Severe Comminution Research Articles

Factors Related to the Inconstancy of Sustentaculum Tali Fragments in Intra-Articular Calcaneus Fractures

Category: Trauma Introduction/Purpose: Since intra-articular fractures are common in calcaneus fractures, anatomical reduction is important. Several ligaments such as spring ligament and deltoid ligament are attached to the Sustentaculum tali (ST). It is known that ST fragment is constant in calcaneus fracture. However, few studies have been reported to prove this. Therefore, we studied to establish criteria for the inconstancy of ST fragments through the analysis of computed tomography (CT) of the unaffected calcaneus, to confirm the prevalence of ST fragment inconstancy by applying these criteria, and to analyze the factors related to the inconstancy of the ST fragment. Methods: From 2012 to 2020, CT scans of calcaneus fractures of 122 patients (101 men and 21 women) were taken, and angulation and diastasis of ST fragment were measured in the semi-coronal plane. As a control, angulation and diastasis were measured in 62 unaffected calcaneus. After establishing criteria for the inconstancy of ST fragments, we evaluated the prevalence of ST fragment inconstancy. After, we analyzed related factors. Patient factors included age, BMI, smoking, and diabetes. Radiographic factors included the degree of comminution of the posterior facet, location of the outermost fracture line of the posterior facet, presence of an intra-articular fracture of the ST, and width of the ST fragment. Results: The upper limit of the 95% CI of angulation and diastasis was 7.58° and 2.51 mm, respectively. Based on these criteria, the inconstancy of the ST fragment was observed in 34.5%. The width of the ST fragment was significantly smaller in the inconstant group. Severe comminution of the posterior facet, intra-articular fracture of the ST, and diabetes were significantly higher in the inconstant group. The inconstancy of the ST fragment was significantly associated with the width of the ST fragment (p < 0.001) (Table 1). Cut-off values for the inconstancy of the ST fragment were 20.5 mm for the width of the ST fragment. Conclusion: In intra-articular calcaneal fractures, ST fragment inconstancy was observed in 34.5%. The width of the ST fragment was significantly associated with the inconstancy of the ST fragment.

Severely Comminuted Transolecranon Fracture Fixation with the Help of Medial Humerus Anatomical Plate: A Case Report and Educational Corner

Background: Transolecranon fracture is an unstable intra-articular injury in the elbow caused by high-energy trauma. Here, we introduce a medial humerus plate for severely comminuted transolecranon fracture.
 Case Report: This article presents the case of a 29-year-old man who had a severely comminuted transolecranon fracture due to a motorcycle accident. A dorsal longitudinal approach was used in order to reach the fracture site. An olecranon anatomical plate and a medial humerus plate were applied for fixation, a new treatment method. The range of motion (ROM) was complete at a two-month follow-up, and the Mayo Elbow Performance Score (MEPS) was obtained 100 with no signs of complications.
 Conclusion: Despite the several methods available for fixing transolecranon fractures, using the medial humerus plate, especially in severe comminution, can yield acceptable results. It should be considered in future studies to prove its efficacy in this type of fracture.

Modified pin and plate fixation for low intercondylar fractures of the humerus: biomechanical study corroborated with a case series.

Establishing fracture union of low and comminuted intercondylar fractures of the humerus is inherently challenging. The purposes of the present study were to investigate the biomechanical effectiveness of pin & plate (PP) fixation compared to other dual-plating techniques by finite element analysis, and to present a technical description as well as retrospectively review the outcomes of PP fixation in such difficult fractures. Low-level intercondylar fracture 3D models of the humerus were virtually stabilized with three fixations on lateral side including PP, lateral pre-contoured locking compression plate (L-LCP), and variable angle lateral pre-contoured locking plate (VA-L-LCP) whereas medial pre-contoured locking compression plate (M-LCP) on medial side. Loading conditions under consideration were axial compression, internal rotation, posterior bending, and valgus rotation. Regarding the clinical series, eight patients with intra-articular and comminuted fractures of the distal humerus (6 intercondylar fractures, 1 fracture-subluxation, and 1 isolated lateral condylar fracture) were operated by isolated PP fixation or combinations of PP and the other standard implants. Data were collected on fracture union, perioperative complications, and objective clinical outcomes. Biomechanical results revealed the most instability of the fracture occurring under posterior bending. PP fixation presented comparable fracture stability and fragment displacement compared to other dual-plating fixations, except stress on the Kirschner wire under internal rotation which was higher than other fixations. Regarding the clinical series, fracture union was achieved in all cases with an average union time of 17weeks (range 12-20). All except one patient had good-to-excellent MEPS results with an average Disabilities of the Arm, Shoulder, and Hand (DASH) score of 14.6 (range 0-45) and an average arc of elbow motion of 107.5 degrees (range 60-140). By the biomechanical performance, PP fixation is a reliable technique for fixation of low intercondylar fractures of the humerus. Supported by the clinical outcomes, the present technique could be an alternative for this particular fracture especially when severe comminution prevents the use of the standard dual plating technique.

Clinico - Radiological Results of Tibial Bicondylar Fractures Managed with Ilizarov Technique with or without Minimal Internal Fixation.

Introduction:Tibial bicondylar fractures are difficult fractures to treat and are usually associated with complications.Materials and methods:Thirty-five patients with Schatzker type V and VI fractures were managed from June 2016 to July 2018 with Ilizarov technique. The mean age of the patients was 46.5 ± 8.9 years, with 28 male and seven female patients. Sixteen patients had Schatzker type V fracture and the remaining had type VI. The functional outcome was assessed by using Modified functional evaluation system by Karlstrom - Olerud and the radiological outcome by Rasmussen's Radiological Score (RRS).Results:All patients achieved radiological union at a mean duration of 16 weeks for type 5 and 17 weeks for type 6 however, full weight-bearing was allowed at a mean of 18 weeks (14 - 22 weeks). Functional results were excellent in 24 cases, good in 10 and poor in one. Most patients achieved functional range of motion at the knee joint (average flexion 1280) except one, who had a flexion of less than 1100. One patient with a delayed union united after bone marrow injection. Other complications included pin tract infections in 9 cases, axial malalignment of less than 100 in 4 cases and a prominent screw in one.Conclusion:Percutaneous restoration of articular anatomy and a ring external fixation with or without minimal internal fixation is an excellent method of treatment in this group of fractures caused by high energy trauma and with a usual association of severe comminution and a poor soft tissue envelope.

Surgical Outcomes of Coronal Shear Fracture of the Distal Humerus in Elderly Adults.

This study evaluated clinical outcomes of elderly adults with coronal shear fractures (CSFs) of the distal humerus treated by open reduction and internal fixation (ORIF). Between April 2002 and March 2019, data from eight elderly patients (76.3 ± 5.1 years) with CSFs of the distal humerus were analyzed retrospectively. Postoperative complications, range of motion of the elbow joint, and functional elbow scoring (Mayo Elbow Performance Score; MEPS) were assessed. The mean follow-up duration was 23.6 ± 13.9 months. CSFs were treated by a buried implantable headless screw or Kirshner wires or bioresorbable screw with/without lateral locking plates. There were no superficial or deep infections or elbow joint instability. Seven patients obtained fracture healing, but one patient exhibited nonunion. Osteochondritis dissecans was present in one patient. Three patients had a step-off deformity (>2 mm) of the articular surface. Two patients exhibited collapse of the fractured articular surface. A patient with severe comminution of both the capitellum and trochlea exhibited collapse of the entire articular surface, with osteonecrosis of the capitellum and trochlea. Mean range of motion of the elbow was 116.3±12.7° of flexion and -28.8±14.1° of extension. The mean MEPS was 78.8±10.2 points, representing patients scored as excellent (n=1), good (n=3), and fair (n=4). ORIF yielded satisfactory outcomes for elderly adults with noncomminuted CSFs of the distal humerus. However, treatment of comminuted articular fracture fragment and complex posterior fracture remains challenging.

Osteochondral Autograft From the Hamate for Treating Partial Defect of the Proximal Interphalangeal Joint

The management of a proximal interphalangeal (PIP) joint fracture dislocation becomes more challenging when the joint surface is damaged because of severe comminution or inadequate treatment in the acute phase. The purpose of this study was to evaluate the clinical outcomes of an osteochondral autograft for the reconstruction of the joint surface in patients with a partial PIP joint defect. Twelve patients underwent osteochondral autograft surgery from May 2007 to July 2018. The average age at the time of surgery was 38 years (range, 21-67 years), and there were 10 men and 2 women. Plain radiographs and computed tomography scans showed a partial middle phalangeal base defect in all the cases. The surgeries were performed 2 weeks to 20 months after the fracture or a previous surgery. Partial hamate grafts were harvested to reconstruct volar lip (n= 7), middle portion (n= 2), and dorsal lip (n= 3) defects of the middle phalangeal base. Bone healing, postoperative range of motion, instability, and pain were evaluated. The average follow-up duration was 27.8 months (range, 12-53 months). Radiographic graft union was observed in all the patients 6-8 weeks after the surgery. The deformity was corrected in 11 patients. The active range of motion of the involved PIP joint was improved from 28.3° (range, 0°-60°) to 75.0° (range, 25°-95°). Complications were observed during follow-up, including degenerative arthritis (n= 2), instability (n= 3), and stiffness (n= 5). Various types of partial joint defects of the middle phalangeal base following a PIP fracture dislocation can be reconstructed using an osteochondral autograft from the hamate. The functional recovery is generally acceptable, with a well-restored joint architecture. Therapeutic IV.

Minimally Invasive Surgery for Traumatic High-Grade Lateral Spondylolisthesis of L1 with Multiple Spinal Fractures: Closed Reduction and Internal Fixation Using Percutaneous Pedicle Screws.

Background:Traumatic high grade lateral spondylolisthesis at the thoracolumbar junction is an extremely severe injury caused by high-energy trauma, commonly resulting in polytrauma. The treatment of this pathology is challenging, and even death following surgery has been reported. Therefore, it is necessary to focus on making surgical invasion minimal.Methods:A 53-year-old female fell from a height and presented with severe back pain and complete paralysis below L1. Computed tomography (CT) showed a Grade 4 traumatic lateral spondylolisthesis and severe comminution of L1, and mild compression fractures at T9 and L3.Results:First, we performed posterior surgery on the day of the injury to reduce the fracture and stabilize the spinal column using percutaneous pedicle screws (PPS). Twelve days later we resected the L1 vertebral body and inserted a cage with an iliac bone graft using an anterior approach. The estimated blood loss from posterior and anterior surgeries was 320ml and 200ml, respectively. Bony fusion was achieved as seen on CT at the 1-year follow-up.Conclusion:A 2-stage combined posterior-anterior approach using PPS can be performed less invasively, enabling adequate reduction, internal fixation, and anterior reconstruction for patients with high grade traumatic lateral spondylolisthesis without spinal shortening or facet interlocking.

Development and Validation of a Post-Operative Non-Union Risk Score for Subtrochanteric Femur Fractures.

Background: Our objective was to develop and validate a predictive model for non-union following a subtrochanteric fracture of the femur. Methods: Following institutional board approval, 316 consecutive patients presenting to our institution (84 non-unions) who fulfilled the inclusion criteria were retrospectively identified. To identify potential unadjusted associations with progression to non-union, simple logistic regression models were used, followed by a revised adjusted model of multiple logistic regression. Results: Having established the risk factors for non-union, the coefficients were used to produce a risk score for predicting non-union. To identify the high-risk patients in the early post-operative period, self-dynamisation was excluded. The revised scoring system was the sum of the following: diabetes (6); deep wound infection (35); simple or severe comminution (13); presence of an atypical fracture (14); lateral cortex gap size ≥5 mm (11), varus malreduction (5–10 degrees) (9); varus malreduction (>10 degrees) (20). On the ROC (receiver operating characteristic) curve, the area under the curve (0.790) demonstrated very good discriminatory capability of the scoring system, with good calibration (Hosmer–Lemeshow test; p = 0.291). Moreover, 5-fold cross validation confirmed good fit of the model and internal validity (accuracy 0.806; Kappa 0.416). The cut-point determined by Youden’s formula was calculated as 18. Conclusion: This study demonstrates that the risk of non-union can be reliably estimated in patients presenting with a subtrochanteric fracture, from the immediate post-operative period. The resulting non-union risk score can be used not only to identify the high-risk patients early, offering them appropriate consultation and in some cases surgical intervention, but also informs surgeons of the modifiable surgery related factors that contribute to this risk.

Evaluation of functional outcome after open reduction and internal fixation of distal femur fractures by locking compression plate

Background: In the supra and intercondylar fractures of femur particularly with intra articular extension, patient may develop stiffness of knee, shortening, rotational deformities, internal derangement of knee with instability, varus and valgus deformities which affect patient’s routine lifestyle. If these cases were treated with locking compression plate, the results obtained were successful, superior, timesaving providing early ambulation and least disability improving the functional outcome. Materials and Methods: This is a prospective interventional study. This study includes 25 supracondylar and intercondylar fractures of femur (both Muller’s Type ‘A’, Type B and Type ‘C’ fractures) treated with open reduction and internal fixation by Locking Compression Plate in the Department of Orthopaedics, Narayana Medical College and Hospital, Nellore from October 2019 to August 2021. There are 16 males and 9 females with age ranging from 20 to 80 years with an average of 44.6 years. Average age for males is 28.9 years and average age for females is 25 years. 18 fractures were due to road traffic accidents and 6 cases are due to fall from significant heights, 1 case due to simple fall from standing (osteoporosis). 15 cases were in right femur (60%) and 10 cases were in left femur (40%). Results: 25 cases were included in the study. There is an increase in the rate of union, decreased time taken for union, increased knee range of motion, decreased time for weight-bearing, postoperative complications and duration for hospital stay. Conclusion: LCP proved to be a good implant which could take the challenges like poor bone stock, severe comminution both metaphyseal and articular and prove successful. The locking head screws distally have prevented varus collapse, even in cases of osteoporosis. The Condylar LCP can be used in either an open or a minimally invasive manner.

Characterisation of fracture evolution of a single cemented brittle grain using in-situ X-ray computed tomography

In this paper, the diametrical fragmentation of a single brittle glass bead cemented by ductile epoxy resin is studied using in-situ X-ray computed tomography, focusing on the fractures within the grain that underpin its crushability. Key quantities of interest include the evolution of fracture regions, paths and orientations, as well as the evolution of fracture statistics within the grain. The complex nature of the fracture process is revealed by qualitative and quantitative analysis based on both continuous X-ray radiography and discrete tomography. A series of image processing techniques are used and developed to obtain the statistical details of fragment volume, surface area, morphological geometry, fracture spatial locality and fracture preferential orientations. The single cemented grain failure consists of an initial splitting fracture process creating large and irregular glass fragments, followed by a further rapid propagation of multiple fractures through the cleavage fragments in the form of severe comminution that tends to generate smaller and more regular fragments. Despite the whole fragmentation process shows a shifting trend of the overall median anisotropy of fragments and a decreasing trend of conversion rate between fracture energy and input energy, it still maintains a constant fragment surface area power law distribution and appears to remain scale-invariant over time. The central region of the glass bead is markedly more susceptible to fracture with a constant preferred fracture orientation along the loading direction, indicating that the tensile-activated fracture is the dominant fracture mechanism during diametrical fragmentation.

Radiological and functional outcome of unstable intertrochanteric fractures treated with proximal femoral locking plate

<p class="abstract"><strong>Background:</strong> Intertrochanteric fracture is a common orthopaedic injury sustained in elderly population because of osteoporosis and trivial fall. Life threatening systemic complications occur mainly due to immobility.</p><p class="abstract"><strong>Methods:</strong> We included 62 patients (40 males and 22 females) of unstable intertrochanteric fracture (AO 31 A2 and A3) attending Department of Orthopaedics. They were all subjected to surgical treatment with proximal femoral locking plate. Patients were followed up at 3rd, 6th and 12th month for outcomes variables i.e.; functional (Harris hip score, Palmer and Parker mobility score) and radiological outcomes (neck shaft angle, loss of reduction, union and implant related complications). Statistical analysis was done using Friedman’s test after calculating the data in terms of mean and median using SPSS 20 software.<strong></strong></p><p class="abstract"><strong>Results:</strong> Mean age of our patients was 64 years, 40 were males and 22 females. 50 patients sustained fracture due to trivial fall and 12 due to RTA. 35 out of 62 patients had medical co-morbidites. 26 patients needed open reduction of fracture and 36 were close reduced. 22 of patients had severe comminution (AO A 3 III type). Average blood loss was 254 ml. Mean degree of loss of reduction was 5 degrees in 6th month and 4 degrees in 12th month. Union was achieved in 48 out of 50 patients at 12th month. Most of the patients achieved fair to good functional outcome scores at 12th month of follow up. We noticed difficulties in fracture reduction as well as complications related to implant.</p><p class="abstract"><strong>Conclusions:</strong> PFLP is an effective implant in comminuted intertrochanteric fractures with broken lateral wall. Complications can be minimised by following principles of locking plate meticulously.</p>

Floating knee injuries – An analytical study using a conglomerated comprehensive classification

PurposeFloating knee injuries are complex high velocity injuries with a simultaneous breach of skeletal integrity both above and below the knee joint. Intraarticular fractures, severe comminution, soft tissue insult, associated other skeletal and systemic injuries have been the most common factors influencing the outcome. With our previous experience we framed a conglomerated comprehensive classification, which includes important prognosticating factors that influences the outcome. Aim of this study is to analyse the efficacy of this classification system for floating knee injury by studying the duration of hospitalisation, number of procedures required for completion of treatment, prognosticating functional outcomes and complications. MethodsThis classification is a conglomeration of the existing standard classifications (Fraser, AO, Gustilo and Andersons) along with modifiers like disruption of exensor mechanism M1, avulsion fractures around knee M2 and fractures around hip and ankle joints M3. This classification system was applied to all FKI cases presented to our institution between 2015 and 2018, it has 4 types, 3 subtypes and 3 modifiers. 92 cases were prospectively analysed, the standard treatment protocol was followed as per flowchart, only stable and borderline stable patients were included, functional outcome and recovery of these patients was assessed using modified Karlstrom and Olerud scoring after fracture union. Demographic data, duration of hospitalisation, number of procedures required for completion of treatment, functional outcomes and complications were collected and statistical analysis was done. ResultsStatistical Analysis showed significant difference between groups I and IV of conglomerated comprehensive classification in the number of days of hospitalisation and number of procedures with p value 0.006 and 0.018 respectively. ConclusionConglomerated comprehensive classification using prognostic factors and existing standard classifications enables better prognostication of these complex floating knee injuries. Identifing and addressing these factors and modifiers included in this classification system will surely improve the outcome. A multicentric study will validate this classifaction in a better way.

Randomised prospective comparison of intramedullary nailing V/S plating in distal tibial metaphyseal fractures

Background: Tibial fractures are the most common long bone fractures, while distal tibial fractures are even more complicated due to their proximity to the ankle and the close relationship with thin, soft tissue envelope and severe comminution. Objectives: To assess and compare fractures' functional outcomes in Group A (treated with plating) versus Group B (treated with intramedullary nailing). To assess the efficacy, advantages, and disadvantages of the treatment modalities and their complications. Materials and Methods: This is a comparative study done from October 2019 to March 2021 in the Department of Orthopaedics, Narayana general hospital, attached to Narayana Medical College, Nellore. In this study period total of 40 patients were taken for study as per inclusion criteria. The patients are randomized into two groups of 20 cases each. Group A treated with plating, and Group B was treated with intramedullary nailing. Results: In our study, good results were observed in Intramedullary nailing groups (51.43%) when compared with the plating group (40.3%). These differences were statically significant with a p-value (p

A review of the surgical management of distal humerus fractures and nonunions: From fixation to arthroplasty

Distal humeral fractures in adults are challenging injuries. They often require surgical intervention in form of internal fixation or total elbow arthroplasty which is being increasingly used in physiologically elderly patients with comminuted fractures. Careful preoperative evaluation including type of fracture, quality of bone, pre-existing conditions and functional demand help in deciding optimal treatment. CT scans including 2D and 3D reconstructions are almost mandatory in proper planning of the surgical treatment. In most cases with a healthy physiologically young patient, ORIF is the treatment of choice. Biomechanical studies have shown that parallel plating resists rotational deformity to a greater degree than 90/90 plating allowing supracondylar union. Accurate realignment of articular fragments and compression at the supracondylar area is key to the success of the internal fixation. Main cause of failure of fixation is the nonunion or malunion in the supracondylar area. The principles described by O'Driscoll et al. allow for rigid fixation of the distal articular fragments and compression at the supracondylar level which is vital to healing and the prevention of hardware failure, and nonunion. Olecranon osteotomy improves the expodure of distal humeral articular surface but has its own share of problems and should be avoided if possible. Irritation of ulnar nerve is a common complication so it should be isolated, kept under vision throughout and if necessary, transposed anteiriorly. Nonunion or malunion of supracondylar fractures can be treated by revision ORIF or total elbow arthroplasty (TEA). Supracondylar shortening, bone grafting and contracture release are important elements of treatment of nonunions.In unreconstructable distal humerus fractures, where open reduction and internal fixation is not possible due to the small size of the fragments, severe comminution and/or poor bone quality, TEA is the treatment of choice. Triceps can be left intact as the excision of fractured fragments usually provide enough space to carry out the operation. Sometimes, the decision to perform TEA is only made after exposing the fracture so the surgeon should be comfortable in performing TEA if ORIF is not possible; and necessary instruments and implants should be available on the shelf. In spite of satisfactory outcome, overall complication rate after TEA remains high and makes surgical efficiency and technical competence of utmost importance.

Hemihamate arthroplasties in pilon fractures: a modified approach and experience in 30 patients.

Hemihamate arthroplasty is an established method of managing difficult Pilon fractures of the proximal interphalangeal (PIP) joint. We present our experience in 30 patients, whose injuries were further complicated by severe comminution and late presentations. Several modifications were utilized, including preoperative distraction, use of smaller size grafts and functional release of collaterals. The average follow-up period was 28months (range 18 to 28). Postoperatively, the average range of flexion at the PIP joint improved from 30° (range 20° to 45°) preoperatively to 104° (90° to 110°) at the final follow-up. The average extension lag was 6° (0° to 20°). Five patients required secondary procedures and no patient had a recurrent dorsal dislocation. We propose these modifications in the use of hemihamate arthroplasty for the management of difficult PIP joint fractures.Level of evidence: IV.

Chronic type C3 distal humeral fracture associated with massive bone defects treated by open reduction and internal fixation with iliac crest autografts: a case report

BackgroundChronic intercondylar fractures of the distal humerus with massive bone defects and severe comminution in the metaphysis are rare and complex injuries that are challenging for surgeons to treat, as reconstructing the triangular structure of the distal humerus is difficult and may have a severe impact on functional outcomes, especially in young patients, for whom total elbow arthroplasty is usually not a suitable option due to significant impairment in upper limb strength. Here, we report a patient in such scenario who was young and active and was treated by structural iliac bone autografting and internal fixation.Case presentationA 26-year-old male patient experienced a major car accident and was diagnosed with an open fracture (Gustilo-Anderson type IIIB) of the right distal humerus with massive bone defects and severe intra-articular involvement, without neurovascular injuries or other associated injuries. Surgical debridement, negative pressure vacuum sealing drainage, and immobilization by braces were initially performed, and the wound was closed after 15 days. When the wound had finally healed and the soft tissue was in good condition without infection or effusion 45 days later, this young and active patient was diagnosed with a chronic type C3 distal humeral fracture associated with massive bone defects at the supracondylar level in both columns and severe comminution at the trochlear groove. We performed surgical debridement and arthrolysis around the fracture site, and then, we successfully reconstructed the triangular structure of the distal humerus using structural iliac crest autografts in both columns as well as in the defective trochlear groove. Finally, internal fixation via a parallel double-plate configuration was performed. Over a follow-up period of 3 years, the patient achieved almost full recovery of range of motion and an excellent functional score, without minor or major postoperative complications.ConclusionIn this study, we proposed a surgical reconstruction strategy for complex chronic distal humeral fractures associated with massive bone defects and severe articular involvement in young and active patients using metaphyseal shortening and structural iliac crest bone autografting together with open reduction and internal fixation via a parallel configuration.

Эффективность кровоснабжаемой и обычной костной пластики в достижении сращения при ложных суставах плечевой кости

Introduction Humeral fractures comprise from 5 % to 8 % of all fractures. Nonunion rate of humeral fractures is 5.5–8.7% with open reduction and internal fixation (ORIF) technique and 3–5.6 % with the use of locked intramedullary nailing technique. Its frequent causes are infection, poor vascularity, severe comminution or technical errors. Purpose Analysis of effectiveness of vascularized bone grafting and non-vascularized bone grafting in humeral nonunion and defect treatment. Material and methods Surgical management of 69 patients with humeral nonunion was performed from 2010 to 2017 at a single institution in two groups. Vascularized bone grafts were used in 41 cases and non-vascularized ones in 28 cases. X-rays and CT-scans of all the patients were studied. Results In the vascularized bone grafting group, union was achieved in 36 cases (88 %) after four to 6 months; in non-vascularized bone group union was achieved in 20 cases (71 %) after eight to 12 months. Conclusion In post-traumatic humeral nonunion and bone defects, after two or more failed surgical procedures performed previously, vascularized bone grafting yields more satisfactory results and reduces the total healing time.

Endosteal substitution with medial plate in the treatment of acute distal femur fracture (AO/OTA type A): surgical technique and case-series.

Distal Femur fractures account for 4- 6% of all femur fractures and can be challenging to treat. The aims of this study are: (1) to describe a surgical technique using a medial distal femur endosteal plate to augment the stability of standard lateral plate fixation; (2) to report the results of a case-series of acute distal femur fractures (AO/OTA Type A/ Vancouver periprosthetic fractures Type C) treated using this technique. This study describes the surgical steps for placement of a medial endosteal plate in combination with lateral locking plate in a cadaver model using fluoroscopy guidance. In addition, a retrospective database chart review for all patients with acute distal femur fractures treated with this technique over the last five years was performed. Exclusion criteria were involvement of type B and C distal femur intraarticular fractures, treatment with other endosteal substitutions (i.e., intramedullary nail fixation and fibula allograft), and treatment for non-union or pathological fractures. Twelve patients were identified with mean age of 75years. All patients were female and all of them were allowed full weight bearing and full range of motion exercises immediately post-operatively. The complete follow up for one patient was not available; however, the mean fracture union was confirmed at 3.8months in 10 of 12 patients. One patient had a failed construct at three months in the context of a periprosthetic fracture with a loose implant that was initially thought to be stable. One acute superficial surgical site infection was reported and healed uneventfully following debridement, primary closure, and antibiotic treatment. We believe that the placement of a medial endosteal plate can be a useful augment for standard lateral plate fixation in acute distal femur fractures, particularly in the context of severe comminution or poor bone quality. Uneventful healing was confirmed in 10 of 12 cases and no patients were restricted with regard to motion or weight bearing immediately post-operatively. Further studies with larger sample size would be required to fully assess this technique. IV. Therapeutic Study (Surgical technique and Cases-series).

The challenge of total knee arthroplasty periprosthetic fracture: a comprehensive review

Total knee arthroplasty (TKA) is a common procedure in orthopeadic surgery. It has been estimated that the incidence of periprosthetic fractures after TKA ranged between 0.3 to 2.5%, but increases to 38% when considering revision TKA.Patient-related risk factors for TKA periprosthetic fracture (TKAPF) include osteoporosis, age, female gender, revision arthroplasty and osteolysis. The choice of the most appropriate fixation device of TKAPF is a matter of debate, considering that locking plates and retrograde intramedullary are both associated with good outcomes in terms of fracture union and joint function.In case of prosthetic component instability, severe comminution or metaphyseal extension of the fracture that precludes fixation, failure of previous treatments, and severe malalignment of the TKA, revision TKA (RTKA) should be considered. Severe bone loss is another issue of concern, that might be addressed using both megaprosthesis or allograft-prosthesis composite. Considering the variability of the clinical scenario of TKAPF, a comprehensive approach based on both fracture fixation and/or revision arthroplashty is needed.

Shoulder arthroplasty for proximal humerus fractures in the elderly: The path from Neer to Grammont.

Shoulder replacement is indicated for the surgical treatment of proximal humeral fractures in elderly patients, when severe comminution and osteoporosis jeopardize the chances of success of any fixation technique. Two different implants are available for this purpose: anatomical hemiarthroplasty (HA) and reverse total shoulder arthroplasty (RTSA). HA for fractures was popularized by Charles Neer in the ‘50s and for several decades remained the only reliable implant for these injuries. However, many authors reported inconsistent results with HA as a consequence of the high rate of tuberosity and rotator cuff failure. In 1987, Paul Grammont designed the first successful RTSA, which was the end result of a long thought process on functional surgery of the shoulder. This implant was initially used to treat cuff tear arthropathy and shoulder pseudoparalysis, but indications have gradually expanded with time. Since RTSA does not rely on a functional cuff for shoulder elevation, it was felt that results in fractures could be improved by this prosthesis. In this study, the salient features of these implants are described to understand the rationale behind both approaches and highlight their pros and cons. Several clinical studies comparing HA vs RTSA for proximal humeral fractures have been published during the last two decades. A literature review is carried out to analyze and compare outcomes of both implants, analyzing clinical results, radiographic findings and complications. The final goal is to provide an overview of the different factors to consider for making a choice between these two prostheses.