A comparative retrospective study of locking plate fixation versus a dedicated external fixator of 3- and 4-part proximal humerus fractures: Results after 5 years.

INTRODUCTION: Fractures of the proximal humerus (PHF) represent a common injury among orthopedic department; especially for three- and four-part fractures no consensus about the best treatment is still achieved. The aim of our study was to compare clinical and radiological outcomes in patients alternatively treated with plates and screws or external fixation system for a type III-IV proximal humerus fracture. MATERIAL AND METHODS: Sixty-nine patients went surgery for type III-IV PHF between January 2011 and January 2014. According to the Neer classification, fractures were classified as type III in 50 cases (72,46%) and type IV in 19 cases (24,56%). 45 patients were treated with plates (65%) and 24 external fixators (35%). The patients' mean age was 62 years (range, 31-87 y). At five years, 60 patients (86,9%) were assessed using the visual analog scale (VAS) pain score, Constant Score (CS), the range of motion, and radiological evaluation. The CS at five years was the primary outcome measure. Results were evaluated and compared with the contralateral unaffected side to avoid bias related to different ages. RESULTS: At the final follow up, we found no clinical differences when comparing the two procedures. Moreover, when age was considered as a variable, a significative difference of the CS was observed in the group of patients younger than 65 years treated with a plate (Plate Group Mean: 79; SD: +/- 15. Ex Fi Mean: 58; SD:+/- 4. P = 0,008). In the group of patients older than 65 years, the two procedures did not show significative differences in outcomes (Plate Group Mean: 69; SD: +/- 15. Ex Fi Mean: 63; SD:+/- 7. P = 0,032). External fixation procedure was overall associated with a reduction in blood loss, surgical time, length of hospital stay. CONCLUSION: Percutaneous techniques have a long tradition in PHF treatment; the introduction of dedicated external fixation system has the advantage to improve the stability and allow early rehabilitation when compared to the classical pinning technique. In our experience, the indication elderly patients with osteoporosis and comorbidities may benefit by this type of mini-invasive surgery with low soft tissue damages.

Hybrid external fixation in the treatment of tibial pilon fractures: A retrospective analysis of 162 fractures.

OBJECTIVES: To determine the efficacy of hybrid external fixation in the treatment of tibial pilon fractures. DESIGN: Retrospective, multicentre study. PATIENTS/PARTICIPANTS: Adult patients with tibial pilon fractures treated with hybrid external fixation. INTERVENTION: Fracture reduction with ligamentotaxis and fixation with XCaliber hybrid external fixator. MAIN OUTCOME MEASUREMENTS: Fracture union, complications, functional outcome (Mazur Ankle Score). RESULTS: Union was obtained in 159 fractures at an average of 125days; there were three delayed unions and three non-unions. The most frequent complication was superficial pin-track infections (48), all of which responded to local wound care and antibiotics. There were no deep infections and no DVT. Only one fracture had loss of reduction that required frame revision. The overall functional scores were 91 (excellent) for AO/OTA type A fractures, 89 (good) for type B fractures, and 75 (satisfactory) for type C fractures. CONCLUSIONS: Hybrid external fixation is an effective method of stabilising tibial pilon fractures, particularly those with marked comminution. The minimally-invasive technique and stable fixation enable early mobilisation, with good functional results and minimal complications. LEVEL OF EVIDENCE: Level IV Case series.

Retrospective review of tibial plateau fractures treated by two methods without staging.

INTRODUCTION: Management of complex tibial plateau fractures can be challenging for orthopaedic surgeons. Wide disagreement still remains about the best surgical technique to use in these fractures. The purpose of this study was to compare the results of complex tibial plateau fractures treated by an open reduction and internal fixation (ORIF) versus hybrid external fixation (EF) in term of clinical and functional outcomes. MATERIALS AND METHODS: We retrospectively examined a series of 79 patients affected by tibial plateau fractures admitted at our Department between January 2006 and November 2011. Forty-one patients were treated using a hybrid EF; in 38 cases, ORIF technique was used. Clinical evaluation was performed using the method of Rasmussen; functional assessment was made using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. Residual pain was detected using a Numeric Rating Scale (NRS). RESULTS: The average time to union in the plate group was 17.2 weeks (9.1-45 weeks), while in the EF one 15.9 (7.5-32). The mean overall hospital stay was 14.2 days for the ORIF group and 7.8 for the EF group. At the last follow-up, the mean Rasmussen score was 24.9 (good) in the patients treated with ORIF and 25 (good) in those who received EF. The WOMAC index disclosed a relatively higher score in the EF group (80.5 ORIF-84.2 EF). Pain evaluation revealed no differences between the groups. In terms of complications, deep infection occurred in four (10.5%) patients belonging to the ORIF group and 2 (4.9%) to EF one. Signs of osteoarthritis (OA) were observed in 4 (10.5%) knees that had open reduction and in 11 (26.9%) that had a hybrid external fixator. CONCLUSIONS: Either ORIF or hybrid EF represents a valid treatment option in complex tibial plateau fractures. However, hybrid external fixation has shown relative better functional outcome results, relative lower rate of infection and decreased hospital stays. These aspects make of EF our best choice in case of high-energy complex tibial fractures.

Management of a humeral shaft non-union after a Gustilo III C fracture.

A 25-year-old man was admitted to our Department with an open humeral shaft fracture (Gustilo III C); two large wounds were noticed with ulnar artery and median nerve completely dissected. Initial primary treatment included irrigation, debridement and fracture stabilization with a monolateral external fixator followed by vascular and nerve repair and wound closure. At 6 months follow up the patient was able to use his arm without any painful stimuli and a CT scan showed the presence of postero-medial callus formation. Consequently, the external fixator was removed and the patient was discharged to physiotherapy. After 7 months, the patient presented with severe pain and functional impairment with no history of trauma. X rays showed recent re-fracture on a background of oligotrophic nonunion. Revision surgery included debridement of the non-union bone edges, reaming of the medullary canal and insertion of a humeral nail. Six months later osseous healing was noted with complete restoration of shoulder and elbow movement and partial recovery of the median nerve.

Hip painful prosthesis: surgical view.

Painful hip prosthesis is the most feared immediate and remote complication of a primary implant and usually represents the failure of one or more therapeutic moments. In cases of aseptic implant failure, the causes invoked may be represented by an incorrect indication, the quality of materials, local and general condition of the patient and especially from a bad joint biomechanics. In cases of septic loosening, however, the cause of failure to be found in the location of pathogens within the implant. In planning a revision is necessary to respect many important steps. They are represented by the exact identification of the causes of failure, the correct preoperative planning, by respecting the skin incisions, the proper choice of the prosthesis, planning the surgical technique, and finally by an appropriate rehabilitation program.In the evaluation of hip failure the first diagnostic step is to recognize exactly those aseptic and septic forms anyway to exclude the diagnosis of infection.