ACUTE FRACTURE OF THE FEMORAL NECK: INTERNAL FIXATION OR PROSTHESIS?
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INTERNAL FIXATION IN DISPLACED FRACTURES OF THE FEMORAL NECK.
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Femoral Neck Fractures↗
Internal fixation versus primary prosthetic replacement in acute femoral neck fractures: a prospective, randomized clinical study.
A prospective, randomized clinical study has been performed on 104 patients with an acute femoral neck fracture, comparing internal fixation (von Bahr screws) with primary prosthetic replacement (Christiansen endoprosthesis). Immediate weight bearing was allowed in both groups. The postoperative mortality rate was similar in the two groups. Internal fixation proved to be a less time-consuming operation, gave a shorter hospitalization time and was associated with a significantly reduced morbidity rate compared with prosthetic replacement. No blood transfusion was needed in the internal fixation group. Primary prosthetic replacement was associated with earlier postoperative mobilization, probably gave a more definitive treatment with fewer reoperations, and showed better results at 1-year follow-up.
Aged↗
Internal Fixation of the Cervical Spine: Current Indications and Techniques.
Numerous techniques for the internal fixation of the cervical spine have been developed in recent years. The indications for surgery must be strictly defined before the optimal type of implant can be selected on the basis of the advantages and potential risks. Wiring techniques are still commonly used for posterior stabilization. Anterior fusion can be accomplished without internal fixation in most cases. The halo vest is still widely used for the conservative management of cervical fractures and for postoperative external immobilization. Posteriorly, traditional wiring methods are still used, as well as newer techniques, such as C1-C2 screw fixation, occipitocervical plate fixation, and lateral-mass lower cervical plating. Anteriorly, meticulous Smith-Robinson surgical approach and grafting techniques are essential. Further studies are needed to define the exact indications for various new techniques, such as anterior odontoid screw fixation and anterior plating. The surgeon must choose an appropriate device on the basis of the mechanism of injury, the pathoanatomy of the lesion, and familiarity with the device, keeping in mind the goals of internal fixation-stabilization, reduction and maintenance of alignment, early rehabilitation, and perhaps enhancement of fusion and avoidance of the need to use an external halo vest.
Journal Article↗
[Clinical studies on maintenance of cross-leg position through internal fixation with Kirschner wire after cross-leg flap procedure].
OBJECTIVE: To study the feasibility of a new method for the cross-leg position maintained by the Kirschner wire internal fixation after the cross-leg flap procedure. METHODS: From December 2004 to October 2005, 5 patients (4 males, 1 female; aged 14-52 years) were admitted to our department, who suffered from the tibia exposure or the internal fixation plate exposure after operation because of the tibia fracture by trauma for 1-8 weeks. The soft tissue defects ranged in area from 2.4 cm x 2.0 cm to 4. 2 cm x 3.0 cm. The soft tissue around the wound in the leg was too poor in condition to perform an operation of the local flap transplantation, but the wound and the tibia had no obvious infection, so an operation of the cross-leg flap transplantation was performed to cover the wounds. The operation was performed with the routine cross-leg flap method introduced in the medical literature. After operation the cross-leg position was maintained through a simple internal fixation with two Kirschner wire, which were inserted through the tibia of the cross region of both the legs, and layers of dressings were placed as a cushion between the crossed legs in case of the crushing skin ulcer formation. The effect of fixation, blood circulation in the cutaneous flap, and the stress of the pedicle were observed postoperatively. After 3-4 weeks the pedicle of the cross-leg flap was cut off; the crossed legs were detached and the Kirschner wire were pulled out. RESULTS: All the flaps survived with a good blood circulation and a low pedicle stress. The patients had a relatively comfortable position because all the areas of the legs could be allowed to make some motions except the cross-area of the legs. Another advantage of this fixation method was its convenience for observing the blood circulation of the cutaneous flap and for changing the dressings. Neither infection in the holes of the Kirschner wire nor crushing skin ulcer formation in the area of the cross-leg could be observed. The follow-up for 3-18 months revealed that all the flaps were in good condition with no edema, contracture or skin pigmentation. CONCLUSION: The method of using the Kirschner wire to maintain the cross-leg position after the cross-leg flap procedure has more advantages than the plaster fixation. This improved method is simpler, and can achieve a tighter fixation in the cross-leg area to maintain the cross-leg position, allowing a micro-motion in other parts of the legs. The patients can have a relatively comfortable posture, and have a more convenient dressing changes and observation on the blood circulation in the flaps.
Adolescent↗
New biological method of internal fixation of the femur.
One of the main goals in fracture treatment is reservation of both intramedular and periosteal vascularisation. The aim of this paper is to show a new method of internal fixation which accomplishes these goals. The paper presents the results of clinical application of Mitkovic Internal Fixator, new self-dynamisable device, which provides fixation of the femur using minimally invasive technique. This device has been investigated experimentally on 60 animals. It has been applied to 267 patients. Here is presented a series of 92 fixations of femoral diaphyses after fresh fractures and after unsuccessful treatment using other methods. Follow-up was 3.1 years (2 to 7 years). Bone healing was achieved in all patients within 3.5 months (2.7-9 months) with big amount of periosteal callus formation. There were no complications in all patients seen. It can be concluded that this method and device meet biological and biomechanical requirements for safe fracture treatment.
Adolescent↗
An assessment of oblique base wedge osteotomy stability in the first metatarsal using different modes of internal fixation.
The modified Juvara osteotomy is a classic oblique base wedge osteotomy of the first metatarsal and is often used to reduce hallux valgus deformity. However, complications attributed to osteotomy instability and currently available modes of osteosynthesis are common. The authors have developed a technique that enables them to quantitatively and objectively evaluate the stability of this osteotomy when various modes of internal fixation are used. Stability testing was performed on fresh, previously frozen human cadaveric specimens using engineering principles. Results indicate that there is no statistically significant difference in stability between crossed 0.062-inch Kirschner wire fixation and internal fixation using a single 3.5-mm. cancellous screw. The tests also indicate that both of these techniques are superior to two 2.7-mm. cortical screws for stability.
Biophysical Phenomena↗
[INTERNAL FIXATIONS FOR PATHOLOGICAL FRACTURES CAUSED BY BONE TUMORS].
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Bone Neoplasms↗
RADIAL NERVE TRANSPLANT AND INTERNAL FIXATION IN CASES OF HUMERUS FRACTURE WITH RADIAL NERVE INJURY.
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Fracture Fixation↗
Fractures of the os calcis: improved results with internal fixation.
A prospective study of 24 patients with displaced intra-articular fractures of the os calcis was performed to compare operative with non-operative treatment. Twelve patients were treated by internal fixation followed by early mobilization, and 12 were managed non-operatively. The patients were assessed 15 months later using eight parameters. Of the 12 patients who were treated by internal fixation, eight had returned to work. Walking distance was significantly longer (4 km) in this group and only one patient needed a change in shoe size. Of the 12 patients who were managed non-operatively, only three had returned to work and eight had a change in shoe size, while the average walking distance without pain was only 1 km. The mean range of subtalar movement was 24 degrees in the operated group but only 12 degrees in the other group (P < 0.05). Radiological follow-up demonstrated partial or full restoration of Böhler's angle in the patients who underwent internal fixation. We recommend plating of displaced intraarticular os calcis fractures through a lateral approach in patients under 40 years of age.
Adult↗
Stability of the Le Fort I maxillary osteotomy after rigid internal fixation.
PURPOSE: The purpose of this study was to evaluate the postsurgical stability of the Le Fort I osteotomy with impaction in which rigid internal fixation was used for stabilization. MATERIALS AND METHODS: Lateral cephalograms of 19 patients were evaluated. Descriptive statistics were compiled that included absolute linear and angular measurements as well as absolute changes in measurements for successive cephalometric radiographs. Comparisons were made from 1) presurgery to immediate postsurgery, 2) immediate postsurgery to splint removal, 3) splint removal to longest follow-up, and 4) immediate postsurgery to longest follow-up. Repeated measures analysis of variance were used to describe significant differences for absolute changes in measurements. RESULTS: All surgical movements were significant except for horizontal position of dental structures, horizontal position of the posterior mandible, and posterior vertical facial height. All significant movement from immediate postsurgery to splint removal was secondary to removal of the occlusal splint. Changes were minimal from splint removal to longest follow-up, with only 3 of 24 measurements showing statistically significant differences. These measurements related to tooth position and were affected by postsurgical orthodontics. The data derived from this study were also compared with those found in similar studies in which fixation was by wire osteosynthesis. CONCLUSIONS: The magnitude of postoperative movement was considerably less with rigid internal fixation than that reported with the use of wire fixation. This is attributed to the increased stabilizing effect of rigid internal fixation.
Bone Plates↗
Propofol-ketamine anesthesia for internal fixation of fractures in racehorses.
To assess the clinical usability of propofol-ketamine anesthesia for internal fixation of fractures in racehorses, hemodynamics, blood pH and gases, and vital responses to the continuous intravenous anesthesia in 7 surgical cases were analyzed. The quality of induction with propofol was variable for individual horses. The vital signs reflecting circulation, breath, and anesthetic depth were kept good without any troubles throughout the surgery. Mean time from the end of anesthesia to standing up was prolonged, however recovery from anesthesia was calm and smooth in all cases. Propofol-ketamine anesthesia may be a clinically usable technique for internal fixation of fractures in racehorses, however induction with propofol alone is not recommended.
Anesthesia, Intravenous↗
[Clinical application of TRAFIX internal fixation system in correction of scoliosis].
OBJECTIVE: To evaluate the results of TRAFIX internal fixation system in correction of adolescent scoliosis. METHODS: From October 1997 to June 1999, 27 patients with idiopathic scoliosis received spinal instrumentation with TRAFIX system. Their average age was 14.2 years (from 11 to 21). Four patients of the 27 underwent anterior release, while 1 patient accepted revision approach. The average follow up time was 26 months (13-37 months). RESULTS: The measurements for primary coronal deformity before and after surgery were 65 degrees (42 degrees-110 degrees) and 29.2 degrees (3 degrees-64 degrees) respectively. The average curve correction was 55.4%. The average fused segments were 11.5 vertebrae. The distance between the center of apex and C7 plumb line was 52.1 mm before operation (25-94 mm) and 28.5 mm after surgery (4-62 mm). CONCLUSION: The TRAFIX internal fixation system provides three-dimensional correction with refinement, convenient and reliable fixation.
Adolescent↗
Treatment of distal femoral nonunion with internal fixation, cortical allograft struts, and autogenous bone-grafting.
BACKGROUND: The purpose of this retrospective study was to analyze the results of treatment of nonunions of the distal part of the femur with internal fixation combined with cortical allograft struts and autogenous bone-grafting. METHODS: Thirteen patients with a distal femoral nonunion were treated with open reduction and internal fixation combined with deep-frozen cortical allograft struts and autogenous iliac bone grafts. The level of nonunion was infra-isthmal in three patients and supracondylar in ten. Ten nonunions were fixed with a blade-plate or condylar buttress plate; two, with an antegrade locked nail; and one, with an antegrade locked nail and a compression plate. Seven unicortical, five bicortical, and one tricortical allograft struts, with an average length of 10 cm, were used. Autogenous iliac bone grafts were inserted into the nonunion site and between the allograft and host femur. The average time from the surgery to the latest follow-up examination was thirty-four months (range, twelve to seventy months). RESULTS: All nonunions united, at an average of five months. The average arc of knee motion improved from 45 degrees preoperatively to 73 degrees postoperatively. According to The Hospital for Special Surgery knee rating system, the average knee score improved from 20 points preoperatively to 71 points at the latest follow-up examination. Three patients had hardware removed after healing of the nonunion, and one patient underwent quadricepsplasty for knee contracture. There were no postoperative infections. Two patients had shortening of the limb of >2 cm. CONCLUSION: Open reduction and internal fixation supplemented with allograft struts and autogenous bone graft is an effective treatment for nonunion of the distal part of the femur. LEVEL OF EVIDENCE: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.
Adult↗
Ankle fractures treated with non-rigid internal fixation.
Two hundred and thirty-seven fractures of the ankle treated with non-rigid internal fixation were reviewed with regard to classification, congruency of joint surface, range of motion and the patients' subjective symptoms. The fractures were divided into either severe fractures consisting of two or more skeletal injuries or simple fractures consisting of only one skeletal injury. Successful operation, i.e. congruency of the joint, was seen in 50 per cent of the severe and in 73 per cent of the simple fractures (significant, P less than 0.001). Disability was significantly more frequent after severe fractures and with incongruent joints. This study shows that the operative technique using non-rigid internal fixation is not sufficient for treating severe fractures, as exact anatomical reconstruction of the joint was not obtained.
Adolescent↗
The stability of the tibio-fibular syndesmosis following rigid internal fixation for type C malleolar fractures: an experimental and clinical study.
In 5 cadavers, type C malleolar fractures of the pronation-eversion rotation type, were produced. The stability of the ankle mortice under stress was tested before and after rigid internal fixation of the fracture in the fibula. The intact interosseous membrane above the fracture in combination with the internal fixation of the fibula was sufficient to keep the lateral malleolus in place. A clinical series of 8 equivalent fractures treated with rigid internal fixation without suture of the syndesmodesis was collected and evaluated clinically and radiologically 3 years after the injury. None of the patients had significant complaints and all ankle joints were stable.
Adult↗
Revolution in plate osteosynthesis: new internal fixator systems.
Conventional plating has been performed since the nineteenth century, and since then Lambotte, Danis, and others have developed new plate designs to restore fractured bones. At the early stage of plating, mechanical aspects were the focus, and the biology of the bone was sometimes neglected. During the 1980s the AO/ASIF group started to work on new plate designs to minimize the disadvantages of plating with respect to cortical perfusion. To overcome the negative effect of compression forces on the periosteum, a new generation of plates, or internal fixators, were created. The key to these internal fixators is the locking mechanism of the screw in the implant, which provides angular stability. This technical detail ensures that compression forces on the bone surface are not necessary to gain stability of the bone-implant construct, which improves fracture healing and provides an excellent holding force even in osteoporotic bone. The locking mechanism also makes the technique of percutaneous plating easier because, in contrast to conventional plates, the fragments are not pulled toward the implant by the locking screws. The new internal fixator systems [LISS (less invasive stabilization system) and LCP (locking compression plates)] offer new approaches to trauma surgery, especially for metaphyseal fractures.
Bone Plates↗
Biomechanical testing of the LCP--how can stability in locked internal fixators be controlled?
New plating techniques, such as non-contact plates, have been introduced in acknowledgment of the importance of biological factors in internal fixation. Knowledge of the fixation stability provided by these new plates is very limited and clarification is still necessary to determine how the mechanical stability, e.g. fracture motion, and the risk of implant failure can best be controlled. The results of a study based on in vitro experiments with composite bone cylinders and finite element analysis using the Locking Compression Plate (LCP) for diaphyseal fractures are presented and recommendations for clinical practice are given. Several factors were shown to influence stability both in compression and torsion. Axial stiffness and torsional rigidity was mainly influenced by the working length, e.g. the distance of the first screw to the fracture site. By omitting one screw hole on either side of the fracture, the construct became almost twice as flexible in both compression and torsion. The number of screws also significantly affected the stability, however, more than three screws per fragment did little to increase axial stiffness; nor did four screws increase torsional rigidity. The position of the third screw in the fragment significantly affected axial stiffness, but not torsional rigidity. The closer an additional screw is positioned towards the fracture gap, the stiffer the construct becomes under compression. The rigidity under torsional load was determined by the number of screws only. Another factor affecting construct stability was the distance of the plate to the bone. Increasing this distance resulted in decreased construct stability. Finally, a shorter plate with an equal number of screws caused a reduction in axial stiffness but not in torsional rigidity. Static compression tests showed that increasing the working length, e.g. omitting the screws immediately adjacent to the fracture on both sides, significantly diminished the load causing plastic deformation of the plate. If bone contact was not present at the fracture site due to comminution, a greater working length also led to earlier failure in dynamic loading tests. For simple fractures with a small fracture gap and bone contact under dynamic load, the number of cycles until failure was greater than one million for all tested constructs. Plate failures invariably occurred through the DCP hole where the highest von Mises stresses were found in the finite element analysis (FEA). This stress was reduced in constructions with bone contact by increasing the bridging length. On the other hand, additional screws increased the implant stress since higher loads were needed to achieve bone contact. Based on the present results, the following clinical recommendations can be made for the locked internal fixator in bridging technique as part of a minimally invasive percutaneous osteosynthesis (MIPO): for fractures of the lower extremity, two or three screws on either side of the fracture should be sufficient. For fractures of the humerus or forearm, three to four screws on either side should be used as rotational forces predominate in these bones. In simple fractures with a small interfragmentary gap, one or two holes should be omitted on each side of the fracture to initiate spontaneous fracture healing, including the generation of callus formations. In fractures with a large fracture gap such as comminuted fractures, we advise placement of the innermost screws as close as practicable to the fracture. Furthermore, the distance between the plate and the bone ought to be kept small and long plates should be used to provide sufficient axial stiffness.
Biomechanical Phenomena↗