Arthroscopically Assisted Treatment of Isolated Comminuted Trapezium Fracture: A Report of Two Cases.

CASES: Two competitive athletes with isolated comminuted trapezium fractures, sustained during American football and rugby, presented with pain and swelling of the first metacarpal base. Computed tomography confirmed isolated comminuted trapezium fractures. Arthroscopic reduction of displacement with screw fixation below the articular surface was performed through a small incision. Both patients returned to their preinjury sports levels within 2 months postoperatively. CONCLUSION: Arthroscopic treatment of isolated comminuted trapezium fractures achieved accurate reduction of articular surface displacement and preserved trapeziometacarpal joint stability with minimal soft-tissue invasion. This facilitated an early return to contact sports for the affected athletes.

OSTEOSYNTHESIS OF COMPLEX COMMINUTED HAND BONE FRACTURES BY APPLYING THE LACING METHOD (A CLINICAL CASE STUDY).

Complex comminuted hand injuries are an urgent medical and social problem of national health systems, which is especially sensitive for countries with a low level of socio-economic development. The work aims to substantiate the effectiveness and safety of the shoelace method of hand bone osteosynthesis in complex comminuted fractures (a clinical case study). Clinical case: A 42-year-old female patient was admitted to the clinic with complaints of the presence of a crushed wound on the 2nd finger of the left hand. The shoelace method was applied for hand bone osteosynthesis. The surgical intervention time was 24 minutes, and the time before returning to work or daily activities equaled 7.1 weeks. The time to bone fusion was less than 45 days. The shoelace osteosynthesis method in complex comminuted fractures of the hand bones has prospects for modern clinical practice with the possibility of improving the performance and safety indicators.

Comparison of 2 different fixation techniques of comminuted acetabular quadrilateral surface fractures using square bracket-shaped tubular plate or interfragmentary screws in addition to supra/infrapectineal plate fixation: An observational study.

The management of comminuted quadrilateral fractures remains challenging, and treatment options are constantly evolving. The purpose of the present study was to examine the outcomes of 2 different fixation techniques in the management of comminuted quadrilateral fractures. Twenty-two patients with comminuted quadrilateral acetabular fractures were surgically treated with interfragmentary lag screw (group 1) and square bracket-shaped tubular (SBST) plate technique (group 2), in addition to suprapectineal and infrapectineal pelvic reconstruction plate fixation between January 2016 and July 2019 at our clinic. 2 years follow-up control data of each group were compared in terms of radiological and functional results, and complications. According to the functional score comparison, the mean Merle d'Aubigne Postel scoring system (MAP) score was 15.2/15.6 (P = .632), and the mean Harris hip scoring (HHS) system score was 74.65/77.3 (P = .664) in groups 1 and 2, respectively. Radiological comparison was performed according to matta radiological criteria (MRC), and 2 excellent, 6 good, 2 poor, 4 excellent, 4 good, and 4 poor radiological results were observed in groups 1 and 2, respectively. intraarticular screw penetration was detected in 3 patients in group 1, while there was no articular implant penetration in group 2 (P = .001). We believe that satisfactory results can be obtained with the SBST plate technique, offering functional and clinical outcomes that are similar to those of the interfragmentary screw technique. The SBST plate technique is superior in terms of avoiding intraarticular screw penetration and related revision surgery.

Quadruple Disruption of Superior Shoulder Suspensory Complex With Proximal Humerus Open Fracture-Dislocation: A Case Report.

CASE: A 34-year-old man was a restrained passenger involved in a high-speed rollover motor vehicle crash. The patient sustained a type 5 AC joint separation, severely comminuted intra-articular glenoid fracture with extension to the coracoid process base, displaced open scapular body fracture, a posterior shoulder dislocation of the glenohumeral joint, and a 2-part proximal humerus fracture. CONCLUSION: To our knowledge, this is the first report describing this injury pattern involving the superior shoulder suspensory complex with an associated open proximal humerus fracture-dislocation.

Locking plate fixation in comminuted coronoid fractures with partial loss of the articular cartilage - Of basal-1 type according to the O'Driscoll classification.

BACKGROUND: We have attempted to restore the arc of motion by considering trochlear-coronoid articulation as a complete circle during fixation of the coronoid, even for comminuted coronoid fractures with partial loss of articular cartilage (CCFPLAC), using various kinds of locking plates. Herein, we report the radiological and clinical outcomes after fixation of the basal-1 type of CCFPLAC (O'Driscoll classification) using our method. METHODS: Thirty-one patients diagnosed with CCFPLAC were admitted between January 2012 and December 2020. Sixteen of these patients met the inclusion/exclusion criteria and were enrolled in this study. Surgically, the lost area (defect of articular cartilage) was never compressed or minimized, but the original height and shape of the coronoid were preserved as is. Provisionally, a few K-wires were used to maintain the original shape and position of the CCFPLAC, and various kinds of locking plates/screws were used to fix the fragment anatomically and firmly. If needed, the plate was bent to ensure stable compression of the coronoid according to its size. In a few cases, locking plates were adjusted by cutting extra screw holes. RESULTS: Among the 16 patients, the mean age was 46.2 years, and the male:female ratio was 10:6. The mean follow-up period was 3.63 years. 8, 6, and 2 patients were designated as group 1 (isolated CCFPLAC), 2 [CCFPLAC in type 4 (terrible triad) injury), and 3 (CCFPLAC in type 5 posterior olecranon fracture-dislocations), respectively. Complete union was achieved after a mean of 8.94 weeks. The mean flexion-extension and pronation-supination arcs were 127.19 ± 4.46° and 135.31.59 ± 8.06°, respectively, which were significantly different from those on the contralateral (normal) side (p < 0.001); however, the arcs were within the functional ranges for ordinary daily living. Additionally, the functional status was satisfactory in all patients. However, Mayo Elbow Performance Score and the degree of arthritis were statistically poor in group 2. CONCLUSIONS: CCFPLAC of the basal-1 type (O'Driscoll classification) can be treated satisfactorily if already designed and widely distributed locking plates are properly manipulated to maintain the original geometry of the coronoid according to the individual joint characteristics. LEVEL OF EVIDENCE: Level IV, Retrospective case series.

Comparative study of retrograde intramedullary nailing versus locking extramedullary plating in complete articular fractures with metaphyseal comminution of the distal femur.

INTRODUCTION: Fractures of the distal femur with metaphyseal comminution and complete intra-articular involvement (AO/OTA classifications 33C2 and 33C3) present challenges for reduction and fixation. However, an optimal fixation method remains unknown. This study aimed to compare the clinical and radiographic outcomes of locking extramedullary plating (LEP) and retrograde intramedullary nailing (RIN) for complete distal femoral intra-articular fractures with metaphyseal comminution. MATERIALS AND METHODS: Between January 2016 and May 2022, 80 patients (45 men and 35 women; average age, 56.7 years) diagnosed with AO/OTA 33C2 and 33C3 were treated with either LEP or RIN and followed up for at least one year. Post-operative evaluations included radiographic assessments of bone union rate, timing, and alignment. Clinically, the knee joint range of motion (ROM), lower extremity functional scale (LEFS), and Kellgren and Lawrence (KL) grade were analyzed. The complications were also compared. RESULTS: 36 underwent LEP and 44 underwent RIN. Bone union was observed in 69.4% and 63.6% of the patients in the LEP and RIN groups, respectively (p = 0.64). The average union time was 6.9 months for the LEP group and 6.6 months for the RIN group (p = 0.51). A tendency toward varus deformity was observed in the RIN group, although the difference was not statistically significant. No significant differences were observed in knee ROM, LEFS, or KL grade. Complications included non-union (33.8%; RIN, 11; LEP, 16), varus deformity (5%; RIN, 4; LEP, 0), infection (1.3%; RIN, 0; LEP, 1), heterotrophic ossification (1.3%; RIN, 0; LEP, 1), and wound dehiscence (2.5%; RIN, 2; LEP, 0). CONCLUSIONS: The surgical fixation methods, RIN and LEP, for complete distal femoral intra-articular fractures with metaphyseal comminution showed similar clinical and radiological outcomes. However, regardless of the type of fixation device used, there was a reduced rate of bone union owing to high energy and a less favorable prognosis.

Modified patient-specific surgical-guide-assisted precise treatment of unilateral comminuted zygomaticomaxillary complex fractures: A 5-year retrospective study.

Our study aimed to evaluate modified patient-specific surgical-guide-assisted precise treatment of unilateral comminuted zygomaticomaxillary complex (ZMC) fractures. The retrospective non-randomized study was conducted in a single hospital in China. All patients diagnosed with unilateral comminuted ZMC fractures between January 1, 2018 and December 31, 2022 were retrospectively reviewed. All patients underwent preoperative spiral computed tomography (CT). CT data were processed using software to DICOM format and transferred to Proplan CMF3.0 for preoperative virtual surgical planning and postoperative evaluation. All data were extracted from standardized electronic medical records. All statistical analyses were performed using SPSS version 20.0. The chi-square test and t-test were used for statistical analyses. The 54 included patients were divided into two comparable, equal cohorts of 27 patients, and followed up for at least 6 months. Fracture reduction was assisted using the modified patient-specific surgical guides in the guide group (23 males, four females; mean age 37.74 ± 12.07 years) and without the modified patient-specific surgical guides in the control group (20 males, seven females; mean age 37.44 ± 13.58 years). In the guide group, the mean eminence deviation between the affected and unaffected sides was 1.01 ± 0.92 mm, and the mean width deviation between the affected and unaffected sides was 1.29 ± 1.32 mm. In the control group, the mean eminence deviation between the affected and unaffected sides was 1.99 ± 1.69 mm, and the mean width deviation between the affected and unaffected sides was 2.68 ± 2.01 mm. The differences in facial protrusion (p = 0.001) and width (p = 0.003) symmetry between the affected and healthy sides of the two groups were statistically significant (p < 0.05). In conclusion, applying the modified patient-specific surgical guides to unilateral comminuted zygomaticomaxillary complex fracture reduction has the advantages of greater predictability and effectiveness, and improved bilateral ZMC symmetry. It should be noted that this approach would be especially beneficial for less-experienced surgeons.

Does simultaneous comminuted fracture of both radial ends represent a distinct fracture pattern?

BACKGROUND: Although isolated distal radius and radial head fractures are common injuries, simultaneous ipsilateral fractures are uncommon. They can range from simple undisplaced fractures at either end to severely comminuted ipsilateral proximal and distal radial fractures. Few cases have been reported with concomitant comminuted distal radius and radial head fractures, and no treatment guidelines are available. Decisions are often based on personal recommendations. The purpose of our study is to increase awareness of this injury pattern and to discuss the mechanism of injury, treatment approach, and functional outcome. METHODS: Skeletally mature patients with comminuted simultaneous ipsilateral fractures of the distal and proximal radius from 2016 to 2021 were identified and studied retrospectively. Demographic information, mechanism of injury, treatment approach, and complication rate were analyzed. Radiographic assessment for inadequacy or loss of reduction and radiographic parameters of the distal radius, including radial inclination, radial length, and palmar inclination, was performed immediately postoperatively and at the final follow-up. Clinical outcomes were determined by calculating the Visual Analog Scale (VAS) score, measuring the range of motion in both joints, and using the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score at the final follow-up. RESULTS: A total of 11 patients met the inclusion criteria. All had ipsilateral Mason III radial head fractures and type C (according to the Arbeitsgemeinschaft für Osteosynthesefragen (AO) classification) intra-articular distal radius fracture. On-table radial head reconstruction and fixation with a proximal radius plate were used for radial head fractures, and osteosynthesis with an anatomic volar locking plate was used for distal radius fractures. The mean follow-up duration was 32 months (range 12-65 months). At the final follow-up, osseous union of both the radial head and distal radius was observed in all patients. The mean VAS score was 1.5 (range 0-7) at rest and 3.9 (range 0-9) with activities, while the mean QuickDASH score was 32 (range 12-65). No significant complications were recorded. CONCLUSION: Simultaneous comminuted fractures of the ipsilateral distal radius and radial head represent a distinct injury pattern, most likely resulting from high-energy trauma, such as falling from a height onto an outstretched hand. Greater emphasis should be placed on clinical examination and radiological imaging of the elbow in cases of wrist injuries and vice versa. Treatment involving on-table reconstruction of the radial head and open reduction and internal fixation with a volar plate can lead to good radiological and functional outcomes.

Megaprosthetic replacement in complex distal humerus fractures in elderly patients: a case series.

BACKGROUND: Managing distal humeral fractures can be challenging for orthopedic surgeons. There are several treatment options for managing this type of fracture, and the treatment method for these fractures should be based on patient-related factors. In elderly patients with osteoporotic bone and severe comminution of the fracture, adequate fixation can be a major challenge for surgeons. The use of megaprosthesis has been recently proposed in traumatology as an alternative to osteosynthesis or conventional prosthesis for the management of comminuted articular fractures in elderly patients with poor bone stock. METHODS: A consecutive case series of 5 patients who underwent reconstruction of the elbow joint with a trabecular hinged modular elbow megaprosthesis was reviewed retrospectively. All patients included had AO/OTA 13C2 and 13C3 fractures with metaphyseal extension and considerable bone loss of the distal humerus. The primary outcome was the evaluation of functional and clinical outcomes with the MEPS score in comminuted distal humerus fractures with metaphyseal extension and poor bone stock in elderly patients treated with elbow megaprosthesis. The secondary outcome was assessing the treatment-related complication rate of this technique in non-oncological fields. RESULTS: Five patients were included in the study with a mean age of 82.66 ± 7.72 years at surgery. The mean MEPS value was 63 ± 24.2 at 1 month, 81 ± 23.53 at 3 months, 83 ± 24.2 at 6 months, and 84 ± 24.57 at 12 months. No intraoperative complications were recorded in our series. Of 5 patients, four patients had excellent clinical and functional outcomes. We did not encounter wound dehiscence, prosthetic joint infection, aseptic loosening, or periprosthetic fractures. CONCLUSIONS: The indication for this type of treatment must be selected and narrowed down, as it is a salvage procedure, and any failure would cause even more complex situations. Short operating times and early mobilization of the elbow are the advantages of this technique.

Biomechanical comparison of distal femoral fracture fixation: Polyaxial vs. uniaxial locking screws with different blocking screw configurations in retrograde femoral nailing.

INTRODUCTION: Clinical studies have indicated reduced reliance on blocking screws with the introduction of polyaxial locking nails, yet the biomechanical superiority of polyaxial locking over blocking screws remains unverified, specifically for distal dia-metaphyseal femur fractures. HYPOTHESIS: We hypothesized that the combination of multiaxial locking using three screws and parallel locking reinforced by two blocking screws would result in superior outcomes compared to utilizing only parallel locking with two screws and one blocking screw. MATERIALS AND METHODS: Third-generation custom-made femur models representing AO/OTA 32 A1.2 dia-metaphyseal comminuted oblique fractures were divided into four groups (n=10/group). Group A employed distal fixation with three 4.5-mm polyaxial screws. Group B used two parallel locking screws and two blocking screws, Group C used two parallel locking screws and one blocking screw, and Group D used only two parallel screws. Specimens underwent axial and torsional load testing to assess fatigue strength, ultimate strength, axial stiffness (N/mm), torsional stiffness (N/mm/deg), axial load to failure (N), torsional load to failure (N/mm), coronal and sagittal angulations, and fracture site collapse. RESULTS: Group C exhibited statistically superior torsional stiffness compared to Groups B and D (p=0.039 and p=0.034, respectively). Axial load to failure was highest in Group B and lowest in Group D (p=0.032). Group C demonstrated the highest torsional strength, while Group B exhibited the lowest (p=0.006). Coronal displacement was greatest in Group B, while Group A showed the highest resistance (p=0.009). Group A demonstrated the greatest resistance to fracture site collapse, with the weakest specimens observed in Groups B and C (p=0.01). DISCUSSION: The performance of a single laterally positioned blocking screw is comparable to using two blocking screws. Medial positioning of a second blocking screw is unnecessary for stability enhancement. Multiaxial locking prevents fracture site collapse and coronal plane angulation more effectively than other methods. Multiaxial locking and/or parallel screws with a single laterally positioned blocking screw provide superior stiffness and stability for treating unstable dia-metaphyseal distal femoral fractures. LEVEL OF EVIDENCE: N/A.

Plate fixation optimization for distal femoral fractures with segmental bone loss: Defining the preferred screw distribution using finite element analysis.

OBJECTIVES: Distal femur fractures can exhibit extensive comminution, and open fractures may result in bone loss. These injuries are under high mechanical demands when stabilized with a lateral locked plate (LLP), and are at risk of non-union or implant failure. This study investigates the optimal LLP screw configuration for distal femur fractures with a large metadiaphyseal gap of 5 cm. METHODS: A finite element (FE) model, validated against experimentally measured strains and displacement, evaluated pull-out forces and stress concentration on typical implants under clinical conditions corresponding with the 10 % point during the stance phase of the gait cycle. RESULTS: Maximum stress was up to 83 % less when the ratio (Cp) between the proximal screw-distribution-length and the distance of the first screw to the fracture was less than 0.2; maximum pull-out force was 99 % less when this ratio was higher than 0.4. CONCLUSIONS: Screw configuration based on either normal or osteopenic bone quality plays an important role in determining the risk of construct failure for a major (50 mm) distal femoral metadiaphyseal segmental defect. This study provides valuable information when planning definitive fixation for distal femur fractures with extensive comminution or segmental bone defects, to mitigate the risk of implant failure and subsequent nonunion.

Comparison of different internal fixation implants in the treatment of talar neck fractures: A finite element analysis.

OBJECTIVES: This study aimed to analyze the biomechanics of cannulated screws (CS) with or without a lateral locking plate (LLP) in talar neck fractures through a finite element analysis. PATIENTS AND METHODS: The computed tomography image of the talus from a healthy volunteer (adult male) was used to reconstruct a three-dimensional talar model. The method for fixing talar neck fractures with CS and an LLP was planned using computer-aided design software. Afterward, the three-dimensional models of comminuted talar neck fractures were used to simulate fixation with anteroposterior parallel dual CS, single CS+LLP, and dual CS+LLP. Finally, finite element analysis was carried out to compare the outcomes of dual CS+LLP to those of single CS+LLP and to those of using dual CS alone. The displacement and von Mises stress values of the three groups with different internal fixation were analyzed. RESULTS: For a simple talar neck fracture, the lowest amount of displacement was obtained with CS+LLP (0.407 mm), while dual CS (0.459 mm) showed the highest amount of total displacement; the lowest amount of peak stresses was obtained with CS+LLP (5.38 MPa), while dual CS (8.749 MPa) showed the highest amount of total peak stresses. For a comminuted talar neck fracture, the lowest amount of displacement was obtained with CS+LLP (0.398 mm), while dual CS (0.408 mm) showed the highest amount of total displacement; the lowest amount of peak stresses was obtained with CS+LLP (129.9 MPa), while dual CS (205.9 MPa) showed the highest amount of peak stresses. CONCLUSION: Compared to the other two groups, the dual CS+LLP group had better biomechanics properties in the displacement and stress peak of the talus and implant. Thus, the use of dual CS+LLP fixation is recommended for the surgical treatment of comminuted talar neck fractures.

Can multiple miniplates improve the treatment of comminuted patellar fracture?

BACKGROUND: We have applied primarily multiple locking compression miniplates in treating multifragmentary, comminuted patellar fracture in combination with conventional fixation methods. METHODS: Medical and radiologic data were retrospectively reviewed for the patients surgically fixated with locking compression miniplates in patellar fracture of AO/OTA 34-C3. The primary outcome was bone union at the final follow-up, and the secondary outcomes were functional outcomes and postoperative complications associated with the procedure. For the functional assessment, the Lysholm score, Tegner scores, and the knee range of motion was compared. RESULTS: A total of twenty patients with AO/OTA 34-C3 patellar fracture were included in the study with an average follow-up period of 15 months (range:11 ~ 18 months) between June 2018 and November 2021. Eleven male and nine female patients presented an average age of 57.15 years. The primary fracture union was seen in all twenty patients, and the average time to the union was 15.6 weeks on serial radiograph follow-up. All patients did not show any postoperative complications, such as fixation failure, infection, or revision operations. Postoperatively, all patients achieved an average range of motion of 130 degrees, and the Lysholm and Tegners scores showed an average of 90.4 and 5.0 at the final follow-up, retrospectively. CONCLUSION: Fixations with miniplates in comminuted patellar fractures can be a useful option for effective osteosynthesis due to their versatile, efficient, and low-profile nature.

Lateral tibial plateau fractures with posterior comminution. Can a rim plate offer sufficient support?

Tibial plateau fractures with posterior comminution are difficult to reduce and stabilise. Standard lateral approach doesn't offer adequate visualisation. Posterior approach is suitable for isolated posterior fractures. The addition of a specifically contoured rim plate can enable fixation of posterior fragments through a modified lateral approach.The purpose of this study was to evaluate the advantages and limitations of this novel technique. We present a prospective series of 16 tibial plateau fractures with posterolateral depression, operated over a period of 7 years (04.2014-09.2021). The mean age of the patients was 52 years .They were followed for an average period of one year.Clinical and functional assessment was performed according to the criteria of Knee Society Clinical Rating Score. The lateral and posterior component of the fracture was stabilised by a horizontal rim plate, through a posterolateral approach, with or without fibular osteotomy. 9 patients had excellent, 5 had good, 2 had average ratings. The average objective rating was 87,5 (70- 97), and the average functional rating was - 74,4 (40-100). The average ROM was 110° (100°-120°). Two of the fractures healed in 5° varus and 8° valgus respectively. One knee joint ended up with 10° flexion deficit. Three knees had medio- lateral instability, with no functional impairment. In 4 cases the K wires of the weber fibular osteotomy fixation migrated. The absence of late articular collapse of the treated fractures may be attributed to the initial stability of fixation.The addition of a rim plate addresses the posterior comminution and makes early rehabilitation safe.

A Type IV Extension Supracondylar Fracture With Comminuted Fracture Pattern: A Case Report.

CASE: A three year, 11 month old girl sustained a right displaced extension supracondylar fracture (ESF) of the humerus with comminution of the lateral column after an indoor fall. At surgery, fracture reduction showed multidirectional instability. Adequate reduction was achieved by applying longitudinal traction of the arm with partial elbow flexion and forearm supination. One percutaneous medial pin, followed by one lateral cross pin, was used to immobilize the fracture. Normal posterolateral new periosteal bone formation was seen on radiograph on the lateral side. At 5-year follow-up, she had full range of asymptomatic and symmetrical elbow motion. CONCLUSION: This case report shows a displaced ESF with a comminuted lateral humeral column, which contributed to a lack of adequate lateral pin purchase on bone. A modified pin fixation technique first with a medial pin and followed by a lateral pin with both placed through the medial column was used for stable fracture fixation. In addition, this case showed that fracture comminution was a contributory factor to the rare multidirectional instability of the Gartland Type IV fracture.

Prevalence and Predictors of Peroneal Tendon Instability Accompanying Calcaneal Fractures.

BACKGROUND: We aimed to find the prevalence of peroneal tendon instability (PTI) accompanying different types of calcaneal fractures and to determine predictors of PTI based on preoperative CT scanning. METHODS: In a retrospective cross-sectional study, preoperative CT scans of 400 consecutive calcaneal fractures undergoing surgery were reviewed for comminuted fragments in the lateral gutter of the ankle, fractures at the tip of the lateral malleolus, dislocated peroneal tendons, excessive displacement of the lateral calcaneal wall, calcaneal fracture-dislocation, superior peroneal retinaculum (SPR) avulsion fracture (fleck sign), and shape of the retromalleolar groove. The correlation of these variables with intraoperative SPR stress test, defined as the diagnostic criteria for PTI in calcaneal fractures, was evaluated. RESULTS: In total, 369 patients (mean age, 39 ± 13; range, 11-72 years), with 321 (87.0%) of them male, were included. Among all calcaneal fractures, 67 cases (16.7%) had associated PTI as confirmed intraoperatively by an SPR stress test. A statistically significant association was found between PTI in calcaneal fractures and comminuted fragments in the lateral gutter of the ankle (P = .03), dislocated peroneal tendons (P < .001), calcaneal fracture-dislocation (P < .001), SPR avulsion fracture (P < .001), and Sanders type IV of calcaneal fracture (P = .02). There was no statistically significant relationship between PTI and the mechanism of injury (P = .98), side of fracture (P = .30), uni- or bilateral calcaneal fractures (P = .27), a fracture at the tip of lateral malleolus (P = .69), shape of the retromalleolar groove (P = .78), or excessive displacement of the lateral calcaneal wall (P = .06). The most specific CT finding to predict PTI accompanying calcaneal fractures was calcaneal fracture-dislocation (99.1%). CONCLUSION: Following calcaneal fracture fixation, PTI was confirmed with intraoperative SPR stress test in one-sixth of cases. With the exception of calcaneal fracture-dislocation, preoperative findings on CT scanning and calcaneal fracture pathoanatomy are insufficient to diagnose PTI accompanying calcaneal fractures. LEVEL OF EVIDENCE: Level III, retrospective case control study.

Impact of Different Osteotomy Techniques on Bone Reserve in the Osteotomy Line in Sagittal Split Osteotomy: Experimental In Vitro Study in Caprine Mandible Model.

OBJECTIVE: The objective of this study was to investigate of the effect of piezzo and conventional osteotomy techniques on bone reserve in the osteotomy line and comminuted fracture ratios that is able to compromise bone to bone contact negatively. METHODS: Bilateral sagittal split ramus osteotomy was performed on 12 fresh male Thracian curly caprine mandible. In the first group (n: 12) osteotomies were performed with piezzo device. In the second group (n: 12) osteotomies were performed with micromotor and manual osteotomes. Operative time was measured. The number of comminuted fractures, length and width of the osteotomy, and the space between the osteotomy lines was evaluated from 3-dimensional computed tomography scans. RESULTS: The mean value of procedure duration was 320.4±10.76 seconds for piezo osteotomy and 238.8±8.29 seconds for conventional micromotor ( P <0.0001). Number of comminuted fractures was 1.41±1.3 in piezoelectric group, 1.5±1.3 in conventional group and the difference was not statistically significant (p: 0,88). Osteotomy lengths and widths were 35.58±5.2, 2.196±1.9 and 36.23±5.05, 2.27±1.85 in the piezzo and conventional groups, respectively. (p lengths :0,75; p widths :0,92) The volume of the bony interface between the distal and proximal segments of the mandible after osteotomy was 166.3±184.2 mm 3 in the piezzo group and 163.5±129.3 mm 3 in the conventional group (p: 0,96). CONCLUSION: The piezo surgery and the conventional osteotomy were found to be similar in terms of the gap between the distal and proximal mandible and the number of comminuted fractures. The duration to perform the conventional osteotomy was found to be shorter than the piezo surgery.

External mandibular fixation for gunshot fractures: report of 2 cases.

High-energy ballistic injuries may cause comminuted facial fractures. Treatment of such fractures might be challenging because of in-fection and soft- and hard-tissue loss. These cases may not be amenable to open reduction and internal fixation. We present 2 cases of gunshot fractures, for which external fixation was used as a surgical step before definitive treatment. With the use of external fixation, existing infection had been controlled and soft tissues had been restored, which allowed oral rehabilitation with reconstruction plates and autogenous bone grafting, if needed.

What makes vertical femoral neck fracture with posterior inferior comminution different? An analysis of biomechanical features and optimal internal fixation strategy.

BACKGROUND AND PURPOSE: Fracture comminution occurs in 83.9%-94% of vertical femoral neck fractures (VFNFs), the majority of which were located in posterior-inferior region, and poses a clinical challenge in fixation stability. We conducted a subject-specific finite element analysis to determine the biomechanical features and optimal fixation selection for treating VFNF with posterior-inferior comminution. PATIENTS AND METHODS: Eighteen models with three fracture types (VFNF without comminution [NCOM], with comminution [COM], with comminution + osteoporosis [COMOP]) and six internal fixation types (alpha [G-ALP], buttress [G-BUT], rhomboid [G-RHO], dynamic hip screw [G-DHS], invert triangle [G-ITR], femoral neck system (G-FNS)) were created based on the computed tomography data. By using the subject-specific finite element analysis method, stiffness, implant stress, yielding rate (YR) were compared. Additionally, in order to elucidate distinct biomechanical characters of different fracture types and fixation strategies, we calculated interfragmentary movement (IFM), detached interfragmentary movement (DIM), shear interfragmentary movement (SIM) of all fracture surface nodes. RESULTS: Generally, in comparison with NCOM, COM showed a 30.6% reduction of stiffness and 1.46-times higher mean interfragmentary movement. Besides, COM had a 4.66-times (p = 0.002) higher DIM at the superior-middle position, but similar SIM across fracture line, which presented as varus deformation. In COM and COMOP, among all six fixation strategies, G-ALP had significantly the lowest IFM (p<0.001) and SIM (p<0.001). Although G-FNS had significantly highest IFM and SIM (p<0.001), it had the highest stiffness and lowest DIM (p<0.001). In COMOP, YR was the lowest in G-FNS (2.67%). CONCLUSIONS: Posterior-inferior comminution primarily increases superior-middle detached interfragmentary movement in VFNF, which results in varus deformation. For comminuted VFNF with or without osteoporosis, alpha fixation has the best interfragmentary stability and anti-shear property among six current mainstream fixation strategies, but a relatively weaker stiffness and anti-varus property compared to fixed-angle devices. FNS is advantageous owing to stiffness, anti-varus property and bone yielding rate in osteoporosis cases, but is insufficient in anti-shear property.