Primary Internal Fixation Research Articles

A biomechanical investigation of a novel intramedullary nail used to salvage failed internal fixations in intertrochanteric fractures

PurposeThe ideal approach for revision surgery following femoral head salvage treatments for an intertrochanteric fracture is still up for debate. A novel variety of proximal femoral bionic intramedullary nail (PFBN) has been created in clinical practice. We aimed to compare the biomechanical results of the novel implant to conventional intramedullary and extramedullary fixation in the treatment of intertrochanteric fracture following primary internal fixation failure.MethodsUsing finite element analysis, we created a three-dimensional model of the intertrochanteric fracture's helical blade cut-out for this investigation. The PFBN 1 group, the PFBN 2 group, the PFNA group, and the DHS group were our four test groups. For each fracture group, the von Mises stress and displacements of the femur and internal fixation components were measured under 2100 N axial loads.ResultsThe values for the femoral displacement in the PFBN1 group, PFBN2 group, PFNA group, and DHS group were 6.802 mm, 6.716 mm, 8.080 mm, and 8.679 mm, respectively. The internal implant displacement values were 6.201 mm, 6.138 mm, 7.396 mm, and 8.075 mm in the PFBN1 group, PFBN2 group, PFNA group, and DHS group, respectively. The maximum von Mises Stress in the femoral was 187.2 MPa, 85.18 MPa, 106.6 MPa, and 386.2 MPa in the PFBN1 groups, PFBN2 groups, PFNA groups, and DHS groups, respectively. In the PFBN1 groups, PFBN2 groups, PFNA groups, and DHS groups, the maximum von Mises Stress in internal fixation was 586.7 MPa, 559.8 MPa, 370.7 MPa, and 928.4.8 MPa, respectively.ConclusionOur biomechanical research demonstrates that intramedullary fixation is more stable than extramedullary fixation when salvaging failed internal fixations in intertrochanteric fracture. Compared with PFNA and DHS, PFBN showed better biomechanical stability in the treatment of patients with revised intertrochanteric fractures. In light of this, we advocate PFBN fixation as the method of choice for intertrochanteric fracture revision. This result still has to be confirmed in more clinical research.

To evaluate the role of VAC therapy in open fractures after primary fixation in term of faster and more effective wound healing

Vacuum-assisted closure (VAC) is a noninvasive, active wound management system that exposes a wound bed to local sub atmospheric pressure, removes fluid from the extravascular space, improves circulation, and enhances the proliferation of granulation tissue. The purpose of this study is to know the rate of wound infection, number of days required for making the wound fit for skin cover procedures, number of days required for formation of uniform granulation tissue bed in the wound healing treated by Vacuum Assisted Closure after primary fixation of fracture.Patients between 18 to 60 years were included in this prospective randomized controlled trial. Primary internal Fixation of fracture was done as soon as possible followed by VAC application. Functional outcome of cases recorded during each follow up according to Johner and Wruh’s (1983).According to this study, 30 patients with open fractures of both bone leg after primary internal fixation with VAC application. During follow up effective decrease (mean ± SD) in wound size after VAC therapy was 9.97±9.59 cm2 with P-value 0.0481. This technique has resulted in the effective decrease in wound size, infection and give a better functional outcome.The greatest advantage of VAC was found to facilitate rapid formation of granulation tissue on wounds with exposed tendons, bones, raw area wounds and exposed implants hence decrease healing time and minimize soft tissue defect coverage procedures.

Sleep Apnea and Postoperative Medical Complications and Health Care Expenditures Following Open Reduction and Internal Fixation of Bimalleolar Ankle Fractures.

Sleep Apnea (SA) is a common sleep disorder that increases postoperative morbidity. There is limited research on how SA influences outcomes following operative fixation of ankle fractures. Therefore, the aim of this study was to determine whether patients who undergo surgical fixation for bimalleolar ankle fractures have higher rates of medical complications and health care expenditures. A retrospective review from January 1, 2005 to March 31, 2014 was conducted using the parts A and B Medicare Data from PearlDiver database. Patients with and without SA on the day of the primary open reduction and internal fixation (ORIF) of their bimalleolar ankle fractures were queried using the International Classification of Diseases, Ninth Revision codes. Welch'st-tests were used to compare costs of care. A multivariate binomial logistic regression model was used to calculate the odds ratio (OR) of adverse events. A P-value <.001 was considered statistically significant. There were 20 560 patients (SA = 3150; comparison cohort = 17 410) who underwent ORIF for bimalleolar ankle fractures during the study period. Sleep apnea patients were found to have significantly higher rates and odds of 90-day medical complications (21.42% vs 7.47%, OR: 3.11, P < .0001) and 90-day costs of care ($7213.12 vs $5415.79, P < .0001). This research demonstrates an increased risk of postoperative medical complications and health care costs among patients with SA undergoing ORIF for bimalleolar ankle fractures. Therapeutic, Level IV: Retrospective.

To evaluate the outcome of vacuum assisted closure in open fractures of tibia

Despite numerous advances, compound fractures of long bones continues to be a challenge for the treating surgeon. Standard wound dressing required prolonged period, repeated debridement, trauma to granulation tissue and had poor patient compliance. Vacuum-assisted closure provides an extremely efficacious method for treating difficult wounds. This research aimed to study whether VAC gives better outcome in open fractures after primary intervention, whether it leads to faster and more effective wound healing and whether it leads to shorter length of stay in hospital. An interventional study was conducted, studying 30 cases of open tibia fractures who were fitting in the inclusion criteria. It followed Gustillo- Anderson classification to classify cases and then mapped out various conclusions on the aim of study whilst also charting the effect of the treatment in different circumstances, demographics and like. Amongst the 30 cases studied,all patients were evaluated clinically after the primary fixation and following VAC application, for an average period of follow up of 12 months. Majority of patients required 4-5 VAC dressings. The mean decrease in wound size was 9.97 cm [21.22%]. Out of 30 patients, 4 patients had excellent, 16 patients had good, 8 patients had fair and 2 patients had poor result.In this study, 30 patients were included with open fractures of tibia after primary internal fixation with VAC application. The greatest advantage of VAC was found to facilitate rapid formation of granulation tissue on wounds with exposed tissue and implants hence shorten healing time and minimize secondary soft tissue defect coverage procedures. This technique has indeed resulted in the effective decrease in wound size, and decrease in hospital stay and given a better functional outcome.

Primary Arthroplasty or Internal Fixation in Intertrochanteric Femur Fractures: A Survey of Surgical Attitudes of Orthopedic Surgeons in Turkey.

This study aimed to examine the primary arthroplasty attitudes of Turkish orthopedics and traumatology specialists and residents to patients with intertrochanteric fractures, of various ages, comorbidity situations and fracture types, using an internet-based questionnaire. Between March and April 2021, a cross-sectional survey was conducted with a total of 159 orthopedics and traumatology specialists and residents in Turkey, using an online questionnaire that consisted of 16 different patient scenarios of varying intertrochanteric fracture types, ages, and comorbidity conditions. Respondents’ preference ratio for primary arthroplasty was 24.1% in the scenarios with patients over the age of 71, while it was 8.4% in the scenarios with patients aged between 50 and 70. The ratios of primary arthroplasty preference were 12.4%, 21% and 27.3% in 2-part, 3-part and 4-part fracture scenarios, respectively. The primary arthroplasty preferences of respondents with 10 years or more of professional experience were observed to be statistically significantly different to those of the respondents with 1 to 10 years of experience in the 4-part fracture scenario where the patient was aged 71 years and above with an ASA (American Society of Anesthesiologists) score of 3–4 (p < 0.05). Despite varying opinions in the literature in recent years, primary arthroplasty can be considered a valuable alternative approach for Turkish surgeons, and in older adult patients with unstable intertrochanteric fractures, particularly those who need early mobilization and have high ASA scores.

Clinical outcomes of patients with Garden I and II femoral neck fractures as verified on MRI: a retrospective case series

BackgroundBetween 2 to 10% of non-displaced femoral neck fractures (nFNF) cannot be diagnosed on plain radiographs and require further imaging investigation to be detected or verified. These fractures are referred to as occult hip fractures. This study aimed to report treatment failures, reoperations and mortality in a consecutive series of occult femoral neck fractures (FNF) treated with internal fixation (IF).MethodsA retrospective multicenter study was performed based on a consecutive series of patients aged ≥ 60 years with an occult magnetic resonance imaging (MRI) verified Garden I and II FNF sustained after a trauma and treated with primary IF. We included 93 patients with a minimum 2-year follow-up. Radiographic assessment encompassed pre- and postoperative tilt, implant inclination, MRI and treatment failure. Data on reoperation and mortality were collected. Treatment failure was defined as fixation failure, nonunion, avascular necrosis or posttraumatic osteoarthritis.ResultsThe study comprised of 93 patients (72% women, 67/93) with a mean age of 82 (range, 60–97) years. Overall, 6 (6%) patients had major reoperations. 2 (2%) had minor reoperations. One-month mortality was 7%, 1-year mortality was 20% and 2-year mortality was 31%.ConclusionThis multicenter cohort study identifies a subgroup of elderly patients with MRI verified Garden I and II FNFs sustained after trauma, i.e. occult fractures. These fractures seem to have a lower complication rate compared to nFNF identified on plain radiographs.Level of evidencePrognostic Level V. See Instructions to Authors for a complete description of levels of evidence.

Ankle Fractures Involving the Posterior Malleolus: 7-Year Results in 100 Cases

Category:Ankle; TraumaIntroduction/Purpose:The presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate and new concepts continue to emerge. The aim of this study was to assess the medium- to long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population treated with an individualized treatment approach.Methods:One hundred patients with ankle fractures involving the PM were identified retrospectively and reevaluated at an average follow-up of 7.0 years. Fixation of the PM was tailored to the individual fracture pattern. Bartoníček-Rammelt type I PM fractures (extraincisural shell-like fragments) were not fixed surgically. Displaced Type II (posterolateral fragments) and type III PM fractures (two-part with medial extension) were mostly fixed with direct posterior screw or plate fixation. Intercalary joint fragments were fixed with lost K-wires or resorbable pins. Type IV PM fractures (large triangular fragments) were treated with either posterior screw / plate fixation or indirect anteroposterior screw fixation with direct transfibular control of reduction, if feasible.Results:Internal PM fragment fixation was negatively correlated with the need for syndesmotic screw placement at the time of surgery (p=0.010). At 7 years, the mean Foot Function Index was 16.5, the Olerud Molander Ankle Score averaged 80.2 and the American Orthopaedic Foot & Ankle Society ankle/hindfoot score averaged 87.5. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 and 50.5, respectively. Range of motion was within 3.4 degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with anterior or posterior shift of the distal fibula of 1 mm within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation (p=0.031). Two patients (2%) needed secondary ankle fusion following deep infection.Conclusion:With an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected. The mere size of the PM fragment is just one of the factors guiding treatment, other important criteria are fragment displacement, impaction of the tibial plafond and incisura involvement. PM fixation provides direct bone-to-bone fixation of the syndesmosis and significantly reduces the need for additional transsyndesmotic fixation with a screw or flexible implant.

Preoperative Anterior and Posterior Tilt of Garden I-II Femoral Neck Fractures Predict Treatment Failure and Need for Reoperation in Patients Over 60 Years.

Background:The purpose of the present study was to estimate the effect of preoperative fracture tilt and to scrutinize the effect of anterior tilt on the risk of treatment failure in patients with Garden Type-I and II femoral neck fractures that are treated with internal fixation.Methods:A retrospective multicenter study was performed on a consecutive series of patients ≥60 years of age who had undergone primary internal fixation for the treatment of Garden Type-I and II femoral neck fractures. The study included 1,505 patients with a minimum follow-up of 2 years. Radiographic assessments encompassed preoperative and postoperative tilt, implant inclination, and treatment failure. Data on reoperation and mortality were collected. The risk of treatment failure was assessed with use of Cox proportional hazard regression analysis.Results:The study comprised 1,505 patients (71% female) with a median age of 81 years (range, 60 to 108 years). Overall, 234 patients (16%) were classified as having a treatment failure and 251 patients (17%) underwent reoperation. A preoperative anterior tilt of >10° and a posterior tilt of >20° were predictors of treatment failure and reoperation, respectively. Treatment failure occurred in 74 (25%) of 301 patients with a posterior tilt of >20° and in 17 (43%) of 40 patients with an anterior tilt of >10°.Conclusions:This multicenter cohort study identified a subgroup of patients with Garden Type-I and II femoral neck fractures with an anterior tilt of >10° as having high treatment failure rates and major reoperation rates comparable with those associated with displaced femoral neck fractures. A preoperative posterior tilt of >20° increases the risk of treatment failure, and the potential benefit of arthroplasty in this subgroup of patients remains to be further investigated.Level of Evidence:Prognostic Level III. See Instructions to Authors for a complete description of levels of evidence.

Study and analysis of effect of calcium sulphate augmented with antibiotics in orthopaedic practice

Background: Open fractures, osteomyelitis, peri-prosthetic infections whether impending or established are challenging situations in orthopaedic practice. Prevention and eradication of infections is a difficult task and incomplete treatment can lead to devastating complications. Treatment protocol involves wound debridement in cases of osteomyelitis and peri-prosthetic infections, primary internal fixation of the open fracture and application of calcium sulphate augmented with antibiotics, is a line of treatment in most of the cases.Aim: To study and analyse the effect of calcium sulphate augmented with antibiotics in orthopaedic practice.Materials and Methods: Patients were admitted in Mallya Hospital, Bangalore in between June 2018 to December 2019. Sample size of 30 was calculated based on the formula. Patients with diagnosis of osteomyelitis, peri-prosthetic infection and open fracture were included in the study. The patients were recruited to the study after due consent. Clinical history was taken and patients were examined, laboratory parameters (TC, ESR, CRP) were taken preoperatively and radiological examination done. Patients were followed up with laboratory parameters (TC, ESR, CRP), radiographs for resorption of calcium sulphate and bone healing at 6 weeks, 3 months and 6 months postoperatively.Results: Minimum age of the patient was 15 years and maximum 83 years, 2 patients were lost to follow up, 21 males and 7 female patients. Cases were divided depending on the type. Postoperatively laboratory parameters with statistical significant P values in cases of osteomyelitis, peri-prosthetic infection, open fracture seen in TC, ESR and CRP are as follows, osteomyelitis (0.016,0.011,

Outcomes of Fast-Track Primary Internal Fixation of Open Fractures in Ballistic Injuries – A Single-Center Experience

Background: Open fractures due to ballistic injuries (bullets and/or splinters due to grenade blasts) have increased in the last decade. Outcome of management of such injuries depends on various factors. Purpose of this study was to frame a management protocol for primary internal fixation of such fractures without significant complications. Materials and Methods: 105 patients (117 fractures) of ballistic injuries evacuated to the trauma care center of this hospital from July 2018 to July 2019 were enrolled. After initial evaluation and optimal resuscitation, patients were considered for primary internal fixation of the fractures followed by multidepartmental rehabilitation involving a physiotherapist, a psychiatrist, and a psychotherapist. Follow-up was done at 3 months, 6 months, and 1 year after the surgery. Results: 74 fractures were due to gunshot-related injuries and 43 due to splinters from grenade blasts. Average interval between time of injury and surgery was 5.68 h. Seventeen patients required repeat debridement after initial surgery, and the subsequent wound healing was uneventful. All fractures united except 15 patients who underwent bone grafting for aseptic nonunion (6–9 months after index surgery). Only six patients were followed telephonically, else there was no loss to follow-up. The study did not encounter any mortality or infection. Conclusions: Open fractures occurring due to ballistic injuries pose a unique challenge in management. Fast-track evaluation and urgent management of the fractures by careful wound debridement and primary internal fixation have shown excellent results, with absolute zero infection rate in 1-year follow-up.

Ankle fractures involving the posterior malleolus: patient characteristics and 7-year results in 100 cases

IntroductionThe presence of a posterior malleolar (PM) fragment has a negative prognostic impact in ankle fractures. The best treatment is still subject to debate. The aim of this study was to assess the medium-to-long-term clinical and functional outcome of ankle fractures with a PM fragment in a larger patient population.Materials and methodsOne hundred patients (69 women, 31 men, average age 60 years) with ankle fractures including the PM were evaluated clinically and radiographically. Patients with Bartoníček–Rammelt type 3 and 4 fracture displayed a significant female preponderance. Fixation of the PM was performed in 63% and tailored to the individual fracture pattern.ResultsInternal fixation of the PM fragment was negatively correlated with the need for syndesmotic screw placement at the time of surgery (p = 0.010). At an average follow-up of 7.0 years, the mean Foot Function Index (FFI) was 16.5 (SD: 21.5), the Olerud Molander Ankle Score (OMAS) averaged 80.2 (SD: 24) and the American Orthopedic Foot & Ankle Society (AOFAS) ankle/hindfoot score averaged 87.5 (SD: 19.1). The maximum score of 100 was achieved by 44% of patients. The physical (PCS) and mental health component summary (MCS) scores of the SF-36 averaged 47.7 (SD: 12.51) and 50.5 (SD: 9.36), respectively. Range of motion was within 3.4 (SD: 6.63) degrees of the uninjured side. The size of the PM fragment had no prognostic value. There was a trend to lower outcome scores with slight anterior or posterior shift of the distal fibula within the tibial incisura. Patients who underwent primary internal fixation had significantly superior SF-36 MCS than patients who underwent staged internal fixation (p = 0.031).ConclusionsWith an individualized treatment protocol, tailored to the CT-based assessment of PM fractures, favorable medium and long-term results can be expected.

The use of circular frame external fixation in the treatment of ankle/hindfoot Charcot Neuroarthropathy

Charcot Neuroarthropathy (CN) of the ankle/hindfoot is a devastating condition that results in a loss of alignment, bony malleolar protrusions and frequently leads to ulceration, infection, and amputation. Major limb amputations in this patient population has a 5-year mortality rate approximating 39%–68%. The treatment goal for CN of the ankle/hindfoot is to provide stability with a plantigrade foot that is infection free, shoeable and allows independent weight bearing. The use of a circular frame external fixator is often required when treating patients with CN of the ankle/hindfoot because they often present late with deformity, soft tissue compromise and infection which are contraindications to primary internal fixation. These patients require urgent surgical attention to salvage the limb or risk amputation. In this narrative review article we will discuss the indications, management options, surgical technique, evidence and describe our experience in the use of circular frame external fixation in patients with ankle/hindfoot Charcot Neuroarthropathy.

Motion-Preserving Navigated Primary Internal Fixation of Unstable C1 Fractures.

Study DesignProspective observational study.PurposeTo assess the safety, efficacy, and benefits of computed tomography (CT)-guided C1 fracture fixation.Overview of LiteratureThe surgical management of unstable C1 injuries by occipitocervical and atlantoaxial (AA) fusion compromises motion and function. Monosegmental C1 osteosynthesis negates these drawbacks and provides excellent functional outcomes.MethodsThe patients were positioned in a prone position, and cranial traction was applied using Mayfield tongs to restore the C0–C2 height and obtain a reduction in the displaced fracture fragments. An intraoperative, CT-based navigation system was used to enable the optimal placement of C1 screws. A transverse rod was then placed connecting the two screws, and controlled compression was applied across the fixation. The patients were prospectively evaluated in terms of their clinical, functional, and radiological outcomes, with a minimal follow-up of 2 years.ResultsA total of 10 screws were placed in five patients, with a mean follow-up of 40.8 months. The mean duration of surgery was 77±13.96 minutes, and the average blood loss was 84.4±8.04 mL. The mean combined lateral mass dislocation at presentation was 14.6±1.34 mm and following surgery, it was 5.2±1.64 mm, with a correction of 9.4±2.3 mm (p <0.001). The follow-up CT showed excellent placement of screws and sound healing. There were no complications and instances of AA instability. The clinical range of movement at 2 years in degrees was as follows: rotation to the right (73.6°±9.09°), rotation to the left (71.6°±5.59°), flexion (35.4°±4.5°), extension (43.8°±8.19°), and lateral bending on the right (28.4°±10.45°) and left (24.8°±11.77°). Significant improvement was observed in the functional Neck Disability Index from 78±4.4 to 1.6±1.6. All patients returned to their occupation within 3 months.ConclusionsSuccessful C1 reduction and fixation allows a motion-preserving option in unstable atlas fractures. CT navigation permits accurate and adequate monosegmental fixation with excellent clinical and radiological outcomes, and all patients in this study returned to their preoperative functional status.

Primary internal fixation in open fractures of tibia following high-velocity gunshot wounds: a single-centre experience.

High-velocity gunshot fractures are primarily a domain of military medicine. Traditionally, the management of choice for these injuries has been an external fixation. However, we present a series of high-velocity gunshot fractures of tibia managed with primary internal fixation. Twenty-nine cases of high-velocity gunshot tibial fractures presenting within six hours of trauma were taken up for primary internal fixation and followed up at two months, four months, six months and one year including telephonic follow-up for five patients. Cases with various grades of open fracture were taken up for debridement and primary internal fixation within a mean period of three hours 40 minutes post trauma. Twenty-two cases were managed with unreamed interlocking nail and fixation was done with plate in seven cases. Five cases developed early superficial infection and four developed deep infection. All tibia united; however, secondary procedures were required in six cases to achieve union. One patient developed infected non-union which was managed with rail fixator. One patient was left with chronic discharging sinus. High-velocity gunshot wounds of leg present special challenge to the orthopaedic surgeons. Timely intervention, through debridement and meticulous soft-tissue handling, can give good results with primary internal fixation. Our results are comparable to open fractures of tibia due to other causes and with other studies using external fixation. Further randomised controlled trials are needed to substantiate our findings.

Open Reduction and Internal Fixation of Distal Tibial Pilon Fractures.

Intra-articular fractures of the distal end of the tibia, more commonly referred to as pilon fractures, account for approximately 5% to 7% of all tibial fractures1,2. Type-C fractures present a unique surgical challenge: a total articular fracture contained within a vulnerable soft-tissue envelope. Treatment options include internal fixation3, external fixation with or without limited internal fixation4, and primary ankle arthrodesis2. The management, and particularly the timing, of surgery is often dictated by the patient's general state of health, soft-tissue condition, and fracture comminution as well as the experience of the surgeon. The surgical goals are to reconstruct the articular surface of the plafond, restore limb alignment, and protect the soft-tissue envelope. Since the publication of the seminal paper by Sirkin et al.5 in 1999, it has become orthopaedic orthodoxy to stage the surgery of pilon fractures, adopting a so-called span, scan, and plan approach. We more commonly operate early, and in a recently published retrospective review of 102 type-C pilon fractures in 99 patients, 73 patients (73 fractures; 71.6%) underwent primary internal fixation6. Outcomes were equivalent to the results of a staged protocol: 36 complications in 28 patients (28 fractures; 27.5%), with superficial (n = 9) and deep (n = 9) infection being the most common. Forty-one fractures (40.2%) required at least 1 additional operation, with removal of symptomatic metalwork being the primary indication (n = 30). No patient required an amputation. At a mean follow-up of 6 years, both the mean Foot and Ankle Disability Index (FADI) and mean Foot and Ankle Outcome Score (FAOS) were 76 (range, 0 to 100). Median patient satisfaction was 7 of 10. The results demonstrated a satisfactory outcome following primary internal fixation in appropriately selected patients. This instructional video outlines the surgical technique used. The key steps of the procedure are (1) preoperative planning with assessment of imaging and soft tissues; (2) application of a thigh tourniquet and placement of the patient predominantly in the supine position, unless the fracture configuration requires a prone position; (3) intraoperative use of a spanning external fixator; (4) careful exposure of the distal end of the tibia, dictated by the fracture configuration, with the anterolateral, anteromedial, and direct medial approaches most commonly used, elevating full-thickness tissue flaps wherever possible; (5) fracture reduction and fixation through a joint arthrotomy and fracture windows, allowing visualization of the articular margins, followed by initial Kirschner wire stabilization and definitive lag screw fixation; (6) application of a low-profile, locking or nonlocking plate in either buttress or bridging mode, joining the articular-metaphyseal block to the distal tibial diaphysis; (7) fixation of an associated fibular fracture, typically with intramedullary nailing and removal of the external fixator; (8) layered closure according to surgeon preference; and (9) postoperative protocol, consisting of a removable orthosis with a strict non-weight-bearing restriction for up to 3 months.

Functional outcomes of conservative versus operative management of displaced midshaft clavicular fracture: a comparative study

Purpose Management of displaced midthird clavicle fractures is still controversial. Recent studies have shown a high incidence of symptomatic malunion and nonunion following nonoperative treatment of displaced midshaft clavicular fractures, with other studies showing no much improvement in shoulder function following operative treatment. The aim of this study is to compare patient-oriented and surgeon-based outcomes after nonoperative treatment with results following operative treatment of acute completely displaced midshaft clavicular fractures. Patients and methods This retrospective study was carried out on 91 patients with a displaced midshaft fracture of the clavicle distributed into two groups, with the first group managed conservatively and the second group with open reduction and internal fixation. Outcome analysis included standard clinical follow-up and the Constant shoulder score, the disability of the arm, shoulder and hand score, as well as radiological evaluation. Deformity evaluation included measurement of displacement, shortening, and angulation in both immediate posttrauma radiograph and final radiographs. Results Mean follow-up duration was 28.7±13.3 months in the nonoperative group and 20.4±5 months in the operative group. The mean time to radiographic union was 16.4±3.3 weeks in the nonoperative group compared with 15.6±3 weeks in the operative group (P=0.00). All fractures in the operative group united compared with six nonunions (12.5%) in the nonoperative group, and 12 symptomatic malunions (25%) occurred in the nonoperative group. Constant shoulder scores were significantly better for the operative group at all follow-ups (P=0.00). The disability of the arm, shoulder and hand score showed also significant improvement within the operative group (P=0.00). Conclusion In this study, primary open reduction and internal plate fixation of acute displaced midshaft clavicular fractures resulted in improved outcomes − including both patient-oriented outcome and surgeon-based outcome − and a decreased rate of nonunion and symptomatic malunion compared with nonoperative treatment. Shorting and displacement were found significantly related to decreased shoulder function.

Cadaveric Study on Retrograde Calcaneotibial Fixation of Unstable Ankle Fractures.

In extensive soft tissue injury, primary internal fracture fixation is not always possible and external fixation for primary immobilization plays an important role. The aim of this study was to compare the accuracy of freehand technique and of a target device for retrograde calcaneotibial fixation in an uninjured bone and an unstable ankle fracture. The calcaneotibial fixation was performed randomly by an experienced surgeon utilizing either a freehand drilling technique or a novel targeting device in four human cadavers before and after producing a bimalleolar ankle fracture. The duration of foot positioning, drilling, number of intensifier shots, and drilling attempts were recorded. The final position of the wire was established using IsoC-3D scan. The mean for definitive wire placement with the target device was 247 sec with a mean of 3.4 attempts, and 92 sec and 2.1 attempts in the freehand technique. Mean intraosseous distance of the K-wire was 45.3 mm and 63.6 mm in the tibia and 39.7 mm and 41.5 mm in the calcaneus respectively. The novel target device for calcaneotibial fixation achieves similar results to a trained surgeon using the freehand technique.

Rebound pain following peripheral nerve block anaesthesia in acute ankle fracture surgery: An exploratory pilot study.

Peripheral nerve blocks (PNB) are increasingly used for anaesthesia and postoperative pain control in acute orthopaedic limb surgery but rebound pain upon cessation of PNBs may challenge the benefits on the pain profile. We aimed to explore the pain profile following acute ankle fracture surgery under PNB anaesthesia and investigate if rebound pain could pose a clinical problem. Exploratory, observational study of adults scheduled for acute primary internal fixation of an ankle fracture under ultrasound-guided popliteal sciatic and saphenous ropivacaine block anaesthesia. Postoperatively, patients regularly registered pain scores while receiving a fixed analgesics regimen and patient controlled morphine on-demand. We analysed morphine consumption and depicted the detailed pain profiles as graphs allowing for visual analysis of pain courses, including rebound pain. Secondly, we compared the area under the curve and peak pain between relevant age-subgroups. We included 21 patients aged 20-83. Depicted pain profiles reveal that PNB supplied effective and long lasting postoperative pain control, but cessation of the PNB led to intense rises in pain scores with six out of nine 20-60-year-olds reaching severe pain levels. The rebound was less pronounced in patients >60years old, but nearly all reached moderate pain levels. Morphine consumption rates were high during the rebound. This study thoroughly analyses the post-PNB pain profile and suggests rebound pain is a clinically relevant and problematic issue with the potential to outweigh the PNB benefits, especially for younger patients. The conclusions are tentative, and a randomised study is pending.

Comparison of primary decompressive internal fixation versus delayed surgery for tibial plateau fractures combined with compartment syndrome

Objective To evaluate the clinical outcomes of primary decompressive internal fixation versus delayed surgery for tibial plateau fractures combined with compartment syndrome. Methods From January 2012 to June 2014, a total of 39 patients were treated at our department for tibial plateau fracture combined with compartment syndrome. Early operation was adopted for 18 patients in whom decompression by incisions via the medial and lateral approaches combined with internal fixation with plate and screws was performed at the primary stage and dermoplasty or wound closure conducted at the secondary stage after conditions of soft tissue allowed. Delayed operation was adopted for 21 patients in whom external fixation and decompression by incisions via the medial and lateral approaches was performed in the emergency management followed by selective open reduction and internal fixation. The 2 groups were compared in terms of indexes associated with surgery and hospitalization, Lysholm scores, EuroQol 5 dimensions (EQ-5D) indexes and visual analogue scale (VAS) at final follow-ups. Results All the patients were followed up for more than 2 years. The early operation group incurred significantly less operation time (229.1±43.7 min), intraoperative blood loss (297.5±51.5 mL), hospital stay (11.9±1.9 d) and expenditure [144,700 (103,200, 179,900) Yuan RMB] than the delayed operation group [322.1±62.2 min, 385.9±56.4 mL, 21.5±3.6 d, and 197,700 (137,200, 234,300) Yuan RMB, respectively] (P 0.05). Conclusions In the treatment of tibial plateau fractures combined with compartment syndrome, both primary decompressive internal fixation and delayed surgery can achieve satisfactory clinical outcomes. The former is more appropriate for those without obvious limb ischemia while the latter more appropriate for those whose priority is limb salvage due to serious osteofascial compartment syndrome. Surgeons should choose reasonable procedures according to the specific conditions of the patients and strict surgical indications. Key words: Tibial fracture; Wounds and injuries; Fracture fixation

Healing, nonunion, and re-operation after internal fixation of diaphyseal and distal femoral fractures: a systematic review and meta-analysis.

Nonunion is a highly morbid complication that exacerbates the pain, disability and financial burden of distal and diaphyseal femur fractures. This study examined the modern rates of healing, nonunion, and other complications requiring reoperation of different fixation methods for distal and diaphyseal femur fractures. A systematic review and meta-analysis of all records from PubMed, Embase and the Cochrane Review system was performed. Included studies had >20 acute, non-pathologic distal or diaphyseal femur fractures treated with primary internal fixation. Excluded were studies on abnormal patient/fracture populations, external fixation, or cement/bone graft use. Thirty-eight studies with 2,829 femoral shaft fractures and 11 studies with 505 distal femur fractures were included. Distal fractures had a lower healing rate (86.6% vs. 93.7%) and a higher re-operation rate (13.4% vs 6.1%) than shaft fractures (p < 0.00001), primarily due to higher rates of mechanical failure (p < 0.00001). Nonunion was the most frequent complication, occurring in 4.7% of distal fractures and 2.8% of shaft fractures. There was no difference between plate and nail fixation of distal fractures in healing, nonunion, or other causes of re-operation. Shaft fractures developed nonunion in 6.6% of unreamed nails and 2.1% of reamed nails (p = 0.002). Nonunion occurred in 2.3% of antegrade nailed fractures and 1.5% of retrograde nailed fractures (p = 0.66). Approximately one out of every eight distal fractures and one of every 16 shaft fractures requires re-operation. The most common cause of fixation failure is nonunion. Further research is needed to improve outcomes, particularly in distal femur fractures.