Posterior Fragment Research Articles

Assessment of the Adequacy of Closed Reduction in Fractures of the Zygomatic Arch Using "C"-Arm Image Intensifier

Major problems in closed reduction of isolated, minimally displaced, and depressed zygomatic arch fractures are blind nature of the technique, reliability on digital palpation, reduction click, and step deformity between fragments. The purpose of this study was to objectively confirm the adequacy of closed reduction intraoperatively and the usefulness of the "C"-arm image intensifier. A total of 12 patients with 1- to 8-day-old unilateral isolated and depressed zygomatic arch fracture underwent closed reduction under "C"-arm image intensifier. Of these patients, 9 were men and 3 were women, with age ranging from 18 to 32 years. Intraoperative prereduction and postreduction images were obtained using the "C"-arm image intensifier. Criteria for adequate reduction were the following: intrafragmentary gap less than 0.5 mm, no overriding of fragments, no depression of fragments, and no step deformity. After being clinically satisfied about the reduction, images on "C"-arm showed no intrafragmentary gap. In 3 patients, there were residual overriding and minimal rotation around the anteroposterior axis of the posterior fragment. In 1 patient, rotation and step deformity remained. In this patient, additional stabilization was provided. The "C"-arm image intensifier shows some poorly reduced or unstable isolated depressed zygomatic arch fractures that remain unidentified even after careful palpation. Thus, it plays a recognizable role to avoid the trouble of second intervention.

Surgical approach for high-energy posterior tibial plateau fractures

Background:High-energy fractures of posterior tibial plateau always need surgical treatment. Generally, posterior fragments of these fractures could not be exposed and reduced well in conventional anterior approaches. Although a posterolateral/posteromedial approach to manage posterior tibial plateau fractures can achieve satisfactory results, there are few presentations concerning the treatment of these high-energy injuries based on posterior approaches combined with anterior approach if necessary.Materials and Methods:Ten cases of posterior tibial plateau fractures from high-energy injuries were retrospectively reviewed and followed up for mean 26.5 months (range 14–45 months). A posterolateral/posteromedial approach was adopted primarily to fix main fragment in posterior tibial plateau, and intraoperative assessment of the stability of knee was done. An anterior approach was added if required.Results:Posterolateral approach was employed in seven cases, posteromedial in three, and additional anteromedial in three, and anterolateral in two cases. The average time to union of all 10 fractures was 3.7 months (range 3–5.5 months). Nine patients had satisfactory articular reduction. The range of motion of the knee averaged 2° of extension to 110.5° of flexion. No patient complained of knee instability. The average postoperative HSS score at the final followup was 92.70.Conclusions:High-energy fractures of posterior tibial plateau could be well treated based on posterior approaches combined with necessary anterior approach if required.

Biomechanical Evaluation of a Locking and Nonlocking Reconstruction Plate in an Osteoporotic Calcaneal Fracture Model

This study evaluated the effects of locking vs nonlocking configuration on the biomechanical performance of a calcaneal reconstruction plate in an osteoporotic cadaveric model. A Saunders II B type calcaneal fracture was created in ten matched pair of cadaveric calcanei. Each pair was fixed with the Ascension calcaneal reconstruction plate using either locking or nonlocking screws in the same hole pattern. Specimens were axially loaded for 1000 cycles through the talus followed by load to failure. Statistical comparisons were made between the locking and nonlocking constructs on the displacements during cyclic loading as well as construct stiffness and load achieved at selected fragment displacements. No significant difference was detected between the locking and nonlocking constructs in displacement during cyclic loading (p > 0.2) for the numbers available. Similarly no significant difference was found in stiffness of the constructs between the groups: 445.7 ± 148.8 (N/mm ± SD) for the locking plate and 395.2 ± 127.7 for the nonlocking plate (p > 0.14). The load achieved at 2 mm displacement of the posterior fragment for the two groups were not different: locking plate at 744.6 ± 237.2 N and nonlocking plate at 739.3 ± 269.7 N (p > 0.99). This study did not reveal a mechanical advantage to locking technology for calcaneal fractures with the selected plate and fracture model. While locking plate technology has shown mechanical advantages for fracture management in other osteoporotic models, in our fracture model and plating construct, this was not found. It is still unclear which fixation technique is most beneficial in these calcaneal fractures.

Surgeon Practices regarding Operative Treatment of Posterior Malleolus Fractures

Operative indications for surgical treatment of posterior malleolar fractures associated with fractures of the distal fibula and tibia are not currently well defined. The purpose of the present study was to determine the current practice among orthopaedic surgeons regarding the management of posterior malleolus fractures. Web-based questionnaires were emailed to members of the Orthopaedic Trauma Association (OTA) and American Orthopaedic Foot and Ankle Society (AOFAS). Requested information included demographics and treatment preferences for five clinical scenarios with different fracture characteristics. Four hundred one respondents completed the survey (20% response rate). Ninety eight (24%) subjects had received specialty training in orthopaedic trauma, 199 (50%) in foot and ankle (F&A) surgery and six (2%) in both orthopaedic trauma and F&A surgery. Ninety five (24%) had either no or other specialty training. The most frequently reported indication for fixation was not based on a fragment size threshold, but rather was ``depends on stability and other factors'' (56%). Trauma surgeons, those with less than 10 years experience, and those who treated more than five ankles fractures per month were significantly more likely to use factors other than size for indications (p = 0.026, <0.01, and <0.01, respectively). Despite this general response, fragment size still affected treatment decisions. A fragment comprising 50% of the articular surface was indicated for fixation by 97% of respondents, while a size of 10% would be treated by only 9% of respondents. For a posterior fragment with 20% articular involvement and a small free osteochondral fragment, fixation was deemed necessary by 44% of respondents. There were no differences in fellowship training, years of experience in practice, or ankle fracture volume per month in these three situations. A larger proportion of trauma trained surgeons considered fixation necessary compared to F&A trained surgeons in this case (p = 0.028). When posterior malleolus fixation was indicated for a large fragment, direct open reduction using the flexor hallucis longus -peroneal tendon interval was the most commonly selected approach in all cases. Trauma-trained surgeons were significantly more likely to choose antiglide plate fixation compared to screw-only fixation (p < 0.05). In this survey study of trauma and F&A surgeons, significant variation existed regarding most aspects of posterior malleolar ankle fracture treatment. Most notably, factors other than fragment size most impacted surgical indications. Newer techniques such as direct exposure and plating of the posterior malleolus are chosen more frequently than traditional techniques of indirect reduction and percutaneous screw fixation.

Inductive activity of the posterior tip of planula in the marine hydroid Dynamena pumila

Activity of organizer regions is required for body plan formation in the developing organism. Transplanting a fragment of such a region to a host organism leads to the formation of a secondary body axis that consists of both the donor's and the host's tissues (Gerhart, 2001). The subject of this study, the White Sea hydroid cnidarian Dynamena pumila L. (Thecaphora, Sertulariidae), forms morphologically advanced colonies in the course of complex metamorphosis of the planula larva. To reveal an organizer region, a series of experiments has been performed in which small fragments of donor planula tissues were transplanted to embryos at the early and late gastrula stage, as well as to planulae. Only transplantations of a posterior tip fragment of a donor planula to a host planula of the same age led, in the course of metamorphosis, to the formation of a secondary shoot, which involved up to 50% of the host's tissues. After transplantations of tissue fragments of the anterior tip and the middle of the planula body, the formation of any ectopic structures was never observed. It was concluded that the posterior tip of the planula has organizer properties in Dynamena.

Ankle Fractures with Posterior Malleolar Fragment: Management and Results

Trimalleolar ankle fractures can be difficult to manage and convey a high risk of long-term morbidity. The question of whether internal fixation of the posterior malleolar fragment is warranted remains open. We conducted a retrospective cohort study involving 45 patients who underwent surgical repair of a trimalleolar fracture. Our goal was to study the effect of the size of the posterior fragment on outcomes. We defined small posterior malleolar fragments as being ≤ 25% of the distal tibial articular surface as viewed on the lateral radiograph. Outcome measures included the radiographic appearance of the reduction, as well as Olerud and Molander (O&M) scores and AOFAS scores. Overall better outcomes were obtained in patients whose fractures involved ≤ 25% of the articular surface, and the difference in outcomes was statistically significant in regard to the AOFAS scores ( P = .05), although not statistically significant in regard to Olerud and Molander scores and the radiographic appearance of the reduction ( P = .14 and P = .45, respectively). Anatomic reduction was achieved in 73.3% of patients, but they did not have better clinical results than nonanatomic reduction patients: AOFAS ( P = .14), O&M ( P = .38), radiographic appearance ( P = .74).

Birth after TESE-ICSI in a man with hypogonadotropic hypogonadism and congenital adrenal hypoplasia linked to a DAX-1 (NR0B1) mutation

DAX1/NR0B1 mutations are responsible for X-linked congenital adrenal hypoplasia (AHC) associated with hypogonadotropic hypogonadism (HH). Few data are available concerning testicular function and fertility in men with DAX1 mutations. Azoospermia as well as failure of gonadotrophin treatment have been reported. We induced spermatogenesis in a patient who has a DAX1 mutation (c.1210C>T), leading to a stop codon in position 404 (p.Gln404X). His endocrine testing revealed a low testosterone level at 1.2 nmol/l (N: 12–40) with low FSH and LH levels at 2.1 IU/l (N: 1–5 IU/l) and 0.1 IU/l (N: 1–4 IU/l), respectively. Baseline semen analysis revealed azoospermia. Menotropin (Menopur®:150 IU, three times weekly) and human chorionic gonadotrophin (1500 IU, twice weekly) were used. After 20 months of treatment, as azoospermia persisted, bilateral multiple site testicular biopsies were performed. Histology revealed severe hypospermatogenesis. Rare spermatozoa were extracted from the right posterior fragment and ICSI was performed. Four embryos were obtained and, after a frozen–thawed single-embryo transfer, the patient's wife became pregnant and gave birth to a healthy boy. We report the first case of paternity after TESE–ICSI in a patient with DAX1 mutation, giving potential hope to these patients to father non-affected children. Furthermore, this case illustrates the fact that patients with X-linked AHC have a primary testicular defect in addition to HH.

No Difference in Functional and Radiographic Results 8.4 Years After Quadricortical Compared With Tricortical Syndesmosis Fixation in Ankle Fractures

To assess long-term functional and radiologic results after two types of syndesmosis fixation, comparing one quadricortical syndesmotic screw fixation with two tricortical screw fixation in ankle fractures. Follow up of a previously conducted prospective, randomized clinical study. University clinic, Level I trauma center. Forty-eight patients with closed ankle fractures and concomitant syndesmotic rupture were operated on with quadricortical (n = 23) or tricortical (n = 25) syndesmotic fixation. Follow-up time was 8.4 years (range, 7.7-8.9 years). There were no statistical differences in the two groups regarding Olerud-Molander Ankle score, Orthopaedic Trauma Association score, or degree of osteoarthritis. Patients with a difference in the syndesmotic width between the operated and the nonoperated ankle of 1.5 mm or more showed a tendency toward poorer functional results (P = 0.056). Twenty-one patients showed synostosis on plain radiographs. Of these, only seven patients had synostosis verified on computed tomography, all of whom had significantly worse function. Patients with a posterior fracture fragment at time of operation had poorer Olerud-Molander Ankle score (73.1 versus 85, P = 0.05) and all had osteoarthritis as compared with 55% of those without a posterior fragment. Obese patients (body mass index greater than 30 kg/m2) also had poorer Orthopaedic Trauma Association score, but neither obesity nor being overweight predicted late arthritis. Follow up 8.4 years after surgery of ankle fractures with syndesmotic injury showed satisfactory functional results with only minor differences between the two groups of syndesmotic fixation. Obese patients had significantly poorer functional results. The presence of a posterior fracture fragment was an important negative prognostic factor regarding functional results. Plain radiographs overestimated tibiofibular synostosis. Synostosis on computed tomography, however, predicted impaired ankle function. A difference in syndesmotic width 1.5 mm or greater between the two ankles seemed to be associated with an inferior clinical result.

Lunate Fracture in an Amateur Soccer Player

The patient was a 19-year-old male soccer player who sustained a right wrist injury after running into a soccer goal post with a clenched fist. The patient eventually sought medical care 9 weeks after the initial injury. Based upon the physical examination findings—including swelling, palpatory tenderness, and decreased range of motion due to pain—and general lack of improvement following the injury, radiographs of the right wrist were ordered. The radiographs were of concern due to an apparent fracture of the lunate. To evaluate the extent of the fracture, a computed tomography scan was completed. It revealed a central transverse fracture of the lunate with a depressed fragment seen centrally, with some comminution. Additionally, the anterior and posterior fragments of the lunate were minimally displaced with impaction of the capitate. Because of the significant delay in patient presentation in this case, a nonoperative treatment strategy was utilized, which involved casting, followed by treatment provided by a physical therapist. J Orthop Sports Phys Ther 2009;39(12):884. doi:10.2519/jospt.2009.0415

Stress fracture of the lumbar pedicle bilaterally: surgical repair using a percutaneous minimally invasive technique

Bilateral pedicle fractures in the spine are uncommon in the absence of bony abnormality, previous surgery, or trauma. The authors report a case of spontaneous bilateral lumbar pedicle fracture in a 50-year-old sedentary woman, which caused intractable pain and did not respond to months of conservative management. The fractures were surgically treated using a percutaneous, minimally invasive technique with screws placed directly through the fractures into the vertebral body. The pedicles were strategically tapped to achieve the lag effect and reapproximate the posterior fragment with the anterior elements. The patient tolerated the procedure well and experienced early improvement of her symptoms, and follow-up imaging showed evidence of fracture healing. Transpedicular fixation and the use of the lag effect could be a useful strategy in the treatment of future cases involving poorly healing pedicle fractures causing persistent symptoms.

Reliability of Radiologic Assessment of the Fracture Anatomy at the Posterior Tibial Plafond in Malleolar Fractures

The aim of this study was to assess the ability to extract surgically relevant information from plain radiographs in trimalleolar fractures and to compare this with the information gathered from computed tomography (CT). Retrospective analysis of consecutive patients. Level 1 trauma center. Retrospective analysis of the records of 22 patients with trimalleolar fractures treated at our institution between 1996 and 2006. Inclusion criteria were a complete radiographic documentation including plain anteroposterior and lateral radiographs and a preoperative CT scan of the ankle joint. The radiographs of the included patients were evaluated twice within 3 months by 8 experienced orthopaedic trauma surgeons. The following criteria were analyzed: the presence or absence of a fracture in the posteromedial corner of the tibial plafond, loose posterior osteochondral fragments, impaction of posterior osteochondral fragments on the anteroposterior and the lateral radiographs, and size of the posterolateral fragment as percentage of the articular surface in the capital diameter of the tibial plafond. The results were compared with the CT scans. All parameters showed a poor to fair reproducibility, reliability, and accuracy except the size of the posterior fragment, where good correlations were achieved. Only the extent of the posterior fragment can be measured reliably, reproducibly, and accurately on plain radiographs. Comminution and impaction of the posterior fracture are underestimated by far. Surgically relevant information is missed, which can lead to intraoperative inability to properly reduce the fracture. Preoperative CT evaluation is recommended in all patients with trimalleolar fractures, independent of the size of the posterior fragment.

Diagnosis and treatment of the tibia shaft fracture accompanied with ipsilateral posterior malleolus fracture

Objective To discuss the cause and prevention of the tibial shaft fracture associated with ipsilateral posterior malleolus fracture. Methods From May 2001 to November 2004, 269 cases of tibial shaft fracture were treated in our department. Of them, 34 were complicated with ipsilateral posterior nialleolus fracture. They were 21 males and 13 females. Their ages ranged from 33 to 71 years old. There were 2 patients with tibial open fracture. Preoperatively conventional plain X-ray of the full-length tibia and ankle region was taken for all the patients. CT scanning was conducted for those who were suspected of the ipsilateral posterior malleolus fracture. Before tibial intramedulary nailing, the posterior malleolar fragments were fixed with an anterior lag-screw. Results The mean duration of follow-up was 11 months. The posterior malleolus fracture healed with excellent ankle function in 33 cases. The only one case whose posterior malleolus fracture had been overlookd until follow-up sufferd from ankle disfunction and pain. Conclusions The tibial shaft fracture is frequently complicated with and the ipsilateral posterior malleolus fracture in clinic which is re-sponsible for the ankle disfunction. Pre-operative CT scanning of the ankle and fixation of the fragments are key elements of the prevention. Key words: Tibial fracture; Ankle injuries ; Fracture fixation, intramedullary

Posterior multifragmentation of the femoral neck: Does it portend a poor outcome in internally fixed intracapsular hip fractures?

Aim To establish whether posterior multifragmentation of intracapsular proximal femoral fractures leads to an increased incidence of non-union and avascular necrosis following internal fixation by contemporary methods. Methods After preoperative radiography which was evaluated for posterior fragmentation, 1042 intracapsular hip fractures (471 undisplaced and 571 displaced) were treated with reduction and internal fixation. The rates of non-union and avascular necrosis in the presence or absence of fragmentation were compared in both undisplaced and displaced groups. Results The undisplaced cases comprised 460 non-fragmented and 11 fragmented fractures. The complication rates were 14% and 18%, respectively. Displaced fractures consisted of 489 non-fragmented and 82 fragmented cases. In this group, complication rates were 43% and 40%, respectively. No difference was statistically significant. Conclusions Using current methods of internal fixation of intracapsular hip fractures, there is no significant association between the posterior multifragmentation of the femoral neck observed on preoperative radiography and the later development of fracture healing complications.

Laparoscopic Resection of Rectal Endometriosis

We aim to present our procedure of laparoscopic management of rectal endometriosis. The first stage starts by the dissection of ureters, followed by unilateral section of involved uterosacral ligaments. Pararectal spaces are opened toward lateral limits of the nodule, then dissection of inferior limit is performed until the elevator muscles of the rectum, toward the rectovaginal space under the nodule. The mesorectum is then sectioned. In the second stage, the nodule is sectioned in an anterior and a posterior fragments.

Buttress plate stabilisation of posterior malleolar ankle fractures: a familiar technique through an unfamiliar approach

<h2>Summary</h2><h3>Introduction</h3> The approach to the distal radius to apply a volar buttress plate for a volarly displaced distal radius fracture is a familiar procedure for orthopaedic surgeons. The stabilisation of distal tibia posterior malleolar fractures is commonly performed by inserting lag or cannulated screws into the posterior fragment from anteriorly. <h3>Method</h3> We discuss the similarity of the application of a posterior buttress plate to the distal tibia via a posterolateral approach compared with a distal radial approach. <h3>Conclusions</h3> The posterolateral approach is easy, safe and allows good access and accurate direct fracture reduction. We recommend this method be considered for the stabilisation of a posterior malleolar fracture.

Treatment of posterior malleolar fractures by fixation with minimally invaslve percutaneous cannulated screws

Objective To discuss clinical results and techniques of treatment of posterior malleolar fractures by fixation with minimally invasive percutaneous cannulated screws. Methods A total of 18posterior malleolar fractures were treated with percutaneous cannulated screws (4.0 ram) between March 2004 and September 2006. According to Lauge-Hansen system, 14 were diagnosed as supination external rotation stage Ⅳ, and 4 as pronation external rotation stage Ⅳ. In all cases, the size of fragment exceeded 25% of the articular surface with displacement of more than 2 mm on the lateral radiograph. We studied the preoperative CT to determine the size of the posterior fragment, displacement and the angle between the bimalleolar axis and the major fracture line of the posterior malleolus. After ORIF of outer and medial malleoli, the posterior malleolus was treated by minimally invasive osteosynthesis. Results Follow-ups of 16.5 (range, 6-35) months on average revealed that all cases healed. According to the Ankle Hindfoot Clinical Rating System of the American Orthopaedic Foot & Ankle Society (AOFAS), the results were rated as excellent in 11 cases, good in 5 cases,moderate in 1 case, and poor in 1 case, with the good-excellent rate being 88.9%. Conclusions Fixation with minimally invasive percutaneous cannulated screws is a good method with advantages of mini-invasion and rigid fixation. Careful preoperative plan according to CT scan is a prerequisite for good results. Key words: Posterior malleolar; Fracture; Fracture fixation,internal

Classification and Treatment of Unstable Intertrochanteric Fracture according to the Existence of Posterior Fragment: Preliminary Report

목 적: 대퇴골 전자간부 골절 치료에서 골절의 양상 및 안정성을 예측하기 위해 술 전 3차원 컴퓨터 단층촬영을 시행하여 불안정 골절에 대해 추가 분류하였고 후방 골편 고정의 중요성 및 중간 치료결과에 대해 보고하고자 한다. 대상 및 방법: 2006년 10월부터 2007년 8월까지 후방 골편이 있는 불안정 골절로 진단 받고 ...

The Hyperplantarflexion Ankle Fracture Variant

Various patterns of ankle fractures that are not accounted for by common classification systems have been the subject of case reports. The first difficulty with these variant patterns is recognizing all associated pathology, followed by the successful application of stable fixation. The purpose of this study was to describe the common morphologic features and ligamentous injuries of a unique variant fracture pattern, as well as the surgical treatment technique and the short-term functional and radiographic outcomes. Of 121 consecutive unstable ankle fractures over a 2-year period, 7 patients were found to have a similar constellation of injuries around the ankle. A vertical shear fracture of the posteromedial tibial rim was the main feature. Six of the 7 also had a fracture of the posterior malleolus. On magnetic resonance imaging, the deltoid and posterior tibiofibular ligaments were intact in all cases. Fractures were treated with open anatomic reduction of the posteromedial and posterior fragments with antiglide plate fixation. All fractures healed at 2 months without loss of reduction, fixation failure, or surgical complications. The average American Academy of Orthopaedic Surgeons lower extremity score was 79 at an average of 8 months' follow-up. The common radiographic and morphologic features associated with this posteromedial fracture indicate that it likely occurs through a common mechanism that involves hyperplantarflexion. The characteristics of this fracture pattern have not been fully described previously, but this ankle fracture variant may occur in up to 6% of cases. Unstable ankle fractures should be evaluated carefully for evidence of posteromedial involvement so appropriate treatment may proceed.

Two-level reconstruction of comminuted posterior-wall fractures of the acetabulum

Our aim was to evaluate the efficacy of a two-level reconstruction technique using subchondral miniscrews for the stabilisation of comminuted posterior-wall marginal acetabular fragments before applying lag screws and a buttress plate to the main overlying posterior fragment. Between 1995 and 2003, 29 consecutive patients with acute comminuted displaced posterior-wall fractures of the acetabulum were treated operatively using this technique. The quality of reduction measured from three standard plain radiographs was graded as anatomical in all 29 hips. The clinical outcome at a mean follow-up of 35 months (24 to 90) was considered to be excellent in five patients (17%), very good in 16 (55%), good in six (21%) and poor in two (7%). The use of the two-level reconstruction technique appears to provide stable fixation and is associated with favourable results in terms of the incidence of post-traumatic osteoarthritis and the clinical outcome. However, poor results may occur in patients over the age of 55 years.

Tratamento cirúrgico da fratura-avulsão da inserção tibial do L.C.P. do joelho: experiência de 21 casos

Avaliamos 21 pacientes, sendo 16 pacientes do sexo masculino e 5 do feminino, com idade média de 30 anos, foram submetidos à tratamento cirúrgico da fratura-avulsão do LCP. Em 57% dos casos a lesão foi secundária a acidente motociclístico e 19% a acidente automobilístico. Em 72% dos casos foi identificada uma lesão na face anterior do joelho. O tratamento cirúrgico consistiu na abordagem posterior do joelho e fixação do fragmento ósseo com parafuso e arruela em 18 casos; e amarrilhas trans-ósseas em 3 casos, onde o fragmento ósseo era muito pequeno. Em 91% dos casos, a cirurgia foi realizada dentro dos primeiros 15 dias apos a lesão. Os pacientes foram avaliados objetivamente (teste de gaveta posterior) e subjetivamente (Escala de Lysholm), apos um seguimento pós-operatório mínimo de 12 meses. A análise estatística não mostrou diferença significativa, ao nível de 5%, entre as avaliações objetiva e subjetiva. A ausência de lesão ligamentar periférica pode ter contribuído para que os resultados clínicos pós-operatórios tenham avaliação subjetiva satisfatória; entretanto, a presença de uma posteriorização tibial residual sugere que a fratura-avulsão do ligamento cruzado posterior deve ser abordada não como uma lesão óssea pura, mas sim, como uma lesão ósteo-ligamentar.