Stable Plate Fixation Research Articles

Comparative Outcomes of Elastic Stable Intramedullary Nailing vs. Plate Fixation in Pediatric Femoral Shaft Fractures. A Prospective Study.

Pediatric femoral fractures are common in emergency rooms, with treatment options varying by age. This study compares elastic stable intramedullary nailing (ESIN) and plate fixation for diaphyseal femoral fractures in children aged 5-10. Conducted at Al-Kindi Teaching Hospital, Baghdad, from December 2017 to December 2019, this prospective study included 32 children with closed transverse diaphyseal femoral fractures. Patients were divided into two groups: 16 treated with ESIN (Group 1) and 16 with plate fixation (Group 2). Criteria excluded comminuted, open, or pathological fractures. Group 1 had a mean age of 7.1 years and weight of 23.7 kg; Group 2 had a mean age of 7.8 years and weight of 30.9 kg. ESIN resulted in shorter operative times (58.4 minutes), earlier weight-bearing, and quicker fracture union (8.8 weeks) compared to plate fixation (76.3 minutes, 11.9 weeks). Blood loss was significantly less in Group 1 (32.8 ml) versus Group 2 (205.0 ml). No significant differences in wound healing or leg length discrepancies were observed. 1. Our study indicates a preference for Elastic Stable Intramedullary Nailing (ESIN) over plate fixation for pediatric femoral shaft fractures in children aged 5-10 years. 2. ESIN is associated with shorter operative times and faster commencement of weight-bearing, critical in pediatric recovery. 3. While ESIN is generally preferable, plate fixation may be better suited in certain clinical scenarios, emphasizing the importance of personalized treatment. 4. Based on our findings, ESIN is recommended for treating transverse diaphyseal femur fractures in the specified pediatric age group. 5. Recommends further studies, including randomized controlled trials, for a more comprehensive understanding of these treatments' long-term outcomes.

Valgising angular stable plate fixation in the treatment of multifragmentary proximal humeral fractures in elderly patients.

The frequency of proximal humeral fractures shows an increasing tendency, especially in the elderly, who are frequently affected by osteoporosis. The adequate treatment of complex, displaced fractures poses a serious challenge. Among surgical treatment options, osteosynthesis with an angular stable plate is preferred, however, the implant-related complication rate may be exceptionally high. In our present study, we report the short-term outcomes of our new method of valgising angular stable plate fixation which we use for multifragmentary, displaced proximal humeral fractures in elderly patients. We retrospectively evaluated the clinical and radiological outcomes of 52 patients (46 female and 6 male, age: 71.9 ± 9.6) who suffered dislocated three- or four-part fractures and underwent valgising angular stable plate fixation. Mean follow-up time was 17.3months, while the functional outcomes were as following: excellent in 26, good in 18, moderate in 5 and poor in 3 patients. The mean Constant-Murley Score was 82.5 ± 11.2. Functional outcomes only showed significant correlation (p = 0.031) with age and were proven unrelated to fracture type, BMI and known primary diseases. The cumulative complication rate was 9.6% and revision rate was 5.8%. Neurological deficit, pseudoarthrosis or avascular humeral head necrosis did not occur during the follow-up period. Valgising angular stable plate fixation that we apply for proximal humeral fractures provided favourable functional outcomes and a low postoperative complication rate due to the optimal head and plate placement. The method is especially effective for the treatment of displaced three- and four-part fractures with weakened, osteoporotic bone structure.

Standardized reduction and palmar plating of dorsally displaced distal radius fractures for safe and atraumatic reconstruction of the anatomy of the radius

Standardization of palmar plate osteosynthesis in order to consequently achieve physiologic anatomy of the distal radius end. Unstable dorsally displaced distal radius fractures or fractures that should be treated functionally. Severe intraarticular joint depression that cannot be reduced with either apalmar or arthroscopic assisted approach. Patient in supine position with the forearm supinated on arm table. Radiopalmar incision along the radial border of the flexor carpi radialis tendon. Detachment of the pronator quadratus muscle from radial to ulnar. Gross reduction with eventual correction of adorsal or radial shift. Placement of the angular stable plate and preliminary fixation with anonangular stable cortical screw in the long hole at the radius shaft. Fluoroscopic control of axial alignment in the anteroposterior view and of correct distal position of the plate in the lateral view under reduction condition. Placement of one or two angular stable screws at the shaft. Under subtle reduction with flexion, ulnar deviation and axial traction placement of two K‑wires via the holes at the distal edge of the plate. These wires mostly keep reduction maintained while reduction maneuver can be paused. Fluoroscopic control in two planes. Replacement of the wires by distal angular stable screws with the help of the wires as an orientation. In case of insufficient reduction, reduction maneuver can be repeated while the first angular stable screw is locked. Final fluoroscopic control in two planes and ulnar deviation, eventually also in tangential view and clinical testing for stability of the distal radioulnar joint. Wound closure only by skin suture. Application of asterile dressing and apalmar cast. Arm consequently in upright position and active and complete movement of fingers. Palmar below-elbow cast for 2weeks, then movement of wrist without exertion. After regular radiographic control 4-5weeks postoperatively, increase of axial load to normal and, if needed, physiotherapy. Clinical control for irritation of tendons by plate or screws after 1year and eventual plate removal.

Treatment of Soft Tissue Defects after Minimally Invasive Plate Osteosynthesis in Fractures of the Distal Tibia: Clinical Results after Reverse Sural Artery Flap.

Introduction: Distal tibial fractures make up approximately 3% to 10% of all tibial fractures or about 1% of lower extremity fractures. MIPO is an appropriate procedure and method to achieve stable metal plate fixation and osseointegration by minimizing soft tissue damage and vascular integrity at the fracture site. MIPO to the medial tibia during distal tibial fractures induces skin irritation due to the thickness of the metal plate, which causes discomfort and pain on the medial side of the distal leg, and if severe, complications such as infection and skin defect may occur. The reverse sural flap is a well-researched approach for covering defects in the lower third of the leg, ankle, and foot. Materials and Methods: Among 151 patients with distal tibia fractures who underwent minimally invasive metal plate fixation, soft tissue was injured due to postoperative complications. We treated 13 cases with necrosis and exposed metal plates by retrograde nasogastric artery flap surgery. For these patients, we collected obligatory patient records, radiological data, and wound photographs of the treatment results and complications of reconstructive surgery. Results: In all the cases, flap survival was confirmed at the final outpatient follow-up. The exposed area of the metal plate was well coated, and there was no plate failure due to complete necrosis. Three out of four women complained of aesthetic dissatisfaction because the volume of the tunnel through which the skin mirror passed and the skin plate itself were thick. In two cases, defatting was performed to reduce the thickness of the plate while removing the metal plate. Conclusions: Metal plate exposure after distal tibial fractures have been treated with minimally invasive metal plate fusion and can be successfully treated with retrograde nasogastric artery flaps, and several surgical techniques are used during flap surgery.

Effect of Anterior Tibial Closing Wedge Osteotomy on Coronal Tibial Alignment in Relation to Preoperative Medial Proximal Tibial Angle and Wedge Height.

The posterior tibial slope has been identified as an anatomic risk factor for anterior cruciate ligament insufficiency and reruptures after anterior cruciate ligament reconstruction. Anterior tibial closing wedge osteotomy for correction of sagittal plane deformities has the potential to cause an unintended change in coronal plane alignment. To evaluate the effects of anterior tibial closing wedge osteotomies for correction of posterior tibial slope on coronal plane alignment using an infratuberosity surgical approach and to identify predictive factors for a change in medial proximal tibial angle (MPTA). Case series; Level of evidence, 4. This study reports on retrospectively obtained data from radiographic measurements of 38 anterior tibial closing wedge osteotomies. All patients underwent revision anterior cruciate ligament reconstruction and had undergone ≥1 previous anterior cruciate ligament reconstruction. In all patients, an infratuberosity approach was used with angular stable plate fixation. Pre- and postoperative radiographs were examined retrospectively to detect changes in the sagittal and coronal plane alignment (posterior tibial slope and MPTA). A multivariate regression analysis was used to identify predictors for a change in MPTA. The study group consisted of 14 women and 24 men whose mean ± SD age at the index procedure was 31.6 ± 8.7 years (range, 17-51 years). Posterior tibial slope decreased significantly (by 7.2° ± 2.3°; P < .001) from 14.6° ± 2.0° preoperatively to 7.4° ± 2.1° postoperatively. MPTA decreased significantly by 1.3° ± 1.5° (P = .005) from pre- to postoperative measurement. Mean wedge height was 9.3 ± 1.1 mm. A lower preoperative MPTA (coefficient = 0.32; P = .017; 95% CI, 0.06-0.59) and larger wedge height (coefficient = 0.48; P = .029; 95% CI, 0.05-0.9) were significant predictive factors for a decrease in MPTA. Anterior tibial closing wedge osteotomy for posterior tibial slope reduction resulted in a slight but significant decrease of the MPTA in the coronal plane. These changes were dependent on the preoperative MPTA and the wedge height.

Double screw versus angular stable plate fixation of scaphoid waist nonunions in combination with intraoperativeextracorporeal shockwave therapy (ESWT).

Over the past years, different fixation techniques focused on rotational stability in order to increase stability and stimulate union rates. Additionally, extracorporeal shockwave therapy (ESWT) has gained importance in the treatment of delayed and nonunions. Purpose of this study was to compare the radiological and clinical outcome of two headless compression screws (HCS) and plate fixation in scaphoid nonunions, in combination with intraoperative high energy ESWT. Thirty-eight patients with scaphoid nonunions were treated by using a nonvascularized bone graft from the iliac crest and stabilization with either two HCS or a volar angular stable scaphoid plate. All patients received one ESWT session with 3000 impulses and energy flux per pulse of 0.41mJ/mm2 intraoperatively. Clinical assessment included range of motion (ROM), pain according to the Visual Analog Scale (VAS), grip strength, disability of the Arm Shoulder and Hand Score, Patient-Rated Wrist Evaluation Score, Michigan Hand Outcomes Questionnaire and modified Green O'Brien (Mayo) Wrist Score. To confirm union, a CT scan of the wrist was performed. Thirty-two patients returned for clinical and radiological examination. Out of these, 29 (91%) showed bony union. All patients treated with two HCS compared to 16 out of 19 (84%) patients treated by plate showed bony union on the CT scans. The difference was not statistically significant.However, at a mean follow-up interval of 34months, no significant differences could be found in ROM, pain, grip strength and patient-reported outcome measurements between the two HCS and plate group. Height-to-length ratio and capitolunate angle improved significantly in both groups compared to preoperative. Scaphoid nonunion stabilization by using two HCS or angular stable volar plate fixation and intraoperative ESWT results in comparable high union rates and good functional outcome. Due to the higher rate for a secondary intervention (plate removal), HCS might be preferable as first choice, whereas the scaphoid plate fixation should be reserved for recalcitrant (substantial bone loss, humpback deformity or failed prior surgical intervention) scaphoid nonunions.

Opening- and closing-wedge high tibial osteotomy are comparable and early full weight bearing is safe with angular stable plate fixation: a meta-analysis.

The purpose of this study was to establish the gold standard for surgical technique, fixation, and rehabilitation for HTO in patients with unicompartmental knee osteoarthritis. Medline, Embase, and SPORTDiscus databases were searched up to April 2022. Included were (1) randomized controlled trials (RCTs) comparing opening-wedge HTO (owHTO) and closing-wedge HTO (cwHTO), (2) biomechanical studies and prospective patient studies comparing biomechanical and clinical results for plate fixators, and (3) RCTs comparing an early versus delayed full-weight-bearing (FWB) protocol. The pooled results for the surgical technique showed no significant differences between owHTO and cwHTO for most PROMs on pain, activity, and risk for conversion to TKA. The cwHTO group showed a slightly better improvement in KOOS/WOMAC pain scores (4.51; 95% CI 1.18-7.85), and a significantly lower change in posterior tibial slope (p = 0.03). The pooled results for the fixation method showed the highest force at maximum failure for the Activmotion (Newclip Technics, France), Aescula (B. Braun Korea, Korea), 2nd generation Puddu (Arthrex Inc., USA), and TomoFix plate (Depuy Synthes, Switzerland). The pooled results for the rehabilitation protocol showed no significant differences between the early full-weight-bearing (FWB) group and the delayed FWB group for functional scores, complication rates, and delayed unions. Both owHTO and cwHTO reduced pain and improved knee function. Locking plate fixation should be used for owHTO. An early FWB protocol has proven to be safe in patients with small corrections, no hinge fractures, and non-smokers. Level II.

10-Year Survival Rates After High Tibial Osteotomy Using Angular Stable Internal Plate Fixation: Case Series With Subgroup Analysis of Outcomes After Combined Autologous Chondrocyte Implantation and High Tibial Osteotomy.

Background:Good-to-excellent midterm results after high tibial osteotomy (HTO) to treat medial compartment cartilage defects or osteoarthritis (OA) have been published, but little is known about long-term survival rates in terms of conversion to total knee arthroplasty (TKA) using angular stable internal plate fixation.Purpose:To determine TKA-free survival rates and functional and radiological outcomes at 10 years after HTO. A subgroup analysis of patients who underwent combined HTO and autologous cartilage implantation (ACI) was also performed.Study Design:Case series; Level of evidence, 4.Methods:Included were 125 patients with a mean follow-up of 9.90 ± 2.25 years; 90 patients underwent HTO for medial OA, and 35 patients underwent ACI and HTO for medial focal cartilage defects. Functional outcome measures included visual analog scale (VAS) for pain, Lysholm, International Knee Documentation Committee (IKDC), and Knee injury and Osteoarthritis Outcome Score (KOOS) subscales and KOOS4 (average of 4 KOOS subscales: Pain, Symptoms, Sport, and Quality of Life). Radiological outcomes included lateral distal femoral angle, medial proximal tibial angle, and joint line convergence angle.Results:Overall, 16 patients required conversion to TKA at a mean 86.75 ± 25.73 months (10-year survival rate, 87.2%). Only 2 patients in the HTO+ACI subgroup required a conversion to TKA (10-year survival rate, 94.3%). The complication rate for all patients was 8.8%. In both the HTO and HTO+ACI subgroups, VAS pain levels decreased and Lysholm scores increased significantly from pre- to postoperatively (P < .001). A higher preoperative Tegner score led to a significantly lower risk for conversion to TKA (P = .001), and a preoperative body mass index of ≥35 was associated with a significantly higher risk (P = .019), as was female sex (P = .046). Radiological parameters remained within physiological ranges. The postoperative joint line conversion angle did correlate with postoperative functional outcome but not with TKA conversion.Conclusion:Long-term results of HTO for medial compartment OA or cartilage defects with underlying varus deformity were good to excellent. In particular, patients who underwent HTO+ACI presented excellent long-term survival rates. HTO, therefore, delays or prevents TKA implantation, especially in young, active patients with medial compartment damage.

Lateral migration resistance of screw is essential in evaluating bone screw stability of plate fixation

Conventional evaluation of the stability of bone screws focuses on pullout strength, while neglecting lateral migration resistance. We measured pullout strength and lateral migration resistance of bone screws and determined how these characteristics relate to screw stability of locking plate (LP) and dynamic compression plate (DCP) fixation. Pullout strength and lateral migration resistance of individual bone screws with buttress, square, and triangular thread designs were evaluated in polyurethane foam blocks. The screw types with superior performance in each of these characteristics were selected. LP and DCP fixations were constructed using the selected screws and tested under cyclic craniocaudal and torsional loadings. Subsequently, the association between individual screws’ biomechanical characteristics and fixation stability when applied to plates was established. Screws with triangular threads had superior pullout strength, while screws with square threads demonstrated the highest lateral migration resistance; they were selected for LP and DCP fixations. LPs with square-threaded screws required a larger force and more cycles to trigger the same amount of displacement under both craniocaudal and torsional loadings. Screws with triangular and square threads showed no difference in DCP fixation stability under craniocaudal loading. However, under torsional loading, DCP fixation with triangular-threaded screws demonstrated superior fixation stability. Lateral migration resistance is the primary contributor to locking screw fixation stability when applied to an LP in resisting both craniocaudal and torsional loading. For compression screws applied to a DCP, lateral migration resistance and pullout strength work together to resist craniocaudal loading, while pullout strength is the primary contributor to the ability to resist torsional loading.

Surgical management of humeral shaft nonunions. Success of a consistent protocol over 17 years

IntroductionSurgical treatment of humeral shaft nonunions is characterized by variability of fixation methods, graft choices, and rates of union and iatrogenic radial nerve palsy. The aim of the current study is to evaluate the union rate of humeral shaft aseptic nonunions and the rate of postoperative complications following a consistent management protocol. Patients and methodsThis is a retrospective review of 41 consecutive adult patients (23 female and 18 male with a mean age of 42 years) with aseptic nonunions of the humeral shaft treated by the senior author in our institution over a 17-year period. Nonunions were located in the middle third of the diaphysis in 33 patients, in the distal third in 6, and in the proximal third in 2 patients. Comorbidities were present in 49% of patients and the most common were smoking in 27% and diabetes mellitus in 17% of patients. Patients were treated at an average of 24 months after their injury. Surgical protocol consisted of careful dissection of the radial nerve, debridement of the nonunion site, stable plate fixation and augmentation of local biology. ResultsThirty-eight patients had mean clinical and radiographic follow-up of 9.4 months. All 38 nonunions healed at a mean time of 3.5 months. There were no persistent nonunions and no failures of fixation. None of the 40 patients with an intact radial nerve preoperatively developed any signs of radial nerve compromise after surgery. Complications consisted of one superficial infection (2%) that resolved with oral antibiotics and one deep infection (2%) that required implant removal and debridement. The mean pain score on the visual analog scale was 0.7. Mean elbow range of motion was 125 degrees with a mean extension deficit of 5 degrees and mean flexion of 130 degrees. ConclusionsOur surgical protocol achieved consistent healing of nonunions of the humeral shaft with a low complication rate and no iatrogenic radial nerve palsy, even in long-standing nonunions in patients with comorbidities.

Results of revision intramedullary nailing with and without auxillary plate in aseptic trochanteric and subtrochanteric nonunion

PurposeAim of this study was to investigate whether limited open auxiliary angle stable plate fixation has an effect on functional and radiologic outcomes one year after revision intramedullary nailing in aseptic trochanteric and subtrochanteric fracture nonunion.MethodsIn a retrospective analysis, surgically revised aseptic trochanteric and subtrochanteric nonunion was evaluated in a total of 190 consecutive patients ranging from 18 to 94 years between 12/2005 and 10/2018.ResultsOne year after revision intramedullary nailing, nonunion healing was assessed in 129 out of 136 patients (95%) in group 1 without auxiliary plate fixation and in 51 out of 54 patients (94%) in group 2 with auxiliary plating (p = 0.23). In group 1, range of motion (ROM) was unrestricted in 88 patients and still restricted in 48 patients. In group 2, ROM was free in 34 patients and restricted in 20 patients (p = 0.25). The mean Lower Extremity Functional Scale (LEFS) was 56 points in group 1 and 55 points in group 2 (p = 0.55).ConclusionThis study did not demonstrate significant differences in functional and radiologic outcomes following revision intramedullary nailing of aseptic trochanteric and subtrochanteric fracture nonunion. Limited open auxiliary plate fixation might be a reasonable option especially in cases of relevant varus axis deviation and comminuted or atypical fracture configurations, regardless of patients’ age.Retrospectively registered with the German Clinical Trials Register (01/25/2021; ID: DRKS00024112).

Radiographic parameter(s) influencing functional outcomes following angular stable plate fixation of proximal humeral fractures

PurposeRadiographic parameters which correlate with poor clinical outcome after proximal humeral fractures could be helpful indicators to answer the question which patients should be followed up closer. Moreover, during surgery, radiographic parameters correlating with unfavourable outcome should be avoided. The primary aim of the study was to compare radiographic measurements between the injured and the contralateral, uninjured shoulder. The secondary aim was to correlate these radiographic parameters with post-operative shoulder function.MethodsFifty-eight patients (age: 55.6 ± 14.4 years, age at surgery) following angular stable plate fixation of a proximal humeral fracture (2-part fractures according to Neer: 24, 3-part: 25, 4-part: 9) were included in this retrospective cohort study. All patients were followed up at least six years (7.9 ± 1.4 after surgical intervention). During follow-up examination, the Constant score (CS) was assessed, and radiographs of both shoulders were taken. Radiographs were analyzed regarding lateral humeral offset, distance between tuberculum and head apex, head diameter, head height, perpendicular height, perpendicular center, vertical height, and angles between head and humeral shaft (CCD and HSA). These parameters were compared between the injured and uninjured shoulder. The cohort was divided in two groups: patients with a CS category of excellent/good and satisfying/worse. Both groups were tested regarding differences of demographic and radiographic parameters.ResultsThe distance between tuberculum and head apex (2.6 ± 3.4 mm vs. 4.3 ± 2.1 mm; p = 0.0017), the CCD (123.1 ± 12.9° vs. 130.1 ± 7.3°; p = 0.0005), and the HSA (33.1 ± 12.8° vs. 40.1 ± 7.3°; p = 0.0066) were significantly smaller on the treated shoulder compared to the uninjured side. Patients reached a Constant score of 80.2 ± 17.4 (95% CI 75.6–84.8) points. Regarding outcome categories of the Constant score, 46 patients had a good to excellent outcome, and 12 patients had a satisfying or bad outcome. The comparison of these groups revealed that patients with inferior outcome in the long-term follow-up were older, female, had a more complex fracture type (AO classification), smaller lateral humeral offset, smaller head diameter and height, lower perpendicular height, and lower CCD and HSA angles.ConclusionIf the abovementioned parameters cannot be restored sufficiently during surgery, (reversed) shoulder arthroplasty might be a better solution to reach good post-operative outcome. Moreover, patients presenting these radiographic characteristics in the follow-up, older patients, and patients with a more complex fracture type should be followed up closer to possibly prevent poor shoulder function.Trial registration: 83 250/2011BO2

Supplemental cerclage wiring in angle stable plate fixation of distal tibial spiral fractures enables immediate post-operative full weight-bearing: a biomechanical analysis

PurposeDistal tibial fractures generally require post-operative weight-bearing restrictions. Especially geriatric patients are unable to follow these recommendations. To increase post-operative implant stability and enable early weight-bearing, augmentation of the primary osteosynthesis by cerclage is desirable. The purpose of this study was to identify the stabilizing effects of a supplemental cable cerclage following plate fixation of distal tibial spiral fractures compared to solitary plate osteosynthesis.MethodsIn eight synthetic tibiae, a reproducible spiral fracture (AO/OTA 42-A1.1c) was stabilized by angle stable plate fixation. Each specimen was statically loaded under combined axial and torsional loads to simulate partial (200 N, 2 Nm) and full (750 N, 7 Nm) weight-bearing. Tests were repeated with supplemental cable cerclage looped around the fracture zone. In a subsequent stepwise increased dynamic load scenario, construct stiffness and interfragmentary movements were analyzed.ResultsWith supplemental cable cerclage, construct stiffness almost tripled compared to solitary plate osteosynthesis (2882 ± 739 N/mm vs. 983 ± 355 N/mm; p < 0.001). Under full weight-bearing static loads, a supplemental cerclage revealed reduced axial (− 55%; p = 0.001) and shear movement (− 83%; p < 0.001), and also lowered shear movement (− 42%; p = 0.001) compared to a solitary plate under partial weight-bearing. Under dynamic loads supplemental cerclage significantly reduced axial (p = 0.005) as well as shear movements (p < 0.001).ConclusionSupplemental cable cerclage significantly increases fixation stiffness and reduces shear movement in distal tibial spiral fractures. This stabilizing effect enables from a biomechanical point of view immediate mobilization without any weight-bearing restrictions, which may improve the quality of care of orthopedic patients and may trigger a change towards early weight-bearing regimes, especially geriatric patients would benefit from.

Radioskapholunäre Arthrodese mit Entfernung des distalen Skaphoidpols von palmar

Radioscapholunate (RSL) arthrodesis with distal scaphoidectomy using an angular stable plate and palmar access in post-traumatic or degenerative osteoarthritis limited to the radiocarpal joint. Osteoarthritis limited to the radiocarpal joint with intact mediocarpal joint after malunited intra-articular distal radius fractures, rheumatoid osteoarthritis, scapholunate advanced collapse (SLAC) up to stageII. Mediocarpal osteoarthritis, poor patient compliance, SLAC from stageIII, osteitis. The palmar RSL arthrodesis is performed using the palmar approach between the flexor carpi radialis tendon and the radial artery. After releasing the pronator quadratus muscle, alongitudinal capsulotomy is performed and the radiocarpal joint is inspected. After correction of avolar or dorsal intercalated segmental instability of the lunate, the lunate is temporarily fixed to the scaphoid using aK-wire. The distal quarter of the scaphoid and the palmar rim of the distal radius is resected and the cartilage between the scaphoid, lunate and distal radius is removed. The scaphoid and lunate are temporarily fixed to the distal radius using K‑wires. Under image intensifier control the angular stable low-profile plate (e.g., volar 2.5 Trilock RSL Fusion plate [Medartis® Aptus® Basel, Switzerland]) is fixed to the distal radius in the long-leg hole. The scaphoid and lunate are fixed distally with two screws each. The carpus is pushed distally using aCodeman distractor and the cancellous bone graft is impacted. Finally, the shaft is fixed with angular stable screws. Immobilization using aplaster cast or thermoplastic short-arm orthosis for 5weeks. After 2weeks, the orthosis can be removed during hand therapy with active wrist and finger exercises. Normal activities permitted after 12 weeks. Palmar RSL arthrodesis and distal scaphoidectomy using angular stable plate fixation shows ahigh union rate and pain relief while maintaining good residual mobility of the wrist.

Open Reduction and Internal Fixation of Posterior Malleolus Fractures via a Posteromedial Approach

Ankle fractures with a posterior malleolus component are complex injuries. The most commonly used operative methods include indirect reduction via a percutaneous anterior approach and direct reduction via a posterolateral approach. For large posterior malleolus fractures with medial extension, direct reduction via a posteromedial approach is an alternative operative option. The authors hypothesized that fixation of large posterior malleolus fractures via a posteromedial approach results in anatomic reduction and stable plate fixation. From 2008 to 2015, 22 (9.0%) of 244 consecutive operative ankle fractures were identified as posterior malleolus fractures treated using a posteromedial approach. Patient charts were retrospectively reviewed for demographics, operative details, follow-up time, and any postoperative complications. Postoperative radiographs were reviewed to ensure that anatomic reduction and stable fixation was maintained. Sixteen (72.7%) of 22 patients were female, and the average age at the time of surgery was 54.1 years (range, 26-86 years). The average follow-up time was 13.0 months (range, 2.0-41.4 months). Twenty-one (95.5%) of 22 patients healed on a radiographic and clinical basis. There was an 18.2% (4 of 22) postoperative complication rate: 1 patient had a nonunion, 1 patient had cellulitis, 1 patient had osteomyelitis involving the fibula, and 1 patient had symptomatic heterotopic ossification. Open reduction and internal fixation of posterior malleolus fractures via a posteromedial approach achieved anatomic reduction, stable plate fixation, and complete healing in all but 1 patient. This study demonstrates that the posteromedial approach is a reasonable alternative to other more commonly used methods for treating these fractures. [Orthopedics. 2020;43(3):e166-e170.].

Mid-term results after proximal humeral fractures following angular stable plate fixation in elderly patients\u2014which scores can be evaluated by a telephone-based assessment?

BackgroundThe aim was to evaluate postsurgical outcome in elderly patients (> 70 years) after open reduction and internal fixation (ORIF) of proximal humeral fractures and compare the test-retest agreement of scores which are frequently used to assess the outcome of upper extremity disorders.MethodsNinety patients (78.1 ± 5.2 years) with a minimum follow-up of 2 years (3.7 ± 0.9 years) following angular stable plate fixation of a proximal humeral fracture (2-part: 34, 3-part: 41, 4-part: 12) were enrolled. Two telephone-based interviews assessed Disabilities of the Arm, Shoulder and Hand Score (DASH), Oxford Shoulder Score (OSS), and Constant Score adjusted for interview assessment (CS) by two independent interviewers. Correlations, Bland-Altman analyses, Cross tabulation, and weighted Kappa measure of agreement (k) were calculated to assess differences and the test-retest agreement between the categories of each score.ResultsIn the first and second interview, we could state fair outcomes: CS 91 (range 40–100) and 65.5 (23–86), DASH 12.5 (0–64.2) and 18.3 (0–66.7), and OSS 58 (33–60) and 55 (25–60) points.The test-retest correlations were r = 0.67, r = 0.77, and r = 0.71 for CS, DASH, and OSS. Bland-Altman analyses showed absolute mean individual score differences of − 22.3, 4.9, and − 3.0 for CS, DASH, and OSS. Limits of agreement represented possible differences of 21.6%, 15.5%, and 9.0% of CS, DASH, and OSS. The category agreements were medium to high: CS 55.9% (k = 0.08), DASH 87.2% (k = 0.62), and OSS 99.3% (k = 0.74).ConclusionPatients showed good subjective outcomes. The test-retest agreement of the interview-adjusted CS was low, but telephone-based assessment of OSS and DASH present as an alternative to collect outcomes in elderly patients.Trial registration(250/2011BO2).

Minimally invasive plate osteosynthesis in midshaft clavicular fracture in adults

Background Clavicle fractures are common injuries in adults, accounting for 5–12% of all fractures and 44% of all shoulder fractures. Fracture of the middle third is the most common fracture in both children and adults. It is ∼80% of clavicle fractures; proximal and distal segments are secured by ligamentous and muscular attachments. Poor outcomes from conservative treatment, including nonunion, malunion, or shortening of the clavicle in displaced or comminuted fractures, have prompted a shift in treatment to surgery. There has been a trend toward operative treatment of clavicle midshaft fractures. There are various methods for treating clavicle midshaft fractures, such as intramedullary K-wires or elastic stable intramedullary nailing and plate fixation. Minimally invasive percutaneous plate osteosynthesis technique may be a good alternative as it has been proven in other long bones. Objective This study is performed to address the technique of percutaneous plating and to evaluate the radiographic and clinical outcomes in midshaft fractures of the clavicle in adults treated with minimally invasive plate osteosynthesis (MIPO). Patients and methods From December 2015 to November 2017, this prospective case series study was done at Al Azhar University Hospitals. In our study, we present the outcomes of 17 patients (12 men and five women) with acute midshaft clavicular fractures who were treated with the MIPO technique with 3.5-mm superior reconstruction plates. The patients had a mean age of 27.76 years (range, 16–45 years). The left arm was affected in nine patients the right arm in eight patients. The fractures were classified using the Robinson classification system: 10 were type 2B1 and seven were type 2B2. Results Fracture union was obtained in all patients at a mean of 11.35±1.90 weeks (range, 8–15 weeks). No delayed unions or nonunions were observed. There were no major complications such as infections, plate breakages, or neurovascular injuries. All of the patients obtained satisfactory shoulder functions. The mean Constant score was 97.47±2.45 (range, 93–100), and the mean Disability of the Arm, Shoulder, and Hand score was 1.29±1.93 (range, 0–5) at the last control visit. Conclusion This study demonstrated that the MIPO procedure that uses superior 3.5-mm reconstruction plates for midshaft clavicular fractures can be a reproducible procedure and an alternative to conventional operative methods. In addition, satisfactory clinical and radiologic outcomes were obtained without serious complications. This technique can provide excellent biological healing and optimal stabilization strength. Level of evidence Level IV, case series, treatment study.

Conical coupling angular stable plate fixation: a retrospective study.

Backgrounds.Conical coupling represents an alternative to screw coupling on angular stable plate fixation. Aims of the present study was to evaluate clinical effectiveness and ease of plate removal of conical coupling locking plates into different scenario regarding quality of bone, type of fracture and operative technique.Methods.From May 2013 to December 2017, 198 patients with 206 fractures underwent open reduction and internal fixation with conical locking plate. In most cases fixation involved wrist (38%) and clavicle (24%) fractures but a varied type of fractures and bone were included in the study.Results.Ten complications related to plate fixation were observed (5,1%). Two case of intra-articular positioning of screws of wrist plate. One case of loss of reduction and breakage of wrist plate due to an inappropriate proximal fracture fixation. Five cases of complications involved clavicle fixation: three cases of non-union, one case of peri-implant fracture, one screw loosening. One non-union of distal tibial fracture, one non-union in olecranon fracture were finally observed. Thirty-four patients that have symptoms that could be traceable to the implants in-situ underwent plate removal. No complications were observed during surgical plates removal. Conical coupling angular stability plate represents an actractive alternative to threaded angular stability plate. Bush titanium insert, eliminating the problems of cold welding and cross-threading, simplifies surgical screws and plate removal

The Initial Modelling of Hybrid Plating For Internal Fixation Construct by Using 3-D Bone Model

The development of locking plate design provides benefits especially for more stable plate fixation in bone and allows better fracture joint development. Hybrid locking plate modelling as fixation on femur fracture by using a real bone model were investigated. Internal fixation modelling were successfully perfomed on ANSYS v.14.5 with the geometry of femur as a 3D bone model which was obtained from CT-scan process. The configuration of screw bone mounting with the N-L-N-L L-N-L-N pattern filled 8 holes in the locking plate. The mounting of bone screws in the fixation process induced the contact areas as the origin of stress development. It is worked as the support of the locking plate that has been locked with locking screw and it is expected to maintain a stable position of the femur bone on its position. The low stress on femur bone were obtained which means that the bone was not much sufferedd due to applied load and may also affect the bone healing process. The use of hybrid plating is expected to guarantee a fixed fixation condition so that the bone healing process by callus formation between broken bones can take place continuously.

Patellar fractures

Patellar fractures are arelatively rare entity with an prevalence of 1%. Preoperative computed tomography has gained asignificant role as adiagnostic tool for patellar fractures in recent years. It enables an exact assessment of the fracture and helps in the decision making for the correct treatment procedure. Therapeutically, the armamentarium was supplemented by angle stable plate fixation, which potentially enables abetter reconstruction of the patella than the conventional tension band fixation. In this context, the results of angle stable plate fixation are promising in terms of functional outcome and lower complication rates. The proven tension band fixation using K‑wires or cannulated screws continues to be widespread in clinical practice and retains significance for simple patellar fractures. The use of polyethylene thread material instead of steel wire has shown advantages in biomechanical studies but the clinical application is more restrained.