Locked intramedullary fixation vs plating for displaced and shortened mid-shaft clavicle fractures: a randomized clinical trial.

BACKGROUND: Recent literature supports surgical intervention for shortened, displaced, mid-shaft clavicle fractures. We present the results of a randomized clinical trial comparing locked intramedullary fixation and plate fixation for short, displaced, mid-shaft clavicle fractures. MATERIALS AND METHODS: Local ethical approval was obtained and power analysis and sample size calculations were performed prior to commencement. Patients randomized to 2 groups to be treated with either locked intramedullary fixation or plating. Patients regularly followed up to clinical and radiographic union. The primary outcome measure was the Constant score, secondary outcome measures included the Oxford shoulder score, union rate, and complication rates. RESULTS: Seventeen patients were randomized to locked intramedullary fixation and 15 randomized to plating. Mean age was 29.3 years. Mean follow-up was 12.4 months. There was no significant difference in either Constant scores (P = .365) or Oxford scores (P = .773). There was 100% union in both groups. In the intramedullary group, 1 case of soft tissue irritation settled after the pin removal; 1 pin backed out and was revised. Three superficial wound infections resulted in plate removal and 8 plates (53%) were removed. DISCUSSION: Intramedullary fixation has the theoretical advantage of preserving the periosteal blood supply, but carries the morbidity of pin removal. Clavicle plates are not routinely removed but require greater exposure and may compromise periosteal blood supply. CONCLUSION: Both locked intramedullary fixation and plating produce good functional results; however, metalwork may need to be removed as a second procedure.

Bilateral glenohumeral septic arthritis secondary to retroperitoneal abscess.

Glenohumeral septic arthritis is rare and usually a result of Staphylococcus aureus infection. Gram-negative septic arthritis is on the increase and is usually associated with intraabdominal pathology. We present a case of bilateral E. Coli glenohumeral septic arthritis associated with retroperitoneal abscess and discuss pitfalls in diagnosis and management.

Evaluation of a bioresorbable polylactide sheet for the reduction of pelvic soft tissue attachments in a porcine animal model.

In an adult porcine model, the effectiveness of a bioresorbable film to minimize soft tissue attachment to the pelvic viscera was evaluated at 4-week and 12-week endpoints. Following a transperitoneal laparotomy through a midline incision, the bladder and uterus were abraded in all animals to promote soft tissue attachment to the viscera. Control animals received no further treatment. The experimental group animals were treated with bioresorbable polylactide (PLa) sheets, 0.02 mm thick, one between the bladder and the abdominal wall, and a second sheet between the bladder and the uterus. Quantitative assessment of the severity and location of soft tissue attachments, and qualitative histologic assessment were performed at 4 and 12 weeks post-operatively. Statistically significant differences in the quantitative soft tissue attachment scores were observed in comparing the PLa film treated animals versus the control animals, at both the 4-week and 12-week time points. In the control animals, the formation of numerous thick fibrous bands was observed at both time points. Histology revealed no adverse reaction to the bioresorbable PLa barrier film. The bioresorbable PLa sheet provided an effective barrier between adjacent anatomical structures and minimized soft tissue attachments to the device when in contact with the viscera as compared to the control groups. Surgical dissection planes between the abdominal wall and adjacent soft tissues were maintained with the use of the PLa sheet at both time points.

Predicting in vivo clinical performance of anterior cruciate ligament fixation methods from in vitro analysis: industrial tests of fatigue life and tolerance limits are more useful than other cyclic loading parameters.

BACKGROUND: Anterior cruciate ligament graft fixations experience cyclic loads in vivo. Present cyclic loading studies testing fixation use "incremental cycling," "residual strength" protocols, or a combination. Industrial standards, however, rely on fatigue life testing and use tolerance limits to determine guaranteed minimum levels of cycles to failure. HYPOTHESIS: Industrial standards of fatigue life and lower tolerance limits provide a more conservative assessment of cycles to failure than do currently used cyclic loading models, and they facilitate interpretation of data toward clinical performance. STUDY DESIGN: Descriptive laboratory study. METHODS: Fatigue life curves and lower tolerance limits were calculated for porcine patellar tendon graft fixations that were tested to failure in single pulls or cycled to failure at 2 different load levels. A log curve was constructed so that the expected values at other load levels could be calculated. Comparison of a metal and a composite resorbable interference screw design was used as an example. RESULTS: Cycles to failure of both screw designs varied widely at each load level. The guaranteed minimum number of cycles calculated by tolerance limits was therefore much lower than the mean cycles to failure at any given load level. For example, at a load of 250 N, the predicted mean life for the composite screw and the metal screw was 2513 and 1490 cycles, respectively, whereas the 80/80 tolerance limits (the value that 80% could be expected to achieve with 80% confidence) were only 63 and 68 cycles, respectively. Small reductions in load level gave very large increases in minimally expected life. CONCLUSIONS: Fatigue testing of anterior cruciate ligament reconstructions better shows the wide variation between specimens and the large effect of load levels on expected life. Wide scatter makes mean levels over-optimistic and difficult to interpret. Tolerance limits give estimates that are more conservative and facilitate data interpretation. CLINICAL RELEVANCE: A method for testing and analyzing fatigue properties was presented, results of which are more readily interpreted to clinical practice.