Successful surgical treatment of a four part fracture dislocations of the proximal humerus and coracoid avulsion.

racture-dislocation of the proximal humerus (usually occurring after violent trauma) may be more frequently associated with a poor long-term results because the destruction of the hinged periosteum is associated with an high-risk of avascular necrosis of the head of the humerus (1, 2). Concomitant coracoid fracture with anterior shoulder dislocation in such case is something extremely rarely reported (8). Herein, we describe a challenging case of a 44 years old man with 4-parts fracture of the right proximal humerus, dislocation of the glenohumeral joint associated with coracoid avulsion. Considering the severe functional damage on the right shoulder, the patient was immediately treated with open reduction internal fixation (ORIF) at the level of the proximal humerus and with the concomitant placement of one screw at the level of coracoid avulsion. At a 15 months follow up we observed an excellent clinical and radiographic results. We take the opportunity of this unusual case for briefly discuss on such clinical condition and surgical options. (www.actabiomedica.it).

Causes and treatments of lag screw's cut out after intramedullary nailing osteosinthesis for trochanteric fractures.

Background. Superior cut-out of a lag screw remains a serious complication in the treatment of trochanteric or subtrochanteric fractures and it is related to many factors: the type of fracture, osteoporosis and the stability of fracture reduction. Little is known about the outcome after revision surgery for complications of the gamma nail. We assessed the outcome in patients who had revision surgery because of lag screw's cut out after gamma nailing for a trochanteric fracture.Material and Method. We present a study of 20 consecutive patients who underwent treatment after 20 cut-out of the lag screw fixation of a trochanteric fracture with Gamma Locking Nail from September 2004 to November 2010. In 16 patients hip prothesis was performed, in 1 the removal of the implant and in 3 the reosteosynthesis. We reviewed 13 patients: 10 total hip arthroplasty, 2 endoprothesis and 1 reosteosynthesis of nail and lag screw (mean follow up: 26 months, mean age: 73 years old), 7 patients died. Patients were reviewed retrospectively by an independent observer. Clinical evaluation was performed, Oxford score and Harris Hip score were measured. X-Ray examination was performed after a minimum of 12 months of follow up.Results. Mean Harris Hip Score mean was 67 and mean Oxford score was 32 in hip prothesis group (12 patients). We had several complications, Implant-related complications were: 2 ipometria > 2cm, 2 recurrent hip arthroplasty dislocations (1 reoperated), 4 persistent thigh pain. In only 4 patients none complications were observed. Another patient,  who had been subjected to reosteosinthesis, obtained better results (HHS:95, Oxford score:45) but with a 2 cm ipometria and occasional pain in the thigh.Conclusion. Cut out after gamma nail is consequent to biological or mechanical causes. Treatment of this complication is hip prosthesis (parzial or total hip arthroplasty), reosteosynthesis of the lag screw and/or the nail and the removal of the implant. Conversion to total/parzial hip arthroplasty may be a demanding operation with a higher complication rate respect to the standard, while reosteosynthesis is possible in selected patients and early cutting out.

Distal radius articular fractures: a comparison between ORIF with angular stability plate and percutaneous Kirschner wires.

PURPOSE OF THE STUDY: To analize and compare vantages and disadvantages in long-term of two different  techniques to treat distal radius articular fractures: ORIF with plate versus percutaneous pinning with K-wires. MATERIALS AND METHODS: We reviewed 77 distal radial articular fractures treated surgically from 2005 to 2009. Fractures were divided in two homogeneous groups according to patient age, gender, fracture-type and follow-up. The first group was treated with ORIF using angular stability volar plate, while the second one with closed reduction, K-wires percutaneous pinning and ante-brachial plaster casting. Functional outcomes were assessed with MAYO and DASH score, wrist range-of-movement and handgrip. Radiographic parameters were calculated in the post-operative and long-term x-rays. RESULTS: ORIF group showed better mean DASH and MAYO score, range of movement and handgrip strength compare to K-wires group. Expecially in type C fractures and in younger patients (<65 years). Minor differences were observed in type B fractures. About complications: two cases of surgically-treated medial nerve compression in ORIF group and one in K-wire group, one case of algodystrophy in K-wire group. Referring to radiographic parameters, long term values show data positive for ORIF. CONCLUSIONS: Though several studies about these techniques has been performed, but no scientific evidence proves the superiority of one surgical treatment. C-type need to be treated with plate in young patients or in elderly patients with high functional demand. Elderly patients with low functional demand can achieve satisfactory results also with percutaneous pinning, especially in Btype fractures.

Displaced mid-shaft clavicular fractures: surgical treatment with a pre-contoured angular stability plate.

The treatment for displaced mid-shaft clavicle fracture is highly controversial. In the last years, several biomechanical studies showed better functional results after surgical treatment. The purpose of this study is to evaluate the use of pre-contoured angular stability plate in this type of fracture. From June 2005 to July 2009, we have surgically treated 89 patients with displaced clavicle fracture. We have reevaluated 68 patients for a total of 70 interventions. Outcomes were assessed with Constant score, Dash questionnaire and X-rays. The mean follow-up period was 2 years. Excellent and good results were achieved for all the patients revaluated. The mean Constant score was 94.1 pt, and DASH score was 4.1. We had two cases of nonunion (2.9 %), while there was no case of infection and vascular or nervous lesions. A review of the international literature indicates that there is not a largely accepted gold standard for the treatment for displaced mid-shaft clavicle fractures. In the last 10 years, biomechanical and clinical studies have shown that nonoperative treatment for this type of fractures, with marked shortening or diastasis of the clavicle superior to 2 cm, may result in lower functional outcomes or higher percentage of nonunion. Nowadays, a lot of surgical options are available for the treatment for displaced mid-shaft clavicle fractures. Our experience with pre-contoured angular stability plates has shown excellent clinical outcome. On the basis of our study, we support the use of pre-contoured angular stability plate.