Long-term results of pronation-external rotation ankle fracture-dislocations treated with anatomical open reduction, internal fixation.
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Adult↗
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Supraintercondylar fractures of the distal humerus: results of internal fixation.
Operative treatment is considered to be the primary method of treatment for supraintercondylar fractures of the distal end of the humerus. Anatomical reduction and stable fixation of the fracture allows for early postoperative functional treatment and, subsequently, better results than other methods. Two series of patients with supraintercondylar fractures of the humerus, one from 1969 to 1980, and the second from 1981 to 1988, are presented. Although these series do not differ widely in their final outcomes, certain philosophies and operative techniques did change for the better.
Adult↗
Cerclage wiring in internal fixation of acetabular fractures.
In the last 100 fractures of the acetabulum surgically treated in our institution, cerclage wires have been used as a reduction tool in 14 patients. In each case the fracture pattern affected both columns, and nine of them were approached through a single ilioinguinal exposure. To evaluate our initial experience with the method, these patients were reviewed using medical records, operative notes, and radiological assessment to determine its indications and effectiveness. In each patient, using a limited further dissection, at least one cerclage wire was passed through the greater sciatic notch, embracing the proximal extent of a posterior column fragment. It was then tightened above the anterior-inferior iliac spine, achieving reduction. In 11 cases reduction was obtained to within 1 mm, and joint congruence with < 3 mm of residual displacement was obtained in 13 hips. This reduction was maintained until union, except in one case, where it was lost postsurgery. Cerclage wires may be used to successfully effect an indirect reduction of the posterior column from an anterior approach in fractures affecting both columns, where the posterior column fracture line is proximal. The technique may contribute to fracture stabilization, but supplementary fixation was added in 12 of our patients.
Acetabulum↗
Healing complications after internal fixation of trochanteric hip fractures: the prognostic value of osteoporosis.
In a 3-year prospective randomized trial, the prognostic value of osteoporosis in terms of predicting healing complications due to implant failures or loss of fracture reduction has been studied in 113 patients with inter-trochanteric hip fractures treated with either a sliding screwplate or Ender nailing. According to the Barnet and Nordin's osteoporosis index, 66 patients were considered to have moderate or severe osteoporosis. There were no differences between patients with or without osteoporosis as regards the number of fractures with collapse in varus > 10 degrees, redislocation > 10 mm, or compression exceeding 10 mm. Six months after surgery, 48 patients failed in healing or healed with complications. These cases disclosed increased osteoporosis in comparison with those showing noncomplicated healing. Patients with osteoporosis who had unstable fractures treated by Ender nailing were found to have the worst prognosis for healing complications (p = 0.006). Of the 33 fractures with implant failures, 25 (76%) occurred in patients with osteoporosis (p = 0.04). In patients with osteoporosis, the frequency of mechanical failures was significantly higher in fractures with the device positioned incorrectly. Independently of the device used, patients with unstable trochanteric hip fractures and osteoporotic bone were the group with the highest risk for failures of the implant.
Aged↗
Limited internal fixation of the tibia with external fixation: an in vivo canine study.
This study reports the results of the healing of canine tibial osteotomies with external fixation alone or in combination with a single lag screw. Twelve dogs had a midshaft tibial osteotomy performed at a 45 degree obliquity. Half of the dogs had a six-pin, unilateral, medial, external half-frame applied after the osteotomy. The remaining six had an identical frame plus a lag screw placed perpendicular to the osteotomy site. When compared with their contralateral controls, the fixator-alone group had a 16.3% (p < 0.05) decrease in bone density, whereas no significant density change was seen in the group with the additional lag screw. Torsional stiffness was 29% higher in the osteotomies treated, and tested, with the lag screw, but this did not achieve statistical significance. Computed tomography scanning revealed that the surface area was increased by an average of 30-40% in both groups, relative to contralateral controls, but there was no difference between the two treatment groups. Three tibias in the group with external fixation alone, and two tibias in the screw group showed primary bone healing without evidence of callus formation. The combination of a semirigid external fixation construct with a lag screw resulted in increased torsional stiffness but healing equal to that seen with external fixation alone.
Animals↗
Internal fixation of calcaneus fractures: an anatomical study of structures at risk.
This study examines the risk of injury to medial soft-tissue structures during the fixation of calcaneal fractures performed through a lateral approach. An L-shaped lateral incision was performed on 10 fresh cadaver feet. The calcaneus was divided into three zones for study. Ten K-wires were inserted in a standard configuration from a lateral starting point extending through the medial cortex. The feet were dissected medially to measure the distance from each exiting K-wire to the medial and lateral plantar vessels, the calcaneal branch of the posterior tibial nerve, and the tendons of the flexor hallucis longus, flexor digitorum longus, and posterior tibialis. The mean risk of injury to these medial structures was calculated for each lateral insertion site. Wires placed in the subchondral bone of the posterior facet or anterior to the critical angle of Gissane were determined to be at high risk of injury to the medial soft tissues. Structures at risk included the medial and lateral plantar nerves and vessels and the flexor hallucis longus tendon. Caution should be exercised when inserting K-wires, drills, and screws into high-risk areas to avoid iatrogenic injury to the medial structures.
Bone Wires↗
Indirect reduction and internal fixation of supracondylar femur fractures without bone graft.
Thirty supracondylar-intercondylar fractures of the distal femur were treated in a prospective series using an indirect reduction technique. From January 1988 to July 1993, patients who entered into this protocol had undergone fixation with a distal lateral plate without stripping of the medial soft tissues and without bone graft. With this technique, 86.6% excellent and satisfactory results were achieved using the Neer rating system. Of the three failures, two were in elderly, osteoporotic women with comminuted intraarticular fractures, and one failure occurred in a renal transplant patient with bilateral quadriceps ruptures despite a good result from her femur fracture. Only one patient with a grade 2 open fracture and comminution developed a nonunion, which eventually healed after bone grafting. The results of this technique compare favorably with other series of osteosynthesis of supracondylar femur fractures in the orthopaedic literature without the added morbidity associated with autogenous bone grafting. The surgical technique is demanding and may not be suitable for patients with severe open fractures with devascularized bony fragments or marked osteoporosis.
Adolescent↗
Open reduction and internal fixation of the calcaneus using minifragment plates.
During a 4-year period, 35 nonconsecutive intraarticular fractures of the calcaneus were fixed with 2.7-mm minifragment plates and 3.5-mm small fragment screws through an extended lateral approach. There were 25 type II and 10 type III fractures by the classification system of Sanders. The reduction of the facet was anatomic in 91%. The reduction of the tuberosity was acceptable (< or = 5 degrees of angulation) in all cases. Early motion was begun in the ankle, subtalar, and midfoot joints in all cases. Two patients had minor edge necrosis amenable to local treatment. There were no deep infections. Using the Maryland foot score, there were 77% good or excellent results. The small size of the minifragment plates allows for their application to a wide variety of fracture patterns. They are also low profile and are therefore easy to cover. Multiple plates were used in many cases without steric interference. They provided rigid enough fixation to allow aggressive early motion exercises without loss of reduction or hardware failure in any case. Minifragment plates with small fragment screws are effective for the fixation of intraarticular calcaneus fractures through an extended lateral approach.
Adolescent↗
Biomechanical comparison of posterior internal fixation techniques for unstable pelvic fractures.
Early reduction and rigid fixation of unstable vertical shear pelvic fractures has been shown to decrease the incidence of late sequelae and facilitate early mobilization. The results of fixation of the posterior pelvic ring without anterior fixation are unknown. The purpose of this study was to perform a biomechanical comparison of the most frequently used techniques of posterior fixation for unstable pelvic sacroiliac dislocations in conjunction with ipsilateral rami fractures, i.e., an unstable vertical shear injury. The four methods of posterior fixation tested included sacroiliac (SI) screws, anterior SI plates, transiliac bars, and a combination of SI screws and transiliac bars. Six cadaveric pelvises were tested in axial compression and torsion on a biaxial servohydraulic testing machine. Compared to the intact pelvis, single posterior methods of fixation provided approximately 70-85% resistance to axial and torsional loading. By combining SI screws with transiliac bars, approximately 90% of intact pelvic stability was achieved. Our results suggest that rigid posterior fixation of sacroiliac dislocations alone may obviate the need for additional complex anterior surgical procedures to fix rami fractures.
Biomechanical Phenomena↗
Open reduction internal fixation of displaced transverse patella fractures with figure-eight wiring through parallel cannulated compression screws.
OBJECTIVE: To evaluate the clinical results of transverse patella fracture fixation with a tensioned anterior figure-eight wire placed through parallel cannulated screws. DESIGN: Prospective, clinical. PATIENTS: Ten patients with displaced transverse patella fractures were managed with a standardized rehabilitation protocol that employed early continuous passive knee motion. OUTCOME MEASURES: Time to clinical and radiographic union, Hospital for Special Surgery Knee Scores, and comparisons with literature cohort studies. RESULTS: Clinical union occurred at an of average eight weeks and radiographic union at a mean of thirteen weeks postoperatively. Early continuous passive motion over a restricted are did not compromise the quality of fracture reduction, even though the majority of patients were elderly and had osteopenic bone. Subjective and functional results using Hospital for Special Surgery Knee Scores were comparable to previously published reports, with 70 percent achieving an excellent or good outcome. CONCLUSIONS: The described fixation technique for transverse patella fractures had clinical results equivalent to reports of patella fractures fixed with modified tension band wiring. Advantages included a low-profile construct that caused lesser degrees of implant irritation to local soft tissue structures, was compatible with the use of early restricted motion, and afforded a method to salvage three cases in which traditional tension band wiring failed to maintain an anatomic reduction in oteoporotic bone.
Adult↗
Internal fixation of supracondylar femoral fractures: comparative biomechanical performance of the 95-degree blade plate and two retrograde nails.
OBJECTIVE: The biomechanical stability of supracondylar femoral fractures fixed with a condylar blade plate (plate), a Green Seligson Henry nail (GSHN), or a new retrograde unreamed supracondylar femoral nail (new nail) based on the AO unreamed femoral nail were compared. DESIGN: A standardized simulated comminuted supracondylar femoral fracture (segmental defect) in fresh frozen paired cadaveric femora was stabilized with one of the implants. The interfragmentary fracture site stiffness in three directions and axial strength of the fixator-bone construct were compared (pairwise). RESULTS: The plate versus the new nail was (a) axially 10 percent as stiff and 50 percent as strong (ultimate strength), (b) as stiff in A/P bending, and (c) five times more stiff in torsion. Varus angle at failure under axial load was significantly greater for the plate than for the new nail. There were no statistical differences in axial stiffness and ultimate strength between the new nail and the GSHN, but the new nail was 50 percent and 30 percent as stiff in A/P bending and torsion, respectively. The magnitude of deformation at failure under axial loading was similar. CONCLUSIONS: In fixation of extraarticular comminuted supracondylar distal femur fractures, results indicate that (a) the new nail provides equal or greater stability than does the plate, except when large torsional loads are anticipated, and (b) the new nail provides stability equal to the GSHN for axial loading and lesser stability against off-axis loads. As is evident in this and other studies, intramedullary implants are less torsionally stiff than are plates. The torsional stiffness of the new nail is expected to be sufficient because it is comparable to many available nails, and low torsional moments are expected for healing femoral supracondylar fractures.
Biomechanical Phenomena↗
Clinical results using the trochanter stabilizing plate (TSP): the modular extension of the dynamic hip screw (DHS) for internal fixation of selected unstable intertrochanteric fractures.
OBJECTIVE: To evaluate whether the implantation of the modular trochanter stabilizing plate (TSP) in addition to the dynamic hip screw (DHS) prevents excessive telescoping and limb shortening in four-part and selected three-part trochanteric fractures. DESIGN: Prospective clinical study. SETTING: The study was conducted at the trauma unit of the Surgical Department of the University of Basel, Switzerland. PATIENTS: Forty-six consecutive patients with unstable intertrochanteric fractures were treated with an additional TSP super-imposed on the regular DHS at our institution between July 1991 and July 1993. Five patients died before the first follow-up, one patient was lost to follow-up, and another patient refused follow-up. Thus, thirty-nine patients were followed for at least twelve months (mean 14 months, range 12 to 20 months). INTERVENTION: The fractures treated were classified according to the OTA classification, which is based on the AO classification. Seventeen were 31-A2.2, seven were 31-A2.3, and fourteen were 31-A3.3 fractures. RESULTS: Lateralization of the greater trochanter was successfully prevented in all fractures. Limited fracture impaction was found in 90 percent (n = 35) of the patients with telescoping of 9.5 millimeters (range 0 to 30 millimeters), resulting in mean limb shortening of 5.37 millimeters (range 0 to 14.9 millimeters). Four patients suffered limb shortening exceeding fifteen millimeters (range 15.6 to 21.3 millimeters). Functional results were excellent and good in 87 percent of patients and fair in 13 percent according to the Salvati-Wilson score. All fractures had healed six months after the operation. Three complications required a secondary procedure: one from not inserting a second screw parallel to the gliding hip screw to prevent rotation of the head-neck fragment ("antirotation screw"), one because of deep infection, and one because of a refracture after premature implant removal. CONCLUSION: In unstable pertrochanteric fractures with small or missing lateral cortical buttress, the addition of a TSP to the DHS effectively supports the unstable greater trochanter fragment and can prevent rotation of the head-neck fragment. Excessive fracture impaction and consecutive limb shortening was prevented by this additional implant in 90 percent of these patients.
Adult↗
Operative treatment of displaced intra-articular fractures of the calcaneus using absorbable internal fixation: a prospective study of twenty-five fractures.
OBJECTIVE: To document the use of absorbable implants in the operative treatment of displaced intra-articular fractures of the calcaneus. DESIGN: Prospective clinical study. SETTING: Level one trauma center, university hospital. PATIENTS: Twenty-five displaced intra-articular calcaneal fractures in twenty-one patients. INTERVENTION: The fractures were reduced operatively and fixed with absorbable self-reinforced polyglycolide rods. MAIN OUTCOME MEASUREMENTS: Reduction, healing, and stability of fixation were assessed on radiographs. The functional result was scored using the method of Crosby and Fitzgibbons. Patient satisfaction was recorded. RESULTS: The mean Böhler angle was -12 degrees (standard deviation 22 degrees) preoperatively and 20 degrees (standard deviation 13 degrees) postoperatively. After a two-year follow-up, seven patients had excellent, five good, three fair, and six poor functional results. Subjectively, fifteen patients were satisfied and six were dissatisfied. Twelve patients returned to work within one year, three were unemployed, two were retired prior to the accident, and four were unable to work because of the calcaneal fracture. The postoperative Böhler angle and later the appearance or absence of posttraumatic subtalar arthritis were significant prognostic factors. CONCLUSIONS: Results with absorbable implants are similar to those with other operative methods. Advantages include the absence of secondary procedures for implant removal and undisturbed computed tomography scans postoperatively.
Absorbable Implants↗
Internal fixation of femoral neck fractures with posterior comminution: a biomechanical study.
OBJECTIVES: This study was performed to determine whether four cancellous lag screws provide significantly improved rigidity and fixation strength compared with three screws for fixation of displaced femoral neck fractures with posterior comminution. DESIGN: Biomechanical cadaver study. INTERVENTION: Eight pairs of mildly osteopenic femurs were selected, and each pair was fixed with three or four cancellous lag screws (randomly assigned) after the creation of a simulated femoral neck fracture with posterior comminution. A separate comparison with an unmatched group of six similar femurs with a simulated femoral neck fracture without posterior comminution and instrumented with three screws was performed to investigate the effect of posterior comminution. MAIN OUTCOME MEASUREMENT: The specimens were non-destructively tested to determine fixation rigidity in axial and anterior loading. Cyclic axial loading was then performed for 10,000 cycles; the femurs were retested for rigidity and finally were axially loaded until failure. RESULTS: The femurs with a posterior defect stabilized with three screws had significantly less resistance to axial and anterior displacement and sustained significantly lower axial loads to failure than those stabilized with four screws. The specimens instrumented with three screws without a posterior defect exhibited greater resistance to displacement in anterior loading and sustained greater axial loads to failure than those with a posterior defect stabilized with three screws. CONCLUSION: This study suggests that there are benefits to using four screws for fixation of femoral neck fractures with posterior comminution.
Biomechanical Phenomena↗
A preliminary study of joint surface changes after an intraarticular fracture: a sheep model of a tibia fracture with weight bearing after internal fixation.
OBJECTIVE: To evaluate the changes in the articular cartilage and subchondral bone after an osteotomy designed to simulate an articular fracture. DESIGN: The contribution of the cartilage and subchondral bone was evaluated twelve weeks after creating a 1.0-millimeter step-off in the medial plateau of the tibia of twelve adult domestic sheep. All animals surviving were labeled with fluorescent markers for bone production, oxytetracycline (fifty milligrams per kilogram), and calcein (twelve milligrams per kilogram) nine and 11.5 weeks after surgery. The knees were loaded in compression using an Instron materials tester with pressure-sensitive film to record joint contact pressures above and below the medial meniscus. SETTING: The studies were performed in the research laboratories of the Orthopaedic Laboratory at Harborview Medical Center in Seattle, Washington and the Madigan Army Medical Center in Tacoma, Washington. ANIMALS: Twelve adult domestic sheep. INTERVENTION: An intraarticular osteotomy of the medial tibial plateau with 1.0 millimeter of displacement was performed. The osteotomy was stabilized with 3.5-millimeter lag screws. MAIN OUTCOME MEASURES: The contact pressures of the knee joint and articular histology were evaluated twelve weeks after surgery. Samples of the articular cartilage were analyzed by light microscopy and electron microscopy to evaluate the response of the articular cartilage and subchondral bone of the differential joint loading because of the irregularity in the articular surface caused by the osteotomy. RESULTS: The knees with an intraarticular step-off had two major contact areas with an intervening zone of reduced load corresponding to the edge of the depressed fragment. Coronal histologic sections through the articular surface showed the presence of thinning and fibrillation on the high side of the step-off and some compensatory hypertrophy of the cartilage. The subchondral bone was not responsible for restoring articular congruity because the rate of bone production was similar between the low side of the articular fracture (1.85 micrometers per day) and the high side of the fracture (1.67 micrometers per day). Scanning electron microscopy showed partial cartilage remodeling by deformation of the high side cartilage with bending of the vertical collagen fibrils, even in the unloaded state. CONCLUSIONS: In this model with a small fracture displacement (1.0 millimeter), which was less than the thickness of the articular cartilage (1.5 millimeters), the contour of the joint improved despite residual articular surface incongruency after the fracture healing.
Animals↗
Internal fixation of a patella fracture using an absorbable suture.
This case report describes the use of an absorbable suture for the fixation of a patella fracture in a child. In this case the fracture was held satisfactorily by the suture until union. This technique means that there is no need for a second operation to remove the fixation material.
Absorbable Implants↗
Internal fixation of a patella fracture using absorbable suture.
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Absorbable Implants↗
Quality of life related to fracture displacement among elderly patients with femoral neck fractures treated with internal fixation. 2002.
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Age Factors↗