Prophylactic Internal Fixation Research Articles

The use of a T-shaped contoured unilocking titanium radial plate for prophylactic internal fixation of the radial osteocutaneous donor site

The radial osteocutaneous flap retains a limited role in reconstructive maxillofacial surgery The application of prophylactic internal fixation, using straight 3.5 mm plates, has become established to substantially reduce the incidence of fracture at the radial donor site. New lower profile T-shaped 2.4 mm plates and anatomically contoured 3.5 mm plates are now available, both with unilocking screw fixation systems. These plates are easy to apply and allow the removal of up to 50% of the circumference of the radial bone, including the maximum amount of good quality bone from the distal radius. Although there have been no reports of complications as a result of a stress shielding effect with larger plates these refinements in plate design should lessen any remaining concerns.

Review of the radial free flap: still evolving or facing extinction? Part two: osteocutaneous radial free flap

The osteocutaneous radial flap is robust, reliable, and relatively simple to harvest, which will ensure that it remains one of the established reconstructive options in most maxillofacial units. Evidence based on clinical observational studies and biomechanical studies supports the routine or selective use of prophylactic internal fixation to strengthen the radial osteocutaneous donor site. This allows safe harvesting of the maximum volume of available bone, up to half of the circumference, with minimal risk of fracture or long term complications. The incidence of fracture with the plate placed either anteriorly or posteriorly is equally low, but the anterior position is technically easier and probably less likely to cause additional morbidity. This approach probably produces the least morbidity that may currently be achieved when managing the inherent flaws of the radial hard tissue donor site. The introduction of prophylactic internal fixation consolidates the role of the osteocutaneous radial flap for repair of defects that require a relatively small volume of bone and an appreciable area of thin soft tissue, particularly when a long vascular pedicle is desirable. This includes low level defects of the maxilla, some defects of the mandible, and niche reconstructions, such as the orbital rim. It remains useful as a first choice of flap when there is appreciable peripheral vascular disease, when there are other serious coexisting medical conditions; if it is the preferred choice of the patient for functional reasons such as mobility of the lower limb or hip, and as a salvage flap when other reconstructive options have been exhausted.

Recurrent intra-articular osteoid osteoma of the hip after radiofrequency ablation: a case report and review of the literature

We present a case of a 53-year-old woman with recurrent intra-articular osteoid osteoma of the hip 6 months after initial treatment with percutaneous radiofrequency ablation. En bloc surgical excision of the osteoid osteoma and prophylactic internal fixation for impending stress fracture was performed. The patient is pain free, has returned to normal function and there is no sign of recurrence at the one-year follow-up. Intraarticular osteoid osteoma, present a diagnostic challenge and often they are misdiagnosed. Minimally invasive ablation techniques can fail in significant percentage and then surgical excision with histological confirmation remains the definitive treatment of choice.

Traitement chirurgical des métastases des os longs des cancers urologiques

Orthopedic surgery is an important part in the treatment of metastatic bone disease of urologic cancers. It integrates in with the multidisciplinary care focused on the improvement of the patient's comfort and autonomy. The long bones affect presents a grave fractural risk that is sometimes difficult to evaluate. There are several different therapeutic possibilities: prophylactic internal fixation, stabilisation of pathologic fracture, orthopedic cement filling, resection arthroplasty and en bloc resection. The choice of surgical treatment stresses the survival and functional risk of the metastasis. From palliative to curative, surgical treatment is evolving with the use of newer chemotherapies.

Osteocutaneous Radial Forearm Free Flap: Long-Term Radiographic Evaluation of Donor Site Morbidity after Prophylactic Plating of Radius

The osteocutaneous radial forearm free flap (ORFFF) is an ideal source of vascularized bone and soft tissue for repair of defects in reconstructions of the head and neck. However, studies have revealed significant donor site morbidity, decreasing the popularity of this procedure. We have previously reported our technique of prophylactic internal fixation of the radius at the time of graft harvest, developed to decrease donor radius fractures. This is a retrospective radiographic review of our long-term radius donor site morbidity. Forearm radiographs more than 3 years after ORFFF with prophylactic plating were evaluated and compared with prior postoperative films. No donor radius fractures were identified. All radiographs exhibited remodeling and/or reconstitution of donor radii. There was no evidence of implant failure, loosening, or surrounding osteopenia. This study lends further credibility to the ORFFF, when prophylactically plated, as a safe and reliable source of vascularized bone and soft tissue for reconstructive procedures.

Torsional strength estimates of femoral diaphyses with endosteal lytic lesions: Dual‐energy x‐ray absorptiometry study

Pathologic fracture is a significant problem for individuals with metastatic bone disease. Current guidelines for prophylactic internal fixation are neither reliable nor easily applied. The purpose of this study was to validate dual-energy X-ray absorptiometry (DXA) as an accurate method for estimating torsional bone strength of diaphyseal bone with endosteal lytic lesions. Endosteal lesions of varying sizes were simulated in the diaphyses of 12 adult cadaveric femurs. Unaltered contralateral femurs served as matched controls. Machined lesions ranged from 3 to 6.5 cm in length, 1 to 3 cm in width, 15 to 48 cm(2) in elliptical area, with 10% to 100% removal of the cortical thickness. Morphology and density data obtained from DXA images were used to estimate torsional strength. All femora were mechanically tested to failure in torsion. Physically measured torsional strength was not significantly correlated to lesion elliptical area (r = 0.542, p > 0.05) or percentage cortical thickness removed (r = 0.257, p > 0.05). Measured torsional strength was significantly correlated to DXA-based torsional strength estimates (r = 0.855, p < 0.01). Lesion size alone did not correlate with the strength of bones with simulated endosteal lytic lesions. In contrast, calculations based on DXA (morphology, density) did correlate with torsional strength. This is the first step in the development of a DXA-based tool for objectively estimating bone strength in the presence of endosteal lytic lesions.

The anterior approach for prophylactic internal fixation of the radial osteocutaneous donor site

Introduction: The popularity of the radial osteocutaneous flap declined as alternative flaps were described because of the small volume of bone available and the morbidity of the donor site. Fracture is not unusual, 15% (Thoma 1999), mean of 25% (Bowers 2000) and 18% (Clark 2004). Fractures are often displaced and require secondary surgery, 46% (Clark 2004) and 67% (Thoma 1999). Limiting the bone resection and bevelling the osteotomy has minimal benefit because 70% of the radial strength is lost after osteotomy (Swanson 1990; Meland 1992). Prophylactic internal fixation of the radius (PIF) to prevent fracture was first described by Nunez in 1999.

Bone Graft for Large Bone Cysts of the Femoral Neck in Patients on Hemodialysis

Pathologic fracture of the femoral neck from an amyloid bone cyst in patients on long-term hemodialysis causes substantial morbidity. For patients with a bone cyst occupying more than 1/2 of the neck width, we have performed prophylactic internal fixation with an autogenous iliac bone graft. We describe our surgical technique and present clinical results from consecutively surgically treated patients. We determined whether our procedure successfully induced healing of the bone cyst, thus preventing a problematic sequel of fracture. From 1990 to 2003, 14 hips in 12 patients were treated, and the clinical results from these patients were retrospectively reviewed. One patient died 3 months after surgery; the remaining patients were followed for at least 3 years. In those 11 patients, bony healing was achieved in all cases with no recurrence of the cystic lesion. Considering the comparatively unsatisfactory results of internal fixation for pathologic fracture and THA for patients receiving long-term hemodialysis, our procedure gives surgeons another option for treating this difficult problem.

Prophylactic internal fixation of the radial osteocutaneous donor site

The technique of prophylactic internal fixation (PIF) of the radial osteocutaneous donor site is described and reviewed. Twenty-two donor sites were reinforced with a 3.5 mm dynamic compression plate across the anterior defect. The incidence of fracture was 4.5% (1 out of 22). The single fracture was due to a technical error and was managed conservatively. Fracture at a donor site that has not been plated is more frequent and often becomes displaced, requiring secondary surgery. In contrast, the incidence of fracture, displacement and secondary surgery following prophylactic internal fixation (PIF) is relatively low. There have been no significant long-term complications with PIF. It is now the method of choice for managing the radial osteocutaneous donor site.

Wide surgical excision for osteoid osteoma. Should it be the first-choice treatment?

Osteoid osteomas (OO) are benign skeletal tumors with a predilection for the long bones of young patients. Many different methods are used for their treatment, conservative or operative, less or more radical, with variable technology applications to destroy the "nidus." We present 38 patients with OO who were treated in our hospital between 1995-2001. Their medical records and radiographs were retrospectively reviewed, and the patients were contacted and interviewed by telephone. In 32 patients, OO were located in the lower limb, in two the upper limb, and in four the spine. Thirty-seven patients were treated operatively using open wide excision of the nidus. In 22 of those patients, additional bone grafting was used. In three patients, prophylactic internal fixation was applied to the bone. Two patients developed deep-vein thrombosis; another two had increased pain in the anterior superior iliac spine from the bone graft harvesting area. We had one recurrence, which was treated with a second operation. We conclude that although the traditional method of treatment is wide surgical excision, this technique has increased morbidity and higher risk for complications compared to more minimally invasive procedures. We suggest that it should be the first choice of treatment for either spinal or recurrent OO.

Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. 1989.

A weighted scoring system is proposed to quantify the risk of sustaining a pathologic fracture through a metastatic lesion in a long bone. This system objectively analyzes and combines four roentgenographic and clinical risk factors into a single score. Retrospective analysis of metastatic long bone lesions was completed in 78 lesions that had been irradiated without prophylactic surgical fixation. Clinical data and roentgenograms were scored prior to irradiation by independent observers. The outcome identified 51 lesions that did not fracture during the subsequent six months and 27 lesions that fractured within six months. A mean score of 7 was found in the nonfracture group, whereas the fracture group had a mean score of 10. The percentage risk of a lesion sustaining a pathologic fracture could be predicted for any given score. As the score increased above 7, so did the percentage risk of fracture. It is suggested that all metastatic lesions in long bones be evaluated prior to irradiation. Lesions with scores of 7 or lower can be safely irradiated without risk of fracture, while lesions with scores of 8 or higher require prophylactic internal fixation prior to irradiation.

The effect of rim mandibulectomy configuration and residual segment size on postoperative fracture risk: An in vitro study

Purpose: This study evaluated the effect that size and shape of rim mandibulectomy has on residual mandibular strength and resistance to fracture, with the ultimate goal of improving the use of this technique and establishing a threshold for the application of prophylactic internal fixation. Materials and Methods: Ten partially dentate dry human mandibles were mounted in a manner replicating the pterygomasseteric musculature. Unilateral midbody serial rim excisions of increasing size were completed in both a curvilinear and right-angled fashion, and physiologic forces were gradually applied to a level of residual segment fracture. Dimensional measurements were taken of the specimens before and after fracture to understand which factors contributed to failure. Results: On average, a curvilinear excision configuration resisted higher occlusal forces with a smaller residual segment than did the right-angled excision configuration. A residual inferior border thickness of less than 9 mm could not predictably withstand force application within the limits of the experimental model. Conclusion: These data support the use of a curvilinear excision configuration for rim mandibulectomies. Reproducibility of the location of the residual segment failure and other consistent residual segment dimensional information have implications regarding the limitations of this technique, beyond which the use of adjunctive support in the form of maxillomandibular fixation or prophylactic internal fixation may be indicated. © 2001 American Association of Oral and Maxillofacial Surgeons

Discussion

In this study, Melugin et al have attempted to evaluate the effect of the size and shape of a rim mandibulectomy on residual mandibular strength and resistance to fracture. Their goal was to improve the use of the rim mandibulectomy technique, as well as to establish a threshold for the application of prophylactic internal fixation. In reviewing their study, it is clear that they have further enhanced our understanding of this procedure. I believe that they have provided further data that the curvilinear shape of the osteotomy is biomechanically more favorable than the right-angled osteotomy and is less likely to fracture when used in similar surgical settings. They also suggest in their analysis that fracture formation was relatively uniform, arising at the posterior aspect of the osteotomy, and that this should be taken into consideration when a surgeon is considering the application of prophylactic internal fixation. I believe that this is an important piece of data that has clinical significance. However, although I believe the study provides a suggestion as to when prophylactic internal fixation should be used, it does not answer this question completely.

Prediction of pathological subtrochanteric fractures due to metastatic lesions.

We report a radiographic review of 54 consecutive patients with 24 impending and 30 actual pathological fractures due to metastatic bone lesions in the subtrochanteric femoral region. In an attempt to develop criteria for metastatic lesions at risk of fracturing, the following variables based on anteroposterior and lateral X-rays were considered: appearance of the lesion, width of the lesion, ratio between width of the lesion and bone width, length of the lesion, length of cortex involvement, proportion of transverse cortical bone destroyed and local pain. Nearly all (99%) of the lesions were radiographically classified as lytic. In 27 cases (50%) they were radiographically unmeasurable. Maximal longitudinal cortical destruction showed a difference between patients with an actual or impending fracture. Prophylactic internal fixation of pathological subtrochanteric fractures due to metastatic lesions has to be considered in cases of increasing pain. If the conventional X-ray can not be evaluated, a computed tomography (CT) scan has to be considered.

Ewingʼs Sarcoma of the Proximal Femur

The cases of 16 patients with Ewing's sarcoma of the proximal femur treated in the era of multiagent chemotherapy were reviewed, with emphasis on the mechanical problem of tumor involvement in this structurally demanding site. Fourteen patients received chemotherapy and local radiotherapy as the initial primary treatment. One patient had chemotherapy and radiotherapy, followed by wide local resection. One patient had amputation, followed by chemotherapy, for pathologic fracture and extensive soft tissue involvement at presentation. Two local recurrences occurred. Excluding the 2 patients whose femurs were fixed prophylactically, the pathologic fracture rate was 79%. In addition, by excluding the 2 patients who died before fracture, the pathologic fracture rate was 92%. Nonunion occurred in 5 (71%) of the 7 pathologic fractures not treated by resection and required as many as 5 additional surgical procedures to obtain union. At latest followup evaluation (average, 6.3 years), 10 patients had no evidence of disease, 1 was alive with disease, and 5 had died of their disease. Options for management should include primary resection and reconstruction or prophylactic internal fixation after completion of chemotherapy plus or minus radiotherapy.

Metastatic Disease in Long Bones A Proposed Scoring System for Diagnosing Impending Pathologic Fractures

A weighted scoring system is proposed to quantify the risk of sustaining a pathologic fracture through a metastatic lesion in a long bone. This system objectively analyzes and combines four roentgenographic and clinical risk factors into a single score. Retrospective analysis of metastatic long bone lesions was completed in 78 lesions that had been irradiated without prophylactic surgical fixation. Clinical data and roentgenograms were scored prior to irradiation by independent observers. The outcome identified 51 lesions that did not fracture during the subsequent six months and 27 lesions that fractured within six months. A mean score of 7 was found in the nonfracture group, whereas the fracture group had a mean score of 10. The percentage risk of a lesion sustaining a pathologic fracture could be predicted for any given score. As the score increased above 7, so did the percentage risk of fracture. It is suggested that all metastatic lesions in long bones be evaluated prior to irradiation. Lesions with scores of 7 or lower can be safely irradiated without risk of fracture, while lesions with scores of 8 or higher require prophylactic internal fixation prior to irradiation.

Metastasis size in pathologic femoral fractures

Radiographic assessment was made of metastases in 69 consecutive patients with pathologic femoral fractures. The following variables were considered: width of metastasis, ratio between width of metastasis and bone, axial length of cortical destruction, and proportion of cortical bone destroyed of the circumference. Differences in size of the metastases were not related to location in the femur or histologic type. In 62 of 69 fractures the ratio between width of the metastasis and bone was greater than or equal to 0.60, axial cortical destruction in the neck was greater than or equal to 13 mm and in other parts of the femur greater than or equal to 30 mm, and cortical destruction of the circumference greater than or equal to 50 percent. Prophylactic internal fixation need not be considered for femur metastatic lesions that do not reach these limits.

Nontraumatic avulsion of the lesser trochanter: a pathognomonic sign of metastatic disease?

Isolated avulsion fractures of the lesser trochanter resulting from trauma are most commonly seen in adolescent athletes and are rare in adults. Standard therapy is nonsurgical with bedrest and immobilization of the leg. However, when this lesion is seen in the adult without significant trauma, it should be regarded as secondary to metastatic neoplasm until proven otherwise. Treatment should be surgical with prophylactic internal fixation of the hip to help prevent the commonly associated subtrochanteric pathologic fracture. In a patient without a known primary malignancy, biopsy should be carried out before therapy. We describe four patients with isolated avulsion fracture of the lesser trochanter due to metastatic carcinoma. Radiologists should be aware of this lesion because its presence has a decisive effect on therapy.

Metastasis size in pathologic femoral fractures

Radiographic assessment was made of metastases in 69 consecutive patients with pathologic femoral fractures. The following variables were considered: width of metastasis, ratio between width of metastasis and bone, axial length of cortical destruction, and proportion of cortical bone destroyed of the circumference. Differences in size of the metastases were not related to location in the femur or histologic type. In 62 of 69 fractures the ratio between width of the metastasis and bone was greater than or equal to 0.60, axial cortical destruction in the neck was greater than or equal to 13 mm and in other parts of the femur greater than or equal to 30 mm, and cortical destruction of the circumference greater than or equal to 50 percent. Prophylactic internal fixation need not be considered for femur metastatic lesions that do not reach these limits.

Stress Fractures of the Femoral Neck

The femoral neck is an uncommon location for stress fractures. In seven such fractures, three occurred in young adults, and four in elderly adults. The characteristic symptom was exertional hip pain. The clinical findings were generally minimal. Four of these fractures were of the transverse and three of the compression type. This radiologic differentiation is important for the planning of treatment. The transverse stress fracture is potentially unstable, and the recommended treatment is prompt internal fixation. The compression stress fracture has a benign prognosis. Restriction of weight bearing for a few weeks is usually sufficient to relieve symptoms. Prophylactic internal fixation should be considered only when the trabecular bone mass has been significantly weakened by internal (i.e., underlying disease) or external causes (i.e., medication-related).