Plate Removal Research Articles

Minimally-invasive plate osteosynthesis in distal tibial fractures: Results and complications.

Distal tibial or pilon fractures are usually the result of combined compressive and shear forces, and may result in instability of the metaphysis, with or without articular depression, and injury to the soft tissue. The complexity of injury, lack of muscle cover and poor vascularity make these fractures difficult to treat. Surgical treatment of distal tibial fractures includes several options: external fixation, IM nailing, ORIF and minimally-invasive plate osteosynthesis (MIPO). Management of distal tibial fractures with MIPO enables preservation of soft tissue and remaining blood supply. This is a report of a series of prospectively studied closed distal tibial and pilon fractures treated with MIPO. A total of 21 patients with closed distal tibial or pilon fractures were enrolled in the study between March 2008 and November 2013 and completed follow-up. Demographic characteristics, mechanism of injury, time required for union, ankle range of motion and complications were recorded. Fractures were classified according to the AO/OTA classification. Nineteen patients were initially managed with an ankle-spanning external fixator. When the status of the soft tissue had improved and swelling had subsided enough, a definitive internal fixation with MIPO was performed. Patients were invited for follow-up examinations at 3 and 6 weeks and then at intervals of 6 to 8 weeks until 12 months. Mean age of the patients was 40.1 years (range 19-67 years). Eighteen cases were the result of high-energy trauma and three were the result of low-energy trauma. According to the AO/OTA classification there were extraarticular and intraarticular fractures, but only simple articular patterns without depression or comminution. The average time for fracture union was 19.7 weeks (range 12-38 weeks). Mean range of motion was 10° of dorsiflexion (range 5-15°) and 28.3° of plantar flexion (range 20-35°). Three cases were metalwork-related complications. Two patients underwent plate removal at 24 weeks because of plate impingement. There was one case of wound breakdown at 11 weeks. One patient had fracture union with tibial recurvatum of approximately 10°, without functional impairment. Two patients had delayed union. MIPO is a reliable method of treatment for distal tibial fractures; it provides a high union rate and good functional outcome with minimal soft tissue complications. Skin impingement remains a common complication with MIPO, but this can be solved by timely plate removal.

Incidence of Hardware Removal Following Volar Plate Fixation of Distal Radius Fracture

To assess the risk of tendon rupture or plate removal after volar plate fixation of distal radius fractures and to determine the incidence of hardware removal. We searched the surgical database of 5 attending hand surgeons at a single institution from 2009 to 2014. All patients who had undergone volar plate fixation were included. Patients were excluded if they underwent an alternate form of fixation, had less than 1 year of follow-up, or could not be reached for follow-up. Postoperative radiographs were examined for Soong grade, plate distance to the critical line, and plate distance to the volar rim. If patients had hardware removed, the reason for plate removal was identified. For all patients who did not have documented hardware removal at our institution, we placed a follow-up call to determine whether they had hardware removed elsewhere. A total of 517 patients underwent volar plate fixation, 143 of whom did not have their hardware removed at our institution but could not be reached for follow-up. Of the remaining 374 patients, 37 (10%) had hardware removed. For group 1 (hardware retained), Soong grades were 13% grade 0, 85% grade 1, and 2% grade 2. For group 2 (hardware removed) the proportions were 11%, 76%, and 5%, respectively, and 8% undetermined. Mean plate distance to the critical line was significantly greater for group 2 (1.9 mm) compared with group 1(1.2 mm). Mean plate distance to the volar rim did not differ (5.1mm vs 5.3 mm). The incidence of hardware removal in our series was 10%. The vast majority of patients had Soong grade 1 prominence. Patients who had hardware removed had a greater plate prominence volar to the critical line. Plate distance to the volar rim was not associated with removal. Prognostic II.

Removal of osteosynthesis plate, an international survey

Removal of osteosynthesis plate, an international survey

Modern Mandible Reconstruction Utilizing the Chimeric Fibula Free Flap and Double-Barreling Techniques

INTRODUCTION: The fibula osteocutaneous flap is now commonly used to reconstruct composite mandibular defects. Difficulties in flap execution are invariably related to the dynamic relationship of the bone orientation and the skin paddle inset. Traditional design has been limited to a single-strut bony design in order to restore mandibular continuity, without restoration of mandibular height and contour. Full chimeric design of the fibula allows for the routine use of a double barrel strut to optimize functional and aesthetic outcomes. The purpose of this study was to critically evaluate these techniques during reconstruction of composite mandibular defects. METHODS: A retrospective review was conducted of all patients who underwent mandible reconstruction by the senior author (CHL) from 2006–2013. All patients had a chimeric fibula design, with a full posterior crural septum release and division. Only patients who underwent composite mandible reconstruction utilizing a double-barrel technique were isolated. Patient demographics, surgical techniques, and outcomes were critically evaluated. RESULTS: Fifty-nine patients were identified during the study period. Average follow-up was 148 weeks. A double free flap was utilized in 27% of patients. The average number of fibula osteotomies was 1.9. The average length of each bone segment was 4.4cm. A double skin paddle was utilized in 7% of patients, with the remainder utilizing a single skin paddle. Early perfusion-related re-operation occurred in 10% of patients. No complete flap losses occurred (0%). Partial paddle skin loss occurred in 12% of patients. Three patients (5%) experienced complications related to the barreled bone segment requiring re-operation. Few subjective patient complaints were found and no cases of drooling were documented. Overall, revision surgery related to contouring and/or plate removal occurred in 34% of patients. CONCLUSION: Utilizing a full chimeric design of the fibula osteocutaneous flap allows for greater degrees of freedom for flap insetting options. The double barrel technique more closely matches the mandibular height. With similar complication rates as traditional methods, utilizing these modern techniques may result in improved functional and cosmetic outcomes.

Does the Fibula Need to be Fixed in Complex Pilon Fractures?

To review a series of patients with complex plafond injuries with a metadiaphyseal dissociation who did not have the fibula fixed and compare with patients who had their fibula fixed using patients without a fibula fracture as a control group. Retrospective case-control study. Level 1 Trauma center at a university hospital. Skeletally mature patients with a complete metadiaphyseal plafond fracture, and adequate presentation, postreduction, and healed radiographs to measure varus and valgus alignment. Surgical treatment [external fixator or open reduction internal fixation (ORIF)] of high energy pilon fractures. Metaphyseal alignment at the time of presentation, after fixation, and at union, surgical procedures performed, and complications. From 364 patients with plafond fractures, 111 had high energy injuries with metadiaphyseal dissociation and form the basis of the study. Radiographs and charts were reviewed for fracture characteristics, metaphyseal alignment at the time of presentation, after fixation, and at union, surgical procedures performed, and complications. Of the 111 study patients, 93 patients were treated definitively with ORIF of the tibia and 18 patients were treated definitively in an external fixator. Within the 93 patients treated definitively with ORIF of the tibia, we identified 3 groups of patients those with a fibula fracture that was fixed (26 patients), those with a fibula fracture that was not fixed (37 patients), and those without a fibula fracture acting as the control group (30 patients). Between the 2 groups having a fibula fracture treated with ORIF of the tibia, there was no difference in fibula fracture pattern or location. For the 26 patients who had fibular fixation, it was performed in 11 patients at an average of 17 days for inability to hold length and alignment and in 15 patients to augment fixation in poor bone stock or to aid in the reduction. Patients with initial valgus deformity were more likely to have their fibula fixed. There was no difference in the postoperative or final alignment between the patients with fibula fractures (with or without fixation) and those without fibula fractures (P = 0.92). When comparing the 3 groups, the only statistical finding between the 2 groups was that those with fibula fixation required plate removal (P < 0.0001). Fibular fixation is not a necessary step in the reconstruction of pilon fractures, although it may be helpful in specific cases to aid in tibial plafond reduction or augment external fixation. We found a higher rate of plate removal if the fibula was fixed. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Plate Fixation of Proximal Fifth Metatarsal Fracture.

Intramedullary screw fixation of fractures of the proximal fifth metatarsal bone may not be satisfactory in comminuted fractures or when the lateral metatarsal bowing has to be restored. We report our experience with plate fixation in these circumstances. Between June 1, 2009, and January 31, 2013, 13 patients who had comminuted fracture or nonunion of fracture of the proximal fifth metatarsal bone underwent plate fixation. Study patients were followed up for a mean of 500 days (range, 51-1238 days). Their medical records and radiographs were retrospectively reviewed for demographic and operative data and radiologic evidence of fracture healing. At their most recent follow-up, patients were evaluated for pain levels with a visual analog scale, for foot function with the Foot and Ankle Disability Index, and for quality of life with the 12-Item Short-Form Health Survey. Fracture union was evident in 12 patients after a mean of 56.8 days (range, 30-92 days). There was only one major complication of sural nerve neuroma and reflex sympathetic dystrophy. Four patients required reoperation for plate removal. Plate fixation of proximal fifth metatarsal comminuted fractures is associated with high union rates, relief of pain, and patient satisfaction. However, plate removal for various reasons was required in approximately one-third of the study patients. This high revision rate might be avoided by better selection of patients and meticulous intraoperative identification and preservation of the sural nerve. We recommend reserving plate fixation for proximal fifth metatarsal fractures for cases of laterally bowed fifth metatarsal or comminuted fractures.

Plate removal following orthognathic surgery.

The objectives of this study are to determine the removal rates of orthognathic plates used during orthognathic surgery at James Cook University Hospital and describe the reasons for plate removal. 202 consecutive orthognathic cases were identified between July 2004 and July 2012. Demographics and procedure details were collected for these patients. Patients from this group who returned to theatre for plate removal between July 2004 and November 2012 were identified and their notes were analysed for data including reason for plate removal, age, smoking status, sex and time to plate removal. 3.2% of plates were removed with proportionally more plates removed from the mandible than the maxilla. 10.4% of patients required removal of one or more plate. Most plates were removed within the first post-operative year. The commonest reasons for plate removal were plate exposure and infection. The plate removal rates in our study are comparable to those seen in the literature.

Hook plate fixation for acute acromioclavicular dislocations without coracoclavicular ligament reconstruction: a functional outcome study in military personnel.

The aim of our study was to evaluate the shoulder function after clavicular hook plate fixation of acute acromioclavicular dislocations (Rockwood type III) in a population group consisting exclusively of high-demand military personnel. This prospective study was carried out at a tertiary care military orthopaedic centre during 2012–2013 using clavicular hook plate for management of acromioclavicular injuries without coracoclavicular ligament reconstruction in 33 patients. All patients underwent routine implant removal after 16 weeks. The functional outcome was assessed at 3, 6 and 12 months after hook plate removal and 2 years from the initial surgery using the Constant Murley and UCLA Scores. All the patients were male serving soldiers and had sustained acromioclavicular joint dislocation (Rockwood type III). Mean age of the patient group was 34.24 years (21–55 years). The mean follow-up period in this study was 23.5 months (20–26 months) after hook plate fixation and an average of 19.9 months (17–22 months) after hook plate removal. The average Constant Score at 3 months after hook plate removal was 60.3 as compared to 83.7 and 90.3 at 6 months and 1 year, respectively, and an average of 91.8 at the last follow-up that was approximately 2 years after initial surgery which was statistically significant (p value <0.05). The UCLA Score was an average of 15.27, 25.9 and 30.1 at 3, 6 months and 1 year, respectively, after removal of hook plate which improved further an average of 32.3 at the last follow-up, which was also statistically significant (p value <0.05). Clavicular hook plate fixation without coracoclavicular ligament reconstruction is a good option for acute acromioclavicular dislocations producing excellent medium-term functional results in high-demand soldiers.

Magnetic resonance evaluation in long term follow up of operated lateral tibial plateau fractures.

BackgroundA lack of data exists on the long-term magnetic resonance imaging (MRI) findings after surgical repair of tibial plateau fractures (TPFs). We evaluated the MRI findings 13 to 31 years after surgical repair of TPFs, focusing especially on the pathological changes in the ligaments, menisci, and cartilage.MethodsTwenty-three patients with 24 TPFs underwent open reduction and internal fixation with the same fork-shaped surgical plate that was used in our institution until 1999. No patient underwent preoperative or immediately postoperative MRI. The knees of all patients who underwent plate removal were examined by axial, coronal, and sagittal MRI. The Knee Injury and Osteoarthritis Outcome Score (KOOS) and whole-organ magnetic resonance score (WORMS) were determined in all patients.ResultsAll 24 knees exhibited MRI abnormalities. An unexpectedly high number of pathological changes in the menisci and ligaments were observed. No meniscal or ligamentous injuries were documented at the time of the injury or initial surgery, but meniscal injuries manifested in the long term. MRI in almost all cases showed a damage to the lateral meniscal, the severity of which was related to the degree of tibial plateau widening, but not to the severity of the lateral joint surface impression. The overall condition of the knee joint was satisfactory as measured by the WORMS, and there was a weak correlation between WORMS and KOOS.

Long-term follow-up of working dogs in New Zealand following pancarpal arthrodesis using dorsal hybrid plating

AIM: To determine the long-term prognosis for working dogs in New Zealand following pancarpal arthrodesis (PCA) utilising a dorsal hybrid plate.METHODS: Owners of 14 dogs who had a PCA performed as part of a previous study conducted at two small animal veterinary surgical hospitals were contacted via phone and asked to participate in a short survey.RESULTS: A phone survey was completed for seven dogs. Five of the seven dogs had returned to full work, one dog had a moderate persistent lameness that prevented returning to normal work and the remaining dog did not return to normal work for reasons unrelated to the study. Removal of the implants was required in four of seven cases at a median interval of 2 (min 0.5, max 2) years following surgery. One dog had no gait abnormality, but developed an occasional mild lameness after jumping, one dog had a constant gait abnormality with a moderate, persistent lameness, and the remaining five dogs had a constant gait abnormality with a mild, intermittent lameness. All owners contacted were very satisfied with the procedure.CONCLUSIONS: Working dogs undergoing a standardised surgical procedure for unilateral PCA using a hybrid carpal arthrodesis bone plate applied dorsally have a good prognosis for return to work.CLINICAL RELEVANCE: Although this study has a small number of cases, this study provides subjective longer-term follow-up data than previously reported for working dogs that have undergone PCA. Owners should be warned that plate removal may be required in approximately 60% of dogs and additional expenditure should be planned for.

Patient discomfort and other side effects after bilateral sagittal split osteotomy or distraction osteogenesis of the mandible: a randomized clinical trial

A randomized clinical trial was conducted to compare bilateral sagittal split osteotomy (BSSO) with distraction osteogenesis (DO) for the advancement of the mandible, with a focus on patient discomfort, postoperative pain, the need for analgesics, and occurrence of infection. All patients were non-syndromal, had a class II hypoplastic mandible, and had not undergone previous mandibular surgery. A total of 66 patients were allocated randomly to the BSSO group (32 patients) or the DO group (34 patients). Sixty-three patients were eligible for evaluation, 29 in the BSSO group and 34 in the DO group. Patients in the DO group experienced more pain after 6 days postoperative, and were administered more analgesics after 5 days postoperative than patients in the BSSO group (P=0.030 and P=0.045, respectively). The operating time was significantly shorter for the BSSO group than for the DO group (78min vs. 100min, P=0.024). All postoperative infections (12 in total) emerged in the DO group (P=0.005). All patients in the DO group had a second surgery in day care to remove the distractor, while two patients in the BSSO group needed plate removal. It is concluded that patients experienced more pain after DO, needed more analgesics postoperatively, and had more infections in comparison to the BSSO group.

Characterization of knee alignment in children with mucopolysaccharidosis types I and II and outcome of treatment with guided growth.

PurposeTo describe knee alignment in children of different ages with severe mucopolysaccharidosis (MPS) I and II and the outcome of treatment with guided growth in a patient subgroup.MethodsThis is a retrospective observational study of 58 knees in 29 children with severe MPS I and II. Long-leg standing radiographs were evaluated to determine mechanical axis deviation, mechanical lateral distal femoral angle and medial proximal tibial angle at different ages throughout childhood. The change in deformity in individual children over time is reported. 20 knees in 10 patients were treated with guided growth using eight-plates. Radiographic measurements were recorded at the time of plate insertion, at plate removal and at 1 year following removal.ResultsAt 8 years of age, all MPS I children and three-quarters of MPS II children had valgus knee alignment. There was deformity progression in two-thirds of MPS I knees and half of MPS II knees. Guided growth corrected the deformities. There was recurrence in most cases 1 year after plate removal.ConclusionsKnee deformity is common in children with severe MPS I and II. Guided growth can be considered where there is significant and/or or progressive deformity with the aim of halting progression and correcting existing deformity and thus minimizing the risk of gross deformity. Patients should be aware of the high rate of recurrence and the need for repeat surgery.

Fabrication Process Qualification of TF Insert Coil Using Real ITER TF Conductor

JAEA is fabricating the toroidal field insert coil (TFIC) in cooperation with Hitachi, Ltd. This solenoidal coil has about 50 m of ITER TF conductor wound in a 1.44-m diameter. In preparation for fabricating the TFIC, fabrication trials of windings, removal of Cr plating of the cable and welding of the terminal sleeve were performed for process qualification. The winding trials were accomplished without breaking any of the superconducting strands. In the trials to remove the Cr plating from the cable, HCl-soaked unwoven cloth was used, and the surface of a strand selected from the cable was confirmed by magnification to be free of Cr plating. In trials to fabricate termination, using electron beam welding (of OFHC copper and SS316LN) and fillet-welding (of SS316LN and SS316LN using JK2LB weld wire), tensile tests of the welds were conducted at room temperature and 4 K, and ultimate tensile strength values equivalent to that of the base metal of the weld were obtained. Also these welds passed test items of JIS Z3040 code, so the weld procedures were qualified. During fillet-welding the maximum temperature of the cable under the weld was 120 °C, not high enough to damage the cable. From the results obtained, the main processes involved in TFIC fabrication were established and qualified.

Influencing factors for difficult removal of locking head screws and locking compression plate

Objective To analyze the factors that may lead to difficult removal of locking compression plate (LCP) and locking head screws (LHS). Methods We retrospectively reviewed medical records of the 308 patients with extremity fracture who underwent implant removal at our institution from September 2004 to November 2013. They were 190 males and 118 females, with an average age of 36.8 years (from 12 to 82 years). The mean interval from hardware implantation to removal was 16.3 months (from 2 to 56 months). Their fractures involved humerus, ulna, radius, clavicle, femur, tibia and ankle joint. We extracted the following data: difficulty in removal; duration of implant stay in the body; size, position, insertion technique and cortical purchase of LHS; positional relationship between LHS and LCP (orthogonal or non-orthogonal). After we identified potential factors that might have been associated with difficult removal of LHS and LCP in fractures of upper and lower limb respectively using Mann Whitney U test and Chi-square test, we used multiple logistic regression analysis to determine the independent influencing factors. Results Of the 308 patients we analyzed, difficult removal occurred in 37. Fractures at distal humerus had the highest incidence of difficult removal (41.7%), followed by fractures at proximal forearm (33.3%), proximal femur (33.3%) and femur shaft (33.3%). The incidence in malleolar fractures was low (4.0%). Logistic regression analysis suggested the following independent risk factors: long implant stay in the body, young age, and bicortical purchase of LHS for patients with upper extremity fracture (P < 0.05); long implant stay in the body, LHS of a small diameter and percutaneous insertion of LHS for patients with lower extremity fracture (P < 0.05). Conclusions If implant removal is indicated, surgery should be performed as soon as radiographs show fracture healing. To reduce the incidence of difficult removal of LHS and LCP, surgeons should in their preoperative plan and actual procedures take into account different fracture locations and different factors that may lead to difficulty in removal. Key words: Bone plates; Bone nails; Device removal; Factor analysis, statistical

Risk Assessment of Tendon Attrition Following Treatment of Distal Radius Fractures With Volar Locking Plates Using Audible Crepitus and Placement of the Plate: A Prospective Clinical Cohort Study

To identify risk factors for tendon attrition after volar locking plate fixation of distal radius fractures. We prospectively assessed attrition of the flexor pollicis longus tendon at volar plate removal in 127 hands in 126 patients. We also evaluated preoperative lateral wrist radiographs, sonographs, and crepitus with flexor pollicis longus tendon motion and compared the demographic and radiographic characteristics of patients with and without tendon attrition. Multivariate logistic regression analysis was employed to identify the factors independently associated with tendon attrition. We found 12 cases of tendon attrition (10%) and 1 that presented with tendon rupture in our cohort. Crepitus was recognized in 14 patients (11%): 6 cases (50%) were among the 12 hands in 12 patients with tendon attrition whereas 8 (7%) were detected in the remaining 114 hands in 113 patients. Logistic regression examination revealed that audible crepitus and volar placement of the plate in lateral radiographs were independent predictors of tendon attrition. Crepitus and volar placement of hardware in lateral radiographs were independent risk factors for flexor tendon attrition after volar plating for distal radius fracture. These results may facilitate surgical decisions regarding early plate removal to prevent possible tendon rupture. Diagnostic II.

Locking plate placement with unicortical screw fixation adjunctive to intramedullary rodding in long bones of patients with osteogenesis imperfecta.

Intramedullary rodding has been the mainstay of long-bone stabilization in osteogenesis imperfecta. However, in some cases, intramedullary rodding cannot provide adequate fixation because of a lack of rotational control and thin diameter of long bones. We have applied adjunctive unicortical locking plate fixation in selected cases of osteogenesis imperfecta to address these biomechanical issues. Thirty-seven bone segments of twenty-four patients with osteogenesis imperfecta (ten type III, nine type IV, three type I, and two type V), in which unicortical locking plate fixation was applied adjunctive to intramedullary rodding and was later removed after union had been achieved, were the study subjects. The mean patient age at the time of surgery was 15.5 years (range, 6.2 to 39.8 years). Medical records and follow-up radiographs were reviewed to evaluate healing, complications, and the fates of screw holes after plate removal. All fractures or osteotomies healed completely. Locking plates were removed postoperatively at a mean time (and standard deviation) of 1.8 ± 0.9 years (range, 0.3 to 3.8 years). In seven of the thirty-seven cases, fractures through the screw hole occurred; all of these were treated conservatively. In eighteen of nineteen cases that were followed for more than a year after plate removal without screw hole-related complication, screw holes healed and were no longer visualized by radiography. Unicortical locking plate fixation effectively supplements intramedullary rod fixation in selected cases of osteogenesis imperfecta. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Use of self-tapping metal screws for temporary fixation of a resorbable plate system in maxillofacial surgery.

Resorbable plate systems have been used in maxillofacial surgery to obviate the need for plate removal. However, resorbable plates and screws are very costly, and refixation with additional screws may be necessary when reduction or repositioning of the bone segment is inaccurate. Here we report the use of self-tapping metal screws for temporary fixation of a resorbable plating system in maxillofacial surgery to avoid the use of additional screws following inaccurate fixation or the reuse of resorbable screws, which may result in loosening.

Modified Stoppa approach for treatment of fracture of anterior pelvic ring

Objective To evaluate the modified Stoppa approach for treatment of fracture of anterior pelvic ring. Methods From March 2009 to June 2013, 40 patients with fracture of anterior pelvic ring (55 sides) were treated through the modified Stoppa approach at our department. They were 24 males (31 sides) and 16 females (24 sides), aged from 21 to 65 years (average, 34.4 years). According to the Tile classification, 2 cases were type A, 21 cases type B and 17 cases type C. The mean time from injury to surgery was 6.5 days (from 3 to 12 days). Simple plate fixation of the anterior pelvic ring was performed in 23 cases while 17 cases underwent plate fixation of the anterior pelvic ring plus additional fixation of the posterior pelvic ring. The incision length, operation time, blood loss, reduction quality and clinical rehabilitation were documented. Results On average, incision length was 8.2 cm, operation time 78.4 min and blood loss 420 mL for this cohort. According to Matta standard, all the 55 fractures obtained excellent reduction. Intraoperative vascular injury occurred in one case and delayed wound healing after plate removal in another. Of this group, 36 were followed up from 8 to 24 months (average, 18 months) and 4 lost. The fractures healed after 3 to 5.5 months (average, 3.8 months). The functional evaluation by the Majeed system scored an average of 84.4 points. Twenty-one cases were rated as excellent, 13 as good and 2 as fair, resulting in an excellent and good rate of 95.0%. No nonunion, delayed union, malunion or heterotopic ossification was found in the follow-ups. Conclusion In treatment of fracture of anterior pelvic ring, the modified Stoppa approach has advantages of small incision, fine visualization, quality reduction, a low rate of complications and rapid rehabilitation. Key words: Pelvis; Fractures, bone; Fracture fixation, internal; Bone plates; Surgical approach

Protective Effect of MFG-E8 after Cutaneous Ischemia–Reperfusion Injury

We recently demonstrated that the secreted glycoprotein and integrin-ligand MFG-E8 promotes cutaneous wound healing by enhancing angiogenesis. Several studies have identified potential roles for MFG-E8 in regulation of ischemia-reperfusion (I/R) injury in the brain, kidney, and liver. Our objective was to assess the role of MFG-E8 in the formation of skin ulcers using a murine model of cutaneous I/R injury-cutaneous pressure ulcers. Cutaneous I/R was performed by trapping the dorsal skin between two magnetic plates for 12 hours, followed by plate removal. Expression of MFG-E8 increased in the dermis during ischemia, and then decreased after reperfusion. Administration of recombinant (r)MFG-E8 in I/R areas at the beginning of reperfusion significantly inhibited the formation of cutaneous pressure ulcers, and the number of CD31(+) vessel and NG2(+) pericytes in wounds were increased in I/R mice treated with rMFG-E8. The number of M1 macrophages and the amount of proinflammatory mediators monocyte chemotactic protein-1,induced nitric oxide synthase, IL-6, tumor necrosis factor-α, and IL-1β in the wound area were reduced by the administration of rMFG-E8. We conclude that MFG-E8 may inhibit the formation of pressure ulcers induced by cutaneous I/R injury by regulating angiogenesis and inflammation. Exogenous application of MFG-E8 might have therapeutic potential for cutaneous I/R injuries, including decubitus ulcers and Raynaud's phenomenon-induced digital ulcers.

Internal Fixation Using Clavicle Hook Plates for Distal Clavicle Fractures

Background: To report the radiological and clinical outcomes of internal fixation using distal clavicle hook plates for distal clavicle fractures. Methods: From April 2008 to December 2012, 32 patients with distal clavicle fractures underwent surgery using an AO hook plate. The reduction was qualified and evaluated according to the radiological findings. The evaluation of the clinical outcomes was performed with the University of California at Los Angeles (UCLA) score, the Korean Shoulder score, and the visual analogue scale (VAS) pain score. Results: By radiological evaluation, we found that 31 of 32 patients showed anatomical reduction and solid bone union. Although we obtained satisfactory UCLA scores, Korean Shoulder Scale scores, and VAS pain scores, 12 cases of complications were present. We found 4 cases of osteolysis of the acromion, 1 case of nonunion, 3 cases of periprosthetic fractures, 3 cases of subacromial pain, and 1 case of skin irritation. We performed re-operations in 2 patients. Conclusions: To avoid complications associated with clavicle hook plates, choosing the appropriate hook size and bending of the hook according to the slope of the acromion undersurface is critical. Also, we believe that early removal of clavicle plates may help reduce complications.