A comparative biomechanical study for complex tibial plateau fractures: nailing and compression bolts versus modern and traditional plating.

AIM: To compare the biomechanical properties of a newly proposed technique, utilizing intramedullary nailing and compression bolts, for the osteosynthesis of intra-articular proximal tibial fractures with meta-diaphyseal comminution, with modern and conventional plating techniques. METHODS: Fifteen left tibia 4th generation composite Sawbones models (in 3 groups of 5 for each technique) with identically reproduced type VI Schatzker tibial plateau fractures, including meta-diaphyseal dissociation, were used. Three different techniques of osteosynthesis were tested: (a) a new technique that combines intramedullary nailing and compression bolts, (b) internal fixation with a single lateral locking plate and (c) internal fixation with dual buttress plating technique. The model-device constructs were successively subjected to 500N, 1000N and 1500N load levels with five cycles applied at each level on both articular compartments and a final load cycle to failure. Four parameters were recorded for each technique: the average reversible or irreversible displacement in vertical subsidence, the horizontal diastasis of the intra-articular fracture, the average passive construct stiffness and the load to failure. RESULTS: The new intramedullary nailing technique provided rigid intra-articular osteosynthesis being statistically similar to dual buttress plating for subsidence at medium and higher load levels. At the same time the proposed technique provided statistically equivalent stiffness values to the single lateral locking plate incarnating the rational of biologic fixation. Average load to failure was 1611N for single lateral locking plates, 2197N for intramedullary nailing and 4579N for dual buttress plating. The single lateral locking plate technique had the worse results in interfragmentary displacement while dual buttress plating was superior in stiffness from the other 2 techniques. The mode of failure differed between techniques, with collapse of medial plateau occurring exclusively in the single lateral locking plates group. CONCLUSION: The proposed new technique of intramedullary nailing and compression bolts demonstrates a flexural behaviour similar to single lateral locking plates, which complies with the terms and benefits of biological fixation, while at the same time maintains a rigid intra-articular stability similar to the stiff dual buttressing plating technique.

New classification system for long-bone fractures supplementing the AO/OTA classification.

This article describes a novel, clinically oriented classification system for long-bone fractures that is simple, reliable, and useful to predict treatment method, complications, and outcome. The reliability and memorability of the new classification were statistically tested and compared with the AO-Müller/Orthopaedic Trauma Association (AO/OTA) long-bone fracture classification. The proposed classification system was also clinically validated with a targeted pilot study designed for content and clinical outcome retrospectively reviewing 122 closed tibial shaft fractures, which were used as a representative paradigm of long-bone fractures. Statistical evaluation showed that the proposed classification system had improved inter- and intraobserver variation agreement and easier memorability compared with the AO/OTA classification system. The clinical validation study showed its predictive value regarding selection of treatment method, complication rate, and injury outcome.The proposed classification system proved simple, reliable, and memorable. Its clinical value appeared strong enough to justify the organization of larger studies for a complete assessment of its clinical usefulness for all long-bone fractures.

Retrograde nailing and compression bolts in the treatment of type C distal femoral fractures.

INTRODUCTION: This is a prospective study that verifies the usefulness of retrograde intramedullary nailing (IMN) combined with 'independent' compression bolts in the management of type C (AO/OTA classification) fractures of the distal femur. PATIENTS AND METHODS: Within a period of 4 years, 17 patients (mean age of 54 years) with intra-articular fractures of the distal femur (type C according to AO/OTA classification) were treated with retrograde IMN and compression condylar bolts. The patients followed an early mobilisation and weight-bearing protocol. RESULTS: All fractures healed in a mean time of 14.78 weeks with no incidences of malunion, nonunion or infections. No secondary failure of fixation occurred. Partial weight bearing was initiated in average 6.35 weeks postoperatively whilst full weight bearing in 14.6 weeks. The patients regained full extension and 117.22° of mean flexion of the knee joint while the mean New Oxford knee score was 42.05. CONCLUSIONS: In the treatment of type C fractures of the distal femur, the combination of retrograde nailing and 'independent' compression condylar bolt (inserted prior to the nailing) provided a strong fixation that facilitated uncomplicated outcomes and uneventful early mobilisation.

Spontaneously Healed Pathologic Fracture over a Critical-Size Calcaneal Cyst.

Simple bone cysts are nonsymptomatic lesions. They typically involve the medullary cavity, but they can also be found in nonlong bones such as the calcaneum. Their treatment remains controversial varying from observation and conservative healing to irritating injections or bone grafting. In the case of a pathologic fracture, surgical treatment seems most appropriate especially when the cyst is situated on a weight-bearing bone. We present herein the rare case of a spontaneously healed pathological fracture over a critical-size calcaneal cyst of a patient reluctant to undergo surgical treatment. An interpretation of the healing procedure as well as a review of the literature is presented.

Compartment syndrome following lower limb arthroplasty: a review.

Compartment syndrome is an urgent clinical entity characterised by an increase in the interstitial pressure within a closed osseofascial compartment. Although well recognised as a potential complication after orthopaedic trauma, it is very rarely presented after elective orthopaedic surgery and especially joint arthroplasty. In these rare cases a number of variables are associated with it (positioning, coagulopathy, extensive soft tissue dissection, previous scarring, and epidural analgesia). In this study we present the current evidence with regard to incidence and causation of compartment syndrome after lower limb joint arthroplasty and make recommendations on how to avoid the development of this devastating complication.

The management of complex fractures of the proximal tibia with minimal intra-articular impaction in fragility patients using intramedullary nailing and compression bolts.

BACKGROUND: Intra-articular fractures of the proximal tibia that extend to the meta-diaphyseal part of the bone represent a severe injury, especially if they occur in osteoporotic patients. Current treatment modalities include either internal fixation with traditional or modern plating techniques or external fixation with circular frames or hybrid systems. However, problems and complications related with these techniques are increasing with age and future reconstructive operations, such as arthroplasty, may be jeopardised. METHOD: This is a prospective pilot study about a novel type of osteosynthesis for complex intra-articular proximal tibial fractures without significant articular impaction in patients over 60 years of age. Within a period of 54 months, eight patients underwent fixation of such fractures with condylar compression bolts and intramedullary nailing. RESULTS: The follow-up period was from 12 to 50 months (mean 24.7 months). There were no neurovascular complications, wound infections, delayed unions or nonunions. All patients had their fractures healed without secondary displacement or malalignment. At the final follow-up, all patients had full extension of the knee joint whilst the flexion ranged from 125 to 140°. The mean new Oxford Knee score was calculated to be 43.75 points. CONCLUSIONS: The management of selected osteoporotic complex intra-articular fractures of the proximal tibia with compression bolts and intramedullary nailing offers specific advantages and, in the present pilot study, provided promising results. These results should be validated and confirmed with larger case series and comparison studies in the future.

Early mobilization after uncomplicated medial subtalar dislocation provides successful functional results.

BACKGROUND: Subtalar dislocation is a rare injury, with the medial type occurring in the majority of cases. The period of postreduction immobilization is a matter of controversy. Most studies set the period of immobilization between 4 and 8 weeks. The hypothesis in this study is that a period of 2-3 weeks of immobilization in a cast, followed by early mobilization, could provide better functional results than longer periods of immobilization. MATERIALS AND METHODS: During a period of 4 years, eight patients (six men, two women) with mean age of 37.2 years and uncomplicated medial subtalar dislocation were treated in our institution. Immediate reduction under sedation and cast immobilization was provided in all cases. Our rehabilitation protocol consisted of two completed weeks of immobilization and thereafter ankle range-of-motion exercises and partial weight-bearing mobilization. Patients were followed up for a mean period of 3 years. Clinical results were evaluated using the AOFAS Ankle-Hindfoot scale. RESULTS: All patients achieved almost normal ankle range of motion and good clinical outcome (mean AOFAS score 92.25). No radiographic evidence of arthritis or avascular necrosis of the talus was detected. Two patients complained of mild pain of the hindfoot. All patients returned to daily routine activities in about 2 months from injury. CONCLUSIONS: Immediate reduction and early mobilization could be key factors for uneventful recovery of uncomplicated medial subtalar dislocation. Multicenter clinical trials are needed for further validation of our initial results. LEVEL OF EVIDENCE: III, prospective clinical series study.

Intramedullary nailing of combined/extended fractures of the humeral head and shaft.

OBJECTIVES: To evaluate the use of intramedullary nailing in the management of both "combined" and "extended" fractures of the humeral head and shaft. DESIGN: Retrospective case series study. SETTING: Level I trauma center. PATIENTS AND INTERVENTION: Twenty-one consecutive patients who underwent intramedullary nail insertion for "extended" or "combined," closed, nonpathologic fractures of the humeral head and shaft between October 1999 and December 2006 were included in the study. Two patients were lost to follow up and one died before fracture healing. MAIN OUTCOME MEASUREMENTS: Evaluation of outcomes was assessed with the use of the Constant score. RESULTS: There were no neurovascular problems or infections. Eighteen fractures united from 4 to 7 months postoperatively. One case of avascular necrosis of the humeral head, one case of acromion impingement, and one case of unacceptable loss of reduction occurred. Shoulder range of motion was not regained fully in any case and mild shoulder discomfort remained in eight patients. The mean Constant score for all 18 patients was 74.4 (range, 20-95) for the affected side and 89.17 points for the uninjured side. The percentage created from the mean affected/unaffected side scores was 83.4%. CONCLUSIONS: Intramedullary nailing for proximal humeral fractures associated with shaft extension or segmental involvement appears to offer a reliable treatment option.

Deep wound infection after a trochanteric fracture internal fixation presenting with hip dislocation: a case report.

We report a rare case of posterior hip dislocation after a low energy trauma. The patient sustained a trochanteric fracture in the same hip six months ago, which was fixed using a sliding hip screw and had healed. At surgery a deep wound infection was found and a methicillin-resistant Staphylococcus epidermidis (MRSE) was cultured. After thorough debridement, an excisional arthroplasty was decided. The patient received specific intravenous antibiotics and after six weeks a total hip arthroplasty was done. In three years follow-up the patients presented with a fully functional hip without any signs of infection. Hip dislocation after a trochanteric fracture internal fixation is rare complication associated with high morbidity and mortality. Infection eradication and a second stage arthroplasty can be life and limb saving.

Intramedullary nailing as a 'second hit' phenomenon in experimental research: lessons learned and future directions.

BACKGROUND: The 'second hit' phenomenon is based on the fundamental concept that sequential insults, which are individually innocuous, can lead to overwhelming physiologic reactions. This response can be expressed in several organic systems and can be examined by measurement of several parameters. PURPOSES: The purpose of this study was to evaluate the incidence of systemic effects of intramedullary nailing and the role of concurrent head and thoracic injuries as they have been recorded in vivo. We also wanted to determine what would be the optimal animal model for future research and what variables should be investigated. METHODS: We reviewed the available literature of animal studies that used surgery, and particularly nailing, as a second hit. The reviewed studies were retrieved through an electronic search of the MEDLINE database. We analyzed the methods of creating the first and second hits (nailing), the characteristics of the animal models, the variables examined, and the pathophysiologic responses, which appeared after the second hit. RESULTS: Second hit reamed intramedullary nailing was found to provoke consumption of coagulation factors, whereas the effect of unreamed nailing on coagulation factors appears inconsistent. Hemodynamic factors were affected only transiently by the second hit, whereas the pulmonary function was affected only when the first hit included lung injury. CONCLUSIONS: Thoracic and head injuries predispose to an aggravated second hit. Primate animal models are considered to be closer to clinical reality and should be preferred for future studies. Future studies should include measurements of proinflammatory and antiinflammatory markers.

Peroneus longus acute calcific tendinitis: a case report.

Calcific tendinitis of the peroneus longus tendon is extremely rare, with only two cases described previously in the literature. Herein we discuss the diagnosis and management of a case with an acute calcific tendonitis of peroneus longus tendon.

Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study.

BACKGROUND: Recent studies have indicated that unmanaged pain, both acute and chronic, can affect mental status and might precipitate delirium, especially in elderly patients with hip fractures. The aim of this study was to assess the effectiveness of fascia iliaca compartment block (FICB) for prevention of perioperative delirium in hip surgery patients who were at intermediate or high risk for this complication. MATERIALS AND METHODS: On admission, all included patients were divided into three groups according to low, intermediate or high risk for perioperative delirium. Eligible patients (those classified as at intermediate or high risk for developing delirium) were sequentially randomly assigned to study treatment (FICB prophylaxis or placebo) according to a computer-generated randomization code. The primary outcome was perioperative delirium. Diagnosis of the syndrome was defined using the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and Confusion Assessment Method (CAM) criteria. Secondary outcome variables were severity of delirium and delirium duration. RESULTS: Delirium occurred in 33 (15.94%) out of 207 patients randomized to FICB prophylaxis or the placebo group. Incidence of delirium in the FICB prophylaxis group was 10.78% (11/102), significantly different from the incidence (23.8%, 25/105) in the placebo group [relative risk 0.45, 95% confidence interval (CI) 0.23-0.87]. Nine of 17 patients with high risk for delirium and included in the FICB prophylaxis group developed delirium, whereas 10 of 16 high-risk patients included in the placebo group became delirious (relative risk 0.84, CI 0.47-1.52). Two of 85 patients with intermediate risk for delirium and included in the FICB prophylaxis group developed delirium, whereas 15 of 89 intermediate-risk patients included in the placebo group became delirious (relative risk 0.13, CI 0.03-0.53). Severity of delirium according to the highest value of the DRSR-98 during an episode with delirium in patients in the FICB prophylaxis group was on average 14.34, versus 18.61 in the placebo group (mean difference 4.27, 95% CI 1.8-5.64, P < 0.001). Mean duration of delirium in the FICB prophylaxis group was significantly shorter than in the placebo group (FICB 5.22 days versus placebo 10.97 days, 95% CI 3.87-7.62, P < 0.001). CONCLUSION: No significant difference was found among high-risk patients between FICB prophylaxis and placebo groups in terms of delirium incidence. However, FICB prophylaxis significantly prevented delirium occurrence in intermediate-risk patients. Thus FICB prophylaxis could be beneficial, particularly for intermediate-risk patients.

An occult acetabular fracture preceding a femoral neck fracture.

This article describes the case of a 69-year-old patient with an occult acetabular fracture complicated by an ipsilateral femoral neck fracture occurring within 2 months. The acetabular fracture remained undiagnosed at examination due to insufficient clinical and radiographic data interpretation. The patient was assured of early mobilization that led to a fall and subsequent hip fracture. We focus on the potential reasons for the nondiagnosis of the acetabular fracture. Acetabular fractures in the elderly may occur after low-energy injuries. The lack of history of violent injury may lead to an incorrect diagnosis. Plain anteroposterior (AP) pelvis radiographs alone may prove an insufficient tool, especially in the hands of inexperienced personnel. As is characteristic, a retrospective review of the AP pelvis radiograph obtained after the first fall in our case revealed the undisplaced fracture of the anterior column that was missed initially. Combined fractures of the hip and the acetabulum are rarely described in the literature and are usually addressed by total hip arthroplasty (THA) alone. Similar fracture patterns that develop in 2 stages (2 injuries), as the 1 presented herein, are even more rare. The uniqueness of this combined fracture required a unique surgical treatment. The senior surgeon (P.V.G.) addressed the acetabular fracture separately to graft the anterior column fracture and facilitate union, as it was already 8 weeks old and the second fall had generated a further gap between the fragments. Stable fixation was felt appropriate prior to the THA. Thus, a double surgical approach was used. Six weeks postoperatively, the patient was able to perform full weight-bearing mobilization without an antalgic gait pattern. At 6-month follow-up, radiographs showed the metalwork to be in place with no displacement, and the fracture had progressed to union.

A new modular nail for the diaphyseal fractures of the humerus.

Over a period of 5 years, 63 traumatic and eight pathological diaphyseal humeral fractures were treated with a new modular humeral nail. The nail is cannulated, square in shape--with concave sides--and has two different extensions that can be used with either the antegrade or the retrograde approach. Adequate rotational and axial stability is provided without the need for distal locking screws in the majority of fractures, while the need for proximal locking screws during the antegrade procedure is abolished. This study aims to present the 'Garnavos' nail and the results of its use, along with proposals and guidelines that should be considered whenever intramedullary nailing is selected for the treatment of diaphyseal humeral fractures.

Hip screw lateral migration with no cut-out or non-union implication: a case report.

Hip screw migration of peritrochanteric fracture fixation devices is a described complication in English literature. Medial migration occupies the majority of these cases whereas lateral migration is rare. We report the case of an 85-year-old woman whose intramedullary osteosynthesis of a trochanteric fracture was complicated by hip screw lateral migration. Mobilization was not influenced and no cut-out or non-union was detected. The migrated hip screw was easily removed and the discomfort vanished. The need for adequate surgical technique and radiographic examination after re-injuries even if the patient remains ambulatory is emphasised.

A humeral shaft fracture complicated with anterior shoulder dislocation in a young male treated with modified Intramedullary nailing prior to reduction: a case report.

INTRODUCTION: Anterior dislocation of the shoulder joint with an ipsilateral fracture of the humeral shaft is a rare injury which may require demanding technical skills. CASE PRESENTATION: A 33 years old male sustained a work accident. Radiographs showed an anterior dislocation of the shoulder with a transverse fracture of the middle third of the humeral shaft on the same side. The dislocation proved to be irreducible in the setting of the fracture humerus. Thus, stabilization of the shaft fracture was successfully applied with an intramedullary nail and a small antirotational plate prior to the reduction. The patient recovered full function of the shoulder. CONCLUSION: Performing primary intramedullary nailing of the humeral shaft fracture before manipulation of the joint resulted to an excellent outcome.

Occult acetabulum fracture. A case report.

Acetabular fractures that are radiographically occult are associated with insufficiency fractures, stress fractures, and fractures secondary to steroid-induced osteoporosis, usually affecting older patients after low-energy trauma. Occult acetabulum fractures in young patients are extremely rare. We discuss herein a case of an occult acetabulum fracture after high-energy trauma, in a young patient. This case illustrates the need for further diagnostic studies such as computed tomography, magnetic resonance imaging, or bone scanning when, despite negative radiographic findings, groin pain is persistent.

An unusual case of elbow dislocation.

The annual incidence of elbow dislocation is 6 to 8 cases per 100,000 in the United States; these dislocations represent 11% to 28% of all elbow injuries. The frequency of elbow dislocation is second to that of shoulder dislocation. Adult elbow dislocations are classified by the direction of displacement and associated fractures. They can be anterior, posterior, lateral, or divergent, with the most common type being posterior displacement of both the radius and ulna in relation to the distal humerus. This case report presents a rare case of a twisting dislocation of the elbow joint without any accompanying fracture. A 55-year-old woman presented with a swollen and painful right elbow joint and a pronated forearm after falling on her outstretched right arm. Closed reduction was performed under local anesthetic. No neurovascular deficit was recorded before or after reduction, and no ectopic calcification was observed at 1 year follow-up. Early mobilization of the elbow resulted in a stable joint with full range of motion. The rehabilitation of elbow dislocation ranges from aggressive immediate active motion to traditional plaster of Paris immobilization for several days. Forceful passive mobilization in the rehabilitation period must be avoided, since the elbow joint has a natural tendency to develop myositis ossificans following passive manipulation.