Locking compression plate fixation in humeral shaft fractures: A comparative study to literature conservative treatment.

INTRODUCTION: Humeral shaft fractures represent about 3% of all fractures. While there are several treatment options for this type of fractures, there is no evidence in literature showing which is the best one. This study aims at analysing the outcomes for patients with humeral shaft fractures treated with Locking Compression Plate (LCP) fixation in our hospital and comparing them with the outcome for patients conservatively treated (according to data from Pubmed),in order to determine the best treatment option. MATERIALS AND METHODS: We treated surgically 220 humeral shaft fractures in our department from February 2005 to March 2012. Seventy-three of them met all the inclusion criteria for this study. All fractures were then classified according to the AO classification. The follow-up considered the radiographic healing of the fracture. All patients were treated with plate fixation (LCP - DePuySynthes Co). At the end of the four-year follow-up, the function was evaluated by means of the DASH score. A systematic review of the literature of the last 20 years was performed on MEDLINE (PubMed). RESULTS: We had 2 infections and 8 patients had postoperative nerve palsy which recovered in average time of 6.7 months. In addition, 4 fractures (5.48%) didn't heal within 6 months and they were considered as nonunions and healed after a second surgery. One of these 4 nonunions was infected. The mean DASH score was 18.24±19.18. No malunions were found. We identified 13 studies that were eligible for our systematic review. The mean non-union rate found was 17% in 2517 fractures with a follow-up that ranging from 67% to 100% of patients and a primary radial nerve palsy ranging from 0 to 115 patients. Malalignment rate ranged from 12.7 to 42%. CONCLUSIONS: After taking into account both the conservative and the surgical treatment, for humeral shaft fractures we suggest the operative treatment, because the patient's function of the upper limb recovers quickly in the immediate postoperative period and the incidence of malunions may be avoided.

Modified Masquelet's technique with nail and allograft: A case report.

The large bone defect treatment is a challenge issue in modern orthopaedic trauma surgery. One of the most used technique is the Masquelet's technique. In this case report we used a modified Masquelet technique to fill a six centimeters bone gap in the proximal femur. A 18-year-old boy with a septic pseudoarthrosis was treated with a two stages procedure: in the first step we used a hollow antibiotic spacer and an intramedullary nail. In the second step, we used both omologous (6 cm of bone allograft) and autologous bone graft with a new intramedullary nail. Immediate partial weight bearing was allowed and after 3 months the patient started walking with complete weight bearing. A year later the fracture had healed uneventfully. The modification of the Masquelet Technique that we have made allows the patient to immediately weight bearing safely, speeding up the functional recovery. Further studies are needed to standardize this type of combined technique.

Predicting the failure in distal femur fractures.

INTRODUCTION: The incidence of nonunion after fractures of the distal femur is up to 6%. The distal femoral nonunion is a disabling disease that needs complex steps in his treatment. Aim of our study is to find predicting factors of non-unions. MATERIALS AND METHODS: We retrospectively analyzed 116 cases of distal femoral fractures and 20 cases of non-unions. In both surgeries we analyzed: accuracy of reduction, stability of fixation, hardware used, residual medial or lateral bone defect, use of autologous or heterologous bone grafts. RESULTS: Malreduction, particularly axial defect, associated with unbalanced fixation, and a medial cortical bone defect of greater or lesser extent were found to be the major risk factors of nonunion. Addressing both the mechanical and the biological environment was associated with successful non union treatment. CONCLUSION: The main principles for solving a distal femoral nonunion are new better reduction, correction of the medial bone defect and biological support with bone grafting. From the mechanical side the association of a medial strut graft or a medial column plate could be very useful in the treatment of these non-unions.

Alleged malpractice in orthopaedics. Analysis of a series of medmal insurance claims.

BACKGROUND: Medical malpractice is an important topic worldwide, and orthopedics is a clinical branch that is considered to be at a high risk for claims. The analysis of a series of medmal insurance claims allows forensic pathologists, clinicians, and insurance companies to probe the risk of a specific clinical branch for medical malpractice claims and highlights areas where care may be improved. We investigated the main features of a major Italian insurance broker's archive in order to identify recurrent pitfalls in this field. MATERIALS AND METHODS: A retrospective study was carried out on orthopedics claims. The archive covered claims from 2002 to 2013 that targeted 1980 orthopedists. RESULTS: 635 claims were found and analyzed with a focus on the clinical activity invocked in the claim, the presence of alleged team malpractice, the clinical outcome of the case, and the final forensic decision regarding the claim. 299 orthopedists had at least one malpractice claim made against them during the available period; 146 orthopedists were subject to more than one malpractice claim. Most of the claims regarded perioperative and operative cases, usually originating from civil litigation. The anatomical sites most commonly involved were the hip or knees, and sciatic nerve lesions were the main contributor. CONCLUSIONS: Orthopedics is a medical specialty with a high risk for malpractice claims. In our study, medical malpractice was observed in nearly 50% of the cases-typically in surgery-linked cases resulting in permanent impairment of the patient. Death from orthopedics malpractice seemed to be rare. LEVEL OF EVIDENCE: IV.

To fix or not to fix? The role of fibular fixation in distal shaft fractures of the leg.

BACKGROUND: The role of stabilisation of the fibula in distal two-bone fractures of the leg is controversial. Some studies indicate the need for fibular stabilisation in 43 AO fractures, but few studies consider the role of the fibula in 42 AO fractures. The aim of the current paper is to explain the role of stabilisation of the fibula in 42 AO fractures, correlating the rates of healing and non-union between patients with and without fibula fixation. MATERIALS AND METHODS: A total of 60 patients with 42 AO (distal) shaft fracture of the tibia with associated fracture of the fibula were selected. Patients were divided into two groups according to whether or not the fibula was fixed: Group I (n=26) comprised patients who had their fibula fixed while Group II (n=34) comprised patients who did not. The fibular fracture was classified according to the AO and related to the level of the tibial fracture. Other parameters examined were the union rate of the two groups correlated to the fracture pattern and position of the fibular fracture; the demographic data, such as age and gender; the presence of an open fracture, and the type of tibial fixation device used (nail or plate). RESULTS: None of the parameters considered (open injury, AO classification, device used and level of the fibular fracture relative to the tibial) were shown to have an influence on the development of a non-union. CONCLUSION: This study showed a higher non-union rate when the fracture of the tibia and fibula were at the same level, the tibia was fixed with a bridging plate and the fibula left untouched. For this reason, we recommend fibular fixation in all 42 distal fractures when both fractures lie on the same plane and the tibial fracture is relatively stabilised.

Post-traumatic hematoma of the iliopsoas muscle with femoral nerve entrapment: description of a rare occurrence in a professional cyclist.

The authors describe a case of iliopsoas muscle injury complicated by nerve entrapment, a rare occurrence both in the literature and in clinical experience. The diagnostic procedure excluded the many differential diagnoses possible. The authors prescribed conservative treatment which achieved nearly full recovery of the athlete approximately 6 months after injury.