Secondary Displacements Research Articles

Acute unstable acromioclavicular joint injuries: quality of life comparison between patients managed operatively with a coracoclavicular suspension device arthroscopically placed versus patients managed non-operatively

The main aim was to compare the quality of life (QoL) of patients with acute unstable acromioclavicular joint (ACJ) injuries (grade IIIB-V according to the ISAKOS diversification of the Rockwood classification), managed operatively with a coracoclavicular suspension device arthroscopically placed versus the QoL of patients managed non-operatively, 24 months or more after shoulder injury. The secondary aims were to describe the prevalence of scapular dyskinesis in each group of treatment and to assess its relation to the magnitude of shoulder pain. Patients with acute unstable ACJ injuries managed operatively or non-operatively, between 2008 and 2012 were included. Grade IIIA and IIIB injuries were differentiated. Grade IIIA injuries were excluded. The QoL was evaluated by means of the Health Survey questionnaire (SF36), the visual analogue scale (VAS) for pain, the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, assessed at the initial visit post-injury and at the last follow-up visit. The difference between values registered at these different moments was calculated. The Constant score, the global satisfaction (scale from 0 to 10), and the presence of scapular dyskinesis were assessed at the last follow-up visit. The VAS was stratified according to the presence or absence of scapular dyskinesis. Comparison between groups was performed. In the SURG-group, the development of secondary displacements was radiologically evaluated. Forty-one patients were included: 21 CONS-group (4 Rockwood IIIB and 17 V) and 20 SURG-group (3 Rockwood IIIB, 3 IV, and 14 V). The mean age was 37 [19–55] years, and the mean follow-up was 36 [24–90] months. The difference between the questionnaires assessed at the last follow-up visit and at the initial visit post-injury was: (1) physical SF36 score (CONS-group 18.6 ± 6.1 and SURG-group 28.1 ± 6.9, p = 0.001); (2) mental SF36 score (CONS-group 10.8 ± 11.2 and SURG-group 10.6 ± 6.8, p = 0.960); (3) VAS (CONS-group −7.3 ± 1.7 and SURG-group −7.7 ± 1.2, p = 0.412); (4) DASH questionnaire (CONS-group −55.7 ± 9.8 and SURG-group −77.4 ± 9,5, p = 0.020). The mean Constant score assessed at the last follow-up visit was (CONS-group 91.1 ± 7.4 and SURG-group 95.3 ± 2.5, p = 0.020). The mean global satisfaction registered at the last follow-up visit was (CONS-group 8.5 ± 1.7 and SURG-group 8.9 ± 0.9, p = 0.371). There was evidence of scapular dyskinesis in 52.4 % (11/21) of the patients of the CONS-group and in 15 % (3/20) of the patients of the SURG-group (p = 0.030). The mean VAS registered at the last follow-up visit in the group of patients that developed scapular dyskinesis was 2 ± 0.96 and in the group of patients with normal scapular motion 0.3 ± 0.47 (p = 0.000). In the SURG-group, anatomic reduction of the ACJ was finally achieved in 60 % (12/20) of the patients; vertical subluxations were observed in 20 % (4/20); and complete dislocations were observed in 20 % (4/20). Patients with acute unstable ACJ injuries managed operatively with a coracoclavicular suspension device arthroscopically placed have a better quality of life in terms of the physical SF36, DASH, and Constant score, than patients managed non-operatively, 24 months or more after shoulder injury. Although the global satisfaction is not different between groups, the prevalence of scapular dyskinesis is greater in the group of patients managed non-operatively and the scapular dyskinesis is significantly associated to a higher pain. Level of evidence: level III, retrospective cohort study

Hydrodynamics of gas–liquid cocurrent downflow in floating packed beds

An innovative experimental setup combining a robot with six-degree-of-freedom motions (translational: surge, sway, heave, and rotational: roll, pitch, yaw) and an embarked column instrumented with a capacitance wire mesh sensor was built to investigate experimentally the two-phase flow hydrodynamics in porous media within inclined stationary and oscillating packed beds under gas–liquid cocurrent descending flows. The hydrodynamic deviations with respect to the stationary straight column were thoroughly analyzed in terms of bed pressure drop, liquid saturation, regime changeover, and pulse flow properties. Non-tilting oscillations had marginal effects on the packed bed hydrodynamics which remained practically similar to the one prevailing in stationary vertical trickle beds. Conversely, tilting oscillations profoundly influenced the flow regime inside the packed bed as a result of the time-dependent nature of the gravitational and inertial (acceleration/deceleration) forces brought about by the hexapod rotational oscillations which caused important secondary transverse displacements of the fluids in the bed. Using moment analysis of the probability density functions of the registered liquid saturation time series, it was found that due to the periodic gravity-driven stratification, the transition to pulse flow shifted towards higher fluid velocities as the oscillation periods of roll or roll+pitch motions were increased.

Factors predicting secondary displacement after non-operative treatment of undisplaced femoral neck fractures.

We quantified the risk and the time of occurrence of secondary fracture displacement in non-operatively treated femoral neck fractures in our clinic, as well as investigated potential predicting patient- and fracture-related factors. The records of 593 patients with femoral neck fractures from January 2000 to December 2009 were reviewed. Sixty-one patients [mean age 83.0years (SD 9.9)] with undisplaced femoral neck fractures initially received non-operative treatment. The occurrence and the time of secondary fracture displacement were documented, as well as demographics and radiological parameters. Radiographs were evaluated independently by two surgeons. Multivariable regression and Kaplan-Meier survival analyses were used. Thirty-four (55.7%) fractures showed secondary displacement occurring within the first 12weeks after initiation of non-operative treatment. Twenty (38%) fractures originally classified as Garden I were found to be Garden II. The risk of secondary displacement was three times higher (RR=2.8; 95% CI 1.7-4.8, p<0.001) for these fractures in comparison with those confirmed as Garden I. Patients with a history of previously diagnosed osteoporosis were at a higher risk of secondary displacement as well (RR=1.3; 95% CI 1.0-1.5). Non-operative treatment of femoral neck fractures is a treatment option, but only in well-selected cases. The majority of secondary displacements were associated with initial misdiagnosis using the Garden classification. For Garden II, primary surgical treatment is likely a better option, and therefore careful application of the Garden classification in this context is essential.

Simulating Earthquake Rupture and Off‐Fault Fracture Response: Application to the Safety Assessment of the Swedish Nuclear Waste Repository

Abstract To assess the long‐term safety of a deep repository of spent nuclear fuel, upper bound estimates of seismically induced secondary fracture shear displacements are needed. For this purpose, we analyze a model including an earthquake fault, which is surrounded by a number of smaller discontinuities representing fractures on which secondary displacements may be induced. Initial stresses are applied and a rupture is initiated at a predefined hypocenter and propagated at a specified rupture speed. During rupture we monitor shear displacements taking place on the nearby fracture planes in response to static as well as dynamic effects. As a numerical tool, we use the 3Dimensional Distinct Element Code (3DEC) because it has the capability to handle numerous discontinuities with different orientations and at different locations simultaneously. In tests performed to benchmark the capability of our method to generate and propagate seismic waves, 3DEC generates results in good agreement with results from both Stokes solution and the Compsyn code package. In a preliminary application of our method to the nuclear waste repository site at Forsmark, southern Sweden, we assume end‐glacial stress conditions and rupture on a shallow, gently dipping, highly prestressed fault with low residual strength. The rupture generates nearly complete stress drop and an M w 5.6 event on the 12 km 2 rupture area. Of the 1584 secondary fractures (150 m radius), with a wide range of orientations and locations relative to the fault, a majority move less than 5 mm. The maximum shear displacement is some tens of millimeters at 200 m fault‐fracture distance.

Arthroscopic assisted percutaneous screw fixation of Bennett's fracture.

Several techniques are used for fixation of Bennett's fractures. The aim of this study was to assess a technique of arthroscopic-assisted reduction and percutaneous cannulated screw fixation of Bennett's fractures. Seven patients (mean age 29 years) with three fractures Type I and four fractures Type II according to Gedda were operated under arthroscopic lavage, fluoroscopic screw fixation, and arthroscopic control of the joint reduction. Arthroscopy, showed satisfactory joint reduction in all cases. At 4.5 months, the mean pain score was 1 (0-4), QuickDASH 15 (0-61), and Kapandji score 9 (5-10). Compared to the contralateral side, first web opening was 86% (58-100), key pinch 73% (45-89), grip strength, and 85% (40-100). Four secondary displacements were noted, two of which had a step of more than 1 mm. Our results showed that the use of arthroscopy for percutaneous screw fixation of Bennett's fractures facilitates joint reduction but does not guarantee stability of fixation.

Distal radius fixation through a mini-invasive approach of 15 mm. PART 1: a series of 144 cases

The volar Henry approach is becoming the gold standard for distal radius fracture fixation. It decreases the incidence of nonunion, limits complications especially complex regional pain syndrome (CRPS) type I, and allows early mobilization of the wrist. Nonetheless, it has some disadvantages such as the size of the incision, which is not esthetically pleasing, and the loss of ligamentotaxis. This is why some authors have developed a mini-invasive approach. The aim of this work was to evaluate the feasibility of the anterior mini-invasive approach of 15 mm in a clinical series of 144 cases of distal radius fracture. All patients were operated under regional anesthesia using the same techniques by five surgeons of the same team. According to the AO classification, there were 83 type A fractures, 2 type B, and 59 type C. A volar plate (Step One(®), Newclip Technics™, Haute-Goulaine, France) was used in all cases. The 2 proximal metaphyseal screws and the 2 distal central epiphyseal screws were monoaxial locking. The 2 distal ulnar and radial epiphyseal screws were placed in polyaxial locking at 20° angulation maximum. Skin closure without drainage was performed. No postoperative immobilization was prescribed, and patients were encouraged to use their upper limb immediately postoperative. No postoperative physiotherapy was prescribed. The mean follow-up was 4.1 months. The final size of the incision was on average 16.1 mm. Mean pain score was 1.8. The Quick DASH score was average 25. Average range of motion was more than 85 %, and global force of the hand was 67 % compared with contralateral side. On X-ray, the mean radial slope was 22°, the mean radial tilt was 8.3°, and the mean radioulnar variance/index was -0.4 mm. There were nine cases of CRPS type I, which all resolved. Specific complications included two secondary displacements and nine tenosynovitis cases. No tendon rupture was noted. Two intra-articular distal radioulnar joint screws had to be removed at 3 months. One epiphyseal screw required removal 1 month postoperative due to loosening. There were no intra-articular radiocarpal screws. Distal radius fracture fixation using a mini-invasive approach is a reliable and reproducible procedure with few complications. It allows anatomical reduction in the distal radius fractures including intra-articular ones. It can be associated with arthroscopy, scaphoid screw fixation or even percutaneous pinning. Thus, most traumatic lesions of the wrist bony or soft tissue can be treated through this mini-invasive approach.

Potential Pitfalls of Using Epichlorohydrin as Starting Material for Oxazolidinone Antibacterials

The importance of oxazolidinone functional group has been well documented in synthetic and medicinal chemistry. In the latter area, recent interests are focused on N-arylsubstituted oxazolidin-2-one structures, as exemplified by linezolid and eperezolid, which represent a new class of antibacterials with activity against drug-resistant Grampositive pathogens, including MRSA. Biologically active enantiomers of the oxazolidinone antibacterials are those with the (S)-configuration. Synthesis of the (S)-enantiomers have been achieved in enantiopure form starting from various glycidol derivatives such as (R)-glycidyl butyrate, (S)and (R)-epichlorohydrin, N-Boc-glycidylamine, and more recently, (R)-glycidyl tosylate. Other enantiopure starting materials include 3-chloro-1,2-propanediol, mannitol, protected glyceraldehyde, and aziridine-2carboxamide. Several routes employing asymmetric reactions have also been reported. Of those enantiopure starting materials, epichlorohydrin and glycidyl tosylate are particularly useful as they are doubly activated (at both C-1 and C-3) toward nucleophilic substitutions. The tandem, three-step sequence of the epoxide ring-opening, carbamate formation and oxazolidin-2one ring-closure (sometimes referred to as “1,3-cycloaddition”) represents an atom-economic key step in the synthesis of oxazolidinone antibacterials (Scheme 1). Yu et al. first employed this process with epichlorohydrin as the starting material; we then followed it up with glycidyl tosylate, and showed that this crystalline and storage-stable compound was a viable starting material for oxazolidinone antibacterials. Our work with glycidyl tosylate reminded us how the issues of regioand stereochemistry were entwined together for the doubly activated glycidol derivatives. It also prompted us to wonder how these issues had played out in Yu’s work with epichlorohydrin. As the details were not discussed in their original communication, we decided to reexamine the tandem, three-step sequence with epichlorohydrin as the starting material. The 1,3-cycloaddition reaction of (R)-epichlorohydrin and phenyl isocyanate was performed with a catalytic amount of LiBr. In the absence of detailed experimental procedure in the original work, also to make a meaningful comparison with our findings with glycidyl tosylate, we maintained the reaction conditions as close as possible to the ones employed in the glycidyl tosylate process [in THF (0.067 M) at reflux with phenyl isocyanate (3 eq) and LiBr (0.1 eq)]. Epichlorohydrin underwent the tandem, three-step sequence more slowly with LiBr than glycidyl tosylate did with LiI. The reaction took 8 h to complete (vs ~30 min for glycidyl tosylate/LiI). The desired chloro oxazolidinone product was isolated in 93% yield, seemingly validating the results in the original report. A careful examination, however, revealed the presence of a by-product, suggesting concurrent sidereaction pathway(s) and potential complications in the process. In order to gain a fuller picture of the process, we postulated possible reaction pathways for the 1,3-cycloaddition reaction of epichlorohydrin/PhNCO/LiBr and set out to assess the significance of each pathway quantitatively (Scheme 2). Model reactions revealed that the products could undergo secondary displacements, not one-way, but in both ways, hence Paths IV and V in addition to Path III. This raised an extra issue for the epichlorohydrin process. In the glycidyl tosylate process, a single reaction pathway was responsible for the formation of the desired product, whose stereochemical integrity was therefore maintained through the entire course of the reaction. In the epichlorohydrin process, on the other hand, we now needed to consider multiple pathways for the formations of the desired as well as undesired products (Paths I, IV and V for 2; Paths II and III for 3), each resulting in a distinct stereochemical outcome. Significance of these pathways may be assessed in a time study in which the enantiomeric purities as well as the chemical yields of both products would be determined at various reaction times.

Influence of Approach and Implant on Reduction Accuracy and Stability in Lisfranc Fracture-Dislocation at the Tarsometatarsal Joint

Besides early diagnosis, an anatomical and stable reduction is paramount for obtaining a favorable outcome. The current study looked at the influence that the type of approach for tarsometatarsal injuries has on the accuracy of the reduction and the effect that the type of fixation has on stability. Consecutive patients treated surgically for an acute Lisfranc injury were included. All radiographs were reassessed for accuracy and secondary displacement following either a closed or an open approach and in terms of the type of fixation (Kirschner wires alone or a combination of screws and plates and Kirschner wires). A total of 28 patients were included. Six patients were treated with closed reduction and percutaneous fixation and 22 with open reduction internal fixation. Sixteen patients were treated with Kirschner wires only (6 closed, 10 open), 7 with screws with or without Kirschner wires, and 5 with medial plating with or without Kirschner wires. In the closed reduction group, 2 of 6 (33%) reductions were considered acceptable versus 19 of 22 (86%) in the open group (P = .021). All 6 secondary displacements occurred in the Kirschner wire fixation group (37.5%) versus none in the rigid fixation group (P = .024). The results demonstrate that open reduction and internal fixation with screws or plate resulted in better reduction and better maintenance of reduction in both low- and high-energy Lisfranc injuries. These results should be further evaluated in light of functional outcome. Level III, retrospective comparative case series.

Prospective continuous study comparing intrafocal cross-pinning HK2® with a locking plate in distal radius fracture fixation

The fixation of distal radius fractures by pinning or locking plates remains controversial. The aim of this prospective continuous study was to compare the results of 28 anterior locking plates with 23 intrafocal cross-pinning HK2® systems. The mean age of group I (SVP®, SBI™ plate) was 61years. There were 15 extra-articular and 13 articular fractures. The mean age of group II (HK2®, Arex™) was 63 years, with 13 extra-articular and 10 articular fractures. Twelve clinical variables were measured: pain, wrist strength, supination strength, pronation strength, quick DASH score, range of wrist motion in flexion, extension, pronation, and supination, ulnar variance, radial slope, and radial volar tilt. At 40weeks follow-up, there was no difference between the two groups for 10 variables; two variables showed differences between the two groups: mean quick DASH score was 10.7 for group I, 19.7 for group II, and mean ulnar variance was −0.95mm for group I, and 1.16mm for group II. Six transient complications were noted for group I: five tenosynovitis, and one carpal tunnel syndrome. We noted 12 complications in group II: four superficial infections, two secondary displacements, one pin migration, two CRPS type II, two tendon ruptures and one nerve irritation. Generally, plates provided a more stable fixation associated with less complications while the HK2® system was quicker and less costly. The indications for its use need to be refined with a larger series and longer follow-up.

Early correction of paediatric malunited distal metaphyseal radius fractures using percutaneous callus osteoclasis (“Calloclasis”)

Closed reduction of secondary displacements of distal metaphyseal radius fractures is an easy procedure only when performed within the first ten to fifteen days post-trauma, prior to the occurrence of malunion. When a hard bony callus prevents proper reduction, an open osteotomy is generally advocated. We suggest the use of a less invasive technique which aims at correcting early malunion when closed reduction is made impossible: the percutaneous callus osteoclasis. Callus osteoclasis consists in a series of multiple bone-drilling in a postage stamp pattern performed under image intensifier using a large diameter pin, at a distance from the growth plate. Once the bone has been weakened, reduction is obtained by using the pin as an intrafocal lever. The pin is then pushed through the opposite cortex to ensure postero-lateral stabilization. Twenty-one patients were managed using this technique and reported good results with no complications. This technique offers a low aggressive management of malunions and may be performed within two to six weeks after trauma. Level IV. Multicenter retrospective study.

The ferroelectric properties of Cd2Nb2O7: a Monte Carlo simulation study

The order–disorder contributions to the ferroelectric properties of Cd2Nb2O7(CNO) have been studied by Monte Carlo simulation of a 12-state modified Potts model on the pyrochlore lattice. Spin configurations obtained by these simulations are mapped to local Nb displacements. Secondary Cd displacements normal to the Nb displacement directions are considered as well. The model correctly reproduces diffuse scattering experimentally observed in CNO. A first-order phase transition is observed forkTp/J= 0.3891 (kis the Boltzmann constant,Tpis the model phase transition temperature andJis the interaction energy). To further adapt the model to the properties of CNO, coupling of local Nb displacements to theT2usoft mode is simulatedviathe addition of an appropriate field term in the model Hamiltonian. The critical temperatureTcof the soft mode is scaled tokTc/J= 0.3704. Similarities to experimental observations,i.e.the occurrence of stable domains with {100} boundaries, as well as spontaneous polarization along the cubic 〈100〉 and 〈110〉 directions, indicate thatTpcan be associated with the transition temperatureT1= 205 K in CNO. Frequency dispersion of the dielectric permittivity of CNO can be attributed to the low-frequency switching of correlated chains of Nb displacement that remain partially disordered in the temperature range between 195 and ∼100 K.

Locking plates for fixation of extra-articular fractures of the first metacarpal base: A series of 15 cases

Extra-articular fractures of the first metacarpal base may lead to retraction of the first web and weakness of the pinch. Conventional surgery (K-wire or non-locking plates) needs six weeks of immobilization. Our goal was to achieve the reduction of such fractures using locking mini-plates to allow early mobilization. Our series included 15 patients, with an average age of 35 years, operated on for an extra-articular fracture of the first metacarpal base. All patients underwent surgery with variable angle locking mini-plates. In 10 patients, we used a double-row plate and for the other five patients T-shaped plates. Fractures were immobilized for two weeks. Outcome evaluation consisted in the assessment of subjective criteria (pain, quick-DASH), objective criteria (Kapandji score, Jamar ®, pinch ®), screening for complications, time off work and radiological consolidation. Follow-up time was 10 months. Pain averaged 2.2/10 and quick-DASH 17.4. Kapandji score was 90%, grip strength 95.5% and pinch strength 88.6% of the contralateral hand. Three secondary displacements occurred with T-plates. Mean time off work was seven weeks. Radiological consolidation was detected at four to six weeks. Our results seem to indicate that locking T-plates do not provide sufficient strength to allow early mobilization. The direct cost of locking plates is high but this must be weighed against the reduced indirect costs when calculating the cost effectiveness of this type of management. Double-row locking plates offer a valuable therapeutic alternative since they allow stable fixation and early mobilization of the thumb, which may outweigh their high cost.

Distal quarter leg fractures fixation: The intramedullary nailing alone option

Intramedullary (IM) nailing is the classical treatment for diaphyseal fractures of the tibia. Stabilizing fractures of the distal quarter is recognized as being delicate. We report a continuous, multicenter prospective study of distal tibia-fibula fractures treated with anterograde intramedullary nailing. The working hypothesis was to identify the problems encountered with IM nailing alone of distal leg fractures. From May 2007 to November 2008, 51 fractures in 51 patients (19 females and 32 males; mean age, 46.2years [range, 17-93years]) were treated with IM nailing. The fractures were classified according to the association pour l'ostéosynthèse (AO) classification, with most type A1 (29/51). Thirteen fractures presented a distal articular extension treated with screws in five cases. Fixation consisted in intramedullary nailing, reamed in all cases, performed on a standard or orthopaedic surgery table. Nailing was static and distally locked (50/51). The patients were evaluated clinically and radiologically, with AP and lateral images of both legs and the Olerud score. We report one death and eight patients lost to follow-up, providing 42 cases to reviewing at 1year. The bone union rate was 97.6% in a mean 15.7weeks. Immediately after surgery, 14 axial deviations greater than 5° were observed, mainly valgus, with only one greater than 10°. The absence of fibular fixation was the only identifiable risk factor for appearance of an initial axial deviation as well as fracture instability over time. Two infections were observed and at 6months four secondary displacements, one of which can be explained by changing the distal locking due to infection. Four dynamizations were performed. No other risk factor was found. The mean Olerud functional score at 12months was 83.5 points. The clinical results are comparable to those reported in the literature. From a radiological point of view, the rates and times to bone union were identical. However, the rates of malunion were clearly higher. The risk factors for malunion found in the literature are metaphyseal enlargement, fracture comminution, a too distal location of fracture site, young patient age, patient installation on a standard operating table, and technical errors. The absence of supplementary fibular fixation, the subject of debate in the literature, was the only statistically significant point found in the present study. Nailing distal fractures of the leg provides good clinical results. However, with regard to the malunion rates, the technique must be precise and rigorous. We recommend systematic fibular fixation and use of an orthopaedic table. Level IV; cohort type prospective study.

Les fractures du radius distal après 70 ans : ostéosynthèse par plaque palmaire ou broches ?

In a growing elderly osteoporotic population, the management of distal radius fractures remains without consensus as to volar distal plate versus K-wires. The goal of this retrospective study was to evaluate these treatments in elderly people. In a series of 38 patients over 70 years, 21 were treated by a volar plate and 17 by percutaneous K-wire fixation. Follow-up was at least 6 months. Results were analyzed using the disabilities of the arm, shoulder and hand (DASH), patient-rated wrist evaluation (PRWE) and Herzberg score by an independent operator. Radiological parameters were radio-ulnar variance, radial inclination and palmar or dorsal tilt. Radio-ulnar variance was better for the plate group (−0.7 mm versus −0.1 mm in K-wires). Mean functional outcomes were good but there were more satisfied patients in the plate group (67% versus 39% for the K-wire group). Secondary displacements were frequent in both groups but more with K-wires (50% versus 37% in case of plates). Six articles about surgical treatment of elderly radius distal fractures were published up to 2009 showing similar results. However, they analyze only global mean scores. Volar plates give more stability and a higher rate of satisfaction, with similar results of wrist mobility and grasp strength. The main advantage of the plates is earlier return to daily activities.

Mini-invasive nail versus DHS to fix pertrochanteric fractures: A case-control study

Fixation devices to treat trochanteric fractures belong to two general categories: dynamic hip screw (DHS) type and intramedullary type implants. In spite of possible pitfalls, both are considered valid options. Comparing a sliding screw-plate system (DHS) along a mini-invasive nailing device (BCM nail) with primary insertion of the cephalic screw, sheds light on the debated management of trochanteric fractures.Due to its design, the BCM nailing system allows a stable internal fixation and promotes enhanced postoperative functional recovery.To test this hypothesis in a comparative prospective case-control study using the DHS screw-plate as a reference.Two groups of 30 patients, older than 60 years old, with trochanteric fractures were included in this study. The screw-plates were placed according to the standard method. Regarding the nailing system, the cephalic screw was positioned first, then the nail was inserted through the screw via a mini-invasive approach and locked distally using a bicortical screw. Comparison between the two groups was based on (1) operative data: operating time, intra- and postoperative blood loss; (2) immediate postoperative course: complications, length of hospital stay, delay to sitting in a wheelchair; (3) the postdischarge evolution: weightbearing, readmission to hospital; (4) functional outcomes: recovery and mobility; (5) anatomical outcomes: restitution and bone healing.The operating time (54+/-8.8 min vs 59+/-13.8 min) and intraoperative (1.37+/-0.98 vs 1.90+/-1.43) and at Day 3 (1.25+/-1.05 vs 1.82+/-1.5) blood loss (haemoglobin loss), were favourable to the screw-plate subgroup (p<0.05). The delay to sitting in a wheelchair (4.76+/-1.53 d vs 4+/-1.44 d) was favourable to the nail subgroup (p<0.05). There was a higher incidence of secondary displacements in the screw-plate subgroup (3/26 [11.5%] vs 0/25 [0%]) (p<0.05). The screw-plate subgroup demonstrated a poorer healing rate at 3 months (88% vs 100%) (p<0.05). Regarding functional recovery, a lesser decrease in the Parker score was observed in the nail subgroup at 3 postoperative months (2.42+/-2.3 vs 1.52+/-1.44) (p<0.05).This study has shown the benefits of the BCM nail in terms of stability. But the potential advantages of this mini-invasive technique were limited by ancillary-related difficulties which need to be rectified. These preliminary results are in favour of a further development of this innovating device.

Does fixed-angle plate osteosynthesis solve the problems of a fractured proximal humerus?

Background and purpose There is considerable controversy about the treatment of complex, displaced proximal humeral fractures. Various types of head-preserving osteosynthesis have been suggested. This prospective case series was designed to evaluate the perioperative and early postoperative complications associated with fixed-angle implants and to record outcome after bone healing.Patients and methods Fractures of the proximal humerus were stabilized surgically in 87 patients (mean age 64 (16–93) years) by application of a fixed-angle plate (65 PHILOS, 22 T-LCP). There were 34 2-segment fractures, 42 3-segment fractures, and 11 4-segment fractures, including 7 dislocation fractures. Follow-up assessment after a minimum of 12 months was based on the Constant, UCLA, and DASH scores and on radiographs.Results Postoperative complications included soft tissue problems (n = 9), humeral head necrosis (n = 9), screw perforation (n = 11), secondary displacements (n = 14), and delayed fracture healing (n = 4). Treatment outcomes recorded on the various scores were very good in 60–82% of the cases.Interpretation Screw perforation of fixed-angle implants has replaced the complications of secondary displacement and implant loosening after using conventional plates. Even with the use of fixed-angle implants, fractures of the proximal humerus are associated with a high complication rate and sometimes poor outcome.

Ostéosynthèse antérieure par plaque à vis verrouillée LCP 3.5® dans les fractures de l’extrémité inférieure du radius à déplacement postérieur. À propos de 24 cas

Fracture of the distal radius with posterior displacement is the most common wrist fracture. Pinning is generally proposed. The problem is that a secondary displacement may persist, even for the least complex fractures. With the advent of the fixed-angle plate with a self-locking screw, we considered using this method in combination with an anterior approach to the radius. We report our preliminary results. From November 1 to March 31, 2003, among the 195 fractures of the distal radius with posterior displacement which we treated in our unit, 135 were treated with orthopedic reduction, 36 with Kapandji pinning and 24 with a T-shaped anterior locking compression plate (Synthès, LCP 3.5. During the early part of this series, the LCP was used for emergency situations in young adults with a posterior displacement exceeding 20 degrees . Starting in November 2002, the technique was also proposed for revisions for secondary displacements after orthopedic reduction or pinning procedures. Secondary displacement was noted on the standard X-rays and the clinical analysis included a measurement of muscle strength, the DASH score and the clinical evaluation score used by the SOFCOT symposium in November 2000. Twenty-four patients (14 female, 10 male, mean age: 54.5 years) presented 14 extra-articular fractures and ten articular fractures. At admission, mean frontal inclination of the radial glenoid was 13 degrees with a posterior displacement of 25.45 degrees and an ulnar variance measuring+4mm. Eighteen patients were reviewed at mean 16 months follow-up. Mean frontal inclination of the glenoid was 23.95 degrees with mean anteversion 5.45 degrees . Using the SOFCOT criteria, 11 outcomes were anatomic and seven presented moderate displaced healing. The wrist force (Jamar was 95% of the value measured on the healthy side. The mean DASH score was 38.47. Outcome was considered excellent for nine cases, good for six, fair for three and poor for zero. Complications were: reflex dystrophy (n=4), carpal tunnel syndrome (n=1), cheloid scar (n=1), glenoids in the pulse gutter (n=10), and secondary fracture along the upper border of the plate (n=3). This study demonstrated that, used on the anterior aspect of the radius, the locking compression plate provides satisfactory treatment for fractures of the distal radius with posterior displacement. Because of the angular stability, the reduction can be maintained over time so that secondary displacement is no longer a problem. This is a difficult technique which requires particular skill. We no longer recommend the LCP 3.5 plate due to the poorly adapted ergonometry, the late fracture over the plate and the fact that the material is not removed.

Une nouvelle technique d’embrochage intrafocal des fractures de cols de phalanges chez l’enfant

Phalangeal neck fractures are unusual, occurring mainly in children. This study aims at assessing the results of treatment of this type of fracture and presents a new technique for displaced fractures namely intrafocal pinning. From January 2001 to January 2007, we treated 49 children (32 boys and 17 girls) with 52 phalangeal neck fractures. The patients were aged between three months and 14 years (average seven years). Five fractures were open but without nerve, artery or tendon damage. The 32 undisplaced or minimally displaced fractures were treated by closed methods. Thirteen displaced fractures (of which three were secondary displacements) were treated with an intrafocal pinning technique inspired by the Kapandji technique for distal radius fractures. Seven fractures (five open and two closed but displaced) were treated using standard osteosynthesis techniques (temporary arthrodesis, crossed K wires or cerclage). We reviewed the patients an average of 18 months later. We classified the results according to Barton's classification: excellent, good, fair and bad. Among the 13 fractures treated with an intrafocal pinning technique, 11 gave excellent results and two gave good results. We did not find any infection, tendon rupture, phalangeal head osteonecrosis or nonunion. We had to reoperate on one proximal phalanx thumb fracture because of delayed consolidation. Percutaneous reduction of the displacement and pinning seems to give the best results for the treatment of displaced fractures. The surgeon aims at getting the best anatomical result whilst limiting soft tissue damage. The proposed technique seems to give good results as it allows a percutaneous reduction of the displacement and an effective means of holding the reduction. Open fractures have a poorer prognosis.

The Use of Intramedullary Helix Wire for the Treatment of Proximal Humerus Fractures

To present the functional and radiographic outcome 1 and 6 years after application of a new intramedullary fixation device for proximal humerus fractures. Retrospective case series. Level II orthopaedic surgery hospital. Twenty-six consecutive patients (average age 68.9 years) with 2-, 3- and 4-part fractures of the proximal humerus were operated at a single institution. Follow-up was performed after 1 year (26 patients) and 6 years (16 patients). All patients were treated with closed reduction and intramedullary helix wires. The Constant-Murley score and the University of California Los Angeles (UCLA) score. Clinical complications and radiological posttraumatic arthritis were recorded. The average Constant-Murley score was 70.3 (points) and 70.7 after 1 and 6 years, respectively; the average UCLA score was 27.2 and 31.5 after 1 and 6 years, respectively. Major complications were 4 revisions for 3 secondary fragment displacements and 1 nonunion with partial avascular osteonecrosis in the first postoperative year. Complications were found predominantly in 4-part fractures (3/5, 60%). There were no further complications or progressive posttraumatic arthritis up to 6 years following surgery. The helix wire is well suited for displaced or unstable 2- and 3-part proximal humerus fractures. Adequate functional outcome, a low number of implant displacements, a low number of application morbidity, and infrequent implant removals were recorded. The use of this device is not recommended for 4-part fractures.

Ostéosynthèse par plaque antérieure verrouillée des fractures complexes de l’extrémité distale du radius: Contribution au maintien de la longueur radiale

Purpose of the study Maintaining radial length, likely to be the main challenge in the treatment of complex distal radius fractures, is necessary for complete grip-strength and pro-supination range recovery. In spite of frequent secondary displacements, bridging external-fixation has remained the reference method, either isolated or in association with additional percutaneous pins or volar plating. Also, there seems to be a relation between algodystrophy and the duration of traction applied on the radio-carpal joint. Fixed-angle volar plating offers the advantage of maintaining the reduction until fracture healing, without bridging the joint. Material and methods In a prospective study, forty-three consecutive fractures of the distal radius with a positivated ulnar variance were treated with open reduction and fixed-angle volar plating. Results were assessed with special attention to the radial length and angulation obtained and maintained throughout treatment, based on repeated measurements of the ulnar variance and radial angulation in the first six months postoperatively. Results The correction of the ulnar variance was maintained until complete recovery, independently of initial metaphyseal comminution, and of the amount of radial length gained at reduction. Only 3 patients lost more than 1 mm of radial length after reduction. The posterior tilt of the distal radial epiphysis was incompletely reduced in 13 cases, whereas reduction was partially lost in 6 elderly osteoporotic female patients. There was 8 articular malunions, all of them less than 2 mm. Secondary displacements were found to be related to a deficient locking technique. Eight patients developed an algodystropy. The risk factors for algodystrophy were articular malunion, associated posterior pining, and associated lesions of the ipsilateral upper limb. Conclusion Provided that the locking technique was correct, this type of fixation appeared efficient in maintaining the radial length in complex fractures of the distal radius. The main challenge remains the reduction of displaced articular fractures. Based on these results, it is not possible to conclude that this method is superior to external fixation.