Type C3 Fractures Research Articles

Comment on Tong et al.: Two-stage procedure protocol for minimally invasive plate osteosynthesis technique in the treatment of the complex pilon fracture

Dear Editor, We have read with great interest the article entitled “Two-stage procedure protocol for minimally invasive plate osteosynthesis technique in the treatment of the complex pilon fracture” by Tong et al. [4]. They describe a two-stage procedure combined with the MIPO technique to treat AO/OTA type C pilon fractures and conclud that this protocol could result in a low infection rate associated with open reduction and internal fixation (ORIF). The limited series achieved good outcomes at an average follow-up of 24 months. However, there are some concerns regarding this study. First, which types of pilon fractures would be suitable for the MIPO technique? The authors used this technique to treat all type C pilon fractures (C1, C2 and C3 were included) and achieved good outcomes, but we do not think this is the best choice for all type C pilon fractures. Undoubtedly, the minimally invasive procedure would minimise surgical trauma and lessen the soft tissue complications. However, we should not forget that most common type C pilon fractures are usually caused by high energy forces and characterised by the severe comminution of the articular surface, especially the type C3 fractures. MIPO emphasises the use of small incisions to restore mechanical axes, decrease tissue injury and preserve blood supply. The procedure appears soft tissue friendly. However, it would cause great difficulty with the articular reduction. The limited incision is usually not large enough to allow direct manipulation of fractured fragments and visualisation of the joint surface. Although the authors mentioned the use of additional punctiform incisions to assist reduction, we believe that it would be not so easy to reduce the comminuted fragments, especially the die-punch fragments. This is partly because the time interval between the first and the second stage was too long in this study. The relatively long time interval, which was from 24 to 38 days, may allow the formation of bony callus. This would make the reduction of both the articular and the metaphyseal fragments too difficult, even if they were approached directly. The unsatisfactory articular reduction would lead to post-traumatic arthritis. This can be certified by another study. Borens et al. [1] who retrospectively evaluated 17 patients with type C pilon fractures, who were treated using MIPO techniques. Articular reduction was maintained in only four patients and seven patients developed moderate arthritis, so the authors recommended using this technique for fractures with simple articular involvement. As far as we are concerned the MIPO technique might be more suitable for type C1 and a few type C2 fractures but not type C pilon fractures. Second, the authors reported there was no infection. They attributed this to the staged procedure in conjunction with the MIPO technique. Whilst agreeing with this view, we thought, in addition to the surgical timing and minimal soft tissue disturbance, the infection rate and wound healing problems are associated with many other aspects, such as the timing of debridement, the fracture patterns, the incidence of open fractures, use of antibiotics and so on. Unfortunately, in this study, we are unable to find detailed information about the timing of debridement, the exact account of each subtype of type C fractures and the accurate number of each subtype of Gustilo type C open fractures. The Gustilo classification has an intimate relationship with the infection. Since 83 % of the patients had closed fractures and Gustilo type B open fractures, the low proportion of Gustilo type C fractures might also contribute to the good outcomes. With regard to the surgical timing, delayed surgery gave the soft tissue the chance to recover. Perhaps, just like many reports in the literature [2, 3], conventional ORIF would also achieve a good result with the tissue’s restoration after a long time, and would also be more helpful in reduction of the articular surface. Third, the authors reported that all patients had normal functioning ankle joints. They identified the outcomes according to the objective criteria (the amount of post-traumatic arthritis, range of ankle movement, number of arthrodeses) and the subjective criteria (pain, swelling, restriction of work or leisure activities). But they only mentioned this in the abstract. Focusing on the whole paper, we cannot know how many patients developed arthritis, how many degrees the range of motion was and which criteria the authors chose, the Mazur scale, the SF-36 scale, the AOFAS scale, the Olerud-Molander scale or the others? “All patients attained normal function in the ankle joints” was ambiguous and could not explain everything. For most type C pilon fractures, one of the major complications is arthritis. Sometimes, many patients with post-traumatic arthritis confirmed by radiography report normal function of the ankle [5]. Besides, in a two year follow-up, perhaps the mild or moderate arthritis had not developed to the level to affect the range of motion.

Pelvic Ring Injury Is Associated With Sexual Dysfunction in Women

Previous studies have reported a negative effect of pelvic trauma on genitourinary and reproductive function of women. However, fracture pattern, injury severity, and final fracture alignment have not been well studied. The purpose of this project was to describe sexual function in women after pelvic ring injury. Cohort study: a prospective collection of sexual function data for women with prior pelvic ring injury versus control groups of uninjured women and other women from the orthopaedic trauma clinic. Level I trauma center. One hundred eighty-seven women younger than age 55 years with pelvic ring injury, including 101 B-type (61-B1: n = 25, B2: n = 69, B3: n = 7) and 86 C-type (61-C1: n = 56, C2: n = 18, C3: n = 12) fractures. Four had open fractures, and 23 had associated genitourinary injury. Seventy-four were treated operatively. Surgical treatment was percutaneous in 62: iliosacral screws (n = 58), external fixation (n = 4), or both (n = 19). Open reduction and internal fixation was performed for the pubis symphysis (n = 27), sacroiliac joint (n = 2), and posterior ileum (n = 3). Sexual function questionnaires were completed for 92 patients (49%) with minimum 12 months and mean 46 months follow-up. Forty-eight patients (56%) reported pain with intercourse. Their mean Musculoskeletal Function Assessment was 44.3 versus 20.9 without dyspareunia (P < 0.0001). Seventy-eight percent of patients with B-type fractures and 43% of patients with C-type fractures had dyspareunia (P = 0.002). Dyspareunia occurred after 91% of anteroposterior compression injuries (P = 0.02) and in 79% with a symphyseal disruption treated with plate fixation (P = 0.005). All patients with bladder ruptures (n = 5) reported dyspareunia. Sacral fracture or sacroiliac injury, type of posterior treatment, and residual malalignment of the posterior ring were not associated with dyspareunia. Fourteen patients each had associated femur fractures and/or tibia fractures. Seventeen of them had pain during intercourse (P = 0.19 for association of femoral or tibial fractures with dyspareunia). Dyspareunia is common in women after pelvic ring fracture. Women with pelvic ring injury are more likely to report dyspareunia than other female patients with musculoskeletal trauma. Dyspareunia was related to anteroposterior compression and B-type injuries. Symphyseal plate fixation is also associated with dyspareunia. Pain with intercourse was also noted in all patients with a history of bladder rupture. Poor functional outcomes as measured by Musculoskeletal Function Assessment scores were reported in women with dyspareunia. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Functional Outcomes in Women After High-Energy Pelvic Ring Injury

Residual dysfunction after pelvic trauma has been previously described, but limited functional outcome data are available in the female population after high-energy pelvic ring injury. The purposes of this study were to determine functional outcomes and to characterize factors predictive of outcome. Prospective collection of functional outcomes data. Level I trauma center. Eighty-seven women with mean age of 33.5 years and mean Injury Severity Score of 23.1 were included. The Orthopaedic Trauma Association classification included 32 B-type and 55 C-type fractures. Four were open fractures and six had bladder ruptures. Forty-nine patients were treated operatively and 38 nonoperatively. Musculoskeletal Functional Assessment (MFA) questionnaires were completed after a minimum of 16 months and a mean of 41 months of follow-up. The mean MFA score was 33. Only 15 women (17.2%) had MFA scores comparable with an uninjured reference value (9.3), and 34 (39.1%) had better than the reference value for prior hip injury (25.5). Anteroposterior compression injuries had worse scores versus other patterns (48.3 vs 31.0, P = 0.01), and trends toward worse outcomes were noted after symphyseal disruption (P = 0.11) and transsymphyseal plating (P = 0.09). Sacral fracture or sacroiliac injury, amount of initial or final displacement, and type of posterior ring treatment were not associated with MFA scores. Mean scores were 32.3 after surgery and 34.0 after nonoperative management (P = 0.67). Functional outcomes were not related to age or Injury Severity Score, but isolated pelvis fractures had better MFA scores (21.1 vs 35.5, P = 0.008) and worse MFA scores (41.7 vs 29.1, P = 0.004) were seen with other lower extremity fractures. Those with bladder ruptures (n = 6) also had poor outcomes, mean MFA 50.0 (P = 0.078). Wide variation is seen in functional outcome of women after high-energy pelvic ring fracture as measured by the MFA with mean scores demonstrating substantial residual dysfunction. Better outcomes were noted after isolated fractures and in women who had not sustained other fractures in their lower extremities. History of bladder rupture or anteroposterior compression injury was associated with poor MFA scores. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pregnancy Outcomes After Pelvic Ring Injury

Previous studies reported negative effects of pelvic trauma on genitourinary and reproductive function with frequent cesarean delivery. Risk factors for cesarean delivery have not been well defined. The purpose of this project was to evaluate outcomes of pregnancy after pelvic ring injury. We hypothesized that cesarean delivery would be more frequent after pelvic fracture with potential causes including patient and physician preference, malunion, and retained hardware. Retrospective review with prospective collection of obstetric information. Level I trauma center. Thirty-one women, 16 to 40 years old, with pregnancy after healed pelvic fracture. Orthopaedic Trauma Association (OTA) classification included 10 B-type and 21 C-type fractures, 17 (55%) of which were treated surgically. Obstetric questionnaires were obtained for 54 pregnancies after a mean 72 months follow-up. Sixteen women had 25 vaginal deliveries; 28% after surgical treatment for their pelvic fracture with retained anterior (16%) and/or posterior (16%) hardware, including transsymphyseal plating in three patients (12%). Thirteen women had 26 cesarean deliveries, 46% after surgical treatment for their pelvis. The new cesarean delivery rate was 44% versus 17% preinjury (P = 0.02). Two had cesarean deliveries as repeat procedures after preinjury cesarean delivery. Four had cesarean deliveries as a result of medical complications (pre-eclampsia, n = 2; breech, n = 1; labor arrest, n = 2). Seven women (54%) reported 12 cesarean deliveries (46%) resulting from pelvic fracture; three elected cesarean delivery despite their physician offering a trial of labor, whereas four were advised by their obstetrician. Cesarean delivery was not related to age, fracture pattern, treatment type, or residual pelvic displacement. A trend for cesarean delivery related to retained hardware was observed (P = 0.06). Uncomplicated pregnancies and deliveries are possible after pelvic fracture. The new cesarean delivery rate among these women is significantly increased with over half related to patient and obstetrical preferences. Fracture pattern, minor malalignment, and retained hardware are not absolute indications for cesarean delivery. Neither surgical care of the pelvis or retained fixation precludes successful vaginal delivery. Development of guidelines and objective indications for trial of normal labor after pelvic fracture is needed. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Critical analysis of tibial fracture healing following unreamed nailing.

Unreamed nails have revolutionised the treatment of tibial shaft fractures. Many authors, however, have reported increasing bone healing complications with these implants. Unfortunately, few studies have addressed the factors affecting bone healing after unreamed tibial nailing. One-hundred and sixty tibial fractures in 158 patients (mean age 39.5 years) fixed using unreamed nails were reviewed. There were 78 AO type-A, 65 type-B and 17 type-C fractures (115 closed and 45 open fractures). Twelve patient, injury and surgery variables were analysed for their influence on fracture healing. Union occurred in all fractures after a mean time of 24.3 weeks. Additional surgery to achieve union, apart from dynamisation, was done in nine (6%) cases. The most important variables affecting healing were the mechanism of trauma (p=0.005), fracture site gap (p=0.01), degree of comminution (p=0.0003), associated soft tissue injuries (p=0.02) and the time to dynamisation (p=0.0001). High-energy trauma and fracture comminution have a negative impact on bone union and require close follow-up. It is essential to avoid distraction over three millimetres with unreamed nailing. Dynamisation is advised within ten weeks in axially stable fractures to encourage bone healing and avoid failure of the locking screws.

Comparison of locking compression plate versus external fixator in the treatment of AO type-C distal radial fractures

Objective To compare the clinical effects of the volar locking compression plate (LCP) and external fixator in the treatment of the AO type-C distal radial fractures.Methods From October 2007 to October 2010,64 cases of AO type-C distal radial fractures which had been treated with volar LCP and external fixator were retrospectively analyzed respectively.LCP group consisted of 38 patients,including 13 males and 25 females with an average age of 45.1 years.According to AO/OTA classification,there were 15 type-C1,18 type-C2,and 5 type-C3.External fixator group consisted of 26 patients,including 12 males and 14 females with an average age of 47.1 years.There were 11 type-C1,13 type-C2,and 2 type-C3.Outcomes were assessed by radiographic parameters,function parameters,and Gartland-Werley functional score.Results All the patients were followed up.X-rays showed all fractures healed.LCP group was followed up for an average of 23.8 months.External fixator group was followed up for an average of 31.2 months.According to the Gartland-Werley score,the excellent and good rate was 81.6％ in the LCP group and 76.9％ in the external fixator group,with a Gartland-Werley score of 4.50±3.55 and 5.04±3.74 respectively.There were no significant differences in wrist flexion,extension,ulnar deviation,radial deviation,pronation,supination,the parameter of ulnar inclination and radial height and the Gartland-Werley score.The volar tilt was better in the LCP group than in the external fixator group.There were 2 cases of wound infection,1 case of median nerve injury,1 case of plate loosening in LCP group; 3 cases of pin tract infection,1 case of fixator loosening,and 2 cases of wrist stiffness in the external fixator group.Conclusion LCP group had better imaging outcomes with a reliable fixation,but both of the groups can achieve satisfactory clinical results.The choices of treatment method depend on the patient's clinical conditions. Key words: Radial fractures; Fracture fixation, internal; External fixators

Double plate for treatment of humeral intercondylar fractures

Objective To evaluate the effects of double plates in the treatment of humeral intercondylar fractures. Methods From January 2004 to March 2011,31 patients with humeral intercondylarfractures were reviewed.According to AO/Muller classification,there were three patients with type C1 fractures,16 with type C2 and 12 with type C3.Trans-olecranon osteotomy or trans-triceps-side approach and internal fixation by standard method of AO double plates were performed in all patients. Results All 31patients were followed up for 12 -18 months,which showed fracture healing 6-12 months after surgery.According to the Cassebaum scoring system,the effects were evaluated as excellent in seven patients,good in 19,fair in four and poor in one,with excellence rate of 87％. Conclusion Double plates is proved to be a good choice for humeral intercondylar fractures,since it can obtain satisfactory outcome with solid fixation,stable mechanical properties,few complications and facilitation for early rehabilitation. Key words: Humerus ; Fracture fixation, internal ; Double plates

Palmar and dorsal fixed-angle plates in AO C-type fractures of the distal radius: is there an advantage of palmar plates in the long term?

BackgroundCurrent surgical approaches to the distal radius include dorsal and palmar plate fixation. While palmar plates have gained widespread popularity, few reports have provided data on long term clinical outcomes in comparison. This paper reports the result of a randomised clinical study comparing dorsal Pi plates and palmar, angle-stable plates for treatment of comminuted, intraarticular fractures of the distal radius over the course of twelve months.Methods42 patients with unilateral, intraarticular fractures of the distal radius were included and randomised to 2 groups, 22 were treated with a palmar plate, 20 received a dorsal Pi-plate. Results were evaluated after 6 weeks, 3, 6 and 12 months postoperatively focussing on functional recovery as well as radiological results.ResultsThe palmar plate group demonstrated significantly better results regarding range of motion and grip strength over the course of 12 months. While a comparable increase in function was observed in both groups, the better results from the early postoperative period in the palmar plate group prevailed over the whole course. Radiological results showed a significantly increased palmar tilt and carpal sag in dorsal plates, with other radiological parameters being comparable. Pain levels were decreased in dorsal plates after hardware removal and failed to show significant differences after 12 months. However, complications such as tendon ruptures were more frequent in the dorsal plate group.ConclusionsFunctional advantage of palmar plates gained within the first 6 weeks prevails over the course of a year. Both groups demonstrate further gradual increase of function after 6 months, although dorsal plates did not catch up completely. Improved early postoperative function seems to be the cornerstone for the best possible results. Patients with dorsal plates benefit from hardware removal more than palmar plates in terms of reduction of pain levels. The advantage of palmar plates is a faster functional recovery with lower complication rates. This is especially important in the elderly population. Radiological results did not show a superiority of palmar plates over dorsal plates.

A Biomechanical Comparison of Volar Locked Plating of Intra-Articular Distal Radius Fractures: Use of 4 Versus 7 Screws for Distal Fixation

To determine whether the number of distal locking screws significantly affects stability of a cadaveric simulated distal radius fracture fixed with a volar locking plate. We created AO/ASIF type C2 fractures in 10 matched pairs of human fresh-frozen cadaveric wrists and then fixed them using volar locking plates. The number of distal locking screws used was 4 screws or 7 screws in each wrist of the matched pair. We loaded the stabilized fractures cyclically to simulate 6 weeks of postoperative stressing during a therapy protocol and then loaded them to failure. Failure was defined as 2 mm or more of displacement of any fracture fragment as recorded by differential variable reluctance transducers. No wrists failed during the cyclic loading portion for either the 4- or 7-screw construct. The average initial stiffness of the 7-screw construct was 69 N/mm (± 38) versus 48 N/mm (± 14) for the 4-screw construct. The average failure load for the 7-screw construct was 139 N (± 78) versus 108 N (± 18) for the 4-screw construct. Neither of these differences was statistically significant. Although there was a trend toward increased initial stiffness and higher failure load in fractures fixed distally with 7 locking screws, the results were not statistically significant compared with fractures fixed with only 4 screws. Both constructs can withstand forces likely encountered in early therapy protocols. The use of extra distal locking screws when fixing distal radius fractures increases expense and may increase the risk of complications, such as extensor tendon irritation or rupture.

Interprosthetic femoral fractures: Analysis of 14 cases. Proposal for an additional grade in the Vancouver and SoFCOT classifications

Interprosthetic fracture is a rare but serious entity, impairing consolidation and stability due to adverse mechanical conditions related to bone fragility and implant volume. The present study highlights the difficulties involved in managing such fractures, details treatment options and reports findings leading to a proposed additional grade in the comparable Vancouver (hip) and French Orthopedic and Traumatologic Surgery Society (Société française de chirurgie orthopédique et traumatologique: SoFCOT) (knee) classification systems. A multicenter retrospective series included 14 interprosthetic femoral fractures: eight type double C (typeC for both hip and knee), five type C for hip and B for knee, and one type double B (type B for both hip and knee) on the Vancouver and SoFCOT classifications. Fracture occurred on standard (n=15) or revision (n =13) implants. Six cases involved a femoral shaft encumbered by a total knee replacement (TKR) femoral extension stem and eight cases TKR without femoral long stem, assimilable to type C fracture. None of the six fractures proximal to a constrained TKR with stem-achieved union by primary intention, whereas seven of the eight type-C fractures did so. Finally, 12 cases showed favorable evolution, with three secondary total femur replacements (TFR) and one death at 6 months without bony union or revision and one patient waiting for TFR. To describe the status of the intermediate femur and its medullary canal encumbrance, we propose adding a category D to the SoFCOT and Vancouver classifications, corresponding to interprosthetic fracture on TKR with diaphyseal extension stem. Interprosthetic fracture internal fixation should begin with long devices bridging the two prostheses. When the implant is loose, it may be replaced; in case of diaphyseal extension, however, the residual femur between the two extensions should be protected against peak stress by a plate extending upward and downward. In case of limited bone stock, due to osteolysis or initial femoral medullary canal compromise, especially if one or both implants are loose, TFR may be indicated as consolidation, is jeopardized by the uncertain mechanical situation.

One-third tubular-hook-plate osteosynthesis for olecranon osteotomies in distal humerus type-C fractures: A preliminary report of results and complications

IntroductionDistal humerus fractures are rare and challenging to treat. Anatomic reduction of the articular surface and stable osteosynthesis are mandatory for satisfactory results. The transolecranon approach allows superior visualisation of the joint. However, controversy exists regarding how best to fix the osteotomy. The purpose of the present study was to investigate the eligibility of a one-third tubular hook plate for osteosynthesis of olecranon osteotomies in distal humerus type-C fractures. Patients and methodsA consecutive series of 34 patients who were treated through an olecranon osteotomy and underwent fixation using a one-third tubular hook plate were identified. Thirty-one patients (17 females, 14 males) with a median age of 50 years (14–87, standard deviation (SD) 18.3) were available for a comprehensive assessment after a mean of 12.3 months (6–20, SD 3.7). Using the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification, six (19.4%) fractures were categorised as type C2 and 25 (80.6%) were categorised as C3. Physical and radiological examinations were performed. The Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand score (DASH) were evaluated. ResultsMean extension–flexion ROM was found to be 102° (50–145°, SD 25). Pronation and supination were only slightly compromised. The mean MEPS was 87.2 points (50–100, SD 12.4). Fourteen patients (45.2%) were rated as excellent, and 15 (48.4%) were rated as good. One patient was rated fair, and one patient was rated as poor, respectively. Mean DASH score was 24.4 points (0–65, SD 20.3). Complications regarding the osteotomy occurred in seven patients (22.5%). Revision surgery was necessary in five cases (16%). At follow-up, all osteotomies went on to union. Mild joint degeneration (Broberg I) was found in 10 patients (32.2%). Implant removal was carried out in 15 patients (48.4%). ConclusionBased on this study, the osteosynthesis of olecranon osteotomies using a one-third tubular hook plate can be regarded as a safe procedure with a low complication rate. The implant needed is widely available and cost-efficient, in contrast to specially designed plates or nails.

Outcome analysis of retrograde nailing and less invasive stabilization system in distal femoral fractures: A retrospective analysis

Background:Two major therapeutic principles can be employed for the treatment of distal femoral fractures: retrograde intramedullary (IM) nailing (RN) or less invasive stabilization on system (LISS). Both operative stabilizing systems follow the principle of biological osteosynthesis. IM nailing protects the soft-tissue envelope due to its minimally invasive approach and closed reduction techniques better than distal femoral locked plating. The purpose of this study was to evaluate and compare outcome of distal femur fracture stabilization using RN or LISS techniques.Materials and Methods:In a retrospective study from 2003 to 2008, we analyzed 115 patients with distal femur fracture who had been treated by retrograde IM nailing (59 patients) or LISS plating (56 patients). In the two cohort groups, mean age was 54 years (17–89 years). Mechanism of injury was high energy impact in 57% (53% RN, 67% LISS) and low-energy injury in 43% (47% RN, 33% LISS), respectively. Fractures were classified according to AO classification: there were 52 type A fractures (RN 31, LISS 21) and 63 type C fractures (RN 28, LISS 35); 32% (RN) and 56% (LISS) were open and 68% (RN) and 44% (LISS) were closed fractures, respectively. Functional and radiological outcome was assessed.Results:Clinical and radiographic evaluation demonstrated osseous healing within 6 months following RN and following LISS plating in over 90% of patients. However, no statistically significant differences were found for the parameters time to osseous healing, rate of nonunion, and postoperative complications. The following complications were treated: hematoma formation (one patient RN and three patients LISS), superficial infection (one patient RN and three patients LISS), deep infection (2 patients LISS). Additional secondary bone grafting for successful healing 3 months after the primary operation was required in four patients in the RN (7% of patients) and six in the LISS group (10% of patients). Accumulative result of functional outcome using the Knee and Osteoarthritis Outcome (KOOS) score demonstrated in type A fractures a score of 263 (RN) and 260 (LISS), and in type C fractures 257 (RN) and 218 (LISS). Differences between groups for type A were statistically insignificant, statistical analysis for type C fractures between the two groups are not possible, since in type C2 and C3 fractures only LISS plating was performed.Conclusion:Both retrograde IM nailing and angular stable plating are adequate treatment options for distal femur fractures. Locked plating can be used for all distal femur fractures including complex type C fractures, periprosthetic fractures, as well as osteoporotic fractures. IM nailing provides favorable stability and can be successfully implanted in bilateral or multisegmental fractures of the lower extremity as well as in extra-articular fractures. However, both systems require precise preoperative planning and advanced surgical experience to reduce the risk of revision surgery. Clinical outcome largely depends on surgical technique rather than on the choice of implant.

Die Ellenbogentotalendoprothese in der Versorgung schwerer Ellenbogenverletzungen des älteren Patienten

The aim of this study was to evaluate the functional outcome of patients with severe elbow injuries treated by primary and secondary implantation of an elbow prosthesis using two different functional scores. To determine whether or not total elbow replacement is an acceptable treatment option in such cases, we analysed the functional outcome of patients after primary or secondary implantation of the semi-constrained Coonrad-Morrey prosthesis. Between March 2005 and September 2009 we implanted 25 Coonrad-Morrey prostheses in 24 patients with acute or chronic elbow injuries. Eight patients had complex type C3 fractures according to the AO classification and were treated with primary implantation. 16 patients received a secondary implantation including 3 chronic luxations, 3 non-unions of the bone, 3 failed osteosyntheses, 7 patients with post-traumatic arthrosis and 1 reimplantation. The mean follow-up after the operation was 12 (± 8) months. The functional outcome was measured by assembling the "Mayo elbow prosthesis score" and the "Mayo elbow performance score". We had 15 female and 9 male patients with a mean age of 67 (± 6) years. All 24 patients achieved very good results based on the used scores with a mean of 97 points each with a maximum performance of 100 points. The mean range of motion concerning extension and flexion was 92 degrees (range 55 to 115 degrees), concerning pronation and supination 144 degrees (range 100 to 160 degrees). The mean flexion deformity was 19 degrees (range 10 to 50 degrees), the mean maximum flexion was 112 degrees (range 90 to 130 degrees). During the follow-up we had two partial ruptures of the triceps tendon, one temporary lesion of the ulnar nerve with complete recovery after surgical revision and one postoperative haematoma which needed surgical treatment. One patient needed revision surgery and resection arthroplasty due to a deep infection, but received a new prosthesis after two months. We recorded no radiographic loosening or other mechanical problems. Due to the good functional outcome and pain relief of patients treated by total elbow replacement, we suggest that total elbow arthroplasty is a reasonable treatment option for complex acute and chronic injuries of the elbow in elderly patients.

Comparison of locking compression plate and external fixator in the treatment of severely comminuted distal radius fracture

Objective To compare the treatment outcomes between locking compression plate and external fixator for treating severely comminuted distal radius fracture. Methods Forty patients of severely comminuted distal radius fractures were treated with either locking compression plate fixation via a volar approach or external fixator. Twenty-one patients were treated with locking compression plate fixation, while the other 19 patients were treated with external fixator. According to AO/ASIF classification, there were 10 type C1 fractures,15 type C2 fractures and 15 type C3 fractures.Wrist range of motion, forearm range of motion, grip and pinch strength, radiographic data (palmar tilt, radial inclination, radial height), scores by the Disabilities of the Arm,Shoulder and Hand (DASH) and by Gartland-Werley were collected at follow-up. The data were statistically analyzed to compare the clinical effects. Results Postoperative follow-up ranged from 6 to 48 months with an average of 18.8 months. According to Gartland-Werley wrist score, the excellent and good rate was 81.0% in the locking compression plate group, and 78.9% in the external fixator group. No significantly difference was detected in the ROM of flexion, extension, radial deviation, pronation, supination, grip and pinch strength, the parameter of palmar inclination, ulnar inclination and radial height and in Gartland-Werley score and DASH score between the two groups (P＞0.05). The ROM of unlar deviation in the locking compression plate group was significantly smaller than that in the external fixation group ( P＜0.05). No complication occurred in the locking compression plate group. One patient developed sympathetic reflex dystrophy postoperatively in the external fixation group. After medication and physical therapy the symptoms had resolved. Infection of the external fixator pin tract was note in another patient which was effectively treated by wound care. Conclusion Locking compression plate and external fixator lead to siunilar treatment outcomes for severely cormminuted distal radius fractures. Patient's functional requirement, age and financial status should be taken into consideration while choosing one of these procedures. Key words: Radius fractures; Fracture fixation,internal; External fixator

Biomechanical testing of a concept of posterior pelvic reconstruction in rotationally and vertically unstable fractures

The purpose of this study was to assess the stability of a developmental pelvic reconstruction system which extends the concept of triangular osteosynthesis with fixation anterior to the lumbosacral pivot point. An unstable Tile type-C fracture, associated with a sacral transforaminal fracture, was created in synthetic pelves. The new concept was compared with three other constructs, including bilateral iliosacral screws, a tension band plate and a combined plate with screws. The pubic symphysis was plated in all cases. The pelvic ring was loaded to simulate single-stance posture in a cyclical manner until failure, defined as a displacement of 2 mm or 2°. The screws were the weakest construct, failing with a load of 50 N after 400 cycles, with maximal translation in the craniocaudal axis of 12 mm. A tension band plate resisted greater load but failure occurred at 100 N, with maximal rotational displacement around the mediolateral axis of 2.3°. The combination of a plate and screws led to an improvement in stability at the 100 N load level, but rotational failure still occurred around the mediolateral axis. The pelvic reconstruction system was the most stable construct, with a maximal displacement of 2.1° of rotation around the mediolateral axis at a load of 500 N.

Selection of Treatment Method for Pelvic Ring Fractures

The pelvis is the central part of the body that receives the weight from the vertebral column and transfers it to the lower extremities. It protects the internal organs with its specific structure and shape. The study aims to compare the clinical outcomes of emergency non-surgical and surgical treatment of such patients, to analyze the types and severity of complications and final functional outcome. We present a series of 47 patients treated in the period between 1999 and 2009 at the Traumatology Clinic, CHC Banja Luka. According to Marvin Tile's classification, fractures were distributed as follows: Type A fractures occurred in 19 patients (40.6%), Type B in 18 (38.1%) and Type C in 10 (21.3%). 30 patients (63.8%) were polytraumatised, with craniocerebral injuries in 12 patients (25.5%), chest cavity injuries in 5 (10.6%) and abdominal organ injuries in 13 patients (27.6%). 27 patients (57.4%) had clinical and laboratory signs of hemorrhagic shock on admission, while 26 patients (56.2%) received conservative treatment and 21 patients (43.8%) were treated using surgical methods of stabilization of the pelvic ring. The analysis of the outcomes of treating pelvic ring fractures in our series of patients by using radiography (x-rays according to Slatis) showed that out of 47 treated patients, the outcomes were excellent in 28 (60%), good in 7 (15%), fair in 5 (12%) and poor in 7 (14%). The functional outcomes in all patients were evaluated according to the D'Aubigne-Postel scale, on average 18 months after the trauma. The outcomes were excellent in 22 patients (45%), good in 15 (31%), fair in 4 (9%) and poor in 6 (14%). The chi-square test showed that there was no significant statistical difference between the outcomes monitored using x-rays and functional outcomes monitored using the D'Aubigne-Postel scale (p = 0.097). The surgical treatment efficiency coefficient was introduced for the purpose of comparative evaluation of treatment outcomes. The surgical treatment efficiency coefficient, compared with conservative treatment, showed that all evaluated parameters were between 1.56 and 16.33 times lower in surgical treatment, which represents the more favorable outcome. We can conclude that conservative treatment is the treatment of choice for Tile's Type A fractures, external fixator for treating Type B fractures (including all subtypes), and internal fixation, as mono therapy or in combination with external fixator, for treating Type C2 and Type C3 fractures. Surgical treatment, compared with conservative treatment, allows faster mobilisation of the patient and it shortens the recovery period, which in turn lowers the total treatment costs.

Implant choice for Weber C ankle fractures

Background Controversy exists regarding the use of one-third tubular plates for fixation of diaphyseal (Weber C) fibular fractures because of increased time to union and concerns about the plate's strength. No study has evaluated the efficacy of this type of plate for Weber C fractures. The purpose of this study was to evaluate one-third tubular plates in the fixation of diaphyseal fibular fractures regardless of whether or not the plate was locking or nonlocking. Methods We prospectively followed 84 patients with displaced, unstable Weber C fractures. We excluded all OTA type 44-C3 fractures and those treated by any means other than a one-third tubular plate. Of the 50 patients who had sustained an OTA type 44-C1 or C2 fracture and were treated with one-third tubular plates, 39 patients (78%) had complete 1-year follow-up. Results Union rates were 97% for Weber C fractures treated with one-third tubular plates. There was one wound infection and the overall complication rate was 10%. Two patients (5%) required revision open reduction and internal fixation. Finally, there was no evidence of wound necrosis, malunion, or post-traumatic osteoarthrosis in this cohort. Conclusions One-third tubular plates provide adequate fixation for Weber C fractures. Theoretical concerns about fixation strength are clinically unfounded. Therefore, we recommend the use of one-third tubular plates for the treatment of Weber C fractures.

Outcome of dorsally comminuted versus intact distal radial fracture fixed with volar locking plates

Objective Distal radial fractures are common. Modern trends favour operative treatment in many instances, providing stable fixation and early functional recovery. Recent biomechanical evidence suggests that volar locking plates (VLPs) enable adequate stability for dorsally displaced fractures, both in dorsally intact (DI) and in dorsally comminuted (DC) fractures. The aim of the study was to compare the clinical outcome of these two fracture groups treated with a VLP. Methods Retrospective case–control analysis of 91 distal radial fractures treated surgically using VLP by a single surgeon between the years 2006 and 2008 was carried out. Fractures were classified according to the Arbeitsgemeinschaft für Osteosynthes/Orthopaedic Trauma Association (AO/OTA) classification. Based on initial pre-reduction X-rays and computed tomography (CT) scans, fractures were classified into two groups of DI and DC fractures. The patients were re-evaluated at 2 and 6 weeks, 3 and 6 months and 1 year. Results Forty-one fractures (45%) were dorsally comminuted. Patients in the DC group were significantly older (mean 59 vs. 46 years, p < 0.01) and included more female patients, as well as significantly more C3 type fractures than the DI group ( p < 0.04). The mean Disabilities of the Arm, Shoulder and Hand (DASH) score at 1 year postoperatively was 6.3 ± 2.3 for the DC group, as compared with 6.6 ± 2.02 for the DI group ( p = 0.64). Average time to return to work was longer in the DC group (81.2 vs. 63.6 days, p = 0.05). Range of motion, volar tilt, and radial inclination were within clinically acceptable values and did not differ significantly among the two groups. Conclusions VLP fixation of DC distal radial fractures results in the maintenance of reduction and comparable functional and radiographical outcome with respect to DI fractures.

Critical analysis of triceps-reflecting anconeus pedicle (TRAP) approach for operative management of intra-articular distal humerus fractures

Abstract In the operative management of intra-articular distal humerus fractures, optimal approach that not only allows good visualization and stable fixation of the entire fracture geometry but also affords aggressive postoperative elbow rehabilitation with minimal complications is critical to achieve a consistently good results in these challenging fractures. Though numerous approaches have been described in the literature, namely Bryan Morrey triceps reflecting, Triceps splitting, paratricipital, triceps reflecting anconeus pedicle (TRAP) and olecranon osteotomy; there is no agreement on ideal approach for these fractures with minimal complications. Hence we envisaged to conduct a study on the critical analysis of TRAP approach for the management of intra-articular AO type C distal humerus fractures with the purpose of studying the feasibility of the approach in affording adequate exposure and fixation of the entire fracture geometry and allowing aggressive postoperative elbow rehabilitation. We also report our short term clinical, functional and radiological outcome using this approach in AO type C distal humerus fractures. Fifteen cases (age group 16-57 years; mean 31.8 years) with AO type C fractures, All fractures united without loss of fixation, fracture displacement, hardware failure or bone grafting. One postoperative ulnar nerve palsies that was surgically explored recovered partially subsequently. Two superficial infections responded to surgical debridement and had final excellent outcome. Wound complications not requiring secondary surgical procedures like postoperative hematoma, superficial skin dehiscence and necrosis over tip of olecranon was seen in 4 cases that eventually healed uneventfully. Heterotopic ossification was seen in 2 cases (1 each of Brooker grade 3 and 1). Three cases had clinically evident (MRC grade 3 or less) triceps weakness. One case needed retightening of 1 distal screw following backout (MEPS 90). The mean MEPS was 85 points. Six cases have excellent, 4 cases had good and 5 cases have fair outcome. TRAP approach allows adequate fracture visualization and stable fracture fixation even in comminuted AO type C3 fracture of the distal humerus, with the advantage of intact olecranon that does serve as a template around which critical intra-articular fracture reduction is afforded. The approach permits aggressive postoperative elbow rehabilitation without elbow instability. However, wound related complications and residual triceps weakness may be of concern in some cases. Accurate and strong reattachment of the reflected extensor mechanism is absolutely critical for postoperative elbow rehabilitation and good functional outcome.

Minimally invasive percutaneous plate osteosynthesis for treatment of proximal humeral fractures

Objective To explore the clinical application and follow-up results of minimally invasive percutaneous plate osteosynthesis (MIPPO) in treating proximal humeral fractures. Methods From December 2006 to September 2008, MIPPO using locking plate was employed to treat 36 patients (23 males and 13 females) with proximal humeral fracture. According to AO classification, there were four patients with type A2 fractures, 10 with type A3 fractures, five with type B1 fractures, 11 with type B2 fractures, three with type C1 fractures and three with type C2 fractures. Longitudinal or transverse incision was made through anterolateral acromial approach to separate the deltoid muscle and expose the fracture fragments. The direct and indirect reduction of the fractures were performed under direct vision. The locking plate was inserted distally beneath the deltoid muscle and a longitudinal incision was made at the lateral end of the plate. Locking screws were inserted to the proximal and distal plates. Postoperative follow-up was done to provide guidance to functional exercise and evaluate the clinical results. Results The operation lasted for (50.1±11.3) minutes, with intra-operative blood loss of(76±18.7) ml and average operative incision of (4.5±0.8) cm. All the patients were followed up for 12-17 months (average 14 months), which showed that the time of bone healing was (10. 1 ±1.2) weeks. Neer scoring standards showed the total excellence rate of 86%. Conclusion MIPPO is an ideal method for treatment of proximal humeral fractures, for it has the advantages such as safety, minor trauma, short bone healing time, alleviation of pain and good X-ray reduction. Key words: Shoulder fractures; Fracture fixation, internal; Locking proximal humerus plate