Comparison of implant failure rates of different plates for midshaft clavicular fractures based on fracture classifications.

BACKGROUNDS: The aim of our study was to investigate failure rates of reconstruction plate and non-reconstruction plate, and find the best strategy for implant selection for different fracture types for midshaft clavicular fractures. PATIENTS AND METHODS: Two hundred twenty-six consecutive patients with midshaft clavicular fractures who received open reduction and plate fixation during Jan 2012 to July 2017 were reviewed. The correlations between implant failure rates and risk factors including demographic data, fracture classifications, and implant types were analyzed. RESULTS: AO/OTA fracture classification and plate types are the most important factors affecting implant failure for midshaft clavicular fractures. Reconstruction plate had a significantly higher failure rate (53%) than that of non-reconstruction plates (3%) in comminuted midshaft clavicular (AO/OTA 15-2C) fractures (P value < 0.01). However, the difference was not significant in AO/OTA 15-2A and 2B classifications. CONCLUSION: Patients with comminuted midshaft clavicular (AO/OTA 15-2C) fractures treated with reconstruction plates had very high implant failure rates compared to non-reconstruction plates. We suggested that patients with comminuted midshaft clavicular (AO/OTA 15-2C) fractures treated with reconstruction plates need more protection and more frequent follow-up in the postoperative period.

Biomechanical behavior of three types of fixation in the two-part proximal humerus fracture without medial cortical support.

BACKGROUND: The purpose of this study was to evaluate the role of a non-locking plate applied to the anteromedial surface of the proximal humerus on loads at the implant-bone interface of non-locking and locking lateral plate fixation of proximal humeral fractures with a medial gap. METHODS: Twenty synthetic humeri models were used. In fifteen, the proximal portion of the humerus was osteotomized to create a two-part surgical neck fracture, with a 10-mm medial gap and a 5-mm lateral gap; five models were controls. In the osteotomized humeri, five models were stabilized with a locking lateral plate (group L), five with a locking lateral plate and an anteromedial non-locking plate (group L+T), and five with a non-locking lateral plate and a non-locking anteromedial plate (group T+T). All humeri were tested under axial loading until catastrophic failure, which was characterized as complete closure of the medial gap. Stiffness was calculated using force vs. displacement curves. The data were analyzed via descriptive and inferential studies, at a 5% significance level. RESULTS: Statistically significant differences were seen among all the constructions. The combination of a lateral locking plate with an anteromedial non-locking plate (group L+T) was the stiffest construction, while the combination of a non-locking lateral plate with a non-locking anteromedial plate (group T+T) was the least stiff, even in comparison with a single locking lateral plate (p = 0.01). When the two groups which utilized a lateral locking plate (groups L+T and L) were compared, the group with additional anteromedial support demonstrated greater stiffness (p = 0.03), and stiffness values for the control group comprised of intact humeri models were even higher (p = 0.01). CONCLUSION: Combining a lateral locking plate with a non-locking anteromedial plate provides a stiffer construction for fixation of unstable two-part proximal humerus fractures with a medial gap. Mechanical benefits of medial support with a second non-locking antero-medial plate seems to be related with better construct stability in terms of strength and fatigue, potentially reducing the risk of varus collapse of the humerus head and fracture healing disturbances.

Tratamiento urgente y diferido de la luxación radiocarpiana: dos casos con desviación dorsal y afectación transestiloidea / Early and delayed treatment of radiocarpal dislocation: two cases with dorsal and transstyloid instability

Objetivo:La luxación radiocarpiana es una entidad poco frecuente que suele estar asociada a daño articular complejo. El manejo definitivo no está bien establecido así como la reducción cerrada o el tratamiento conservador por sí solos no aseguran una buena evolución. Se presentan dos pacientes además de una revisión de la literatura con énfasis en el entendimiento de la patogenia de la lesión.Material y métodos: Se describen dos casos de fractura-luxación radiocarpiana dorsal. En el caso 1 se sintetizó la estiloides radial únicamente, y en el caso 2 además se reinsertaron las estructuras capsuloligamentosas.Resultados: Con una media de seguimiento de 18 meses, la puntuación fue media para un paciente y buena para el otro. Se constató traslación ulnar en el caso 1, el más sintomático. En ambos el balance articular era bueno. Los dos pacientes han vuelto a su actividad laboral habitual. Discusión: De acuerdo a las propuestas de tratamiento de Dumontier y Moneim, hay que considerar todos los aspectos del daño articular de cara a lograr una adecuada estabilidad que limite el riesgo de artrosis y traslación ulnar. La fijación de ambas estiloides o la reparación de los ligamentos radio-carpianos son puntos críticos para una reducción anatómica

Objetives: Radiocarpal dislocation is an uncommon and severe injury which involve soft-tissue and osseus trauma. No consensus on optimal treatment for this wrist disorder. Closed reduction or non-operative treatment may not optimize outcome. This paper is a report of two patients and we also reviewed the literature with emphasis on understanding the pathogenesis of the lesion. Material and methods: Two cases of posterior radiocarpal fracture- dislocation are described. Case 1 was just treatedby styloradial osteosynthesis and case 2 the same reduction was done in addition to capsuloligamentous suture with anchors. Results: At last follow-up (mean 17 months), the score was higher in case 2 (85/100 - 65/100). Ulnar translation appeared in the first case. Both ranges of motion were good. The two patients returned to their original jobs. Discussion: According to Dumontier and Moneim's treatment proposal, all aspects of joint injury must be considered in order to limit the risk of future arthritis and ulnar translocation. The restoration of the radial and ulnar styloids, and radiocarpal ligamens, are critical to achieve anatomic reduction

Mechanical Construct Characteristics Predisposing to Non-union After Locked Lateral Plating of Distal Femur Fractures.

OBJECTIVES: To identify discrete construct characteristics related to overall construct rigidity that may be independent predictors of nonunion after lateral locked plate (LLP) fixation of distal femur fractures. DESIGN: Retrospective case-control study. SETTING: Three level-1 urban trauma centers. PATIENTS/PARTICIPANTS: Two hundred and seventy-one supracondylar femoral fractures treated with LLP at 3 affiliated level 1 urban trauma centers between August 2004 and December 2010. METHODS: Nonunion was defined as a secondary procedure for poor healing. Construct variables included: (1) combined plate design and material variable, (2) Plate length, (3) # screws proximal to fracture, (4) total screw density (TSD), (5) proximal screw density (PSD), (6) presence of a screw crossing the main fracture, and (7) rigidity score multivariable analysis was performed using logistic regression to identify independent risk factors for nonunion. INTERVENTION: LLP fixation. MAIN OUTCOME MEASURE: Nonunion. RESULTS: Nonunion rate was 13.3% (n = 36). There was a significant association between plate design/material and nonunion with 41% of stainless constructs and 10% of titanium constructs resulting in a nonunion (P < 0.001). Rigidity scores reached significance (P = 0.001) with constructs resulting in a nonunion having higher scores. No significant univariate differences with respect to number of proximal screws, plate length, total screw density, or proximal screw density were observed between healed fractures and those with nonunion. Results of the multivariate analysis confirmed that the primary significant independent predictor of nonunion was plate design/material (odds ratio, 6.8; 95% CI, 2.9-16.1; P < 0.001). CONCLUSIONS: When treating distal femur fractures with LLP, combined plate design and material variable has a highly significant influence on the risk of nonunion independent of any other construct variable. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Proximal humeral fractures: internal fixation.

Fractures of the proximal humerus are common injuries that are increasing in incidence as the population ages. These fractures are often treated nonsurgically; however, surgery is indicated if displacement, concurrent dislocation, or unacceptable alignment is present. Knowledge of the anatomic and physiologic characteristics of the proximal humerus and shoulder joint and familiarity with the available fixation elements will help surgeons make informed and patient-specific decisions regarding treatment. Reduction and internal fixation of proximal humeral fractures has expanding indications in comparison with arthroplasty, in part because of improvements in fixation technology and a better understanding of anatomy and physiology. The outcomes of proximal humeral fractures managed with percutaneous pinning, open reduction and locked-plate fixation, and intramedullary fixation are being actively investigated.

[Examples of erroneous coding in trauma surgery]. / Beispiele für fehlerhafte Kodierung in der Unfallchirurgie.

The G-DRG-System is complex, mistakes in accounting are common. Therefore diagnosis with CCL-value are important because of the possibility of increasing revenues. Also procedures may lead to DRGs with a higher cost weight. So their acquisition is mandatory. The exact medical documentation is essential. High revenues have to be understood according to unvoidable expenditures.

Classification of surgical approaches to the mandibular condyle.

Published articles on surgical approaches to the mandibular condyle seem to be confusing. We present a classification system that describes and differentiates between surgical approaches to the mandibular condyle and is based on the relation to the facial nerve, height of the approach, and choice of skin incision.

Which is the ideal point of time to perform intraoperative 3D imaging in dorsal stabilisation of thoracolumbar spine fractures? A matched pair analysis.

INTRODUCTION: After dorsal stabilisation of vertebral fractures by an internal fixateur the postoperative computed tomography is a standard procedure to control the positions of the pedicle screws, the success of the reposition, the clearance of the spinal canal and to plane an additive secondary ventral stabilisation. An intraoperative scan with a 3D image intensifier may clarify these questions directly after the implantation with the possibility of an immediate correction of the implants. The aim of this study was to find out the optimal point of time to perform an intraoperative 3D scan and if a postoperative computed tomography is dispensable. PATIENTS AND METHODS: Intraoperative 3D scans were carried out on 33 patients with thoracolumbar spine fractures (T11-L5) after bi-segmental fixateur interne montage (Group 1). A matched pair group of 33 patients (Group 2) with a 3D scan after implantation of pedicle screws was built. A postoperative computed tomography of the instrumented spinal section was done in all patients. The following measurements were done in sagittal and axial reconstruction planes and were compared: classification of screw positions, maximal axial diameter of pedicles, cortical perforation of the screws. Additionally in Group 1 the distance between the upper and lower end plates of the injured section, the height of posterior vertebral body wall, the dislocation of the posterior wall and the minimal diameter of the spinal canal were measured. RESULTS: The intraoperative scoring of pedicle screws positions and the measurement of pedicle width showed in both groups a significant accordance with the computed tomography determinations. The measurements "posterior wall dislocation" and "diameter of spinal canal" were only possible in 24 3D scans and showed a significant difference compared with the CT data. The picture quality in Group 2 was scored significantly better than for Group 1 with the complete assembly of the fixateur. CONCLUSION: The ideal point of time for an intraoperative 3D imaging with the present intensifier generation is directly after pedicle screw insertion. The reliable determination of the spinal canal diameter, of posterior wall fragments and of the exact fracture morphology is only possible by postoperative computed tomography.

Los principios generales de la osteosíntesis / General Principles of Osteosynthesis

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Infiltración de partes blandas por mieloma, tras la fijación interna de una fractura patológica femoral / Infiltration of soft tissue by myeloma after internal fixation of pathologic femoral fracture

Paciente varón de 75 años con antecedentes de mieloma múltiple que acudió por una fractura patológica a través de la diáfisis femoral distal derecha. Dicha fractura fue fijada con clavos de Enders. Dos meses y medio más tarde el paciente reingresó por aumento de tamaño rápidamente progresivo del muslo derecho.Se realizó ecografía, TC y RM que reveló infiltración de la musculatura anterior del muslo derecho con extensión craneal hacia el músculo iliopsoas y al espacio retroperitoneal, por encima de la vena renal homolateral.Una biopsia guiada ecográficamente de las partes blandas del muslo mostró infiltración mielomatosa difusa por células plasmablásticas (AU)

Interrater reliability for the basic categories of the AO/ASIF's system as a frame of reference for classifying distal radial fractures.

This study is about agreement on the assignment into the three basic classes or categories (A, B, C) of the Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation's (AO/ASIF) classification system for distal radial fractures. A random sample of 124 distal radial fractures was classified by two experienced observers. Their agreement was calculated according to Cohen's kappa statistic. To investigate the possible bases for disagreement, all conflicting X-ray assessments were discussed in a consensus meeting. It appeared that the kappa value was .65 (good agreement) before the meeting; kappa rose to .86 (excellent agreement) after the consensus meeting. It appeared that the undisplaced fractures were a major source of disagreement. Further, the presence of articular involvement was an important issue. It was frequently noted that one observer classified the fracture as extraarticular (basic Class A), while the other observer chose classification as an intra-articular fracture (basic Class C) or vice versa. This phenomenon has been called the A/C reversal shift. It is concluded that radiological innovations might enhance agreement on articular involvement, and a separate category for undisplaced fractures should be defined in the Arbeitsgemeinschaft für Osteosynthesefragen (AO) system. However, agreement on relevant distinctive features and discussion of conflicting assessments may also be important in achieving excellent agreement.

Carga controlada de peso mediante un sistema de poleas para la temprana rehabilitación de extremidades inferiores con fracturas estabilizadas / Controlled weight bearing with the help of pulley system for early rehabilitation of the lower limbs after fracture stabilization

Se recomienda un sistema de poleas para permitir al individuo fracturado de las extremidades pélvicas, la carga de peso corporal parcial de manera controlada, en etapas en el postoperatorio, inclusive en pacientes, polifracturados. El presente programa de tratamiento puede establecerse en cuanto la extremidad fracturada se encuentra estabilizada

[Classifications of methods for osteosynthesis in mandibular fractures and of the devices for its performance]. / Klassifikatsii sposobov osteosinteza pri perelomakh nizhnei cheliusti i ustroistv dlia ego osushchestvleniia.

The authors review the known classifications of methods and devices for direct and direct osteosynthesis for the treatment of mandibular fractures. They suggest a classification of their own, including all current osteosynthesis methods and auxiliary devices and instruments used in osteosynthesis.