Type C3 Fractures Research Articles

Analysis of the Сauses of the Development of Osteoarthrosis of the Shoulder Joint in Patients After Fractures of the Proximal Epimetaphysis of the Humerus

Summary. Posttraumatic (secondary) arthrosis of the shoulder joint, which develops as a result of fractures of the proximal epimetaphysis of the humerus, accounts for about 10% of all arthrosis cases of the shoulder joint, regardless of therapeutic tactics. Objective: to investigate the main causes of the development of post-traumatic arthrosis of the shoulder joint in patients with fractures of the proximal epimetaphysis of the humerus. Materials and Methods. The clinical group consisted of 295 patients with fractures of the proximal epitaphysis of the humerus, who from 2009 to 2020 were treated at the departments of the SI “Institute of Traumatology and Orthopedics of NAMS of Ukraine” (Kyiv). Of these, 55 (18.64%) were patients who had post-traumatic arthrosis of the shoulder joint. The age of the patients ranged from 27 to 68 years (mean age 42.7±9.5 years); men were 155 (52.5%), women 140 (47.5%). The presence of post-traumatic omarthrosis was determined in terms of 3 to 5 years after the fracture. All patients with post-traumatic osteoarthrosis of the shoulder joint, depending on the treatment, were divided into two groups: group A – patients after metal osteosynthesis of the proximal epimetaphysis of the humerus, group B – patients who underwent conservative treatment. Group A included 35 (63.6%) patients, group B – 20 (36.4%) patients. A general AS/ASIF classification was used to determine the type of a fracture. Conclusions. The highest number of cases of post-traumatic omarthrosis after conservative treatment was found in patients with type A1 fractures – 10.9% and A2 – 14.6%; after surgical treatment, post-traumatic omarthrosis was developed in patients with type C3 fractures – 12.6% and A3 – 14.6% (p≥0.05). The main reason for the development of post-traumatic omarthrosis is aseptic necrosis of the shoulder head – 61.8% (p≤0.05), which is more common in patients with type B and C fractures according to AO. The greatest impact on the development of omarthrosis in patients with fractures of the proximal epimetaphysis of the humerus is the load on the shoulder joint, both during rehabilitation and in daily life, and the presence of contracture in the shoulder joint.

Early fixation failure of locked plating in complex distal femoral fractures: Root causes analysis

Orthopaedic Trauma Association (OTA) C-type distal femoral fractures can be very challenging to treat effectively. While locked plating is widely used in the complex distal femoral fracture, failure of locked plate fixation is not uncommon. First, we tried to determine the risk factor related to early failure of multiplanar OTA C-type fracture in the distal femur after fixation with lateral locked plate. Second, we tried to provide a strategy for surgeons to prevent pitfalls of early failure in the complex distal femoral fractures treated with lateral locked plating. We retrospectively reviewed 44 adults with OTA C-type fractures of the distal femur treated with locked plate fixation between 2010 and 2016at Tri-Service General Hospital. Average length of follow-up was 27.6 months (range, 12-54 months). Univariate and multivariate logistic regression were used to determine the association of variables on early failure of fixation. A p-value < 0.05 in univariate and multivariate analyses were considered significant. There were six patients experiencing early failure, and the early failure rate was 13.6%. The risk factors associated with early failure of complex distal femoral fracture identified by univariate analysis included sagittal oblique fracture pattern, longer working length and post-operative sagittal malalignment (odds ratio [OR] and 95% confidence intervals [CI]: 90.00 (6.85-1183.33), 0.55 (0.31-0.98) and 8.63 (1.077-69.075) respectively). The multivariate analysis showed only sagittal oblique fracture pattern was associated with early failure [OR: 52.348 (3.06-895.23)]. Sagittal oblique fracture was more likely to result in early postoperative failure. Early recognition of the fracture pattern should be considered to avoid catastrophic results.

How do pilon fractures heal? An analysis of dual plating and bridging callus formation

Objectives1) To determine the effect of single versus dual plate metaphyseal fixation for pilon fractures on callus formation and reoperation rates, 2) to determine the effect of biomechanically matched versus unmatched fixation, and 3) to determine whether patient or surgical factors were independent predictors of bridging callus formation or need for reoperation. DesignRetrospective comparative study. SettingSingle level one trauma center. PatientsFifty patients with AO/OTA type C2 or C3 pilon fractures treated with plate fixation. InterventionInternal fixation with a plate and screw construct, with comparisons made between patients with single versus dual plate fixation, and patients treated with biomechanically matched or unmatched fixation. Main Outcome MeasurementsModified RUST (mRUST) scores at three and six months and reoperation rate. ResultsAt six months, mean mRUST scores were significantly lower in patients treated with dual metaphyseal plates compared to a single plate (8.7 vs 10.4, p=0.046) There were 15 open fractures; eight were treated with supplemental fixation, while seven were treated with single-column fixation. Open fracture (OR 51.05, p=0.008) was a risk factor for reoperation. Screw density between 0.4 and 0.5 was a protective factor against reoperation (OR 0.03, p=0.026). Biomechanically unmatched fixation did not affect mRUST scores or reoperation rates. ConclusionsPilon fractures treated with a single plate had more callus formation six months after surgery compared to those treated with dual plate fixation, and there was no difference in reoperation rates. Screw density between 0.4-0.5 was protective against reoperation. These data may serve as the basis of future work to determine the ideal fixation construct for the frequently comminuted metaphysis in pilon fractures. Further work is necessary to determine whether callus formation in these injuries is desirable. Level of EvidenceThree

Fracture Patterns and Comminution Zones in OTA/AO 34C Type Patellar Fractures.

To characterize the fracture patterns and comminution zones for complete articular (OTA/AO 34C type) patellar fractures, using a computed tomography mapping technique. Eighty-three OTA/AO 34C type patellar fractures were included. Images of patellar fractures were superimposed on a coronal template of the patella, created from a healthy right knee, to identify fracture patterns and comminution zones. Our analysis was based on 83 computed tomography images of patellar fractures, contributed by 69 male and 14 female patients (mean age, 52 years; range, 18-79 years), and included 13 type C1, 26 type C2 and 44 type C3 fractures. A transverse fracture, including both the medial and lateral facets, was the most common fracture pattern, identified in 92.8% of cases. In the C1 and C2 types, the fracture line affecting the medial and lateral joint surface was either transverse or oblique. In the C3 type, the transverse and vertical fracture line of the medial articular surface extended to the inferior pole of the patella, with transverse and oblique fractures lines on the lateral joint surface. In addition, a concentration of the fracture lines around the vertical ridge was observed. The patterns of fracture lines and comminution zones OTA/AO 34C type fractures were repeatable on the constructed maps. A transverse fracture line on the inferior pole which was observed in the C2 and C3 type fractures may be used for the modification of current classification systems to direct treatment.

Description and Reliability of the AOSpine Sacral Classification System.

Background:Several classification systems exist for sacral fractures; however, these systems are primarily descriptive, are not uniformly used, have not been validated, and have not been associated with a treatment algorithm or prognosis. The goal of the present study was to demonstrate the reliability of the AOSpine Sacral Classification System among a group of international spine and trauma surgeons.Methods:A total of 38 sacral fractures were reviewed independently by 18 surgeons selected from an expert panel of AOSpine and AOTrauma members. Each case was graded by each surgeon on 2 separate occasions, 4 weeks apart. Intrarater reproducibility and interrater agreement were analyzed with use of the kappa statistic (κ) for fracture severity (i.e., A, B, and C) and fracture subtype (e.g., A1, A2, and A3).Results:Seventeen reviewers were included in the final analysis, and a total of 1,292 assessments were performed (646 assessments performed twice). Overall intrarater reproducibility was excellent (κ = 0.83) for fracture severity and substantial (κ = 0.71) for all fracture subtypes. When comparing fracture severity, overall interrater agreement was substantial (κ = 0.75), with the highest agreement for type-A fractures (κ = 0.95) and the lowest for type-C fractures (κ = 0.70). Overall interrater agreement was moderate (κ = 0.58) when comparing fracture subtype, with the highest agreement seen for A2 subtypes (κ = 0.81) and the lowest for A1 subtypes (κ = 0.20).Conclusions:To our knowledge, the present study is the first to describe the reliability of the AOSpine Sacral Classification System among a worldwide group of expert spine and trauma surgeons, with substantial to excellent intrarater reproducibility and moderate to substantial interrater agreement for the majority of fracture subtypes. These results suggest that this classification system can be reliably applied to sacral injuries, providing an important step toward standardization of treatment.

Biomechanical Stability of Volar Plate Only Versus Addition of Dorsal Ulnar Pin Plate: A Dorsal Ulnar Fragment, C-3-Type, Distal Radius, Cadaver Fracture Model.

To determine if the addition of a dorsal ulnar pin plate provides improved stability characteristics in the management of intra-articular distal radius fractures with an associated dorsal ulnar fragment. OTA/AO type C3 fractures, with a dorsal ulnar fragment of one-third or one-half the width of the distal radius, were simulated in 9 matched pairs of fresh-frozen cadaveric arms randomized between fixed-angle volar plate only versus volar plate with addition of a dorsal ulnar pin plate. Prepared specimens were mounted in a custom load frame and loaded in extension with stepwise cyclic load increase. Dorsal plane interfragmentary displacements were compared between the 2 fixation constructs at 50-N and 100-N cyclic load. The addition of the dorsal ulnar pin plate significantly reduced interfragmentary displacements for the dorsal ulnar fragment at the 50 N load application, resulting in mean interfragmentary displacements of -0.1 ± 0.2 mm in comparison to -0.3 ± 0.2 mm with the volar plate-only construct. No other interfragmentary displacement comparisons were significant. No differences were found comparing the one-third and one-half size fragments. The addition of a dorsal ulnar pin plate improved stability characteristics with respect to the dorsal ulnar fragment. The addition of the dorsal ulnar pin plate, although statistically significant, improved displacement by less than 0.3 mm on average and thus may not prove to be important in clinical scenarios.

Deterioration of initially accepted radiological alignment of conservatively treated AO type-C distal radius fractures: mid-term outcome

Background and aimsIt still remains controversial how often the once-accepted radiological alignment of an AO type-C distal radius fracture deteriorates after conservative treatment, and to what extent this deterioration is perhaps associated with patient-rated outcome measures (PROms). Thus, we aimed to evaluate this radiological deterioration and its association with mid-term functional follow-up.Patients and methodsWe retrospectively reviewed 66 patients (mean age at fracture 53 years, SD 14.1, range 18–73, female 65%) with 68 C-type distal radius fractures at a mean of 6.7 years (SD 0.5 years, range 5.8–7.7 years) after primary closed reduction and cast immobilization. Radiographs of the wrists were taken and analysed for any radial shortening, dorsal tilt or step-off at the joint surface. Range of motion and grip strength were measured. In addition to the radiological result, primary outcome measures included Quick Disabilities of the Arm, Shoulder and Hand (QDash) and Patient-Rated Wrist Evaluation (PRWE).ResultsAt mid-term follow-up, an acceptable anatomical radiological result was seen in only 22 wrists (32%). Deterioration of the once-achieved and accepted primary alignment was seen in a majority of cases (68%). Radial shortening of ≥ 2 mm was found in 34 wrists (51%, mean 4 mm, range 2–8 mm), with no association with QDash (12.8 vs. 5.5, p = 0.22) or PRWE (9.1 vs. 5.7, p = 0.40). Only four patients (6%) showed step-off at the joint surface (mean 1.1 mm, range 0.5–2 mm). Twenty-two wrists (32%) showed dorsal tilt of ≥ 10° (five with volar tilt of 15°–25°), with no effect on QDash or PRWE (14.7 vs. 6.5, p = 0.241 and 10.1 vs. 5.8, p = 0.226). Altogether, patients with dorsal tilt, step-off or shortening did not show significantly worse QDash (10.3 vs. 5.7, p = 0.213) or PRWE (8.1 vs. 5.1, p = 0.126) versus those with none. Twenty-nine (43%) of the patients had deficits in range of motion (ROM), either in extension (39%), flexion (43%), supination (16%) or pronation (4%), or combinations of these. Worse extension was associated with worse QDash (15.9 vs. 5.0, p = 0.037), flexion deficit with worse PRWE (11.5 vs. 4.4, p = 0.005) and supination deficit with both QDash (21.7 vs. 6.8, p = 0.025) and PRWE (18.9 vs. 5.2, p = 0.007).ConclusionsThe initially accepted radiological alignment of AO type-C radius fractures deteriorated in a majority of cases during conservative treatment. However, this deterioration was fairly mild and showed no significant association with functional outcome. Restricted ROM showed some association with PROms.Level of evidenceIV.

Navigation-Assisted Posterior Open Reduction and Internal Fixation in a C-CLAMP Fashion for an Isolated C1 Fracture.

C1 fractures with an intact transverse ligament are usually treated conservatively. Patients who present with a progressive diastasis of bone fragments and a progressive articular subluxation mainly attributed to progressive lengthening of the transverse ligament (TAL) fibers can be treated with a C1 “C-clamp” fusion.A 75-year-old male who sustained a motor vehicle accident was neurologically intact. A computed tomography (CT) imaging demonstrated a Jefferson's type-C1 fracture with a slight lateral displacement of the C1 left lateral mass (LM) and a rotatory subluxation on the right. MRI showed an intact TAL and demonstrated an isolated rupture of the left alar ligament. Conservative treatment was chosen. Radiographic follow-up showed, at 3 months, progressive lateral mass displacement, most likely due to elongation of the TAL fibers; this was also associated with a persistent mechanical neck pain. For this reason, we performed a posterior reduction and internal fixation in a C-clamp fashion by placement of C1 lateral mass screws and posterior compression sparing the C1–2 joint. Using navigation, a 3.5-mm screw was inserted into the LM bilaterally. The screw heads were then connected with a rod and compression was applied before tightening. Postoperative CT scan demonstrated a satisfying reduction and further imaging will be made during the follow-up. The patient had a considerable relief of neck pain. Simple lateral mass fixation with C-clamp technique is a reasonable option in case of isolated C1 fractures in patients who have failed conservative management while preserving the range of motion (ROM) at the atlanto–axial joint. The link to the video can be found at: https://youtu.be/x8bsVwzCt_M .

Management of Complex Distal Femur Fractures: Comparative Study between Ilizarov External Fixation and Double Plating

Abstract Background In this prospective randomized clinical study, we report results of management of type C2 and C3 distal femur fractures by Ilizarov external fixator in comparison with double plating through separate medial and lateral approaches with a mean of 42.8 ± 6.84 weeks follow-up. Patients and Methods In this study we managed 30 cases with highly comminuted distal femoral fractures AO classification type C2 or C3. Fifteen cases were surgically managed by Ilizarov technique and the other fifteen cases were surgically managed by double plating technique. We compare between both group as regard clinical, radiological results and rate of complications. Results while using Knee society score, the results are the following: In Ilizarov group: 7 cases (46.67%) are excellent, 4 cases (26.67%) are good, 3 cases (20.00%) had fair results while 1 case (6.67%) had poor results. In internal fixation group, 8 cases (53.33%) had excellent results, 3cases (20%) had good results, 2 cases (13.33%) had fair results while 2 cases (13.33%) had poor results. Conclusion In fixation of complex distal femur fracture, both Ilizarov and double plating methods had no significant difference in clinical outcome by knee society score and in rate of complications. Ilizarov allow earlier weight bearing and less blood loss while double plating gives better ROM of knee joint and rapid radiological healing. Level of Evidence Level I Randomized controlled study.

Volar plate for intra-articular distal radius fracture. A prospective comparative study between elderly and young patients

IntroductionTreatment of the distal radius fracture in elderly remains controversial. The objective was to assess the outcomes of volar locking plate for displaced complete intra-articular distal radius fractures in elderly as compared to younger patients. HypothesisThe outcomes in elderly patients would be comparable with those in younger patients with a low rate of complications. Material and methodsNon-randomised prospective comparative study between 70 patients older than 65 years and 46 younger patients with AO type-C fractures. The main outcome was Disabilities Arm, Shoulder and Hand (DASH) score. Secondary variables were Patient-Rated Wrist Evaluation (PRWE) score, range of motion, Visual Analogue Scale (VAS) for pain, and grip strength. Radiological measurements were also performed. ResultsThe mean follow-up was 30.9 (range, 24–53) months. There were no significant differences in mean DASH, PRWE, VAS-pain, wrist motion or radiological parameters at final follow-up. Multivariate analysis showed that the functional outcomes were significantly influenced by baseline ulnar positivity greater than 3mm at baseline but not by age. DiscussionThe study hypothesis was confirmed. Surgical treatment with volar locking plate for displaced complete intra-articular fractures of the distal radius in elderly patients represents a safe and effective treatment alternative with similar early complication rate than in younger. Level of evidenceIII, cohort study.

Reverse Shoulder Arthroplasty Is Superior to Plate Fixation at 2 Years for Displaced Proximal Humeral Fractures in the Elderly

UpdateThis article was updated on May 20, 2020, because of a previous error. On page 482, in the legend for Figure 5, the sentence that had read “The Oxford Shoulder Score consists of 12 questions concerning shoulder pain, shoulder function, and activities of daily living and ranges from 12 points (worst) to 60 points (best)” now reads “The Oxford Shoulder Score consists of 12 questions concerning shoulder pain, shoulder function, and activities of daily living and ranges from 0 points (worst) to 48 points (best).”An erratum has been published: J Bone Joint Surg Am. 2020 June 17;102(12):e63.Background:Almost one-third of patients with proximal humeral fractures are treated surgically, and the number is increasing. When surgical treatment is chosen, there is sparse evidence on the optimum method. The DelPhi (Delta prosthesis-PHILOS plate) trial is a clinical trial comparing 2 surgical treatments. Our hypothesis was that reverse total shoulder arthroplasty (TSA) yields better clinical results compared with open reduction and internal fixation (ORIF) using an angular stable plate.Methods:The DelPhi trial is a randomized controlled trial comparing reverse TSA with ORIF for displaced proximal humeral fractures (OTA/AO types 11-B2 and 11-C2) in elderly patients (65 to 85 years of age). The primary outcome measure was the Constant score at a 2-year follow-up. The secondary outcome measures included the Oxford Shoulder Score and radiographic evaluation. Results were reported as the mean difference with 95% confidence interval (CI). The intention-to-treat principle was applied for crossover patients.Results:There were 124 patients included in the study. At 2 years, the mean Constant score was 68.0 points (95% CI, 63.7 to 72.4 points) for the reverse TSA group compared with 54.6 points (95% CI, 48.5 to 60.7 points) for the ORIF group, resulting in a significant mean difference of 13.4 points (95% CI, 6.2 to 20.6 points; p < 0.001) in favor of reverse TSA. When stratified for fracture classification, the mean score was 69.3 points (95% CI, 63.9 to 74.7 points) for the reverse TSA group and 50.6 points (95% CI, 41.9 to 59.2 points) for the ORIF group for type-C2 fractures, which yielded a significant mean difference of 18.7 points (95% CI, 9.3 to 28.2 points; p < 0.001). In the type-B2 fracture group, the mean score was 66.2 points (95% CI, 58.6 to 73.8 points) for the reverse TSA group and 58.5 points (95% CI, 49.6 to 67.4 points) for the ORIF group, resulting in a nonsignificant mean difference of 7.6 points (95% CI, −3.8 to 19.1 points; p = 0.19).Conclusions:At a 2-year follow-up, the data suggested an advantage of reverse TSA over ORIF in the treatment of displaced OTA/AO type-B2 and C2 proximal humeral fractures in elderly patients.Level of Evidence:Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Clinical results of volar locking plate fixation in radius distal fractures

Aim: This study aimed to evaluate the results of 41 surgically treated radius distal fracture patients. Average follow-up time was 9.8 months (6-19) and mean age was 44.04 (20-81). All patients treated surgically with volar locking plate between the dates October 2010 and November 2018. Material and Methods: There were 11 type A2 (26%), 10 type C2 (24%), 4 type A3 (9%), 3 type B1 (7%), 3 type B3 (8%), 6 type C3 (14%) and 4 type C1 (9%) fractures, respectively according to the AO Classification System. Stewart’s radiological criteria and range of motion were used in clinical and radiological evaluation. QuickDASH-T and Gartland-Werley scores were used for functional assessment.Results: Twenty-three patients (56%) had excellent, 14 patients (34%) had good and 4 patients (9%), respectively had moderate functional scores according to Gartland-Werley scoring scale. Thirty-four patients (83%) were excellent and 7 patients (17%) were good, respectively according to Stewart’s radiological criteria. Average QuickDASH-T score was 5.92 (0-22.7) and average Gartland-Werley score was 3.26 (0-13). Two patients suffered reflex sympathetic dystrophy as a complication.Conclusion: Volar locking plating in distal radius fractures is a reliable treatment method with successful results with careful preoperative planning, attentive surgical approach and systematical rehabilitation. It should be considered as treatment of choice for all but especially active and demanding patients.

Surgical stabilization of supracondylar fracture femur with locking compression plate: A Study on functional outcome

Fractures of the distal end of femur especially comminuted, intra- articular extension remain some of the most challenging fractures facing orthopaedic surgeons. The present study is justified for the fact that it will be one of the solutions for the age-old complications associated with the treatment of supracondylar fractures with traditional fixed angle plates and nails of, postoperative loss of reduction (varus collapse) and malalignment due to the inherent lack of rigidity and in some cases, eventual implant failure. After the proper preoperative evaluation fitness for surgery was obtained. The limb to be operated was shaved and prepared a day before scheduled surgery. Antibiotic was injected intravenously at least 10 minutes before surgery. Although various approaches like direct lateral-standard approach, minimally invasive lateral approach, medial approach and antero-lateral approach are described however in the current study direct lateral approach was used which is the standard one generally followed by the various previous studies. Out of 30 fractures, 19 fractures accounting for 63.3% were open fractures. Rest of the fractures were closed. In this study majority of the cases 19 (63.3%) were due to road traffic accidents seen in below 50 years of age. Long term results were rated using Neer’s rating system. Neer’s score was assigned for each patient after 24 to 36 weeks. Using this scale 16 cases (53.3%) shown excellent, 11 cases (36.7%) good and 3 cases (10%) poor result. Out of three varus malalignments two were of type C3 fracture and one type C2. Factors contributing to malalignment were severe comminution and improper reduction.

Results of plate fixation for humerus fractures in a large single-center cohort.

This study aims to describe the results of plate fixation in one of the largest single-center cohorts that employs plate fixation as the golden standard. Additionally, risk factors related to a negative outcome were identified. This was a retrospective cohort study of all patients treated for a humeral shaft fracture in a level-one trauma center between January 2010 and December 2017 with a mean follow-up of 1year. Plate fixation was performed in 102 patients with a humeral shaft fracture. The mean age was 50 (SD 20) years with 54.9% (n = 56) being male. Forty-eight percent (n = 48) had an AO type-A, 34.3% (n = 35) type-B, and 18.7% (n = 19) type-C fracture. Deep surgical site infections and non-union occurred in 1% (n = 1) and 3.9% (n = 4) of patients, respectively. Revision of the implant was performed in 15.7% (n = 16) mainly due to implant-related complaints. Only one patient developed radial nerve palsy after surgery. The median duration to radiological fracture healing and full-weight bearing was 18 (range 7-65) weeks and 14 (range 6-56) weeks, respectively. Risk factors for negative outcome included higher age, osteoporosis, open and higher AO class fractures, performing surgery during out-office hours, and the use of LCP 3.5-mm plate and an anterolateral approach. Plate fixation for humeral shaft fractures has low risks of complications. It should be emphasized that the complications can be further minimized with a greater surgical expertise and by refraining from performing a surgery during out-office hours.

Challenges of Plate Fixation for Vancouver Type-C fractures after a Well-fixed Hip Arthroplasty Femoral Stem.

The fixation of distal femoral fractures (Vancouver type-C fractures) following a well-fixed hip arthroplasty femoral stem has become a challenging issue for orthopedic surgeons due to the inter-prosthetic biomechanical effects such as negative, positive, and torsional strain. Surgeons have applied a range of constructs to overcome these difficulties. To minimize the risk of inter-prosthetic fracture between well-fixed femoral stem and lateral femoral plate, many surgeons prefer to fix these fractures by overlapping the lateral femoral plate over the tip of the well-fixed femoral stem or overlapping with the proximal femoral component along with soft tissues sparing techniques using long plates, while others prefer to separate (non-overlap) the palate from the femoral stem.

The "FraMo" System: A New Mini-Invasive Technique in the Treatment of Proximal Humerus Fractures.

Fractures of the proximal humerus are relatively common injuries in adults accounting for 5% of fractures. Nowadays the most common technique used is open reduction internal fixation with LCP plates. The risks associated with open reduction internal fixation had led us to develop and apply a "hybrid" system, which is based on external fixation and closed surgery principles. This system is capable of stabilize up to 4 fragment fractures on different planes while conferring a strong enough fixation to maintain fracture reduction while allowing the patient to perform passive and active movement since the first day following the surgery. Our study group started on November 2009 until December 2015 and consisted of 118 patients with a mean age of 68.84±10.52 years for females (76) and 65.62±12.56 for males (44). Patients were classified according to the AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma association) Classification. In a few patients we performed mini lateral accesses to allow reduction of the humeral head and greater tuberosity. Shoulder mobilization was initiated from the first day following surgery. The external fixator was removed at 5 weeks with successive check-ups at 3, 6, and 12 months. The majority of type B and type C1 fractures had almost a complete functional recovery. Patients also, especially in the elderly, reported a good quality of life without pain during any range of motion. Our group of patients, after removal of the apparatus at 5 weeks following the surgery, had a mean articular range of motion with active abduction of 90 degrees and about 100 degrees with passive abduction. Postoperative CS scores at 12 months follow-up was 75,47±8.02. In addition there was also significant (P<0.05) improvement between preoperative and postoperative visual analog scale measurements (in cm), 7.67±2.70 and 1.71±2.08, respectively. This technique has shown good functional results with reduced surgical risks and complications that are typical of open reduction surgical fixation of proximal humerus fractures, is quick in execution and minimally invasive. Given the very good results of the study of this new external fixation technique has shown to be a viable option for the treatment of proximal humerus fractures.

Effectiveness and complications of primary C-clamp stabilization or external fixation for unstable pelvic fractures

Background and purposeUnstable pelvic fractures frequently require emergency stabilization using a C-clamp or external (CC/EF) fixation. However, the effectiveness of this intervention and associated complications are still a matter of debate. Patients and methodsThe analysis used data available from the German Pelvic Trauma Registry to study general complications, infections and mortality after primary stabilization using CC/EF in 5,499 patients (n = 957 with vs n = 4,542 without). Furthermore, the subgroups with secondary surgery (n = 713 vs n = 1,695), and ilio-sacral screw implantation following C-clamp stabilization were evaluated (n = 24 vs n = 219). Calculated odds ratios were adjusted for potential confounders. ResultsPatients treated by CC/EF were younger (45 ± 20 vs 62 ± 24 years), had more C-type fractures (65% vs 28%), higher ISS (≥25 63% vs 20%) and displacement (≥3 mm 81% vs 41%), and more complex fractures (32% vs 5%). These features were independent risk factors for complications (p < 0.001). While mortality was reduced after CC/EF stabilization by 32% (OR 0.68 95%CI 0.49-0.95), the risk for general complications was slightly increased (OR 1.25 95% CI 1.02–1.53). In patients undergoing secondary surgery, CC/EF fixation had no influence on mortality, general complications or infections. Related to preceding C-clamp stabilization (OR 4.67 95% CI 1.06–20.64), the risk for infection increased from 3.2% to 20.8% in ilio-sacral screw fixation. InterpretationPrimary stabilization of unstable pelvic fractures with C-clamp or external fixation is associated with a decreased mortality and was not an independent risk factor for complications after secondary surgery. However, the risk for infection after ilio-sacral screw fixation increased almost 5-fold after C-clamp use.

Efficacy comparison between plate fixation with in situ reinforcing ulnar nerve and anterior transposition for humeral intercondylar fracture

Objective To investigate the clinical efficacy of plate fixation with in situ reinforcing ulnar nerve and anterior transposition by olecranon osteotomy approach in the treatment of type C2 and C3 humeral intercondylar fractures. Methods A retrospective case control study was conducted to analyze the clinical data of 23 patients with humeral intercondylar fractures admitted to the Affiliated Hospital of Hangzhou Normal University from June 2014 to January 2017. There were 17 males and six females, aged 19-56 years, with an average of 41.2 years. According to AO classification, there were 15 patients with type C2 and eight with type C3. All patients were treated with plate internal fixation by olecranon osteotomy approach. The patients were divided into anterior group (11 patients) which was treated with ulnar nerve release anterior transposition and in situ reinforcing group (12 patients) which was treated with ulnar nerve release in situ. The operation time, intraoperative blood loss, fracture healing time, elbow flexion and extension range, elbow joint Mayo score, and excellent and good rate were compared between the two groups. Postoperative complications were recorded. Results All patients were followed up for 15-43 months, with an average of 26.7 months. All patients had no need of blood transfusion. There were no significant differences between anterior group and in situ reinforcing group in operation time [(219.1±15.1)minutes vs. (211.2±17.1)minutes], intraoperative blood loss [(263.6±35.3)ml vs. (237.5±25.6)ml] and fracture healing time [(18.2±2.4)weeks vs. (18.9±1.7)weeks] (P>0.05). No significant differences were found between the two groups in elbow flexion [(120.3±7.1)° vs. (120.3±4.1)°], straightness [(3.7±2.7)° vs. (4.1±2.4)°], Mayo score [(89.09±9.17)points vs. (86.67±10.29)points] and excellent and good rate [ 91% (10/12) vs. 83% (10/12)] (P>0.05). After operation, no complications such as infection, heterotopic ossification, ulnar neuritis, elbow valgus deformity, or internal fixation failure occurred. Conclusions For humeral intercondylar fracture, the plate fixation with in situ reinforcing ulnar nerve and anterior transposition by olecranon osteotomy approach both have advantages such as small surgical trauma, strong fixation, fewer complications, satisfactory recovery of elbow function. Ulnar nerve anterior transposition or not does not affect the occurrence of ulnar neuritis, and both can obtain satisfactory clinical efficacy. Key words: Humeral fractures; Intra-articular fractures; Fracture fixation, internal; Ulnar nerve

Functional Outcomes of Revision Osteosynthesis after Failure of Surgical Treatment of Patellar Fractures.

Patellar fractures account for approximately 1% of all skeletal fractures. These fractures are rare; however, because of the crucial function of the patella in the extensor mechanism of the knee, they may lead to serious impairment. New data are revealing functional impairment remains common even with improved surgical techniques. The aim of this study was to assess the functional outcomes of patients after revision surgery in cases of secondary fracture dislocation or persistent articular incongruity. This study included 16 patients with a mean age of 51.8 years (range: 16-85 years) with a mean follow-up of 35.1 months. According to the AO/OTA classification, 15 patients had a C-type fracture, including 10 patients with C3 fracture. Thirteen patients were initially treated with tension band wiring via K-wires or cannulated screws. Revision surgery was performed because of persistent articular incongruity in five patients and secondary fracture dislocation or refracture in 11 patients. We analyzed pain (visual analog scale [0-10]), satisfaction, range of motion (ROM), Böstman's score, Lysholm's score, and knee injury and osteoarthritis outcome score (KOOS) after revision surgery and could extract follow-up data from 15 patients. Mean pain score at rest was 0.57 (range: 0-3.5) and on exertion 2.79 (range: 0-8). The measurement of the ROM of the affected knee compared with that of the opposite knee revealed complete extension. Mean flexion was 123 degrees, in the corresponding knee it was 136 degrees (p = 0.05). The mean postoperative Böstman's and Lysholm's scores were 25.11 (good, maximum: 30) and 78.67 (moderate, maximum: 100), respectively. KOOS was as follows: symptoms, 66.8 points; pain, 77.55 points; activity of daily living (ADL), 75.67 points; and quality of life, 56.25 points. The results of this study suggested that early revision surgery after failure of primary osteosynthesis with secondary anatomic reconstruction and good radiological results leads to satisfactory functional outcomes with persistent functional deficits.

Open Reduction and Internal Fixation of Distal Tibial Pilon Fractures.

Intra-articular fractures of the distal end of the tibia, more commonly referred to as pilon fractures, account for approximately 5% to 7% of all tibial fractures1,2. Type-C fractures present a unique surgical challenge: a total articular fracture contained within a vulnerable soft-tissue envelope. Treatment options include internal fixation3, external fixation with or without limited internal fixation4, and primary ankle arthrodesis2. The management, and particularly the timing, of surgery is often dictated by the patient's general state of health, soft-tissue condition, and fracture comminution as well as the experience of the surgeon. The surgical goals are to reconstruct the articular surface of the plafond, restore limb alignment, and protect the soft-tissue envelope. Since the publication of the seminal paper by Sirkin et al.5 in 1999, it has become orthopaedic orthodoxy to stage the surgery of pilon fractures, adopting a so-called span, scan, and plan approach. We more commonly operate early, and in a recently published retrospective review of 102 type-C pilon fractures in 99 patients, 73 patients (73 fractures; 71.6%) underwent primary internal fixation6. Outcomes were equivalent to the results of a staged protocol: 36 complications in 28 patients (28 fractures; 27.5%), with superficial (n = 9) and deep (n = 9) infection being the most common. Forty-one fractures (40.2%) required at least 1 additional operation, with removal of symptomatic metalwork being the primary indication (n = 30). No patient required an amputation. At a mean follow-up of 6 years, both the mean Foot and Ankle Disability Index (FADI) and mean Foot and Ankle Outcome Score (FAOS) were 76 (range, 0 to 100). Median patient satisfaction was 7 of 10. The results demonstrated a satisfactory outcome following primary internal fixation in appropriately selected patients. This instructional video outlines the surgical technique used. The key steps of the procedure are (1) preoperative planning with assessment of imaging and soft tissues; (2) application of a thigh tourniquet and placement of the patient predominantly in the supine position, unless the fracture configuration requires a prone position; (3) intraoperative use of a spanning external fixator; (4) careful exposure of the distal end of the tibia, dictated by the fracture configuration, with the anterolateral, anteromedial, and direct medial approaches most commonly used, elevating full-thickness tissue flaps wherever possible; (5) fracture reduction and fixation through a joint arthrotomy and fracture windows, allowing visualization of the articular margins, followed by initial Kirschner wire stabilization and definitive lag screw fixation; (6) application of a low-profile, locking or nonlocking plate in either buttress or bridging mode, joining the articular-metaphyseal block to the distal tibial diaphysis; (7) fixation of an associated fibular fracture, typically with intramedullary nailing and removal of the external fixator; (8) layered closure according to surgeon preference; and (9) postoperative protocol, consisting of a removable orthosis with a strict non-weight-bearing restriction for up to 3 months.