Tubular Plate Research Articles

Double-Plating Of Proximal Humeral Fractures - Good Clinical Mid- To Longterm Results In Complex And Highly Unstable Fractures

Aim of this study was to evaluate an operative technique using an angular-stable lateral plate supported by a one-third tubular plate positioned anterior at the lesser tuberosity for unstable proximal humeral fractures.

Concomitant bilateral medial malleolus stress fracture: a case report and review of literature of an extremely rare injury

<p>Medial malleolus stress fractures are rare stress injuries and account for 4% of all the stress fractures. Bilateral medial malleolus stress fracture (MMSFs) is extremely rare with only five such cases reported in existing literature. We report an extremely rare injury pattern in the form of concomitant bilateral MMSF in a young military recruit who presented with severe pain in both his ankles for one month.<strong> </strong>A 20-year military recruit undergoing rigorous physical training presented to us with severe bilateral ankle pain of one month duration. Clinico-radiological examination revealed bilateral MMSFs. He was managed with open reduction and internal fixation using a one-third tubular plate in buttress mode. Patient was gradually rehabilitated and on one-year follow up, he is asymptomatic and performing all strenuous physical activities. Bilateral MMSFs are extremely rare injuries with only five such cases reported in existing medical literature and this is the fourth instance where bilateral MMSFs were diagnosed at the time of clinical presentation and managed simultaneously, in the same surgical setting.</p><p><strong> </strong></p>

Stacked 1/3 Tubular Plates for Fixation of Pediatric Forearm Fractures: A Biomechanical Study

IntroductionAmong operatively treated pediatric forearm fractures, many different fixation constructs are described. The goal of this study was to define the biomechanical properties of a double stacked 1/3 tubular plate construct used by the senior author for some fractures and to review available literature regarding the use of stacked plates.MethodsBiomechanical testing was performed by 4-point bending of three different plate constructs: 1/3 tubular plate, stacked 1/3 tubular plates, and 2.7 mm LC-DCP plate. Five test specimens were evaluated for each of the three plate constructs. From stress-strain curves, flexural stiffness (N/mm), force to cause plastic deformation (N), and force to cause 10° bend (N) were calculated and compared using standard t-test statistics.ResultsKey outcome parameter means (± SD) for the three plate constructs (1/3 tubular plate, stacked 1/3 tubular plates, and 2.7 mm LC-DCP plate) were reported respectively as follows: flexural stiffness (55.4 ± 3.5 N/mm, 131.7 ± 3.5 N/mm, 113.3 ± 12.1 N/mm), force to cause plastic deformation (113.6 ± 11.0 N, 242.1 ± 13.0 N, 192.2 ± 17.9 N), and force to cause a 10° bend (140.0 ± 8.4 N, 299.4 ± 14.1 N, 265.5 ± 21.2 N). Mean values of all three measures were significantly larger for the stacked 1/3 tubular plates than for the other plate constructs.ConclusionsThe stacked 1/3 tubular plate construct was biomechanically superior to the other plate constructs tested. Stacked plating significantly improved stiffness of the fracture fixation construct supporting the use of this technique in selected trauma cases.

Analysis of the Effect of Posterior Lateral Malleolus Plate Fixation on the Curative Effect and Mechanical Stability of Complex Ankle Fractures.

This paper investigates the effect of lateral and posterior 1/3 tubular plate bone plate fixation on the curative effect, wound healing, and mechanical stability of complex ankle fracture. 80 patients with complex ankle fractures treated in our hospital from January 2018 to July 2020 are selected for the study, and 80 patients are randomly divided into posterior fixation group and lateral fixation group according to the number table method, with 40 patients in each group. Patients in the posterior malleolus fixation group are treated with posterior lateral malleolus plate fixation, and patients in the lateral malleolus fixation group are treated with lateral malleolus plate fixation. The differences in efficacy, mechanical stability, wound healing, visual analog scale (VAS) pain score, and American Association of Foot and Ankle Surgery (AOFAS) ankle function are compared. The subjects are followed up for 6 months until January 2022. In patients with complex ankle fracture, 1/3 tubular plate osteoplate fixation in the posterior lateral malleolus can improve clinical efficacy and mechanical stability, which is helpful to promote incision healing and reduce the risk of complications. The 1/3 tubular plate osteoplate fixation in the posterior lateral malleolus is worthy of clinical promotion and application.

To determine functional and radiological outcome of various surgical modalities for treating malleolar fractures: Observational study

Purpose: To determine functional and radiological outcome of various surgical modalities for treating malleolar fractures. Materials and Methods: The present prospective observational study was conducted among 40 admitted in the department of Orthopedics, Sir T Hospital, Bhavnagar with Ankle Fracture. Standardized clinical and functional evaluation at 2 weeks (suture removal), 3 months and 6 months were done. Surgical technique used were open reduction and internal fixation of the lateral malleolus with semi tubular plate; medial malleolus with cancellous screws or tension band wiring ; posterior malleolus with cancellous screws. Radiological assessment of each patient was done. The outcome measures were calculated using the Karlsson and Peterson functional scoring system at 3 and 6 months postoperatively. Similarly radiological outcome was calculated using Kristenson’s Radiological criteria at 6 month. Results: In our series, most of the patient affected by the fracture belongs to age group of 41- 50 years which was16 (40%). The commonest mode of injury is fall (50%) and road traffic accident (32.5%). 23 were male patients (57%) and 17 were female patients (43%). 23 cases involved the right ankle and 17 cases involved the left ankle. The mean duration of stay was 4.5days. In the present study out of 40 patients, 5 patients presented with persistent swelling, 8 patients presented with residual pain while 9 patients presented with both of the complaints In our study of 40 cases, 29 cases (72.5%) achieved good results and 7 cases (17.5%) achieve fair results and 4 cases (10%) achieved poor results at 6 months follow up.1 patients develops superficial infection postoperatively and treated by dressing and antibiotics. Conclusion: Ankle fractures are among the most common injuries treated and these are best managed by open reduction and internal fixation. Anatomical reduction is essential in all Tri-malleolar fracture to achieve good functional outcome and to avoid complications like arthritis and loss of range of movements. Immobilization for 6 weeks doesn’t reduce the final functional outcome. Good physiotherapy is recommended for adequate range.

An Oblique Trans-Syndesmotic Screw to Augment Fixation of Distal Fibula Fractures: A Technique Guide

Category:Trauma; AnkleIntroduction/Purpose:A subset of patients with low, transverse fractures of the lateral malleolus are at increased risk of malreduction and late loss of reduction. In patients with poor bone quality and transverse or short oblique fractures at or distal to the tibiotalar joint, distal fixation is often inadequate with a single interfragmentary lag screw. Furthermore, these fractures are susceptible to malreduction by pre-contoured locking plates. To address this, a technique was developed to augment fixation of the distal fragment and decrease the likelihood of loss of reduction. The senior author's technique for this procedure, as well as indications for the technique and a few representative cases, are provided.Methods:This technique involves placement of an oblique tricortical or quadricortical screw from the distal fibula into the tibia in an distal-lateral to proximal-medial direction. The screw is placed either outside of or through the distal-most hole of a one-third tubular plate placed in a neutralization position. The screw trajectory is similar to that of a typical syndesmosis screw in the sagittal plane but is aimed proximally rather than parallel to the tibial plafond. The screw enters the tibia at Chaput's tubercle, just lateral to the joint. The indications for this technique are transverse and short oblique Danis-Weber B distal fibular fractures in which there is inadequate purchase between the plate and the distal fragment. While the purpose of this screw is not to stabilize the syndesmosis, it can be used with other augmentation techniques, such as trans-syndesmotic screws, in high-risk patients with osteoporosis and/or neuropathy.Results:This technique has been used for many years by the senior author. There have been no implant failures (e.g. broken screws) or major complications associated with this technique. Three representative cases demonstrate appropriate indications and outcomes for this technique. These include patients with significant neuropathy or osteoporosis who present with a particularly troublesome fracture pattern (transverse fibular fracture at or below the level of the tibiotalar joint). This screw, along with any other syndesmotic screws, is removed at 3-4 months according to the senior author's protocol.Conclusion:A distal oblique trans-syndesmotic screw can be used to supplement current fibular fracture fixation constructs. It is easy to place under fluoroscopic guidance and generally is removed after fracture union, similar to standard syndesmosis screws. The use of this screw helps prevent the malreduction that can potentially occur when treating transverse or short-oblique Weber B distal fibular fractures with a locking plate. In our series of patients at a large urban tertiary referral center, this technique has produced good outcomes with no reportable complications.

Design and Development of Low Cost Solar Powered Automobile System for Eco-friendly Transportation

Solar car can be categorized as a ‘green vehicle’ with zero carbon emission. With an aim to develop low cost eco-friendly commuting system, a prototype of solar car has been designed and developed in the College of Renewable Energy and Environmental Engineering, S.D. Agricultural University, S.K. Nagar, India. Engine and transmission system of anold petrol car were completely removed to refurbish it by Variable Drive Brushless Direct Current Motor (VBLDC), battery bank, control mechanism, sensors and solar modules. 48 V, 105 Ah Valve Regulated Lead Acid (VRLA) tubular thin plate battery bank was designed to operate a VBLDC motor of 1248 W capacity. 300 Wp polycrystalline solar array has been installed on the car rooftop to deliver synchronized power through charge controller. Results revealed thatin the course of insolation array of 5.0-6.00 kWh/m2, the solar modules were found to deliver consistent Voltage in between 71 V to 83 V, sufficient to charge battery bank reliably through the protection ofMaximum Power Point Tracker(MPPT) charge controller.Maximum instantaneous power values found were 224.84 W and 222.98 at corresponding voltage and current measurement of 49.2 V, 4.57 A and 48.9 V, 4.56A respectively. The battery bank took complete two days to achieve full charging status of 52.1 V when charged by solar array. Lab test showed that the car kept working for 2 hours and 57 minutes till the battery bank gets exhausted to 40.4 V. During field test the solar car performed for 1 hour and 50 minutes at an average speed of 30 km/h. Life Cycle Cost of solar car was found about five times less as compared to traditional petrol car.When compared with petrol car, average payback period and CO2 emission reduction were found to be about 02.32 years and 1679 kg/year.

Mini-Blade Plate to Obtain Length Across Lateral Malleolus Fractures: Surgical Technique and Biomechanical Evaluation.

Restoration of fibular length is the main determinant in preventing mal-union and early ankle arthritis in lateral malleolus fractures. A 1/3 tubular plate fashioned into a mini-blade plate can be used to distract the distal fragment and achieve length in a controlled fashion over time. The purpose of this study was to describe the surgical technique and perform a biomechanical comparison of the blade plate to a locking plate. A 1/3 tubular plate is fashioned into a 135° blade plate. Blades are seated into the lateral malleolus and a distally directed force is applied on the plate to obtain length.A lateral malleolus fracture was created in 20 cadaveric ankles. The distal fragment was fixed with either a blade plate (BP, n = 10) or a locking plate (LP, n = 10). A distally directed force was applied by an Instron machine and fracture distraction, maximal load and construct stiffness were measured and compared. The average maximal load was 262.06N compared to 255.52N for the BP and LP groups, respectively. The maximal distraction was 3.57mm compared to 4.57mm for the BP and LP groups, respectively. The loading pattern of the blade plate over time differed from that of a locking plate as the blades seat into bone. A 1/3 tubular mini-blade plate demonstrates biomechanical similarities in terms of load and distraction to the more expensive locking plate. We recommend using this technique for fractures with late presentation or with significant shortening. Level V-Mechanism-based reasoning.

A prospective study of functional and radiological outcome of open reduction and internal fixation of malleolar fracture and associated complications

Background: Malleolar fractures are a kind of regularly seen fractures in orthopedic department. As with all intra articular fractures, malleolar fractures necessitate anatomical reduction and stable internal fixation.Objective: To study functional and radiological outcome of open reduction and internal fixation of malleolar fracture and associated complications and to study role of early mobilization and graded weight bearing.Materials and Method: This study prospectively evaluated clinical, radiological and functional outcome of 39 patients of malleolar fracture treated with open reduction and internal fixation at Madras institute of orthopaedics and traumatology, Chennai from May 2016 to May 2017. After open reduction, patients were followed clinically and radio logically at 6 weeks, 3 months and 6 months. After operative procedure, functional and radiological outcome was assessed using Baird and Jackson score system.Results: Majority were Supination-External Rotation injuries 19 cases. Most common implant used for medial malleolus fracture was 3.5mm cortical screw (84.6%) cases and for lateral malleolus semi tubular plate (64.1%). According to Baird and Jackson scoring system our results were excellent in 6 cases (15.4%), good in 22 cases (56.4%), fair in 8 cases (20.5%), poor in 3 cases (7.7%). Good results were observed in maximum patients, one patient developed infection and two patients developed ankle stiffness.Conclusion: Open reduction and internal fixation of malleolar fracture is necessary to achieve anatomical reduction of the fracture fragments, ankle mortise congruity, restoration of the length of the fibula and restoration of syndesmotic integrity. We recommend to apply POP cast to prevent equines deformity and to start early range of motion of ankle as early as possible in cast after making dorsal window cut for 1 month.

A long-snouted late Eifelian arthrodire from Aragon (Spain)

Carolowilhelmina geognostica Carls, 1995 is a large arthrodire (Placodermi) from the Tortodus kockelianus Conodont Zone, late Eifelian, in the Eastern Iberian Cordillera in southern Aragón. The somewhat incomplete but articulated skull is preserved, showing a long tubular rostral plate, very small postnasal plates, low toothless inferognathals, and a small, slender and flat parasphenoid. Supraorbital and central sensory lines meet their antimeres at the midline of the skull, forming a straight double line. Lines along the ventral surface of the rostral plate probably belong to the suborbital branches of the infraorbital sensory lines. The combination of characters of Carolowilhelmina points to a separate taxonomic position of suprageneric rank. The specimen is from a pumilio bed of the unit E of the Moyuela Formation. It lived in pelagic environment with floats of algae bearing epiplankton.

Mobilization protocol and early postoperative weight-bearing in transyndesmal ankle fractures

Objective: To disseminate a rehabilitation protocol with early mobilization and ambulation, with no external supports, reducing the time until full weight-bearing and providing greater postoperative comfort. Methods: We prospectively assessed a series of 68 patients, with level of evidence IV, mean age of 33.3 years. We performed open reduction with ankle lateral approach (Kocher) and internal fixation with an interfragmentary compression screw and a one-third locked tubular plate for neutralization. All patients were subjected to a rehabilitation protocol with early mobilization and weight-bearing. Results: No fracture displacements were observed on the postoperative radiographic controls, neither loosening nor ruptures of implants. There was no need to change rehabilitation guidelines either due to pain or to other subjective limitation. Conclusion: We can state that early joint mobilization and controlled progressive support, with appropriate osteosynthesis, resulting in an early return to everyday activities, both work and sports ones. Level of Evidence IV; Therapeutic Studies; Case Series.

Study of distal tibial extra-articular fractures fixed with locking compression plate using MIPO technique

Background: Fractures of distal tibial metaphysis present a management challenge because of their inherent instability, scarcity of soft tissue, subcutaneous nature and poor vascularity of bone. MIPO techniques are advantageous because of limited soft tissue strapping, maintenance of the osteogenic fracture haematoma without interrupting vascular supply to the individual fracture fragments. Materials and Methods: This is a study of 20 patients of closed extra articular distal tibial fractures treated with anatomical LCP applied on antero-medial surface of lower end tibia with MIPO technique. Age was ranging from 20 to 60 yrs. 14 male and 6 female patients were there. 7 patients were having fibula fracture at same level of tibia fracture, they were fixed with DCP/ 1/3 tubular plate before fixing tibia. Results: AO/OTA type 43 A1 fractures were there in 15 patients. 4 pts. were having 43 A2 and one pt. was having 43 A3 type fracture. Average operation time was 80 mins. Average union time was 18.5 weeks. One pt. was having delayed union, one having superficial skin infection, one having 6* varus angulation and one having malleolar skin irritation. No pts. required second surgery of bone grafting. No implant failure. Conclusion: MIPO with LCP is a reliable and effective method of treatment for the distal tibial extra-articular fractures, preserving most of the osseous vascularity and fracture haematoma and thus providing a more biological repair. Using indirect reduction technique and small incision is technically demanding. Keywords: Anatomical LCP, Distal tibial fractures, MIPO.

Surgical Outcome of Closed Bi-Malleolar Fracture in adult, Bangladesh Perspective

Treating of ankle injuries is challenging due to swelling, risk of infection and skin necrosis in the postoperative period. After subside of swelling closed displaced bi-malleolar fracture in adult. Above the age of 18 years are treating with a one-third tubular plate for lateral malleolus and distal threated cancellous screw or tension band wiring for medial malleolar fracture, which can be evaluated clinically and radiologically. This multicenter, nonrandomized, experimental comparative study has been carried out in Rajshahi Medical College Hospital, Rajshahi and Sador Hospitals Joypurhat in Bangladesh. From June 2017 to December 2020 in this study. Total 30 patients were split into two groups: 'A,' consists of a one-third tubular plate and distal threaded cancellous screw and another group 'B' ORIF with Small DCP or one-third tubular plat with tension band wiring for medial malleolus. The mean surgery injury interval was 11.6 days. The mean hospital stay was 4.2 days. We have an assessed all patients with The Olerud C and Molander H functional score system. There were excellent practical results in 11 cases in the partially threaded vice with one-third tubular plate (73.3 percent), In 3 cases good (20%), in one case fair (6,7%) good. There were also very good functional results in 6 cases (40%), good (5%), fair in 4 cases in tension bowing wiring with one-third tubular plate (26.7 percent). The p-values were >0.05. We have classified all patients with the Danis-Weber classification system, operated Type A, B, and C categorized patients. We have used a syndesmotic screw in10 patients that have been removed at the end of 12 weeks. All implants were removed within 2.5 years in both groups. Both the operational techniques used in the study produce excellent union rates and functional results. The study was limited in samples small and lacked long-term follow-ups in both groups.

Less steam for more: Hybrid tubular plate heat exchangers the cleverer heating elements for falling film evaporators

Less steam for more: Hybrid tubular plate heat exchangers the cleverer heating elements for falling film evaporators

The effect of calcar femoral neck plating on vascularity of the femoral head and neck.

AimsSurgical treatment of young femoral neck fractures often requires an open approach to achieve an anatomical reduction. The application of a calcar plate has recently been described to aid in femoral neck fracture reduction and to augment fixation. However, application of a plate may potentially compromise the regional vascularity of the femoral head and neck. The purpose of this study was to investigate the effect of calcar femoral neck plating on the vascularity of the femoral head and neck.MethodsA Hueter approach and capsulotomy were performed bilaterally in six cadaveric hips. In the experimental group, a one-third tubular plate was secured to the inferomedial femoral neck at 6:00 on the clockface. The contralateral hip served as a control with surgical approach and capsulotomy without fixation. Pre- and post-contrast MRI was then performed to quantify signal intensity in the femoral head and neck. Qualitative assessment of the terminal arterial branches to the femoral head, specifically the inferior retinacular artery (IRA), was also performed.ResultsQuantitative MRI revealed a mean reduction of 1.8% (SD 3.1%) of arterial contribution in the femoral head and a mean reduction of 7.1% (SD 10.6%) in the femoral neck in the plating group compared to non-plated controls. Based on femoral head quadrant analysis, the largest mean decrease in arterial contribution was in the inferomedial quadrant (4.0%, SD 6.6%). No significant differences were found between control and experimental hips for any femoral neck or femoral head regions. The inferior retinaculum of Weitbrecht (containing the IRA) was directly visualized in six of 12 specimens. Qualitative MRI assessment confirmed IRA integrity in all specimens.ConclusionCalcar femoral neck plating at the 6:00 position on the clockface resulted in minimal decrease in femoral head and neck vascularity, and therefore it may be considered as an adjunct to laterally-based fixation for reduction and fixation of femoral neck fractures, especially in younger patients.Cite this article: Bone Jt Open 2021;2(8):611–617.

Provisional reduction plating in the treatment of ankle fractures: a technical trick

Reduction plating is a concept used to provisionally maintain reduction in the treatment of various fractures throughout the body. It is often used in challenging fracture patterns where the use of reduction clamps hinders placement of the definitive fixation construct. In this article, we present a technique for fixation of ankle fractures, in which a mini-fragment plate is used to keep provision reduction of the fracture, while the definitive plate is applied. This technique is particularly useful when using a posterolateral one-third tubular plate as your definitive construct. This study provides Level V evidence.

Syndesmotic diastasis and it’s relation to the functional outcome in ankle fractures

Ankle fractures are among the most common injury treated by orthopaedic surgeons. Syndesmotic injuries represent the severity of the ankle injuries. However, they are difficult to evaluate, have a lengthy recovery period, and may disrupt normal joint functioning if not appropriately treated. These ankle injuries are disastrous if not appropriately treated specially to athletes and those engaged in heavy work on irregular surfaces. Hence treating these ankle injuries are of utmost importance. The aim of this study was to assess the functional outcome in ankle fractures with syndesmotic diastasis and without syndesmotic diastasis. To provide guidelines for intra-operative assessment of syndesmotic stability. To find out the complications occurring in each group. This was a prospective observational study conducted in yenepoya medical college hospital from October 2017 to October 2020. In this study 42 patients were treated and each equally were divided into two groups with syndesmotic injury and without syndesmotic injury. Open reduction and internal fixation with locking / one third tubular plate with 3.5 system for lateral malleolus and 4 mm CC screws for medial malleolus for fractures without syndesmotic injury and fracture with syndesmotic injury additional 4mm screw was put, which was evaluated. Diagnosing the syndesmotic instability preoperatively wasn’t adequate. However when combined with intraoperative assessment by checking for translational movements and cottons test; it was found to be more reliable. Open reduction and anatomical fixation is required to obtain good results. A simple syndesmotic screw will suffice the job and the screw needs to be removed before weight-bearing in order to avoid screw breakage. To conclude, the functional outcome scores were lower in syndesmotic group. However, we need to assess the functional outcomes in a longer time frame to see if any statistically significant difference actually exists or not.

Surgical Treatment of Distal Tibiofibular Syndesmosis Injuries Using Open Reduction Internal Fixation by Plate and Screws: A Case Series and Literature Review

Treatment of distal tibiofibular syndesmosis injuries requires an early and accurate reduction to prevent poor outcomes. Screw fixation technique remains the gold standard for syndesmosis injuries despite the increasing popularity of suture button fixation. We report the cases of three patients with acute distal tibiofibular syndesmosis injuries treated by open reduction and internal fixation using a plate and two screws. The objective of this study was to describe a different syndesmosis fixation technique with a two holes one-third tubular plate and two screws, relate the radiologic findings and analyze the functional outcomes. Clinical and functional outcomes were assessed using the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale. Reduction of the syndesmosis was assessed radiographically by measuring the tibiofibular clear space, tibiofibular overlap, and the medial clear space at the final follow-up. Compared to preoperative values, postoperative values were improved with this method. Our findings suggest this new technique as a safe and reliable option to consider for the treatment of acute distal tibiofibular syndesmosis injuries. The main advantage is an optimal positioning of the screws on the lateral fibular cortex in the anteroposterior plan with an ideal space between them.

Double plating - surgical technique and good clinical results in complex and highly unstable proximal humeral fractures

IntroductionA stable fixation of highly unstable proximal humerus fractures remains challenging and complication rates, especially secondary varus dislocation, remains high. Different techniques of double plate osteosynthesis have been suggested for the treatment of complex proximal humeral fractures as they are well established for other fractures. The aim of this study was to evaluate an operative technique using an angular stable lateral plate supported by a one-third tubular plate positioned anteriorly at the lesser tuberosity for unstable proximal humeral fractures. Patients and methodsRetrospectively, patients treated with a double plate osteosynthesis were included between January 2014 and December 2017. Out of 31, 25 patients (80.6%) with an average age of 53.1 years ± 12.5 were available for follow-up. 60% of the patients were male. The clinical evaluation consisted of a physical examination and standardised questionnaire including subjective and objective shoulder scores like the Constant-Murley Shoulder Score, Simple Shoulder Score, and Subjective Shoulder Value. ResultsAfter a mean follow-up of 30.9 months (range, 12-76 months) eighteen patients (72%) had either excellent or good results regarding the Constant-Murley Shoulder Score with a mean value of 77 points ± 17. Average Simple Shoulder Score was 76% ± 0.2 and Subjective Shoulder Value 72% ± 0.2%. Mean NSA at time of follow-up 135° ± 13°. Nine patients had an implant-removal, five in combination with arthrolysis after a mean of 7.2 months. Three patients underwent surgery for secondary arthroplasty. The study shows a complication rate of 16%. No revision-surgery because of secondary varus dislocation was reported. DiscussionArthroplasty is the less favourable treatment for a younger, active cohort of patients with highly unstable proximal humeral fractures as results are not as good and options for revision are limited. Double plate osteosynthesis can be used in addition to calcar screws, bone graft augmentation, cement augmentation and additional free screws for more multidirectional stability and shows good clinical results despite a higher rate of avascular necrosis and high primary stability with comparable complication-rates to single plate osteosynthesis. It seems to be a valid alternative to primary fracture arthroplasty and can prevent secondary varus displacement.

The forgotten fragment: additional lesser tuberosity fixation of 4-part proximal humeral fractures-a biomechanical investigation.

Fractures of the proximal humerus are common. The most frequent surgical treatment option is open reduction and locking plate fixation. Multifragmentary fractures, including 3- and 4-part fractures, are especially challenging to treat because they correlate with an increased risk of fixation failure. In the past, several mechanisms of additional fixation were investigated, but none directly addressed the lesser tuberosity (LT). The goal of this study was to investigate the biomechanical impact of additional anterior fracture fixation in lateral locked plating (LLP) of 4-part proximal humeral fractures (PHFs). Twenty-seven fresh frozen human shoulder specimens (mean age, 80 years) with intact rotator cuffs (RCs) were randomized into 4 groups: 3-part PHF with LLP and RC cerclage (n = 6); 4-part PHF with LLP and RC cerclage as standard of care (n = 7); 4-part PHF with LLP, RC cerclage, and 2 anterior 3.5-mm cortical screws (n = 7); and 4-part PHF with LLP, RC cerclage, and additional anterior one-third tubular plate (additional anterior plating [AAP], n = 7). Static load of the RC was simulated with weights. A force-controlled cyclic loading test was performed with a servo-hydraulic testing machine, followed by load-to-failure testing. An optical motion capture system recorded humeral head range of motion. LLP of a 4-part PHF showed more humeral head motion than LLP of a 3-part PHF without fracture of the LT (P < .001). Fixing the LT to the humeral head with two 3.5-mm screws significantly reduced humeral head motion compared with LLP with RC cerclage alone (P < .006). Using AAP significantly increased the construct stiffness compared with the standard of care (P = .03). LLP of a 4-part PHF is biomechanically less stable than LLP of a 3-part PHF without fracture of the LT. Additional screw fixation of the LT in 4-part PHFs improves stability compared with LLP alone. In case of metaphyseal comminution, AAP is favorable from a biomechanical perspective.