Revision Internal Fixation Research Articles

Outcomes of Humerus Nonunion Surgery in Patients With Initial Operative Fracture Fixation.

To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population. Retrospective case series. Eight, academic, level 1 trauma centers. Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019. Success rate of nonunion surgery. Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate. This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Should nails be locked dynamically or statically in atypical femoral fractures? – A radiological analysis of time to union and reoperations in 236 displaced fractures with 4 years average follow-up

IntroductionAtypical femoral fractures (AFFs) are associated with delayed union and higher reoperation rates. Axial dynamization of intramedullary nails is hypothesized to reduce time-to-union (TTU) and fixation failure as compared to static locking. MethodsConsecutive acutely displaced AFFs fixed with long intramedullary nails across five centres between 2006 and 2021 with a minimum postoperative follow-up of three months were retrospectively reviewed. The primary outcome was TTU, compared between AFFs treated with dynamically or statically locked intramedullary nails. Fracture union was defined as a modified Radiographic Union Score for Tibial fractures score of 13 or greater. Secondary outcomes involved revision surgery and treatment failure, defined as non-union beyond 18 months or revision internal fixation for mechanical reasons. ResultsA total of 236 AFFs (127 dynamically locked and 109 statically locked) were analysed with good interobserver reliability of fracture union assessment (intraclass correlation coefficient = 0.89; 95% CI = 0.82–0.98). AFFs treated with dynamized nails had significantly shorter median TTU (10.1 months; 95% CI = 9.24–10.96 vs 13.0 months; 95% CI = 10.60–15.40) (log-rank test, p = 0.019). Multivariate Cox regression revealed that dynamic locking was independently associated with greater likelihood of fracture union within 24 months (p = 0.009). Reoperations were less frequent in the dynamic locking group (18.9% vs 28.4%), although the difference was not statistically significant (p = 0.084). Static locking was an independent risk factor for reoperation (p = 0.049), as were varus reduction and lack of teriparatide use within three months of surgery. Static locking also demonstrated a higher frequency of treatment failure (39.4% vs 22.8%, p = 0.006) and was an independent predictor of treatment failure in logistic regression (p = 0.018). Other factors associated with treatment failure included varus reduction and open reduction. ConclusionsDynamic locking of intramedullary nails in AFFs is associated with faster time to union, lower rate of non-union, and fewer treatment failures.

Early hip survival after open reduction internal fixation of acetabular fracture.

To estimate survival of acetabular fracture repair by tracking patients across healthcare encounters. We hypothesized that hipsurvival estimated this way would be lower than reported by single-surgeon or single-center series not capturing censored reoperations. Retrospective health insurance administrative database cohort study. All claimed healthcare encounters for employer-sponsored health insurance beneficiaries aged 18-65years without pre-existing hip pathology with a newly diagnosed acetabular fracture were identified between October 1, 2015, through December 31, 2018. The intervention was open reduction internal fixation of acetabular fracture during index admission. The primary outcome was survival of the acetabular fracture repair to subsequent reoperation by arthroscopy, arthrotomy for drainage of infection, implant removal, revision acetabular fixation, hip arthroplasty, hip resection, or arthrodesis. 38 reoperation procedures on the fractured acetabulum in 852 patients occurred within 2years (incidence 4.5%). Total hip arthroplasty (2.5%) and revision internal fixation (1.5%) accounted for most early reoperations. Multivariable Cox regression identified an association between reoperation and increasing patient age (hazard ratio = 1.4 per decade, p < 0.01). The prevalence of any mental health condition was 29%. Non-elderly adults with employer-sponsored insurance who sustain acetabular fractures have a greater burden of mental health disease than similarly insured patients without these injuries. Survival of the native acetabulum after fracture fixation exceeded 95% at 2years and decreased with increasing patient age. Level III, Prognostic Study.

Bacterial Identification and Visualization of Bacterial Biofilms Adjacent to Fracture Sites After Internal Fixation.

Objectives: The primary aims of this study were to determine if any correlation exists in cases of fracture fixation among: (1) bacterial profiles recovered from the instrumentation and adjacent tissues; (2) the type of orthopedic injury; and (3) the clinical outcome-union versus nonunion. A secondary goal was to compare culture and molecular diagnostics for identifying the bacterial species present following fracture fixation. Design: Single-institution, prospective case-control cohort study. Setting: Single level 1 trauma center. Patients: Forty-nine bony nonunion cases undergoing revision internal fixation and 45 healed fracture controls undergoing removal of hardware. Intervention: Bacterial infection was detected by standard microbial culture methods and by a pan-eubacterial domain, molecular diagnostic (MDx) assay. Confirmation of culture and MDx results was achieved with bacterial ribosomal 16S rRNA fluorescence in situ hybridization (FISH) to visualize bacterial biofilms. Main Outcome Measurements: MDx and microbial culture methods results were the primary study outcomes. Results: Ninety-four percent of the nonunion cohort and 93% of the union cohort had bacteria detected by the MDx. Seventy-eight percent of the nonunion cases and 69% of the controls were culture negative, but MDx positive. Although no significant differences in bacterial composition were observed between the cases and controls, differences were observed when cases were divided by comorbidities. Conclusion: The MDx is more sensitive than microbial culture in detecting bacterial presence. The lack of significantly different findings with regard to bacterial profile identified between the cases and controls suggests that host factors and environmental conditions are largely responsible for determining if bony union will occur. Level of Evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Anterior Open-Wedge Osteotomy in Posterior Cruciate Ligament Deficient Knees: From a Historical Perspective to First Clinical Results.

Recently, the bony anatomy of the proximal tibia has gained strong interest, particularly in the cruciate ligament deficient knee. Regarding the anterior cruciate ligament (ACL), several studies outlined that a steep tibial slope (≥12 degrees) contributes to early failures after ACL reconstruction. As a consequence, the first clinical reports are available on slope reducing osteotomies in revision ACL surgery. Vice versa, biomechanical as well as clinical reports suggest that a flat slope increases the load on the posterior cruciate ligament (PCL) and might contribute to a poor result after PCL reconstruction. Since many decades, slope increasing anterior open wedge osteotomies are used to treat a symptomatic genu recurvatum. The aim of the current report is to describe different surgical techniques and report our first clinical experience of an anterior open wedge osteotomy as a sole procedure in chronic PCL deficient knees with a flat tibial slope. In six cases, a mean preoperative slope of 3.7 degrees (range = 2-5 degrees) was increased to a mean of 11.5 degrees (range = 9-13 degrees). There was one case with a delayed bone healing, which was successfully treated without loss of correction by revision internal fixation and bone grafting.

Hip arthroplasty as a salvage procedure for failed fixation of hip fractures

Failed surgical treatment of hip fractures presents a significant challenges in elderly osteoporotic population typically leads to profound functional disability and pain. Revision internal fixation and a salvage treatment with hip arthroplasty are two accepted treatment options. The purpose of this study was to assess the intra operative difficulties encountered and to evaluate the functional outcome of hip arthroplasty performed after failed internal fixation of intertrochanteric (IT) and fracture neck of femur (NOF). 20 patients with failed internal fixation (June 2012 to October 2013) were enrolled and operated during the study period. Functional assessment was done using the Harris Hip Score (HSS) and complications, if any, were documented. There were 11 cases (55%) with failed IT fracture and 9 cases (45%) of failed fixation of NOF fractures. Total hip replacement (THR) was performed in 13 patients (6 cemented and 7 uncemented) and bipolar hemiarthroplasty was done in 7 patients (4 cemented and 3 uncemented). The mean time interval to failure was 3.31 years (SD ± 3.17). The Harris hip score improved from preoperative 32.95 (SD ± 7.54) to 77.80 (SD ± 9.22) at final follow up which was significant (p < 0.001). Also the mean difference of improvement in preoperative Harris hip score and any postoperative score or between any two successive post-operative Harris hip scores was significant (P value

Treatment of nonunions of the humeral shaft with nonvascularized fibular strut allograft: postoperative outcomes and review of a surgical technique.

HypothesisPersistent humeral shaft nonunions result in continued pain and disability of the affected arm and are difficult to treat even with several surgical procedures and locked plating. A fibular allograft provides bony purchase for fixation as well as rotational stability and bridging of nonunion defects.MethodsWe conducted a retrospective review of a single surgeon’s clinical practice between July 1995 and January 2011. The inclusion criteria were patients aged ≥ 18 years who underwent revision surgery for a humeral shaft nonunion by open reduction and revision internal fixation with a supplementary fibular strut allograft.ResultsThirteen patients who met the inclusion criteria were evaluated with physical examinations, validated functional outcome measures, and radiographs to assess union rates. The mean follow-up period was 7.5 years (range, 0.5-15.6 years); there were 11 women (85%) and 2 men (15%). Of the patients, 3 (23%) had proximal-third nonunions, 7 (54%) had middle-third nonunions, and 3 (23%) had distal-third nonunions. After revision surgery with fibular allograft, 10 of 13 patients went on to achieve healing, giving a union rate of 76.9%. The mean postoperative Disabilities of the Arm, Shoulder and Hand score was 38.1 points (standard deviation [SD], 27.6 points). The mean Constant score was 55.2 points (SD, 24.0 points), representing a 62% return of function compared with the contralateral side. The mean postoperative American Shoulder and Elbow Surgeons score was 65.4 points (SD, 28.5 points), and the average visual analog scale pain score (out of 10) was 2.1 (SD, 3.3) at final follow-up.ConclusionFibular allograft is an effective and straightforward option for treating humeral midshaft and distal-shaft nonunions; however, treatment of proximal-third nonunions remains challenging.

Light syringe barrel (external fixator) for phalangeal and metacarpal fractures: A case series

Background: External fixation is a well-established technique for management of displaced metacarpal and phalangeal fractures. External fixation can achieve adequate fixation with relatively low complications. Methods: This is a study of 45 patients (48 digits) with phalangeal and metacarpal fractures that were managed using a simple light external fixator system. Eighteen patients had a comminuted fracture pattern, sixteen had a transverse, ten had an oblique, and two had a spiral fracture pattern. Radiographic outcomes were reviewed on a regular basis after surgery. Functional outcomes were assessed using total active motion of the digit and plotted using the American Society for Surgery of the Hand (ASSH) score. Results: All the patients achieved radiographic fracture union at a mean duration of 6 wk (average 4-8 wk). As for functional outcomes according to the ASSH score, excellent results were achieved in 34, good results in three, fair results in nine, and poor in two. One patient had redisplacement that required revision internal fixation. Fair and poor results were found mainly in elderly and uncooperative patients due to noncompliance with postoperative hand mobility exercises. Conclusions: The light external fixator system provided a simple, easy, cheap, and adequate technique for management of displaced metacarpal and phalangeal fractures, with good radiographic and clinical outcomes. Strict adherence to hand motion exercises is mandatory to achieve favorable outcomes. Level of Evidence: Level IV.

Management strategy and indications for revisionary internal fixation after percutaneous kyphoplasty/percutaneous vertebroplasty in cancellous vertebral fractures

Objective To explore the management strategy and indications for revisionary internal fixation after percutaneous kyphoplasty/percutaneous vertebroplasty (PKP/PVP) in cancellous vertebral fractures. Methods A retrospective analysis was made of the 676 cases of single-segment PKP/PVP at Department of Orthopaedics, The Affiliated Hospital to Qingdao University from January 2008 to January 2019. They were subjected to 4 different managements after their primary PKP/PVP: rehabilitation without any treatment in 637 cases, conservative treatment in 19 cases (including 3 ones who refused any revision), KP/VP revision in 12 cases and internal fixation revision in 8 cases. The rate of volume reduction after bone cement dispersion (Vx) was calculated using software Mimics 17.0 on the basis of primary CT data of all the patients. The correlation regression analysis was made between the revision rate and the approximate quantization value of Vx. The Glasgow Coma Score (GCS) of conscious state was used to evaluate the 39 patients after failure of their primary surgery before the surgical strategy for revision was worked out. The cobb angle, pelvic incidence angle (PI), pelvic inclination angle (PT), sacral inclination angle (SS), sagittal deviation (SVA), pain visual analogue scale (VAS) were measured and recorded before operation and at the last follow-up for the KP/VP revision group and internal fixation revision group, indicated as Δcobb, ΔPI, ΔPT, ΔSS, ΔSVA and ΔVAS, respectively. The indexes were compared between the 2 groups. Results The incidence of osteoporotic vertebral fractures treated with internal fixation revision was 1.18% (8/676). The correlation between Vx and revision rate was y=0.53+0.04x (P 0.05). There was a significant difference in Δcobb between the 2 revision groups (6.3°±7.5° versus 19.2°±14.8°) (P 0.05). Conclusions The outcomes of primary PKP/PVP have a great impact on the decision-making of internal fixation revision. The mode and extent of diffusion after initial vertebral cement perfusion are particularly related to the revision rate. The revision plan should depend on clinical symptoms. The internal fixation revision should be individualized to ensure the quality of life of the patients in line with the principles of resolving symptoms and moderate correction . Key words: Osteoporosis; Vertebroplasty; Fracture fixation, internal; Revision; Indication

Hip Fracture Nonunions: Diagnosis, Treatment, and Special Considerations in Elderly Patients.

In the United States, more than 300,000 hip fractures occur annually in the elderly population with associated significant morbidity and mortality. Both intracapsular and extracapsular hip fractures have inherent treatment challenges and therefore are at risk of nonunion complications. A systematic assessment including radiographic, metabolic, and infectious evaluations should be completed for all patients suspected of nonunion. Failed internal fixation of intracapsular hip fractures is typically treated with arthroplasty, while extracapsular proximal femur nonunions may be amenable to revision internal fixation or arthroplasty. While not a classic hip fracture, bisphosphate associated subtrochanteric femur fractures affect a similar patient population and are historically difficult to treat. Atypical subtrochanteric femur fractures are at increased risk of nonunion given the altered biologic environment secondary to bisphosphonate use; therefore adjuvant therapies may be beneficial in setting of revision fixation. Having a thorough understanding of nonunion risks, recognition, evaluation, and treatment is necessary for appropriate patient care.

Composite Fixation of Proximal Tibial Nonunions: A Technical Trick.

Nonunion after a proximal tibia fracture is often associated with poor bone stock, (previous) infection, and compromised soft tissues. These conditions make revision internal fixation with double plating difficult. Combining a plate and contralateral 2-pin external fixator, coined composite fixation, can provide an alternative means of obtaining stability without further compromising soft tissues. Three patients with a proximal tibia nonunion precluding standard internal fixation with double plating were treated with composite fixation. All 3 patients achieved union with deformity correction at a mean of 5.2 months (range, 5-5.5 months). The average range of motion (ROM) arc was 100° (range, 100°-115°) and postoperative ROM returned to pre-injury levels.Composite fixation can be a helpful adjunct in the treatment of this challenging problem.

Masquelet Reconstruction for Posttraumatic Segmental Bone Defects in the Forearm

The Masquelet technique is a procedure increasingly utilized for addressing segmental bone defects. The technique involves staged procedures consisting of bone debridement and temporary spacer placement to induce membrane formation, followed by delayed bone grafting. This report summarizes our center's experience with the Masquelet technique to reconstruct bone loss exclusively in the forearm. We reviewed all cases in which the Masquelet technique was used to reconstruct segmental bone defects in the forearm resulting from acute trauma or nonunion, with or without infection, between 2014 and 2017 at a level-1 trauma center. Injury mechanism, prior surgeries, extent of bone defect, and demographic data were collected. Union was assessed along with treatment-related complications or reoperations. We identified 9 patients with segmental bony defects in the forearm treated with the Masquelet technique. Among this cohort, 5 patients had bone defects associated with acute open fractures and 4 patients presented with nonunion (1 atrophic and 3 infected nonunions). The median bony defect was 4.7 cm (range, 1.7-5.4 cm) at the time of grafting. Second stage grafting was performed with Reamer Irrigator Aspirator autograft from the femur in 8 patients and iliac crest bone cancellous graft in 1 patient. Union was achieved in all 9 patients. Six patients achieved union by 3-month follow-up, 2 patients by 6 months, and 1 patient by 12 months. One patient required a reoperation for plate fracture prior to union treated with revision internal fixation and grafting. The Masquelet technique effectively reconstructed traumatic and posttraumatic segmental defects in the forearm with a low incidence of complication. Therapeutic V.

Management of Distal Femoral Nonunions

The surgical strategy for the patient with distal femur nonunion needs to be individualized respecting both host and injury-related factors. Prehabilitation prior to nonunion reconstruction is essential, focusing on optimization of general health, nutrition, and cessation of negative social behaviors. Surgical tactic is dictated by the type of nonunion and previous surgical method. Considerations should include enhancing both the mechanical and biological environment towards bone union and ultimate functionality. Strategies include addition of medial plate to existing laterally based hardware, plating over pre-existing intramedullary nail, exchange nail, and thin wire fixation. Revision internal fixation with or without bone grafting is preferable while arthroplasty, specifically distal femoral replacement has a role in the more infirm patient

Long-Term Outcomes of Glenohumeral Arthrodesis.

Glenohumeral arthrodesis is associated with a high rate of complications. Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. The purpose of this study was to examine the clinical outcomes of glenohumeral arthrodesis. Twenty-nine patients with 29 affected shoulders underwent primary glenohumeral arthrodesis between 1992 and 2009. Surgical indications included rotator cuff arthropathy and pseudoparalysis (n = 7), neurologic injuries (n = 12), chronic infection (n = 3), recurrent dislocations (n = 3), and proximal humeral or shoulder girdle tumors (n = 4). Surgical fixation techniques included plates and screws in 18 patients and screws only in 11 patients. All patients were examined, with a mean follow-up of 12 years (range, 2 to 22 years). Twelve patients (41%) had postoperative complications, including 6 periprosthetic fractures, 7 nonunions, and 3 infections. Eleven patients (38%) required additional surgical procedures after arthrodesis, including revision internal fixation to achieve glenohumeral fusion after nonunions (n = 7), irrigation and debridement with antibiotic treatment for deep infections (n = 2), open reduction and internal fixation to treat fracture (n = 2), and implant removal to treat symptomatic patients (n = 3). Patients experienced reasonable overall pain relief. The mean postoperative scores were 35 points for the Subjective Shoulder Value, 58 points for the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, and 54 points for the Short Form-36. Eighty-seven percent of patients reported postoperative limitations. Patients with neurologic injuries had worse functional outcomes, and an arthrodesis position of ≥25° yielded better functional outcomes. Glenohumeral arthrodesis is associated with a high rate of patients with complications (41%). Although patients experience reasonable pain relief and shoulder stability, they experience marked limitations in their upper-extremity function. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Three-Year Follow-up of a Trial of Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults

Three-Year Follow-up of a Trial of Close Contact Casting vs Surgery for Initial Treatment of Unstable Ankle Fractures in Older Adults

Application of a cementless modular revision femoral prosthesis for Vancouver B2 periprosthetic femoral fractures

Objective To evaluate the clinical effects in treating periprosthetic femoral fractures classified Vancouver B2 with a cementless modular revision femoral prosthesis. Methods Twenty-six patients (7 males and 19 females with mean age of 66.5 years, range 60-69 years) who suffered from periprosthetic femoral fractures classified Vancouver B2 were treated with a cementless modular revision femoral prosthesis in hip revision and open reduction and internal fixation with cables or plates from March 2007 to February 2014. The previous femoral prostheses included 21 cementless and 5 cemented hip stems. The period from former procedures to fractures was 16 months, range from 7 to 32 months. Harris hip scores and numerical rating scales were analyzed statistically. Time of leaving bed, discharging, fracture union postoperative complications and radiographic imaging were also recorded. Results The operation duration were 143 (range 105-165) minutes. Blood loss volume was 450 (range 270-780) ml. Blood transfusion volume were 330 (range 0-800) ml. All patients were followed up at least two years, averagely 3.5 years after surgeries. All fractures healed at 6.5 (range 3-12) months averagely after surgeries. Harris hip scores improved significantly from 11.8±2.5 before surgeries to 80.3±5.3 one month and to 91.4±7.3 six months after surgeries separately (F=0.715, P=0.001). Numerical rating scales were 9.6±0.3, 9.4±0.4 and 9.1±0.7 points averagely in aspect of information acquisition, postoperative pain control and function recovery respectively one month after surgeries. Average time of leaving bed and discharging from surgeries was 68.3 (range 51-75) hours and 6.5 (range 5-9) days respectively. No postoperative complications was found except dislocation in 1 hip, lower limb discrepancy in 1 hip, DVT in 1 hip, and heterotopic ossification in 3 hips. Conclusion Due to achieving prosthetic stability and fracture union, periprosthetic femoral fractures classified Vancouver B2 treated with a cementless modular revision femoral prosthesis combined with open reduction and internal fixation with cables or plates can reach good clinical outcomes. Key words: Arthroplasty, replacement, hip; Periprosthetic fractures; Femur; Bioprosthesis

The use of recombinant morphogenic protein-2(rhBMP-2) in children undergoing revision surgery for persistent non-union.

The purpose of the study was to evaluate the safety and efficacy with the use of BMP-2 for treating persistent non-unions in children with underlying complex conditions. Between October 2006 and November 2010 in our unit, 15 patients were treated with rhBMP-2 to enhance bone union. There were nine females and six males with a mean age of 9.5 years (range 4–15) at time of surgery. Seventy-five per cent of the patients required revision of internal fixation with insertion of rhBMP-2 to the non-union site, and the reminder had freshening of the non-union site with rhBMP-2 application. Patients had undergone a mean of 2 (1–5) operations prior to implantation of rhBMP-2. All the patients in the study group were available for review with mean follow-up of 44 months (range 21–70). The mean time to union was 16 weeks (range 10–28 weeks). No adverse events related to BMP-2 application were noted in our study group. Healing occurred clinically and radiographically in 16 of the 17 sites. Our study demonstrates that BMP-2 enhances healing of the persistent non-unions without any adverse events

Vascularised Iliac Bone Grafting in the Treatment of Femoral Neck Nonunion in Young Adults: A Retrospective Study

Revision internal fixation for femoral neck nonunion in young patients can pose a surgical challenge. Hip salvage protocols include osteotomy and osteosynthesis using various implants and grafting techniques (muscle pedicle, vascularised or nonvascularised fibular graft). The purpose of this study was to evaluate the clinical outcomes of vascularised iliac grafting for femoral neck nonunion in patients younger than 50 years. A total of 22 patients underwent vascularised iliac grafting and internal fixations for femoral neck nonunion were retrospectively analysed. Their mean age was 36.6 years. The cases were evaluated radiographically and clinically. All the patients were followed-up for an average of 64.6 months. The mean time to union for all patients was 5.4 months. The mean Harris Hip Score had increased from 55.3 preoperatively to 85.2 at the latest follow-up. The average neck-shaft angle had changed from 127.4° preoperatively to 128.3° postoperatively. Postoperative progression of osteonecrosis of the femoral head was seen in 3 patients, 2 patients were pain free and 1 patient required total hip arthroplasty 9 years after the revision procedure. There was no further progression in 3 patients with preoperative radiological evidence of the femoral head osteonecrosis. This study indicates that vascularised iliac grafting is a viable option in treatment of femoral neck nonunion in the young adult.

Long contoured locking plate fixation of traumatic proximal humeral fractures with distal extension.

There is a paucity of data available with respect to outcome on long contoured locking plate fixation for proximal humerus fractures with distal fracture extension. Thirty-four patients with traumatic proximal humerus fractures with distal extension underwent fixation with long contoured locking plates. Twenty-five patients (74%) were included in the study: one patient died, two patients had unrelated illnesses resulting in them being unable to complete follow-up assessment and six were lost to follow-up. Patients' case notes and radiographs were retrospectively reviewed, and patients were contacted to assess functional outcome using the Visual Analogue Scale (VAS) for pain, Disabilities of the Arm, Shoulder and Hand (DASH) score, Oxford Shoulder Score (OSS) and Stanmore Percentage of Normal Shoulder Assessment (SPONSA). Mean follow-up was 27 months (range 11 months to 60 months). Mean pain at final follow-up was 3.6 [95% confidence interval (CI) = 2.5 to 4.8] with only four patients having residual pain greater than 5 on the VAS scale. Mean DASH score was 41.2 (95% CI = 32.0 to 50.4), mean OSS was 29.1 (95% CI = 24.3 to 33.9) and mean SPONSA was 63.9% (95% CI = 50.8 to 77.2). There was one wound infection. Three patients had non-unions that required bone grafting and revision internal fixation. We feel long contoured locking plates represent a useful treatment option for complex proximal humerus fractures.

Vascularized fibular grafting for reconstruction of bone defect of the radius

BackgroundThe vascularized bone graft is indicated in patients where conventional bone grafting has failed or long bone defects, exceeding 6 cm, are observed in the radius. Fibular grafts allow the use of a segment of diaphyseal bone that is structurally similar to the radius and of sufficient length to reconstruct most defects of the radius.Patients and methodsBetween 2005 and 2008, seven patients with segmental bone defects of the radius were managed with vascularized fibular grafts: six females and one male, aged 12 years on average (range, 3-21 years). The length of bone defect was 7.5 cm on average (range, 4-13 cm). In six cases, the fibular graft was harvested as a vascularized osseous flap and in one case, as an osteoseptocutaneous flap. To achieve fixation of the grafted fibula, intramedullary Kirschner wires were used in six cases and plate in one case. The follow-up period ranged from 4 to 39 months.ResultsAll flaps were successful. Four patients required secondary procedures in the form of revision of internal fixation, iliac bone grafting, and ulnar shorting. The mean period to radiographic bone union was 4.8 months (range, 2.5-8 months).ConclusionVascularized fibular graft is a reliable technique for reconstruction of bone defects of the radius even in the presence of infection.Level of evidenceLevel IV, therapeutic case series.