Previous Internal Fixation Research Articles

Is Previously Implanted Osteosynthesis Material an Obstacle for the Use of Customized Guides?: A Case Report.

We present the case of a 46-year-old patient with asymmetric deformity in the posterior tibial slope after previous high tibial osteotomy surgeries with the presence of a medial osteotomy plate. A customized cutting guide was designed to fit on the plate to perform a single surgery and avoid possible soft-tissue complications after multiple surgeries. The presence of a previous internal fixation device may affect the manufacture of 3-dimensional cutting guides. However, in this case, the previously placed osteosynthesis plate was used as an aid for creating the guide.

Strain reduction screws for nonunions following fixation around the elbow - A case series and review of the literature

BackgroundNonunions following fracture fixation result in significant patient morbidity and financial burden. Traditional operative management around the elbow consists of removal of metalwork, debridement of the nonunion and re-fixation with compression, often with bone grafting. Recently, some authors in the lower limb literature have described a minimally invasive technique used for select nonunions where simply placing screws across the nonunion facilitates healing by reducing inter-fragmentary strain. To our knowledge, this has not been described around the elbow, where traditional more invasive techniques continue to be employed. AimsThe aim of this study was to describe the application of strain reduction screws for management of select nonunions around the elbow. Methods & ResultsWe describe 4 cases (two humeral shaft, one distal humerus and one proximal ulna) of established nonunion following previous internal fixation, where minimally invasive placement of strain reduction screws were used. In all cases, no existing metal work was removed, the nonunion site was not opened, and no bone grafting or biologic stimulation was used. Surgery was performed between 9 and 24 months after the original fixation. 2.7 mm or 3.5 standard cortical screws were placed across the nonunion without lagging. Three fractures went on to unite with no further intervention required. One fracture required revision fixation using traditional techniques. Failure of the technique in this case did not adversely affect the subsequent revision procedure and has allowed refinement of the indications. ConclusionStrain reduction screws are safe, simple and effective technique to treat select nonunions around the elbow. This technique has potential to be a paradigm shift in the management of these highly complex cases and is the first description in the upper limb to our knowledge.

Real-time ultrasound-guided neuraxial anesthesia for cesarean section in parturients with previous internal fixation surgery for lumbar fracture: a case series

Real-time ultrasound-guided neuraxial anesthesia for cesarean section in parturients with previous internal fixation surgery for lumbar fracture: a case series

Total Elbow Arthroplasty for Distal Humerus Fractures Provided Similar Outcomes When Performed as a Primary Procedure or After Failed Internal Fixation.

To compare clinical and functional outcomes of total elbow arthroplasty (TEA) for distal humerus fractures (DHF) performed either as a primary procedure or after internal fixation. Retrospective, observational study. Mayo Clinic, Rochester, MN (1998 through 2016). Twenty-two TEA for acute DHF and 66 TEA after previous internal fixation. Primary outcome measures included the Mayo Elbow Performance Score and motion. Reoperation rates and complications were also compared. The mean time between internal fixation and arthroplasty was 7.3 years, and the main indications for conversion to TEA were nonunion (36%) and posttraumatic osteoarthritis (32%). There were female predominance (70%) and significant differences in age (74 years vs. 60 years, P < 0.0001) and tobacco use (0 vs. 23%; P = 0.02) between the primary and the salvage cohorts, respectively. Cohort demographics were otherwise comparable. TEA provided similar outcomes in both cohorts in terms of the Mayo Elbow Performance Score (acute 85, salvage 81, P = 0.32) and motion (acute 95/82/75 degrees, salvage 112/81/72 degrees in ulnohumeral/pronation/supination, P = 0.07/P = 0.85/P = 0.65). Reoperation rates were also similar (36% acute vs. 39% salvage, P = 1.00). Aseptic loosening (2 acute, 8 salvage) and deep infection (2 acute, 7 salvage) were the most common complications. The clinical outcomes and reoperation rates of TEA for DHF seem to be similar when performed as a primary procedure or as salvage after previous internal fixation. The benefit of avoiding elbow arthroplasty in the acute setting needs to be balanced with the potential for 2 surgical procedures if internal fixation was to be unsuccessful. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Primary treatment of complex proximal humerus fractures using Humelock cementless reversible shoulder arthroplasty in the elderly.

Proximal humerus fractures are quite common, constituting 5% of all fractures. Plate osteosynthesis of comminuted fractures in the elderly with osteoporotic bones is prone to complications, including loss of reduction, intraarticular protrusion of screws, avascular necrosis and non-union. Hemiarthroplasty may be preferred to achieve a stable fixation, which permits early shoulder motion. Prerequisites for the successful functional outcome of this surgical technique are to have an intact rotator cuff, which is often torn, and achieve proper soft tissue balance, which is technically demanding. In RSA design, deltoid muscle replaces the function of the supraspinatus, compensating for a dysfunctional rotator cuff or a displaced tuberculum. We designed a retrospective study to evaluate the results of proximal humerus fractures treated with reverse shoulder arthroplasty using Humelock II reversible prosthesis in elderly patients. Thirty-one patients (25 females, six males) above 65 years old who underwent reverse shoulder arthroplasty between 2014 and 2019 for Neer 3-4 part fractures or head split injuries were included in this study. Patients with a previous internal fixation attempt, cases with neurological deficit or previous upper extremity fractures, patients who presented later than three weeks after the trauma, cases with less than six months follow-up and patients with additional fractures were excluded. Twenty-eight patients were available for final analysis. Fracture mechanism, time from trauma till surgery, hospital stay and preoperative ASA scores were noted. Humelock II Reversible (FX Solutions) implants were used in all cases. Patients' shoulder range of motion and functional outcome using UCLA, DASH and Constant scores at minimum six months follow-up were evaluated. The mean age was 72.2 (65-95) years, and mean follow-up time was 15.5 (6-48) months. The mean UCLA, Constant and Dash scores at the last follow-up were 27.6 (14-35), 67.9 (38-80) and 30.8 (9.9-79.2), respectively. Mean shoulder flexion, abduction, internal and external rotation were 130 (110-160), 100 (70-140), 40 (15-60) and 39 (15-75) degrees, respectively. RSA is a very reliable treatment for proximal humerus fractures in patients over 65 years old. Early active and passive shoulder exercises can be started postoperatively, and good functional outcome and wide ROM can be achieved with this age group. Although stable fixation of the tuberculum is not required for shoulder abduction, it facilitates external rotation and should be attempted in all cases. Clinical outcomes of patients who underwent RSA due to proximal humerus fracture are as good as the outcomes of patients with different etiologies.

Problems in plating periprosthetic femur fractures

Periprosthetic fractures are typically defined as fractures occurring adjacent to a total joint arthroplasty. However, fractures may occur adjacent to a previous internal fixation device used to treat a prior fracture in the same patient, or between implants (the interprosthetic fracture). All of these injuries tend to occur in frail patients with severe osteopenia, and therefore are very challenging to treat. This article provides a brief but thorough review of the current state of the art regarding the treatment of these challenging problems.

Reverse total shoulder arthroplasty for type I fracture sequelae after internal fixation of proximal humerus fractures.

Complications after internal fixation of proximal humerus fracture are common and may require surgical revision. Reverse total shoulder arthroplasty (RTSA) is frequently performed in such cases. The aim of the present study was to evaluate the functional results and complications after RTSA for the treatment of type I fracture sequelae after internal fixation of proximal humerus fractures. 26 patients (18 female, 8 male) underwent surgical revision of type I fracture sequelae of the proximal humerus after locking plate (n=22) or intramedullary nail (n=4) fixation. The mean age of the patients at the time of the revision was 75years (range 65-89). After a mean follow-up of 36months (range 18-58), clinical examination was performed and the age- and gender-related Constant-Murley Score (CMS) and the Oxford Shoulder Score (OSS) were obtained from all patients and compared to the pre-revision values. The mean age- and gender-related CMS of the affected shoulder increased from 44% (range 17-65) to 73% (range 44-97). This difference was statistically significant (p<0.001). The CMS of the unaffected shoulder was 93% (range 72-98). This relates to a ratio in the CMS of 78% between the affected and the contralateral shoulder. The mean OSS was 28 points (range 12-54) for the operated shoulder and 43 points (range 34-48) for the unaffected side, resulting in 66% ratio. Again, the OSS improved significantly when compared with the preoperative values (p<0.001). A total of five complications including two periprosthetic fractures were observed and required surgical revision. Satisfying results can be obtained with RTSA as a salvage procedure for type I fracture sequelae after previous internal fixation of proximal humerus fractures.

Total hip replacement the ideal joint for failed osteosynthesis of hip fractures

Introduction: Most proximal femoral fractures are successfully treated with internal fixation but a failed surgery can be very distressing for the patient due to pain and disability. For the treating surgeon it can be a challenge to perform salvage operations. Management of failed internal fixation of proximal hip fractures includes revision osteosynthesis or conversion total hip arthroplasty (THA). Total hip arthroplasty is generally accepted as the most successful salvage procedure for failure of these fixation devices. Conversion of failed hip surgeries to THA is indicated where the bone quality is poor, head is damaged due to previous internal fixation, poor bone stock, or limb shortening. Total hip arthroplasty in these patients may be difficult because of presence of previous implant, poor bone stock, scarred tissues and increased risk of infection. Aim: The aim of this study was to analyze the short-term followup of functional results of 31 uncemented total hip replacement surgeries for failed osteosynthesis of hip fractures prospectively. Materials and Methods: We had done 31 porous-coated uncemented total hip replacement surgeries in 29 patients for a variety of indications. The patients were reviewed regularly at 1 month interval for first 3 months, then at 6 months, 1 year and periodically thereafter for every 6 months. At the end of this study the patients were called back for review. Patients were reassessed clinically using the Harris hip score. X-rays of the hip were taken and were compared with the initial x-rays for signs of loosening, migration, wear and implant failure. Results: All patients were evaluated clinically and radiologically preoperatively and at various followup periods. In our study, 15 hips showed excellent results, 10 hips showed good results, 3 hips showed fair results and 3 hips showed poor results. In a study performed by Kim YH et al, Seventy-five hips (65%) were excellent, 11 (9%) were good, and 30 (39%) were poor. Conclusion: The uncemented total hip arthroplasty is the best choice of surgery for failed reconstructive surgeries of the proximal femur in individuals with good bone quality. As this is only a short term study, further follow-up and evaluation is essential to come out with a definitive conclusion.

Different surgical approaches for the treatment of adjacent segment diseases after anterior cervical fusion: A retrospective study of 49 patients.

Studies in the literature have not delineated the surgical approaches of symptomatic adjacent segment diseases (ASDs) in patients undergoing reoperation after an initial anterior cervical fusion (ACF). The purpose of this study was to determine the optimal surgical approaches of ASD and the incidence of the dysphagia after reoperation.This was a retrospective study of 49 patients with ASD after an initial ACF surgery, which had undergone a reoperation at our medical center between January 2010 and December 2014. The surgical approaches were used by anterior cervical discectomy and fusion (ACDF), ACDF with the Zero-profile device, laminoplasty, and laminectomy with internal fixation. Patients were classified according to the different surgical approaches of anterior (n = 38) versus posterior (n = 11) groups and ACDF (n = 25) versus Zero-P (n = 13) groups. Clinical evaluations were performed preoperatively and repeated in 24 months after operation.This retrospective study included 26 men and 23 women with a mean age at revision surgery of 54.3 years and ASD onset time of 7.3 years. The patients were followed up with an average of 4.1 years. The reoperation rate was 5.4% in this study. The Japanese Orthopaedic Association (JOA), Neck Disability Index (NDI), and visual analogue scale (VAS) scores demonstrated significant improvements compared with preoperative in both anterior and posterior groups (P < .05). However, there were no differences between the 2 groups (P > .05). The operation time of ACDF group was more than Zero-P group, with significant differences (P < .05). However, there were no differences in JOA, NDI, and VAS scores between the ACDF and Zero-P groups pre- and postoperative (P > .05). A total of 12 (24.5%) patients had dysphagia after reoperation. The incidence of dysphagia in Zero-P group (1/13) was less than ACDF group (11/25), with significant differences (P < .05). There were no cases of major neurological or vascular complications, and wound complications.The clinical situation, initial operation, and secondary preoperative imaging findings were analyzed comprehensively, anterior or posterior approach were chosen, which can effectively relieve spinal cord compression and improve spinal cord function. In ACDF with the Zero-profile device surgery, there was no need to remove the previous internal fixation, shorten the operation time, and reduce the incidence of postoperative dysphagia.

Clinical and functional outcome of total hip arthroplasty in failed proximal femoral fracture osteosynthesis

Introduction: The use of internal fixation for hip fractures can fail secondary to nonunion, loss of fixation, femoral head osteonecrosis, posttraumatic arthritis, malunion, infection, or symptomatic hardware. Conversion of failed hip surgeries to THA is indicated where the bone quality is poor, head is damaged due to previous internal fixation, poor bone stock, or limb shortening Methodology: Detailed history and proper clinical examination was done to find out – duration of illness, focus of infection in the body, sensory and motor examination, vascularity of the limb, ambulatory status of the patient, deformities of the hip, Range of Movements (ROM) of the hip, limb length discrepancy and status of the other joints Results: The average pre-operative Harris Hip Score was 36.28 and the Harris Hip Score at most recent follow-up was 83.19. The result was excellent in 8 patients, Good in 6 patients, fair in 5 patients and poor in 2 patients Conclusion: Uncemented total hip arthroplasty is the procedure of choice for the patients with failed proximal femoral osteosynthesis providing pain relief, preservation of mobility, range of motion and easy rehabilitation

A report of a novel technique: The comprehensive fibular autograft with double metal locking plate fixation (cFALP) for refractory post-operative diaphyseal femur fracture non-union treatment

IntroductionThe refractory post-operative diaphyseal femur fracture (DFF) non-union is extremely difficult to treat and remains severe challenges for orthopedists. Although several traditional internal fixations and novel biomedical techniques have been used in managing this complication, its treatment is still fraught with severe challenges. Patients and methodsStarting from 1999, 5 patients after three previous internal fixation operations showing refractory DFF non-union underwent the comprehensive fibular autograft with double metal locking plates fixation (cFALP) surgery. The autogenous fibular was first harvested and non-evenly split into two halves in a longitudinal manner. After retracting all previous internal fixation(s), the larger half strut fibula was hammered into the femur canal while the smaller half was fragmented into small pieces and filled surrounding the DFF site. Two locking compression plate were fixed on the lateral and anterior (or antero-lateral) side of the femur, respectively. ResultsThe follow-up ranged from 60 to 96 weeks. All cases (100%) achieved bony union without severe complications. The mean time to union was 36±14.7 weeks (range 24–60 weeks). ConclusionThe cFALP is a promising surgical modality for DFF non-union treatment. However, because fibular harvest may cause severe complications, the cFLAP should only be considered in refractory DFF non-union cases.

When femoral fracture fixation fails

Most hip fractures treated with modern internal fixation techniques will heal. However, failures occasionally occur and require revision procedures. Salvage strategies employed during revision are based on whether the fixation failure occurs in the femoral neck, or in the intertrochanteric region. Patient age and remaining bone stock also influence decision making. For fractures in young patients, efforts are generally focused on preserving the native femoral head via osteotomies and repeat internal fixation. For failures in older patients, some kind of hip replacement is usually selected. Disuse osteopenia, deformity, bone loss, and stress-risers from previous internal fixation devices all pose technical challenges to successful reconstruction. Attention to detail is important in order to minimise complications. In the majority of cases, good outcomes have been reported for the various salvage strategies.

Outcome of locking compression plates in humeral shaft nonunions

Background: Nonunion of diaphyseal fractures of the humerus are frequently seen in clinical practice (incidence of up to 15% in certain studies) and osteosynthesis using dynamic compression plates, intra medullary nails and Ilizarov fixators have been reported previously. Locking compression plates (LCP) are useful in the presence of disuse osteoporosis, segmental bone loss and cortical defects that preclude strong fixation. We report a prospective followup study of the outcome of the use of LCP for humeral nonunion following failed internal fixation in which implants other than LCP had been used. Materials and Methods: Twenty four patients with nonunion of humeral shaft fractures following failed internal fixation were included in the study. The mean followup period was 3.4 years (range: 2.4 to 5.7 years) and the minimum followup period was 2 years. Mean age of the patients was 41.04 years (range: 24 to 57 years). All 24 patients underwent osteosynthesis using LCP and autologous bone grafting (cortico‑cancellous iliac crest graft combined with or without fibular strut graft). Main outcome measurements included radiographic assessment of fracture union and pre and postoperative functional evaluation using the modified Constant and Murley scoring system. Results: 23 out of 24 fractures united following osteosynthesis. Average time to union was 16 weeks (range: 10 to 28 weeks). Complications included delayed union (n = 2), transient radial nerve palsy (n = 2) and persistent nonunion (n = 1). Functional evaluation using the Constant and Murley score showed excellent results in 11, good in 10, fair in two and poor outcome in one patient. Conclusions: Locking compression plating and cancellous bone grafting is a reliable option for achieving union in humeral diaphyseal nonunion with failed previous internal fixation and results in good functional outcome in patients with higher physiological demands.

Outcome of locking compression plates in humeral shaft nonunions

Background:Nonunion of diaphyseal fractures of the humerus are frequently seen in clinical practice (incidence of up to 15% in certain studies) and osteosynthesis using dynamic compression plates, intra medullary nails and Ilizarov fixators have been reported previously. Locking compression plates (LCP) are useful in the presence of disuse osteoporosis, segmental bone loss and cortical defects that preclude strong fixation. We report a prospective followup study of the outcome of the use of LCP for humeral nonunion following failed internal fixation in which implants other than LCP had been used.Materials and Methods:Twenty four patients with nonunion of humeral shaft fractures following failed internal fixation were included in the study. The mean followup period was 3.4 years (range: 2.4 to 5.7 years) and the minimum followup period was 2 years. Mean age of the patients was 41.04 years (range: 24 to 57 years). All 24 patients underwent osteosynthesis using LCP and autologous bone grafting (cortico-cancellous iliac crest graft combined with or without fibular strut graft). Main outcome measurements included radiographic assessment of fracture union and pre and postoperative functional evaluation using the modified Constant and Murley scoring system.Results:23 out of 24 fractures united following osteosynthesis. Average time to union was 16 weeks (range: 10 to 28 weeks). Complications included delayed union (n = 2), transient radial nerve palsy (n = 2) and persistent nonunion (n = 1). Functional evaluation using the Constant and Murley score showed excellent results in 11, good in 10, fair in two and poor outcome in one patient.Conclusions:Locking compression plating and cancellous bone grafting is a reliable option for achieving union in humeral diaphyseal nonunion with failed previous internal fixation and results in good functional outcome in patients with higher physiological demands.

Review Article: Risk Factors of Infection following Total Knee Arthroplasty

22 PubMed articles in English were identified using the key words: 'risk factors', 'infection', and 'primary total knee arthroplasty (TKA)'. The 10 most relevant articles were reviewed. In one study, obesity and diabetes were considered risk factors for infection following TKA. In another study, postoperative infection correlated with a history of open reduction and internal fixation, male gender, remnants of previous internal fixation material, and body mass index. In yet another study, the risk factors were (in decreasing order of significance): congestive heart failure, chronic pulmonary disease, preoperative anaemia, diabetes, depression, renal disease, pulmonary circulation disorders, obesity, rheumatologic disease, psychoses, metastatic tumour, peripheral vascular disease, and valvular disease.

Locking compression plates and autologous bone graft for the humeral shaft nonunion after surgical failure

Objective To evaluate the efficacy of secondary revision with locking compression plates (LCP) and autologous bone graft for nonunion of humeral shaft fracture after surgical failure. Methods Included in this study were 26 patients with nonunion of humeral shaft fracture after various surgical treatments who had received secondary revision with LCP and autologous iliac graft in our department between March 2006 and June 2008 and had been fully followed.They were 19 men and 7 women,with an average age of 46.7 years (range,19 to 63 years).There were 17 cases of hypertrophic nonunion,7 cases of atrophic nonunion and 2 cases of pseudarthrosis.The mean interval between the primary operative treatment and the secondary revision was 9.3 months (from 9.1 to 9.6 months). All nonunions were managed with removal of previous implants,open reduction and internal fixation with LCP,supplemented by cancellous bone graft.Functional recovery was evaluated by Mayo Elbow Performance Index and the modified scale of Constant and Murley. Results The average follow-up was 25.6 months (range,25 to 33 months).The secondary revision led to postoperative bone union in 25 patients after a mean time of 5.2 months (range,4 to 9 months).Only one patient suffered nonunion caused by wound infection before he eventually obtained bone union after anti-infective therapy for 5 months.Temporary palsy of the radial ncrve occurred in 2 cases.The mean functional scores for the shoulder (Constant) and the elbow (Mayo) were 79.1 ±0.1 and 85.7 ±0.8,respectively.Conclusions In revision of the nonunion of humeral shaft fracture after surgical failure,LCP and autologous bone graft can greatly increase the rate of union and reduce complications to ensure good functional recovery of the upper extremity.We believe the key to the procedure lies in complete resection of the nonunion ends and fibrous tissue,cortex-to-cortex apposition with stalwart compression across the entire site and wide use of autologous bone. Key words: Humeral fractures; Fractures, ununited; Fracture fixation, internal; Bone plates

Arthroscopic Ankle Arthrodesis After Tibial Pilon Open Reduction Internal Fixation

Ankle arthrodesis is an essential tool in the foot and ankle surgeon's armamentarium. Despite the evolving technology and ongoing research in ankle arthroplasty, arthrodesis continues to be a proven and safe option for the majority of patients with ankle arthritis refractory to conservative management. Here, the authors present their technique of an arthroscopic ankle arthrodesis specifically in the setting of a previous open-reduction internal fixation (ORIF) for a tibia plafond type fracture. They have found this to be a reliable technique to achieve a solid ankle arthrodesis while minimizing soft-tissue trauma and dissection in an already compromised soft-tissue envelope.

Previous fracture surgery is a major risk factor of infection after total knee arthroplasty

Total knee arthroplasty (TKA) has been proven to be the most effective treatment for patients with severe joint disease. Although infection is not a frequent complication, it is certainly one of the most dreaded. The purpose of this study was to identify factors associated with infection after TKA. Between 1995 and 2006, 2,022 primary TKAs in 1,146 patients were evaluated. Flexible Nichidai Knee (FNK) was used as a prothesis in all subjects. Twenty-four patient-specific data items were collected via chart review for each patient. Revision arthroplasty procedures and infected knees were excluded. The medical records were reviewed to extract the following information: age, gender, body mass index (BMI), preoperative C-reactive protein (CRP), preoperative erythrocyte sedimentation rate (ESR), preoperative total protein (TP), duration of surgery, operative blood loss, total blood loss, duration of surgical drain, duration of antibiotic prophylaxis, primary diagnoses, smoking, diabetes mellitus, steroid or disease modifying anti-rheumatic drugs (DMARDs) therapy, previous operation around the knee joint, previous arthroscopic surgery, previous non-arthroscopic surgery, previous high tibial osteotomy (HTO) or open reduction internal fixation (ORIF), remnants of previous internal fixation material, bone graft, patella replacement, and bone cement. The median age of the patients at the time of primary TKA was 72 (range, 26-91) years. The median follow-up period after primary TKA was 42 (range, 6-145) months. During the study period, 17 infected knee arthroplasties in 17 patients were identified. Previous history of ORIF, male gender, remnants of previous internal fixation material, and BMI showed significant correlation with postoperative infection. This study identified previous history of fracture and remnants of internal fixation as major risk factors of infection after TKA. For clinical relevance, surgeons should be aware of potential infection when performing TKA in patients with these risk factors and patients should be informed of the potential risks.

Secondary reconstruction of displaced three and four-part proximal humeral fractures with locking plate system

Introduction Symptomatic neglected and displaced three- and four-part proximal humeral fractures are often difficult to reconstruct. Replacement has been reported to give poor functional outcome and hence is not the ideal treatment option. We report our results of secondary reconstruction of these difficult fractures with a locking plate system. Material and methods Between 2003 and 2005, 15 healthy active patients with displaced three- to four-part fractures underwent revision/secondary open reduction and internal fixation with a locking plate system (Philos, Stratec UK Ltd). Ten patients had delayed presentation. Three patients had failed previous internal fixation. One patient had non-union and one had malunited fracture. Their average age was 63 years. Objective assessment was measured by the Constant score, subjective assessment by the Oxford questionnaire. The mean follow-up was 14 months. Surgical technique In revision cases, the fracture was approached through the same incision. All metal work was removed. Careful attention was given to restore the normal anatomy of the humeral head with correct placement of the tuberosities. Reduction was held with Ticron sutures through the rotator cuff followed by fixation with the locking plate. Two patients required arthroscopic repair of their labral tears. The shoulder was immobilised in a sling for four weeks followed by a gradual mobilisation programme. Results All fractures united. No failure of fixation was observed. The mean Constant score was 73. The pain component improved from 3 pre-operatively to 14 at follow-up. The average range of flexion was 1100, abduction of 950 and external rotation of 350. All patients had good to excellent subjective outcome. We encountered poor rotator cuff function in one patient. Conclusion Successful reconstruction of three- and four-part proximal humeral fractrures is possible. Anatomical restoration of humeral head and tuberosities prior to plate fixation is essential for good outcome.

Revision surgery for nonunion after early failure of fixation of fractures of the distal humerus

Sixteen patients who underwent a revision operation for nonunion of fractures of the distal humerus following previous internal fixation were reviewed at a mean follow-up of 39 months (8 to 69). The Mayo elbow performance score was excellent in 11, good in two, fair in two and poor in one. In 15 patients union was achieved and in one with an infected nonunion a subsequent bone graft was necessary in order to obtain union.Age, gender, a history of smoking, mechanism of the injury and the AO classification of the initial fracture did not correlate with the development of nonunion. In 12 patients (75%), the initial fixation was assessed as being suboptimal. The primary surgery was regarded as adequate in only three patients. Our findings suggest that the most important determinant of nonunion of a distal humeral fracture after surgery is the adequacy of fixation.