors method of extra-articular and antegrade osteosynthesis of the fractures of the neck of the main phalanges in children made it possible to achieve better functional results in comparison with the standard method.

Standing osteosynthesis of an accessory carpal bone fracture in a Warmblood mare with a 6‐hole 3.5 talonavicular fusion plate and 3.5‐mm screws

SummaryA 9‐year‐old Warmblood, high‐level showjumping mare sustained an acute, closed, vertical, comminuted fracture of the left accessory carpal bone (ACB) during a fall. The fracture was repaired under standing sedation and local anaesthesia, using a 6‐hole APTUS® 3.5 TFP and 5 × 3.5‐mm self‐tapping TriLock© screws. The mare recovered from surgery without complications. Upon follow‐up examination 9 months post‐operatively the mare was sound in all gaits and back to full athletic activity. The ACB fracture had completely healed. The displaced dorsoproximal fracture fragment was in a stationary position and there was evidence of mild nonprogressive osteoarthritis of the antebrachiocarpal joint.

Plate osteosynthesis combined with bone cement provides the highest stability for tibial head depression fractures under high loading conditions

Older patients sustaining tibial head depression fractures often cannot follow the post-operative rehabilitation protocols with partial weight-bearing of the affected limb, leading to osteosynthesis failure, cartilage step-off and arthritis development. Therefore, the aim of this study was to analyse the biomechanical performance of different types of osteosyntheses alone and in combination with bone cement simulating cyclically high loading conditions of tibial head depression fractures. Lateral tibial head depression fractures (AO: 41-B2.2; Schatzker type III) were created in synthetic bones and stabilized using three different osteosyntheses alone and in combination with a commonly used bone cement (chronOS™): 2 screws, 4 screws in the jail technique and a lateral angle-stable buttress plate. After fixation, the lateral tibial plateau was axially loaded in two, from each other independent testing series: In the first test protocol, 5000 cycles with 500 N and in the end load-to-failure tests were performed. In the second test protocol, the cyclic loading was increased to 1000 N. Parameters of interest were the displacement of the articular fracture fragment, the stiffness and the maximum load. The osteosyntheses revealed a higher stiffness in combination with bone cement compared to the same type of osteosynthesis alone (e.g., 500 N level: 2 screws 383 ± 43 N/mm vs. 2 screws + chronOs 520 ± 108 N/mm, increase by 36%, p < 0.01; 4 screws 368 ± 97 N/mm vs. 4 screws + chronOS 516 ± 109 N/mm, increase by 40%, p < 0.01; plate: 509 ± 73 N/mm vs. plate + chronOs 792 ± 150 N/mm, increase by 56%, p < 0.01). Bone cement reduced the displacement of the plate significantly (500 N level: plate: 8.9 ± 2.8 mm vs. plate + chronOs: 3.1 ± 1.4 mm, reduction by 65%, p < 0.01; 1000 N level: 16.9 ± 3.6 mm vs 5.6 ± 1.3 mm, reduction by 67%, p < 0.01). Thus, the highest stiffness and lowest displacement values were found when using the plate with bone cement in both loading conditions (500 N level: 2 screws + chronOs 3.7 ± 1.3 mm, 4 screws + chronOs 6.2 ± 2.4 mm; 1000 N level: 2 screws + chronOs 6.5 ± 1.2 mm, 4 screws + chronOs 5.7 ± 0.8 mm). From a biomechanical perspective, plate osteosynthesis of tibial head depression fractures should always be combined with bone cement, provides higher stability than 2-screw and 4-screw fixation and is a valid treatment option in cases where extraordinary stability is required.

Post-Operative Priapism: Often Overlooked after Spinal Anaesthesia in Orthopaedic Surgery

Priapism is defined as an abnormal persistent erection of the penis or clitoris. It is unrelated to sexual stimulation and unrelieved by ejaculation. Overall incidence of priapism is 1.5 to 2.9 per 100000 person-year. Defining the etiology of a case of postoperative priapism following orthopedic surgery can be difficult, and many times cannot be determined. We present a rare case report of priapism following an elective open reduction and internal fixation with minimally invasive percutaneous plate osteosynthesis for right lower leg bone fracture performed under spinal anaesthesia in a 21-year-old man and reviewed some literatures and potential etiologies of this rare complication. We also highlighted the problems in delayed recognition of the complication and a good functional outcome despite delayed management.

Biomechanical evaluation of femoral neck fracture osteosynthesis

Bone geometry, density, and thickness of the cortical layer of the femoral neck (FN) contribute to the mechanical strength in osteosythesis of femoral neck fractures (FNF) in young adults. The available techniques for fracture fixation of the FN are reviewed with respect to the biomechanical stability.A biomechanical study of the osteosynthesis stability of the FNF with three cannulated screws was carried out using synthetic models of the proximal part of the femoral bone (FB). The experimental models were divided into 4 groups. Each group related to the configuration of screws in the FN. The vertical and horizontal FNF stability was assessed using two series of load. In series I, models were loaded with forces in the longitudinal axis to the FB and in series II, forces acted in the perpendicular direction to the FB axis. The loading forces were evaluated when the displacement of 2 mm fragments was achieved. The highest stability strengths were obtained in group I in the both series ‒ 1898 N with a vertical load and 1046 N with a horizontal load. Further, in decreasing order, the results of stability were obtained in groups II, III and IV.In this study, it was found that the consideration of the position of screws according to architectonics of the FN is crucial for fragment stability. The triangular position of screws with three points of contact with the compact bone ensures the maximum stability of the construct in osteosynthesis of the FN fractures, which is comparable to the normal walking load conditions.We hypothesize that osteosynthesis of FN fractures with three screws in a triangular manner could provide a better stability when inserted into the dense tissues of the proximal FB with relation to bone architectonics. To ensure a maximum stability, each screw should have three points of contact with the compact bone – the lateral cortical wall of the subtrochanteric region of the FB, the inner wall of the FN, and the compact part of the FB head. New triangular configuration of screws’ placement could have a better neutralization of share forces in FN fractures.

Operative Approaches to the distal radioulnar Joint and distal Ulna

At the distal radioulnar joint (DRUJ) and the ulnocarpal joint several anatomical structures are in a limited space. Therefore, the operative approach has to consider the pathology to be treated. The DRUJ may be approached from the dorsal or the palmar side. Procedures to treat the arthrotically destroyed DRUJ involving bone resection of the ulnar head and destabilizing ligamentous injuries of the triangular fibrocartilage complex (TFCC) are best approached from the dorsal side. This approach allows excellent visualization of the ulnar head and the ulnar and radial attachment of the TFCC. The arthroscopic, half open refixation of the ulnar avulsion of the TFCC may be performed using a variety of limited and small approaches over the dorsal or lateral ulnar head. Pathologies with an origin at the palmar aspect of the DRUJ as the palmar dislocation of the ulnar head in the DRUJ or the shrinkage and scaring of the palmar capsule with consecutive pronation contracture require a palmar approach. Reduction and osteosynthesis of fractures in the area of the ulnar head are preformed using a lateral approach along the styloid process and the ulnar head between the flexor and the extensor carpi ulnaris tendons. Along the ulnar shaft elective ulnar shortening osteotomy as well as fracture reduction and osteosynthesis are best performed from an ulno palmar approach.

Influence of associated femoral head fractures on surgical outcomes following osteosynthesis in posterior wall acetabular fractures

BackgroundTo date, no study has compared the surgical outcomes between posterior wall acetabular fractures with and without associated femoral head fractures. Therefore, we evaluated whether an associated femoral head fracture increases the incidence of fracture sequelae, including post-traumatic osteoarthritis (PTOA) and osteonecrosis of the femoral head (ONFH), following osteosynthesis for posterior wall acetabular fractures.MethodsThis retrospective clinical study enrolled 183 patients who underwent osteosynthesis for posterior wall acetabular fractures between 2009 and 2019 at a level-1 trauma center. The incidence of PTOA, ONFH, and conversion to total hip arthroplasty (THA) was reviewed.ResultsThe incidence of PTOA, ONFH, and conversion to THA following osteosynthesis were 20.2%, 15.9%, and 17.5%, respectively. The average time for conversion to THA was 18.76 ± 20.15 months (range, 1–82). The results for the comparison of patients with associated femoral head fractures and isolated posterior wall acetabular fractures were insignificant (PTOA: 27.3% vs. 15.7%, p = 0.13; ONFH: 18.2% vs. 14.3%, p = 0.58; conversion to THA: 20.4% vs. 15.7%, p = 0.52). Upon evaluating other variables, only marginal impaction negatively affected ONFH incidence (odds ratio: 2.90).ConclusionsOur methods failed to demonstrate a significant difference in the rate of PTOA, ONFH, or conversion to THA in posterior wall acetabular fractures with and without an associated femoral head fracture. Beyond femoral head fractures, the marginal impaction of the acetabulum could have led to early sequelae.Level of evidenceLevel III

Effectiveness of Cement Augmentation on Early Postoperative Mobility in Patients Treated for Trochanteric Fractures with Cephalomedullary Nailing: A Prospective Cohort Study.

Fixation using cephalomedullary nails (CMNs) with additional cement augmentation (CA) was developed as a novel treatment option for the osteosynthesis of osteoporotic trochanteric fractures, though the effectiveness of CA on early postoperative mobility remains uncertain. This multicenter prospective cohort study aimed to estimate the effectiveness of CA on early postoperative mobility in patients with trochanteric fractures. We enrolled patients with femoral trochanteric fractures aged >60 years who were able to walk independently before the injury. The primary outcome was the postoperative 3-day cumulated ambulation score (CAS); the secondary outcome was the visual analog scale (VAS) pain score at rest and during movement on postoperative days 1–3. The outcomes of the patients treated using CMNs with or without CA were compared. Sixty-three eligible patients were categorized into CA (n = 32) and control (n = 31) groups. In univariate analysis, the CA group had significantly higher CAS values, lower VAS scores at rest on day 1 postoperatively, and lower VAS scores during movement on day 3. In multivariable linear regression analyses, the CA group had significantly higher CAS values (beta, 2.1; 95% confidence interval, 0.5 to 3.6; p = 0.01). The CA group had a negative adjusted beta value in their VAS scores during movement. This study indicated that CA was associated with a high CAS value in patients with geriatric trochanteric fractures. However, CA was not associated with pain reduction at rest and during movement during the initial postoperative days.