Comparison of a 2.7-mm and 3.5-mm locking compression plate for ulnar fractures: a biomechanical evaluation.

Objectives: Implant prominence after ulnar fracture fixation may be mitigated by the use of lower profile plates. The biomechanical strength and stability of 2.7-mm and 3.5-mm locking compression plates for fixation were compared. Methods: Two fracture conditions, transverse (N = 10) and oblique (N = 10), were evaluated in an in vitro study. Half of the specimens for each condition were fixed with 2.7-mm plates and the other half with 3.5-mm plates, all fixed with conventional dynamic compression mechanisms. Specimens were loaded under ±2 Nm of cyclic axial torsion, then under 10 Nm of cyclic cantilever bending, and bending to failure. Interfragmentary motion and strain were analyzed to determine construct stability as a function of fracture pattern and plate size. Results: Interfragmentary motion was significantly larger in all constructs fixed with 2.7-mm plates, compared with 3.5-mm plates (P < 0.01). The 2.7-mm constructs with transverse fractures had the greatest motion, ranging between 5° and 10° under axial rotation and 5.0-6.0 mm under bending. Motions were the lowest for 3.5-mm constructs with oblique fractures, ranging between 3.2 and 4.2 mm under bending and 2°-3.5° for axial rotation. For oblique fractures, the bending moment at ultimate failure was 31.4 ± 3.6 Nm for the 2.7-mm constructs and 10.0 ± 1.9 Nm for 3.5-mm constructs (P < 0.01). Similarly, for transverse fractures, the bending moment was 17.9 ± 4.0 Nm for the 2.7-mm constructs and 9.7 ± 1.3 Nm for the 3.5-mm constructs (P < 0.01). Conclusions: Although 3.5-mm plates were more effective at reducing fracture motion, they were consistently associated with refracture at the distal-most screw hole under load to failure. By contrast, 2.7-mm plates plastically deformed despite excessive loads, potentially avoiding a subsequent fracture. Level of Evidence: Level V.

How Feasible Are Digital Intraoperative Plain Radiographs in Orthopaedic Trauma Surgery?

The purpose of this study is to evaluate the feasibility and outcomes of obtaining routine intraoperative plain radiographs during orthopaedic trauma surgery. Seventy consecutive orthopaedic trauma patients in which intraoperative plain films were obtained in addition to fluoroscopy were reviewed. For each patient the time it took to obtain intraoperative plain radiographs was prospectively measured, in addition to the number of images taken, and quality of image. Then relative imaging times based on fracture locations were compared and the need for revision surgery based on mal-reduction or implant mal-positioning assessed. The average time required for intraoperative plain films to be obtained and reviewed by the surgeon was 3 minutes and 45 seconds. On average, 2.8 images were taken during each surgery. Proximal images took on average 44 seconds longer than distal images to obtain (p = 0.047). There was no significant difference in imaging times for upper versus lower extremities (p = 0.448). High quality images were obtained on all patients. There were no re-operations required in this series for mal-reduction of fracture, mal-positioning of implants or infection. In this study, there were no re-operations or perioperative complications when intraoperative plain films were obtained. Intraoperative plain films are a valuable tool for complex periarticular surgery or other cases where fracture reduction or implant location may be in question. (Journal of Surgical Orthopaedic Advances 32(3):160-163, 2023).

Dual Versus Single-Plate Fixation of Midshaft Clavicular Fractures: A Retrospective Comparative Study.

BACKGROUND: Implant-related symptoms are the most common reason for reoperation after open reduction and internal fixation (ORIF) of midshaft clavicular fractures. Dual mini-fragment plate fixation is a relatively new solution that may decrease implant prominence while maintaining fixation strength and function. There are minimal published data comparing reoperation rates and clinical outcomes between single, superior-plate constructs and dual mini-fragment plate constructs in the fixation of midshaft clavicular fractures. We hypothesized that reducing plate size with the use of dual mini-fragment plating compared with standard, 3.5-mm, superior plating would minimize implant symptoms and the corresponding need for reoperation while still providing sufficient fixation to allow fracture-healing and return to function. METHODS: We retrospectively reviewed the cases of 44 consecutive patients who underwent ORIF of displaced midshaft clavicular fractures utilizing either a single, 3.5-mm, superior plate construct (21 patients) or a dual, 2.7-mm and 2.4-mm, plate construct (23 patients). Outcomes at a minimum of 2 years were assessed. Primary outcome measures included reoperation for any reason and the American Shoulder and Elbow Surgeons (ASES) Standardized Shoulder Assessment Form, patient self-report section. RESULTS: There was a 100% union rate in both groups. None (0%) of the 23 patients who received the dual (2.7-mm and 2.4-mm) plate construct and 6 (29%) of the 21 patients who received the single (3.5-mm) plate construct underwent reoperation for implant-related symptoms. Using a Fisher exact test, the rate of reoperation was compared between the groups, and the difference was found to be significant (p = 0.008). Using an unpaired t test, the difference in mean ASES scores was not significant (p = 0.138) between the dual-plate group (98 of 100) and the single superior plate group (96 of 100) with retained implants. CONCLUSIONS: In our comparative retrospective series, dual fixation utilizing a 2.7-mm superior plate and a 2.4-mm anterior plate for the treatment of displaced midshaft clavicular fractures was associated with a significantly lower rate of reoperation when compared with single, 3.5-mm, superior plate fixation. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

An Early Look at Operative Orthopaedic Injuries Associated with Electric Scooter Accidents: Bringing High-Energy Trauma to a Wider Audience.

BACKGROUND: There is a new method of transportation that started in our community in late 2017- rideshare electric scooters (e-scooters). These scooters have proven immensely popular and can now be found in many cities around the world. Despite the pervasiveness of e-scooters, their associated injury patterns are poorly understood. The purpose of this study was to describe our department's experience at the epicenter of the e-scooter phenomenon that is sweeping the globe and to characterize operative orthopaedic injuries that are related to e-scooter accidents. METHODS: We performed a retrospective chart review of all of the operative orthopaedic cases and trauma consults at 2 trauma centers (a level-I center and a level-II center) between September 2017 and August 2019. We identified all operative injuries in which the cause of injury was an e-scooter accident. Data that included demographics, mechanism of injury, diagnosis, and treatment were collected. RESULTS: Seventy-five operative injuries were identified in 73 patients during the study period. The mean patient age was 35.4 years (range, 14 to 74 years), and the median age was 32 years. There were 4 pediatric patients (14, 15, 15, and 17 years old). Thirty-two patients (43.8%) sustained upper-extremity injuries, and 42 patients (57.5%) sustained lower-extremity injuries; 1 of these patients had both upper and lower-extremity injuries. Nine patients (12.3%) had open fractures. There were 7 hip fractures in patients with an average age of 42.4 years (range, 28 to 68 years). Seventy-one (97.3%) of 73 patients were e-scooter riders, and 2 (2.7%) were pedestrians who were struck by e-scooter riders. CONCLUSIONS: E-scooters can cause serious injury. Seventy-three patients required operative treatment in just the first 2 years of e-scooter use in our community. Operative injuries occurred throughout the skeletal system, and several were injuries that are typically associated with high-energy trauma. Although, as a rule, e-scooter use is limited to adults and banned in high pedestrian-traffic areas in our city, the inclusion of 4 underage riders and 2 pedestrians in our cohort suggests that these rules are not always followed. As e-scooters continue to increase in popularity, additional steps should be taken to regulate their use and protect riders and the public.

Operative treatment of acetabular fractures in an older population through a limited ilioinguinal approach.

OBJECTIVES: To compare treatment of acetabular fractures in elderly patients through a limited approach versus a standard ilioinguinal approach and assess changes in outcome and morbidity. DESIGN: Retrospective cohort comparison analysis. SETTING: Tertiary referral center. PATIENTS/PARTICIPANTS: Between January 1992 and January 2006, 143 patients 55 years of age or older were treated for acetabular fractures. Of these, 41 were treated through either a traditional or limited ilioinguinal approach. Patients with unilateral surgeries and a minimum follow-up of 2 years were included. INTERVENTION: Open reduction and internal fixation of acetabular fractures through a limited (lateral two windows) approach versus traditional three window ilioinguinal approach. OUTCOME MEASURES: Radiographic assessment of healing, reduction quality, progression to arthritis and total hip arthroplasty, operative time, length of stay, complications, SF-36, Musculoskeletal Functional Assessment, and the Short Musculoskeletal Functional Assessment. RESULTS: The two groups were equivalent in terms of preinjury comorbidities, mechanism of injury, type and severity of fracture pattern, time to surgery, length of hospitalization, and incidence of postoperative complications. The overall rate of secondary total hip arthroplasty was 26.8% and was equivalent between the two groups. Functional outcome scores were comparable. The use of the lateral two windows was associated with a significant reduction in both blood loss and operative time. CONCLUSIONS: The limited ilioinguinal approach to certain fracture patterns commonly seen in the elderly was associated with a decreased blood loss and surgical time. Moreover, there was no negative impact on outcomes in our cohort. The benefits of decreased blood loss and shorter operative time have a potential positive impact on management of these injuries. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Nonunions around the knee joint.

Nonunions of the distal femur are relatively rare but can occur with or without previous surgery. Many surgical methods have been described for the treatment of these nonunions including external fixation, intramedullary nailing, arthroplasty, and fixed angle plating. While arthroplasty may have a limited role in the elderly patient with osteoporosis and severe communiution, most nonunions can be reliably treated with revision fixation using a fixed angled device, lag screws, and bone grafting as needed. Fixed-angle plating also has the advantage of stabilising a small distal segment where intramedullary nailing has proven to be less effective. Any surgical intervention must include restoration of the normal mechanical axis of the distal femur for a satisfactory clinical outcome. Proximal tibia nonunions are a similarly rare clinical entity due to the excellent blood supply in the metaphysis. Extra-articular proximal tibial nonunions are often due to malreduction during the index surgery resulting in poor bone contact and biomechanical stability. Soft tissue forces and improper use of intramedullary implants often predispose these fractures to malalignment. Revision surgery consisting of deformity correction and at least a lateral tension band plate with lag screws has led to predictable union and good clinical results. Tibial plateau nonunions are exceedingly uncommon but are difficult to treat because of small, often devascularised fragments, post-surgical scarring, and osteopenia. Revision surgery with meticulous soft tissue handling to restore the articular surface and mechanical axis with repair of meniscal pathology gives the patient the best chance of recovering knee function.

The effects of cyclic mechanical strain and tumor necrosis factor alpha on the response of cells of the meniscus.

OBJECTIVES: Cells of the knee meniscus respond to changes in their biochemical and biomechanical environments with alterations in the biosynthesis of matrix constituents and inflammatory mediators. Tumor necrosis factor alpha (TNF-alpha) is a pro-inflammatory cytokine that is involved in the pathogenesis of both osteoarthritis and rheumatoid arthritis, but its influence on meniscal physiology or mechanobiology is not fully understood. The objectives of this study were to examine the hypothesis that cyclic mechanical strain of meniscal cells modulates the biosynthesis of matrix macromolecules and pro-inflammatory mediators, and to determine if this response is altered by TNF-alpha. METHODS: Cells were isolated from the inner two-thirds of porcine medial menisci and subjected to biaxial tensile strain of 5-15% at a frequency of 0.5Hz. The synthesis of proteoglycan, protein, nitric oxide (NO), and prostaglandin E(2) were determined. RESULTS: Cyclic tensile strain increased the production of nitric oxide through the upregulation of nitric oxide synthase 2 (NOS2) and also increased synthesis rates of prostaglandin E(2), proteoglycan, and total protein in a manner that depended on strain magnitude. TNF-alpha increased the production of NO and total protein, but inhibited proteoglycan synthesis rates. TNF-alpha prevented the mechanical stimulation of proteoglycan synthesis, and this effect was not dependent on NOS2. CONCLUSIONS: These findings indicate that pro-inflammatory cytokines can modulate the responses of meniscal cells to mechanical signals, suggesting that both biomechanical and inflammatory factors could contribute to the progression of joint disease as a consequence of altered loading of the meniscus.