Secondary Displacement Research Articles

Non-operative treatment is a reliable option in over two thirds of patients with Garden I hip fractures. Rates and risk factors for failure in 298 patients

BackgroundNon-operative treatment for impacted femoral neck fractures is a now rarely used strategy whose indications are controversial. No outcome predictors have been convincingly identified, in part due to the small sizes of available studies. We conducted a large retrospective study with the following objectives: (1) to evaluate the percentage of patients older than 65 years of age with non-operatively treated Garden I femoral neck fractures who experience secondary displacement, (2) to identify predictors of secondary displacement, and (3) to determine the frequency of non-operative treatment failure due to any cause and requiring joint replacement surgery. HypothesisNon-operative treatment is reliable in patients older than 65 years of age with Garden I femoral neck fractures. Material and methodsApproval was obtained from the French data protection authority to conduct a retrospective observational study of information in the Marseille university hospitals database. Consecutive patients who were older than 65 years of age at traumatology department admission for Garden I femoral neck fractures managed non-operatively between January 2007 and December 2017 were included. Non-operative treatment consisted in a walking test on day 1 followed by radiographs on days 2, 7, 14, 21, and 45 and after 3 and 12 months. Patients with secondary displacement underwent hip arthroplasty. Demographic data, cognitive performance, and radiological parameters were collected for each patient. We evaluated the rates of secondary displacement avascular necrosis, and non-union. ResultsWe included 298 patients with a mean age of 82 years (range, 65–101). Mean follow-up was 5±3 years. Secondary displacement occurred in 91 (30%) patients, at a mean of 16 days (range 2–45 days) after the fracture. Avascular necrosis of the femoral head developed in 13 (4.3%) patients and non-union in 11 (3.7%) patients. Secondary displacement was significantly associated with hypnotic treatment (OR, 4.1; 95%CI, 2.2–7.5; p=0.039), institutionalisation (OR, 6.7; 95%CI, 3.1–14.8; p=0.028), a history of repeated falls (OR, 13.5; 95%CI, 6.3–8.4; p<0.0001), having three or more comorbidities (OR, 3.2; 95%CI, 1.7–5.8; p=0.046), and having dementia (OR, 3.5; 95%CI, 1.7–6.9; p=0.0003). Secondary displacement occurred in 18 (12%) of the 151 community-dwelling patients with normal cognition and no history of repeated falls compared to 37 (75%) of the 50 institutionalised patients with dementia. DiscussionNon-operative treatment was effective in 196 (66%) of 298 patients with Garden I femoral neck fractures. Significant risk factors for secondary displacement were dementia, institutionalisation, hypnotic treatment, multiple comorbidities, and a history of repeated falls. Of 151 community-dwelling patients with normal cognition and no repeated falls, 133 (88%) achieved a full recovery with non-operative treatment alone. Level of evidenceIV, retrospective cohort study.

Optimal tuning and assessment of inertial dampers with grounded inerter for vibration control of seismically excited base-isolated systems

In this paper, the concept of an ideal grounded linear inerter, endowing supplemental inertia to passive linear tuned mass-dampers (TMDs) through its inertance property without increasing the TMD mass, is considered to reduce lateral displacement demands in base isolated structural systems (BISs). Optimal tuned mass-damper-inerter (TMDI) design parameters are numerically determined to maximize energy dissipation by the TMDI under stationary white noise support excitation. Performance of these optimally designed TMDI-equipped BISs is assessed for stationary white and colored noise excitations as well as for four recorded earthquake acceleration ground motions (GMs) with different non-stationary frequency content. It is found that for fixed mass ratio the inclusion of the grounded inerter reduces significantly secondary mass displacement and stroke for all considered excitations while it improves appreciably BIS displacement demands except for the particular case of a near-fault accelerogram characterized by early arrival of a high-energy low-frequency pulse as captured in its wavelet spectrogram. More importantly, it leads further to reductions to BIS acceleration demands with the exception of colored noise excitation for which an insignificant increase is noted. The positive effects of the inerter saturate with increasing inertance and BIS damping ratio demonstrating that small inertance values are more effective in vibration suppression of BISs with low inherent damping. Overall, it is recommended to combine low damping isolation layers with large inertance and low secondary mass TMDIs.

Posterior tension band plate osteosynthesis for unstable sacral fractures: A preliminary study

IntroductionStable reduction and rigid fixation of the sacrum and posterior ring structures are of paramount importance in the management of complex pelvic ring disruptions, Tile B and C. The major concern with the use of conventional methods, like iliosacral screws and iliolumbar fixations is the increased risk for surgical and implant-related morbidity, especially in difficult situations, such as comminuted, bilateral sacral fractures, and fractures in the dysmorphic sacrum. Although various biomechanical studies have reported the posterior trans-iliac plates to provide maximum resistance to distracting forces by the principle of tension band, the literature pertaining to this implication in clinical studies has been limited. The purpose of our study was to assess the efficacy of the trans-iliac plate in the management of unstable sacral fractures and its utility in pelvic disruptions associated with surgical site morbidity. MethodologyThe patients with unstable pelvic fractures (Tile B and C) between 2013 and 2017 were retrospectively analyzed at a trauma center. First, the anterior ring disruptions were stabilized, and then, the sacral fractures (Denis Zone 1–3) treated by posterior tension band plate osteosynthesis (3.5 mm reconstruction plate) were included. Demographic and perioperative data were assessed. The outcome variables studied were surgical morbidity, pain, loss of reduction, and union and implant-related complications. The outcomes were graded using Lindhal's (radiological) and Majeed (functional assessment) scores. ResultsThirteen patients (nine male/four female) with a median age of 42 years, had sacral fractures in Denis zones 1/2/3 (four/ten/one, respectively), resulting from Tile pelvic injury B and C were included. The pelvis in five patients was stabilized only with the posterior plate due to the anteriorly-associated surgical site morbidity (Morel-Lavallee lesions and urinary tract injuries). The mean follow-up was 21.5 ± 2.8 months. All fractures had a radiological union by 22 weeks; Lindhal's grade A in ten patients and grade B in three patients. Two out of three patients recovered from preoperative neurological involvement. Two had complained of implant prominence (BMI<19 kg/m2) and there were no implant failures. Four had excellent, six had good, and three had fair or poor functional outcomes. ConclusionThe posterior trans-iliac plate is a minimally invasive and safe procedure that can be used in a wide range of unstable sacral fractures with notably less implant failure rate. The rigid posterior construct restores the principle tension between the iliac blades and minimizes the secondary displacement of the anterior disrupted structures, thereby useful in managing ring disruptions with surgical site morbidity.

Removal of a yield stress fluid by a heavier Newtonian fluid in a vertical pipe

The present work aims to investigate, experimentally, analytically and computationally, the removal of a light yield stress fluid displaced by a slightly heavier Newtonian fluid, in a long vertical pipe. The fluids of interest are miscible and the displacement flow is downward. In general, the flow is controlled by at least four dimensionless numbers, and their combinations, namely the Newtonian Bingham number, 0 ≤ BN ≤ 18600, the viscosity ratio, 1 < m < 9723, the Newtonian Reynolds number, 13 ≤ ReN ≤ 2480, and the densimetric Froude number, 0.15 ≤ Fr ≤ ∞. In the definitions of BN, m and ReN, the displacing fluid’s constant viscosity is used as the viscosity scale. The experiments present a variety of different flow patterns, for which a number of regime classifications can be made. First, fully static residual wall layers are observed at BN ≳ 100 and moving residual layers are found below this transition value, which can be predicted by a simple analytical (lubrication type) model. Second, for displacement flows with BN < 100, the displacements can be divided into nearly-stable and unstable flow regimes, for which the transition occurs at a critical buoyancy number, χ=2ReN/Fr2≈120. Third, for fluid flows with BN ≳ 100, the residual layer patterns can be classified into three distinct sub-regimes, including corrugated, wavy and smooth regimes, as a function of ReN/(BN+m) and ReN/Fr. Fourth, to analyse secondary displacement front features, the experiments are phenomenologically classified into central and periphery displacements, for which the transition can be reasonably predicted by an appropriate analytical model. However, the long time displacing front velocities cannot be estimated by the analytical model. Finally, computational fluid dynamics simulations in a simpler channel geometry demonstrate that some of the complex displacement flow features may be predicted computationally.

Diagnostic échographique des fractures peu déplacées du condyle huméral chez l’enfant : une nouvelle technique

IntroductionManagement of minimally displaced lateral humeral condyle fractures in pediatric patients is controversial. This is primarily because with current imaging modalities it is difficult to accurately and conveniently determine the stability of the fractures by detecting the integrity of the cartilage hinge. Nevertheless, transverse ultrasonography has not been intensively reported in previous studies. HypothesisTransverse ultrasonography can determine the integrity of the cartilage hinge in minimally displaced lateral condyle fractures. Materials and methodsWe retrospectively reviewed the medical records of 39 pediatric patients with minimally displaced fractures of the lateral humeral condyle who underwent transverse ultrasonography between 2014 and 2017. Conservative treatment was given to pediatric patients with intact cartilage hinges that had been confirmed by transverse ultrasound images. Surgical treatment was recommended for pediatric patients with disrupted cartilage hinges. Data regarding healing of the lateral humeral condyle fractures were recorded and analyzed. ResultsAccording to transverse ultrasonography, there were 14 children with intact cartilage hinges and 25 children with disrupted cartilage hinges. Fourteen children with intact cartilage hinges of the fracture were treated conservatively, and none of them showed secondary displacement. There were 16 children in whom there was surgical intervention, and 9 other children decided to have conservative treatment among the 25 children with disruption of the cartilage hinge. Five of these 9 children who underwent conservative treatment were found to have further displacement during an average of 12.6 days after the fracture event, and no other patient was found to have further displacement. ConclusionTransverse ultrasonography can simply and accurately determine the stability of minimally displaced lateral condyle fractures without sedation, ionizing radiation or invasive techniques. We recommend routine use of transverse ultrasonography to detect stability of the fractures, which can effectively avoid inadequate treatment and unnecessary surgery in pediatric patients with minimally displaced fractures of the lateral humeral condyle. Level of evidenceIV, retrospective cohort study.

Evaluation of Efficacy of 3-Dimensional Delta Versus Trapezoidal Condylar Plates in Internal Fixation of Mandibular Subcondylar Fractures: A Clinical Study

Introduction: Among condylar fractures, surgical treatment is most commonly done for subcondylar fractures. Although 2 plate system is most commonly recommended, specially designed delta plate or trapezoidal condylar single 3-dimensional plate have been found to provide early functional rehabilitation with similar stability. Though studied in vitro, not much in vivo study has been done in clinical scenario. Aim and Objectives: Comparative assessment of functional and radiographic outcomes of patients who underwent subcondylar fracture fixation with trapezoidal and delta condylar plate. Methods: 20 patients presenting with subcondylar fracture requiring open reduction and internal fixation were included in this 2-year study from 2014 to 2016. Patients were randomly assigned to either one of the groups, with 10 being treated by each plate. Patients were evaluated regularly during 3 months follow-up on clinical parameters, such as occlusion, mouth opening, range of jaw movements, and radiologic parameters, such as fracture alignment, plate fracture, plate bending, screw loosening, secondary displacement of condylar fragment and its direction, ramus height, and any deviation. Results: In both groups, statistically significant improvement in occlusion seen from the third day to the third month ( P value = .04). Postoperative mouth opening, right and left lateral movements, and protrusive movements were statistically nonsignificant in both group A and group B. But within a group, improvements in the results were variable with regard to all these parameters at different intervals. Clinical and radiographic complications were nonsignificant in both group A and group B. Conclusion: This study is a preliminary effort to evaluate and compare different special plating systems in the management of condylar fractures with the new 3-dimensional trapezoidal and delta plating system, which gives excellent stability and rigidity. Improvement in occlusion was found to be gradual in both the plating system over a period of 3 months. Delta plate showed significant improvement in mouth opening at all intervals in comparison to Trapezoidal plate. Improvement in protrusive movement was found to be gradual and better with delta plate. A trapezoidal condylar plate holds goods for low subcondylar fractures owing to its wider dimension, though delta plate is versatile for both high and low subcondylar fracture.

Déplacement secondaire après traitement orthopédique des fractures isolées du tubercule majeur : une étude des facteurs de risque portant sur 82 cas

IntroductionThe optimal treatment of isolated fractures of the greater tuberosity is an important topic of current surgical research. While non-displaced fractures are amenable to conservative treatment, displacement of the fragment can result in rotator cuff malfunction and impingement. For the present study, risk factors predicting secondary fragment displacement were analyzed. HypothesisCertain risk factors determine a higher risk of secondary displacement in patients with greater tuberosity fractures. Patients and methodsAll patients diagnosed with a fracture of the greater tuberosity and initially treated non-surgically at our Level I trauma center between January 2008 and July 2015 were included in this retrospective analysis. Patients were grouped into: no secondary displacement (group 1) and secondary displacement at follow-up (group 2). The following risk factors were analyzed: age, gender, side of fracture, initial displacement, fragment/head-ratio, fragment shape, dislocation, concomitant fractures and concomitant fractures to the same extremity. ResultsEighty-two patients (42 male, 40 female) were eligible for further analyses. Median follow up was 8.0±39.5 days. Patients with secondary displacement (group 2) were significantly older (group 1: 51.7±15.5, group 2: 68.3±14.3; p<0.001) and had significantly more shoulder dislocations (p=0.024), whereas gender (p=0.299), side of fracture (p=0.189) and fragment/head ratio (p=0.660) showed no significant different distribution between both groups. Finally, split-type fractures increased the risk of secondary displacement. DiscussionThe present study identified age older than 65 years to be an important risk factor for secondary displacement in the conservative management of fractures of the greater tuberosity. Furthermore, fracture type and shoulder dislocations are factors associated with an increased relative risk for secondary displacement. Level of ProofIII, Retrospective comparative study.

A novel transverse ultrasonography technique for minimally displaced lateral humeral condyle fractures in children

IntroductionManagement of minimally displaced lateral humeral condyle fractures in pediatric patients is controversial. This is primarily because with current imaging modalities it is difficult to accurately and conveniently determine the stability of the fractures by detecting the integrity of the cartilage hinge. Nevertheless, transverse ultrasonography has not been intensively reported in previous studies. HypothesisTransverse ultrasonography can determine the integrity of the cartilage hinge in minimally displaced lateral condyle fractures. Materials and methodsWe retrospectively reviewed the medical records of 39 pediatric patients with minimally displaced fractures of the lateral humeral condyle who underwent transverse ultrasonography between 2014 and 2017. Conservative treatment was given to pediatric patients with intact cartilage hinges that had been confirmed by transverse ultrasound images. Surgical treatment was recommended for pediatric patients with disrupted cartilage hinges. Data regarding healing of the lateral humeral condyle fractures were recorded and analyzed. ResultsAccording to transverse ultrasonography, there were 14 children with intact cartilage hinges and 25 children with disrupted cartilage hinges. Fourteen children with intact cartilage hinges of the fracture were treated conservatively, and none of them showed secondary displacement. There were 16 children in whom there was surgical intervention, and 9 other children decided to have conservative treatment among the 25 children with disruption of the cartilage hinge. Five of these 9 children who underwent conservative treatment were found to have further displacement during an average of 12.6 days after the fracture event, and no other patient was found to have further displacement. ConclusionTransverse ultrasonography can simply and accurately determine the stability of minimally displaced lateral condyle fractures without sedation, ionizing radiation or invasive techniques. We recommend routine use of transverse ultrasonography to detect stability of the fractures, which can effectively avoid inadequate treatment and unnecessary surgery in pediatric patients with minimally displaced fractures of the lateral humeral condyle. Level of evidenceIV, retrospective cohort study.

Is non-operative treatment still relevant for Garden Type I fractures in elderly patients? The femoral neck impaction angle as a new CT parameter for determining the indications of non-operative treatment

BackgroundThe indications of non-operative treatment of undisplaced femoral neck fractures are controversial. The objective of this study was to assess whether two computed tomography (CT) parameters, the femoral neck impaction angle (IA) and the femoral neck posterior tilt angle (PTA), were effective in predicting the risk of secondary displacement after non-operative treatment of Garden I femoral neck fractures in patients aged 65 years or over. HypothesisThe working hypotheses were that the IA in the coronal plane and PTA in the axial plane predicted secondary displacement after non-operative treatment of Garden I femoral neck fractures, could be reproducibly and reliably measured on CT scans, and could serve to identify Garden I fractures at risk for secondary displacement after non-operative treatment. MethodsForty-nine patients aged 65 years or over with Garden I fractures treated non-operatively were included in a prospective single-centre study. CT images were used to measure the IA as the position of the fracture line relative to the femoral head in the coronal plane and the PTA as the position of the femoral head centre relative to the femoral neck axis in the axial plane. ResultsAfter non-operative treatment, secondary displacement occurred in 22 (45%) patients. The PTA was not significantly different between the groups with vs. without secondary displacement (p=0.62). IA values≤135° were significantly associated with secondary displacement (odds ratio, 11.73; 95% confidence interval [95%CI], 3.04–45.28; p=0.004). An IA≤135° was 72.73% sensitive and 81.48% specific for predicting secondary displacement. IA measurement was reproducible, with intra-class and inter-class Cohen's kappa values of 0.94 (95%CI, 0.90–0.97) and 0.9011 (95%CI, 0.83–0.94), respectively. DiscussionThe IA measured on CT images may hold promise for identifying Garden I hip fractures at high risk for secondary displacement after non-operative treatment. IA measurement is reproducible and reliable and may help to determine the indications of non-operative treatment. Level of evidenceII, prospective cohort study.

Anterior fracture dislocation of the proximal humerus

Anterior fracture dislocations are among the most severe forms of proximal humeral fractures. Because of potential devascularization of the humeral head, it is unclear whether open reduction and internal fixation (ORIF) offers superior results to primary hemiarthroplasty (HAS) or reverse shoulder arthroplasty (RSA). We retrospectively compared functional outcomes, complications, and revision surgeries after ORIF, HSA, and RSA in 81 patients with anterior fracture dislocations. Functional results were assessed with the age- and gender-normalized Constant Score (nCS). Of 81 anterior fracture dislocations, 40 (49.4%) were treated by ORIF (mean age 61.5 ± 13.9 years, range 29–89), 19 (12.3%) by HSA (mean age 71.6 ± 10.1 years, range 53–85), and 22 (27.2%) by RSA (mean age 79.8 ± 10.8 years, range 58–91). Of 81 patients (75.8% women, mean age: 67.4 ± 12.5 years, range 29–91 years), the mean nCS after 3.4 ± 2.9 years of follow-up was 63.4 ± 10.3 after ORIF, 52.4 ± 12.9 after HSA, and 74.5 ± 11.1 after RSA (ANOVA, p = 0.001). The complication rate in ORIF procedures was 22.5% (secondary displacement n = 2, avascular necrosis n = 7), in HSA, 36.8% (tubercle dislocation n = 4, tubercle resorption n = 2, septic loosening n = 1), and RSA, 13.6% (acromial fracture n = 1, tubercle displacement n = 1, tubercle resorption, n = 1; p < 0.001). Avascular necrosis was observed in 17.5% of cases following a primary head-preserving treatment. Treatment of anterior fracture dislocations is demanding. Open anatomic reduction and internal fixation can lead to good and excellent functional outcomes in young patients with good bone quality and should be performed in these patients as soon as possible. Elderly and frail patients may profit from RSA as a primary treatment. HSA should be reserved for cases where anatomic reduction and stable fixation in patients <65 years has failed; however, functional outcomes are poor.

Complications after non-surgical management of proximal humeral fractures: a systematic review of terms and definitions

BackgroundA majority of proximal humeral fractures can be managed without surgery. Recent randomized clinical trials and meta-analyses even question the benefit of surgical treatment for displaced 3-, and 4-part fractures. However, evidence-based treatment recommendations, balancing benefits and harms, presuppose a common reporting of complications and adverse events, which at the moment is largely missing. Therefore we systematically reviewed the use of terms and definitions of complications after nonsurgical management of proximal humeral fractures.MethodsWe searched PubMed, EMBASE, Cochrane Library, Scopus and WorldCat (2010–2017) and included articles and book chapters containing complication terms or definitions. Two reviewers independently extracted and grouped terms and definitions according to a predefined scheme. Terms and definitions concerning non-surgical management were tabulated, grouped and analyzed qualitatively.ResultsThe initial search identified 1376 references from which 470 articles were selected for full-text retrieval. Data-extraction included first articles published in 2017, was then performed iteratively in batches of 20 articles, and terminated after retrieval of 91 articles when no additional definitions or terms was found. In addition, 12 book chapters were reviewed from an initial list of 100. No general definition of a complication was found. A total of 69 terms for complications after non-surgical management were identified from 19 articles. Sixty-seven terms regarded local events. The most commonly reported event terms regarded osteonecrosis, malunion, secondary displacement and rotator cuff problems. Seven individual terms were accompanied by some kind of definition. Most terms and definitions were based on radiographical assessments.ConclusionsWe found no consensus in the use of terms and definitions of complications after nonsurgical management of proximal humeral fractures. Multiple terms, some synonymous, some partly synonymous, some distinct, were used. Few complication terms were explicitly defined. Development and validation of an internationally consensus-based core event set for complications after proximal humeral fractures managed non-surgically is needed.

Low complication rates in Minimally Invasive Plate Osteosynthesis (MIPO) for proximal humeral fractures at 5 years of follow-up

Introduction: Purpose of this study was to analyse the medium term follow-up of minimally invasive plate osteosynthesis (MIPO) for proximal humeral fractures in terms of postoperative shoulder function, radiological outcome and complications.Methods: 76 consecutive patients with unstable proximal humeral fractures were treated using locking plate with a minimally invasive antero-lateral approach in two surgical centers. Constant score and radiographic evaluation of 74 patients were available at mean follow up of 5 years (minimum 4 years).Results: Mean Constant score was 74 (range to 28–100). Results were comparable in the two centers. Younger patients registered significantly higher scores (p < 0.05). 20 patients (27%) developed complications. Subacromial impingement occurred in 16,2% of cases for varus malreduction (6,7%) and for too proximal plate positioning (9,5%). Primary screws perforation (2,7%), secondary perforation due to cut-out (1,4%), avascular necrosis (AVN) of humeral head (1,4%), partial resorption of greater tuberosity (2,7%), secondary displacement of the greater tuberosity (2,7%) and stiffness (2,7%) were observed.Discussion and conclusions: Even at a medium term follow-up, MIPO for proximal humeral fractures ensured good and reproducible results for most common pattern of fractures. Major complications were lower respect to open procedures, because of soft tissue, deltoid muscle and circumflex vessels sparing.

Buddy taping versus splint immobilization for paediatric finger fractures: a randomized controlled trial

The purpose of this single-centre randomized controlled trial was to assess the non-inferiority of buddy taping versus splint immobilization of extra-articular paediatric finger fractures. Secondary fracture displacement was the primary outcome; patient comfort, cost and range of finger motion were secondary outcomes. Ninety-nine children were randomly assigned to taping or splinting. Sixty-nine fractures were undisplaced; 31 were displaced and required reduction before taping or splinting. Secondary displacement occurred in one patient in the taping and three in the splinting group. The risk difference was below the predefined non-inferiority level of 5%. All secondary displacements occurred in the 31 displaced fractures after reduction and were in little fingers. Patient comfort was significantly higher and cost lower in the taping group. We conclude from this study the non-inferiority of buddy taping versus splint immobilization of extra-articular paediatric finger fractures in general. We advise treatment may need to be individualized for patients with displaced fractures because we cannot make any absolute conclusions for these fractures. Level of evidence: I.

Distal interphalangeal joint arthrodesis with the intramedullary Lync® implant: Prospective study of 22 cases

Several techniques have been described for fusion of the distal interphalangeal joint. The intramedullary Lync® implant (Novastep™) may be superior to other options as it is available in straight or bent configurations, does not need to be removed and does not require fingertip incisions. The objective of our prospective study was to determine the effectiveness of finger distal interphalangeal (DIP) arthrodesis with Lync® implants. Between February 2016 and June 2017, we performed 22 cases of DIP arthrodesis with this implant. Pain was assessed with a visual analog scale, the joint range of motion was measured using a digital goniometer, the pulp to palm distance was measured using a ruler, and the QuickDASH Questionnaire was filled out. AP and lateral X-rays were used to look for secondary displacement at 3 weeks and joint fusion at 6 weeks, 3 months, 6 months and 12 months. The primary endpoint was clinical and radiological union defined as the presence of trabecular bone bridges across the arthrodesis site. The patients’ mean age was 57.8 years ± 9.9 (36–73). The mean follow up was 10 months ± 4.9 (3–15). The pre-operative pain level was 6/10 ± 2.4 (0–10) and it was 1.3/10 ± 1.7 (0–6) at 3 months post-operative (P < 0.0001). The mean pre-operative DASH Score was 64/100 ± 16 (15.9–86.3) and it was 19/100 ± 14 (2.3–45.4) at 3 months post-operative (P < 0.0001). At the end of the study, 20 DIP joints were fused (91%); 18 joints had fused at the 3 month follow-up visit (82%). Three cases required reoperation. DIP arthrodesis with the Lync® implant resulted in DIP fusion in 91% of cases. When fusion was achieved, it provided pain relief and improved function. The Lync® implant is less bulky than other arthrodesis devices and does not need to be removed.

Imaging study of midface growth with bone-borne trans-sutural distraction osteogenesis therapy in growing cleft lip and palate patients

Trans-sutural distraction osteogenesis (TSDO) promotes midface growth in growing cleft lip and palate (CLP) patients with midfacial hypoplasia. The superficial skeletal changes after therapy revealed rotation advancement of the midfacial skeleton associated with differential displacement in each segment, but reports rarely focus on the changes of internal structures, including circummaxillary sutures, the maxillary tuberosity and the maxillary sinus, which may play a crucial role during this process. This study evaluated the computed tomographic (CT) images of 26 growing CLP patients who received bone-borne TSDO therapy. The results revealed that the most prominent new bone formation occurred in the pterygomaxillary suture and pushed the P-point forward. The maxillary first molar exhibited significantly greater advancement compared with the P-point due to the growth of the maxillary tuberosity. The contribution ratio values of the advancement of the maxillary tuberosity and P-point to the maxillary first molar were 26% and 74%, respectively, in UCLP and 25% and 75%, respectively, in BCLP. Furthermore, the maxillary sinus volume was also significantly increased. In conclusion, midface growth with bone-borne TSDO therapy depends on both secondary displacement promoted by sutural bone formation mainly in the pterygomaxillary suture and primary displacement by growth of the maxillary tuberosity and maxillary sinus volume.

Early palmar plate fixation of distal radius fractures may benefit patients aged 50 years or older: a randomized trial comparing 2 different treatment protocols

Background and purpose — There is no consensus regarding optimal treatment of displaced distal radius fractures (DRFs). We compared the results of 2 treatment protocols: early palmar plating vs. primary nonoperative treatment of displaced DRFs.Patients and methods — We performed a prospective randomized controlled study including 80 patients aged ≥ 50 years with dorsally displaced DRFs, excluding AO type C3 fractures. Patients were randomized to undergo either immediate surgery with palmar plating (n = 38), or initial nonoperative treatment (n = 42) after successful closed reduction in both groups. Delayed surgery was performed in nonoperatively treated patients showing early loss of alignment (n = 16). The primary outcome measure was Disabilities of the Arm, Shoulder, and Hand (DASH) score.Results — Mean DASH scores at 24 months in the early surgery group were 7.9 vs. 14 in the initial nonoperative group (difference between means 6, 95% CI 0.1–11, p = 0.05). Delayed operation was performed on 16/42 of patients due to secondary displacement in the initial nonoperative group. In “as treated” analysis, DASH scores were 7 in the early surgery group, 13 in the nonoperative group, and 17 after delayed surgery (p = 0.02). The difference in DASH scores between early and delayed surgery was 9 points (CI 0.3–19, p = 0.02)Interpretation — Treatment of DRFs with early palmar plating resulted in better 2-year functional outcomes for ≥50-year-old patients compared with a primary nonoperative treatment protocol. Delayed surgery in case of secondary displacement was not beneficial in terms of function.

ВПЛИВ МЕХАНІЧНИХ ФАКТОРІВ ПРИ НАКІСТКОВІЙ ФІКСАЦІЇ ДІЛЯНКИ ПЕРЕЛОМУ НА ПРОЦЕС ЙОГО КОНСОЛІДАЦІЇ

The main principle of treatment of bone fractures of the musculoskeletal system is the repositioning of the chips with their subsequent fixation by various designs until the consolidation of the fracture. This process is influenced by a significant number of factors, such as general (the age of the patient, the presence of concomitant diseases, metabolic disorders, the use of drugs, etc.) and local (the quality of the fragment fragmentation, blood supply to this site, the presence of infection in this area, etc.). Of considerable importance are mechanical factors, optimization of which allows to achieve fracture joining in optimal terms. Traditionally it is believed that the most durable structural materials should be used for the bone osteosynthesis purposes, because as a result of the load, the phenomena such as the migration of the latches, their fracture, secondary displacement, non-fracture fracture are often noted. In connection with this, there was a need for an analysis of the mechanical factors that influence fracture joints, the choice of materials and the construction of structures in which these parameters will be optimized. An analysis of the main mechanical factors influencing the results of osteosynthesis of the fracture by the plate was performed. There are three main groups of factors - biological character, factors depending on the design and material from which the fixator is made, and the factors associated with the features of surgical technique. The best choice should be considered biotechnical systems with less rigid fixation. This effect can be achieved by using materials from Young's lowered module. According to the authors, the combination of a metal plate with polymer screws, combinations of a polymer plate with metal screws or a polymeric plate with polymer screws will help to create optimal mechanical parameters for fracture joints. The use of biodegradable materials for the manufacture of components of the fixing system allows dynamically to reduce the stiffness of the fixation and provides a gradual loading of this site.

Risk factors for secondary displacement in conservatively treated isolated greater tuberosity fractures: An analysis of 82 cases

IntroductionThe optimal treatment of isolated fractures of the greater tuberosity is an important topic of current surgical research. While non-displaced fractures are amenable to conservative treatment, displacement of the fragment can result in rotator cuff malfunction and impingement. For the present study, risk factors predicting secondary fragment displacement were analyzed. HypothesisCertain risk factors determine a higher risk of secondary displacement in patients with greater tuberosity fractures. Patients and methodsAll patients diagnosed with a fracture of the greater tuberosity and initially treated non-surgically at our Level I trauma center between January 2008 and July 2015 were included in this retrospective analysis. Patients were grouped into: no secondary displacement (group 1) and secondary displacement at follow-up (group 2). The following risk factors were analyzed: age, gender, side of fracture, initial displacement, fragment/head ratio, fragment shape, dislocation, concomitant fractures and concomitant fractures to the same extremity. Results82 patients (42 male, 40 female) were eligible for further analyses. Median follow-up was 8.0±39.5 days. Patients with secondary displacement (group 2) were significantly older (group 1: 51.7±15.5, group 2: 68.3±14.3; p<0.001) and had significantly more shoulder dislocations (p=0.024), whereas gender (p=0.299), side of fracture (p=0.189) and fragment/head ratio (p=0.660) showed no significant different distribution between both groups. Finally, split-type fractures increased the risk of secondary displacement. DiscussionThe present study identified age older than 65 years to be an important risk factor for secondary displacement in the conservative management of fractures of the greater tuberosity. Furthermore, fracture type and shoulder dislocations are factors associated with an increased relative risk for secondary displacement. Level of proofIII, Retrospective comparative study.

Antegrade elastic stable intramedullary nail fixation for paediatric distal radius diaphyseal metaphyseal junction fractures: A new operative approach

Background and purposeThe treatment of paediatric distal radius diaphyseal metaphyseal junction (DRDMJ) fractures is a challenge. The purpose of this study was to introduce a new operative approach at the proximal “safe zone” of the posterior interosseous nerve (PIN) to treat paediatric DRDMJ fractures and analyse the safety and efficacy of antegrade elastic stable intramedullary nail (ESIN) fixation. MethodsThirty paediatric patients with unstable and displaced DRDMJ fractures were treated by antegrade ESIN fixation from November 2015 to September 2017. We created the entrance site at the posterolateral side of the proximal radius and 2˜4 cm distal to the articular surface of the radius, using the ESIN to immobilise the fractures. In the study, we reviewed patient demographics, complications, time until removal, and intraoperative time for hardware removal. ResultsComplete fracture healing was achieved between 6 and 12 weeks after surgery. Except for 3 patients presenting with irritation of the skin, we did not observe any complications. Radiologically, no secondary displacement, nail migration, loss of fixation, consolidation delay, non-union, or refracture was noted. ConclusionsThe antegrade ESIN fixation is a minimally invasive, easy-to-learn, alternative operative method to treat paediatric DRDMJ fractures. Level of evidenceTherapeutic Level IV.

Short-column acetabular fracture fixation through a mini-pararectus approach in anteriorly displaced acetabular fractures: A case series

Background: A mini-pararectus approach has been described as a minimally invasive approach for stabilizing acetabular fractures. This approach allows a direct view of anteriorly displaced acetabular fractures. In this preliminary study, we report the outcomes of short-column plating, using either a pelvic-brim plate or a spring plate to stabilize anteriorly and medially displaced fractures. Methods: Nine patients were included in this report, which was conducted between June 2015 and October 2016 in Assiut University Hospital, which is a level 1 trauma center in Upper Egypt. Eight patients had a transverse fracture of the acetabulum, and a single patient had a posterior hemi-transverse fracture of the anterior column. After the mini-pararectus approach through which anatomical reduction of the fracture was achieved, short-column plating, either a pelvic-brim plate or spring plate was introduced through this 3-5 cm incision. Outcomes were assessed. Results: The mean operative time was 88.8 min (range, 60-120 min). The mean blood loss was 78.8 mL (range, 50-150 mL). The maximal fracture displacement mean was 7 mm (range, 4–18 mm) preoperatively. According to the Radiologic Matta score, anatomical reduction of the fracture (0–1 mm displacement) was achieved in all patients. No complications of metal failure or secondary fracture displacement were encountered. Conclusions: Short-column plating through a mini-pararectus approach can be an alternative option for stabilizing acetabular fractures in a minimally invasive way in selected patients. Level of Evidence: Level IV.