Minimally invasive plate fixation in femoral shaft fractures

Limb Fractures Treated With the Novel Plate Osteosynthesis Application Technique: Second to Minimally Invasive Plates osteosynthesis

BACKGROUND

The main aim of this article was to propose a new concept of minimally invasive surgery for treating limb fractures, named as second to minimally invasive plates osteosynthesis (STMIPO).

METHODS

We have described the STMIPO technique in a step-wise and standardized manner based on our findings from a study involving six patients treated at our institution. All patients with fracture achieved satisfactory outcomes.

RESULTS

Ours clinical trials have shown that the STMIPO technique can be successfully applied in various limb fractures, including fibula fractures, tibial fractures, femur fractures, humerus fractures, ulna fractures, and radius fractures. All fracture patients achieved satisfactory outcomes.

CONCLUSION

As a new minimally invasive technology, the STMIPO technique can serve as an alternative solution for fractures that are difficult to reduce with minimally invasive plates osteosynthesis (MIPO).

A review of minimally invasive fracture stabilization in dogs and cats

OBJECTIVE

To summarize and discuss peer-reviewed studies on minimally invasive osteosynthesis (MIO) of long bone, physeal, and articular fractures in dogs and cats.

STUDY DESIGN

Invited review.

METHODS

A critique of literature was performed to assess MIO feasibility, outcomes, and complications through PubMed, Scopus, and CAB abstracts research databases (2000-2020).

RESULTS

More than 40 MIO articles have been published in the last 15 years, but most studies had small numbers, lacked control groups, and used limited outcome measures. Studies generally showed that MIO was feasible in dogs and cats with low complication rates. The current evidence does not demonstrate superior bone healing or functional outcomes with MIO when compared to standard methods. Although treatment principles, case selection, and techniques varied depending on the anatomical location, there were no salient differences in complication rates among long bones, physeal, and articular fractures treated by MIO.

CONCLUSION

The current available evidence and the personal experience of the authors support MIO as a promising fracture management modality. MIO can yield excellent outcomes when applied in carefully selected cases, performed by surgeons experienced in the technique. We cannot, however, conclude that MIO is superior to open fracture stabilization based on the available evidence in veterinary literature. Randomized controlled studies are warranted to prospectively compare MIO with other osteosynthesis techniques and thereby validate its role in fracture management for dogs and cats.

Role of mini-invasive bridge plate in the complex femoral fracture in school going children: A prospective clinical study of 30 cases

Objective:

Pediatric femoral fracture including supracondylar and subtrochanteric fracture constitutes 1.6% of all paediatric fracture. Elastic nails remain the standard treatment of choice in a midshaft transverse femoral fracture in children weighing less than 45 kg. But in subtrochanteric and spiral femoral fracture, the failure rate of elastic nails are quite high. Hence, in accordance with AAOS guidelines, we treated complex femoral fracture in children with submuscular mini-invasive bridge plate because of its advantage of minimal incision, early union with proper alignment and lower failure.

Material and Methods:

We retrospectively reviewed 30 complex femur fracture in children treated with Submuscular bridge plate by mini-invasive approach. Patients were analysed according to their age, type of fracture, time of union in weeks, complication and results were evaluated with modified Flynn's criteria.

Result:

Out of 30 patients 28 were boys and 2 were females, with an average age of 11.5 years in which Spiral fracture (n = 12), subtrochanteric fracture (n = 9), Complex Shaft fracture (n = 10). All fracture united well on an average of 11 weeks. And 29 patients has excellent results and in 1 patient there is Acceptable result. The single complication was 3 mm limb lengthening but it didn't change gait of the patient.

Conclusion:

Mini invasive bridge plating is an easy and soft tissue preserving procedure for managing complex femoral fracture in children. It has shown promising results in achieving union without any major complication. We strongly recommend the SBP in a complex femoral fracture in children.

A novel closed reduction technique for treating femoral shaft fractures with intramedullary nails, haemostatic forceps and the lever principle

Background

Faster, easier, more economical and more effective versions of the minimally invasive reduction procedure for femoral shaft fractures need to be developed for use by orthopaedic surgeons. In this study, a fracture table was used to restore limb length, and long, curved haemostatic forceps and the lever principle were utilized to achieve minimally invasive reduction and intramedullary nail fixation of femoral shaft fractures.

Methods

A retrospective analysis involving 20 patients with femoral shaft fractures reduced with a fracture table; long, curved haemostatic forceps; and the lever principle was conducted. The operative effect was evaluated on the basis of the operative time, reduction time, fluoroscopy time, and intraoperative blood loss.

Results

All 20 cases were reduced in a closed fashion, and no conversions to open reduction were needed. The average operative time and fracture reduction time for all patients were 69.1 ± 13.5 min (range, 50–100 min) and 6.7 ± 1.9 min (range, 3–10 min), respectively. The fluoroscopy exposure time during the reduction process was 5–15 s, with an average time of 8.7 ± 2.7 s. The average intraoperative blood loss was 73.5 ± 22.5 mL (range, 50–150 mL). The patients exhibited excellent alignment in the injured limb after intramedullary nailing. Seventeen patients successfully completed a follow-up after fracture healing. The healing time ranged from 4 to 6 months.

Conclusions

Displaced femoral shaft fractures in adults can be treated by a labour-saving lever technique involving fragments, 2 haemostatic forceps and soft tissue envelope-assisted closed reduction and intramedullary nail fixation. This technique is easy to perform; reduces blood loss, the fluoroscopy time and the surgical time for intraoperative reduction; and leads to excellent fracture healing.

Minimally invasive plate osteosynthesis (MIPO) versus open reduction and internal fixation (ORIF) in the treatment of distal fibula Danis-Weber types B and C fractures

Background

Minimally invasive plate osteosynthesis (MIPO) has been reported to be superior to open reduction and internal fixation (ORIF) in the treatment of different long bone fractures. Nevertheless, in distal fibula fractures, the evidence of MIPO remains scarce. The aim of this retrospective study was to compare the clinical and radiological outcomes of the minimally invasive techniques applied to the distal fibula with open reduction and internal fixation within a 12 months follow-up.

Methods

A consecutive series of patients who underwent surgery using either ORIF or MIPO for the treatment of distal fibula fractures between 2010 and 2014 were retrospectively analyzed. All distal fibular fractures requiring an operative treatment (Danis-Weber type B ≙ AO type 44 B1, 2, 3 and Danis-Weber type C ≙ AO type 44 C1, 2) were included (ORIF n = 35, MIPO n = 35). Patients were assessed for postoperative pain using a visual analog scale (VAS) for pain (ranging from 0 to 10) and classified into 4 groups: “no pain” for VAS = 0, “low” for VAS = 1–3, “moderate” for VAS = 3–5, and “severe” for VAS = 5–10. In addition, complications of postoperative fracture-related infection, wound healing disorders, vascular and nerve injury and development of nonunion were evaluated and analyzed. Radiologic outcome measures assessing the talocrural angle, lateral and medial clear space, tibiofibular overlap, and talar tilt angle were evaluated postoperatively.

Results

The overall complication rate showed to be lower in the MIPO group compared to the ORIF group (14% vs. 37%, p = 0.029). Even though not statistically significant, specific surgery-related complications such as skin necrosis (3% vs. 9%, p = 0.275), nonunion (0% vs. 6%, p = 0.139), infections and wound healing disorders (9% vs. 20%, p = 0.141), as well as postoperative pain (17% vs. 26%, p = 0.5) were found more frequently in the ORIF group. The tibiofibular overlap demonstrated to be significantly lower in the ORIF group (3.3 mm vs. 2.7 mm, p = 0.033). The talocrural angle, talar tilt angle, and lateral and medial clear space showed to be equivalent in both groups.

Conclusion

In this retrospective single-center consecutive series, MIPO was superior to ORIF in the surgical treatment of distal fibula fractures with respect to the overall complication rate.

Trial registration

EKNZ Project-ID: 2019-02310, registered on the 20th of December 2019 with swissethics

Biomechanical analysis of the stability of anterograde reamed intramedullary nails in femoral spiral fractures

Femoral shaft fractures present high morbidity and important complications and consequences, being spiral fractures the most complicated from a biomechanical point of view, being unstable and without possibility of getting a good contact between nail and femoral endosteum. Femoral diaphyseal fractures are treated, usually, by means of intramedullary nailing. So, it is necessary to know the osteosynthesis stability and which locking screws combination is optimal. This work studies the use of reamed locked intramedullary nails in spiral femoral fractures located along zones 2 and 4 of wiss, depending on the spire length, corresponding to 32-A spiral type in AO/OTA classification, which represent a percentage of 23% within the total of diaphyseal fractures. A three-dimensional finite element model of the femur was developed, modeling a spiral fracture with different spiral lengths and gaps. A femoral nail was used, considering two transversal screws both at the proximal and the distal parts. The study was focused on the immediately post-operative stage, verifying the appropriate stability of the osteosynthesis. Reamed intramedullary blocked nails provide appropriate stability of femoral spiral fractures, considering global mobility of femoral head with respect to femoral condyles, relative displacements between fragments at fracture site, stresses at nail and locking screws, and stresses at cortical bone. The obtained results show that the use of blocked reamed nails in spiral femoral fractures can be considered as an appropriate surgical technique, providing sufficient stability in order to obtain an adequate fracture healing.

Biomechanical Evaluation of Dual Plate Configurations for Femoral Shaft Fracture Fixation

Aim

This study aimed at comparing the mechanical properties of conventional and locking dual plates in adjacent and orthogonal orientations for the surgical fixation of transverse femoral shaft fractures. It also assessed the failure mechanics after dual adjacent and orthogonal locking plate removal.

Methods

Thirty-two composite femurs were transversally osteotomized and randomly assigned for fixation with either dual locking or compression plates in an adjacent or orthogonal configuration. Sixteen specimens were preloaded axially to 20 N and single-leg stance loads were simulated. The remaining sixteen constructs were subjected to torsional loads of 10 Nm at a rate of 10 Nm/s in external and internal rotation of the femoral head in relation to the knee. Overall combined rotational stiffness was calculated. Eight different specimens with no osteotomy underwent the same experiments after dual locked plate removal and were tested to failure in combined eccentric axial and torsional modes. Data were statistically processed using a two-tailed t-test and one-way analysis of variance for the comparison of means between two or more groups, respectively.

Results

Orthogonal constructs were statistically stiffer in axial loading compared to their adjacent counterparts in both conventional and locking configurations (p<0.001). Dual locking plates provided higher torsional stiffness than conventional ones within each plate orientation (p<0.01). Neither axial/torsional strength nor failure loads differed between constructs that had adjacent or orthogonal dual locking plates instrumented and then removed (p>0.05).

Conclusions

In both orthogonal and adjacent orientations, double locking plates provide higher stability than their dual conventional counterparts. Orthogonal dual plate configuration is more stable and biomechanically superior to dual adjacent plating for constructs fixed with either standard compression or locking plates.

Clinical outcomes of intramedullary nailing of femoral shaft fractures with third fragments: a retrospective analysis of risk factors for delayed union

Background

This study retrospectively evaluated the clinical outcomes of intramedullary nailing of femoral shaft fractures with third fragments and analyzed the risk factors for delayed union.

Methods

Retrospective analyses involving 51 patients who underwent intramedullary nailing of femoral shaft fractures with third fragments (AO classification type B, 35 cases; type C, 16 cases) were conducted. Delayed union was defined as either more than 10 months required for callus formation in more than three of the four cortical bone surfaces observed in the frontal and lateral radiographic views or the requirement for additional surgery such as nail conversion or bone transplantation. Seventeen patients developed delayed union (D group). Thirty-four patients achieved bony union within 9 months (U group). The following background variables were compared between groups: age at the time of the injury; AO classification; ratio of open fracture; waiting period before surgery; rate of the infraisthmal fracture; diameter of the intramedullary nail; ratio of the intramedullary nail to the femur; length and displacement of the third fragment; and use of open reduction, poller screws, or dynamization.

Results

Significant differences were found between the D and U groups for age (32.2±14.1 vs. 25.3±9.6 years), open fracture ratio (35.3% vs. 11.8%), and displacement of the third fragment (13.7±6.4 vs. 9±6.3 mm). Multiple logistic regression analysis only identified displacement of the third fragment as a risk factor for delayed union (p=0.03; OR 1.13; 95% CI 1.01 to 1.26).

Discussion

Delayed union was observed in 17 cases (33.3%) after intramedullary nailing of femoral shaft fractures with third fragments. Displacement of the third fragment influenced delayed union.

Level of evidence

Level III.

Extra Articular Distal Femoral Fractures in the Elderly Treated with Retrograde Nailing Using a Spiral-Locking Blade System

BACKGROUND

The number of elderly patients sustaining long bone fractures is increasing with the rise of elderly population in the western world. Management of distal femur fractures is particularly difficult due to osteoporosis and other associated comorbidities. The key to management would be by surgical stabilization, which allows early mobilization. This study was devised to look into the radiological outcome and complication rate in a series of elderly patients who were treated with retrograde nail using spiral locking blade system for extra articular distal femur fractures.

MATERIALS AND METHODS

This is a retrospective study of patients who have undergone retrograde nailing with spiral-locking blade for distal femoral fractures (extra articular) above the age of 70 years in a major trauma center from 2001 to 2015. Notes were assessed for postoperative complications; time to union and final postoperative followup radiographs were assessed for alignment using a scoring system.

RESULTS

Forty one patients with an average age of 80 years and an average followup period of 9 months were included. The mean radiological score at final followup was 10.34 (range 8-12), with no significant shortening in any of the patients. Thirty patients had excellent radiological score (>10) and 11 patients scored good (8-9). The difference in time to union between Group 1 - simple fracture pattern (3.42 months) and Group 2 - complex comminuted fracture pattern (4.74 months) was not statistically significant (P = 0.072). There were five delayed unions but no cutout or metal work failure.

CONCLUSION

The retrograde femoral nail with distal spiral-locking blade system can be a good surgical option for the treatment of extra articular distal femoral fractures in the elderly with the possibility of early weightbearing.

Are there too many screw holes in plates for fracture fixation?

Background

Implant breakage after the fixation of traumatic fractures is rare; however, when it occurs, it is debilitating for the patients and a challenge for surgeons. The purpose of this study was to analyze and identify the independent risk factors for implant breakage of traumatic fractures treated with plate osteosynthesis.

Methods

We reviewed the medical records of patients with a fracture to any part of their four extremities, clavicle, hand or foot, who underwent surgical plate osteosynthesis from January 2005 to January 2015, and who sustained a subsequent implant breakage. Kaplan–Meier univariate and multivariate Cox regressions were performed to identify independent associations of potential risk factors for implant breakage in this cohort.

Results

We identified 168 patients who underwent plate osteosynthesis surgery and had subsequent internal fixator breakage. The mean patient age was 40.63 ± 16.71 years (range, 3 to 78 years), with 72.0% (121) males and 28.0% (47) females. The average time between surgery and implant breakage was 12.85 ± 12.42 months (range, 1 to 60 months). In the final regression model, we show that inserting screws close to the fracture line is an independent predictive risk factor for implant breakage (HR, 2.165, 95%CI, 1.227 to 3.822; P = 0.008).

Conclusions

We found that inserting screws close to the fracture line is related to an increased risk of internal fixator breakage in patients treated with plate osteosynthesis after fracture. Plates with additional holes likely lead to an increased risk of implant breakage, presumably because surgeons cannot resist inserting extra screws into the holes adjacent to the fracture line, which reduces the stiffness of the plate. We have addressed this problem by designing a plate without holes adjacent to the fracture line.

The Internal Brace for Midsubstance Achilles Ruptures

The efficient and effective function of the Achilles tendon is essential for normal gait and sporting performance. The optimal technique for the operative repair of the Achilles midsubstance rupture remains controversial. Suboptimal outcomes are common even after successful Achilles repair. Factors contributing to poor outcomes include a tenuous soft tissue envelope (leading to wound complications, peritendinous adhesions, and poor tendon healing,) as well as failure to maintain appropriate musculotendinous length, even after successful repair.We present a new technique using the InternalBrace (IB) and a modification of the Percutaneous Achilles Repair System (PARS; Arthrex Inc, Naples, FL), the Achilles Mid-Substance Speed Bridge Repair. This IB approach is knotless, respects the soft tissue envelope, and allows the appropriate musculotendinous length to be set intraoperatively. The IB principle enables direct fixation to bone allowing early mobilization while minimizing the risk of knot slippage, accelerating recovery, and allowing for restoration of normal function.

LEVEL OF EVIDENCE

Level V, expert opinion.

Effects of ligation of lateral intermuscular septum perforating vessels on blood supply to the femur

INTRODUCTION

With a subvastus approach to the femur, the vessels that perforate the lateral intermuscular septum (LISP-vessels) must be ligated. The effect on the blood supply to the femur remains unclear. The purpose of the current study was to investigate the effect of ligation of the LISP-Vessels on the blood supply and to examine the anatomy of the LISP-vessels and the anastomoses around the femur.

MATERIALS

In six human cadavers the LISP vessels were ligated by a lateral subvastus approach on one side. The contralateral side served as control group. After bilateral injection of different coloured silicon dyes into the lateral and medial circumflex femoral artery (green), deep femoral artery (red) and the superficial femoral artery (blue) dissection was performed bilaterally. The arterial perfusion on both sides was compared and the anatomy of the LISP vessels studied.

RESULTS

The medullary perfusion of the femur was not altered by the ligation of the LISP vessels. It did also not lead to a decrease in periosteal vessel filling. The LISP vessels were shown to be a part of a complex and rich anastomotic network and play an important role in the perfusion of the femur and quadriceps muscle group. The ligature could be compensated for by this anastomotic network. Branches to the periosteum separate from the LISP vessels immediately after perforating the lateral intermuscular septum. The linea aspera turned out to be an important area for the femoral blood supply.

DISCUSSION AND CONCLUSIONS

Exposure of the femur through a lateral subvastus approach with ligation of LISP vessels causes a certain degree of soft tissue trauma. However, by using a gentle surgical technique the periostal perfusion of the femur can be preserved by a potent anastomotic network after ligation of the LISP vessels if they are not ligated to close to the lateral intermuscular septum and the linea aspera is not unnecessarily exposed.

Role of the compression screw in the dynamic hip-screw system: A finite-element study

The dynamic hip-screw (DHS) system is a common implant for fixation of proximal femur fractures. During assembly, it has been recommended to remove the compression screw after initial compression has been obtained; however, related complications had been reported. So far, the role of compression screw in the reconstructed stability of hip fractures as well as the mechanical strength of the DHS system has rarely been mentioned. This study investigated the function of this screw in the DHS system during fracture healing. Based on the FE method, six numerical models of proximal femur were employed to analyze the mechanical response of a DHS implant with various fracture types and different fixation strategies (with or without a compression screw). The displacement of the femur head and peak von Mises stress were selected as indices of the stability of a fractured femur stabilized by a DHS device and of the risk of implant failure, respectively. Our results showed that a retained compression screw increased reconstructed structural stiffness, reducing the displacement of the femur head. This screw also helped to lessen mechanical failure of side plate by reducing the peak von Mises stress around the connection between the barrel and side plate. Both findings were evident in the proximal femur fracture involving the intertrochanteric part, and even more obvious in the setting of bony defects. Thus, we recommend the maintenance of compression screw in the DHS system while treating the intertrochanteric fracture, particularly in cases with bony defects.

Submuscular bridge plating for complex pediatric femur fractures is reliable

BACKGROUND

Complex, high-energy pediatric femur diaphyseal fractures cannot be treated reliably by conventional methods: casting is not suitable for polytrauma and large children, external fixation is associated with a high rate of malalignment and refractures, elastic nails are unsuitable for unstable fractures and metaphyseal areas, and lateral trochanteric entry rigid nails cannot address proximal and distal fragments and need relatively large medullary canals. A few centers have reported that submuscular bridge plating (SBP) is associated with minimal complications, but these findings require confirmation.

QUESTIONS/PURPOSES

We asked whether SBP (1) reproducibly leads to union in unstable fractures with a low complication rate, (2) leads to reasonable alignment and leg length equality (3), is unaffected by age, weight, or location of fracture, and (4) is associated with no or minimal refracture after hardware removal.

METHODS

We retrospectively reviewed 60 fractures in 58 patients with pediatric diaphyseal femoral fractures treated with SBP from 1999 to 2011. The average age was 9 years. Forty (67%) of the fractures were unstable. Minimum followup was 2.4 months (average, 15.5 months; range, 2.4-50.6 months).

RESULTS

All fractures healed well and all patients returned to full activity. Two of the 58 patients (3%) had major complications leading to unplanned surgeries: one implant failure and one deep infection in an old open fracture. None of the patients developed clinically important malalignment or leg length discrepancy. Implant removal was performed in 49 patients without complications.

CONCLUSIONS

SBP provided reliable fixation and healing for complex pediatric femur fractures and can have a broader application in the orthopaedic community. SBP is our preferred method for unstable fractures or fractures of the proximal and distal shaft.

Minimally invasive osteosynthesis of adult tibia fractures by means of rigid fixation with anatomic locked plates

Main principle of biological fixation by minimally invasive locked plate osteosynthesis (MILPO) in lower extremity long bone fractures is relative stability which is provided by using long plate with limited number of screws. Some biomechanical studies have been reported about this issue. However, clinical studies are still missing. The aims of this retrospective extended case series were to evaluate the clinical and radiological results of adult tibia fractures treated by MILPO and the effect of plate length and screw density on complication rates. Twenty tibia fractures in 19 patients (mean age 42.3 years) operated by MILPO were reviewed. According to the AO classification, diaphyseal and metaphyseal fractures without intraarticular extensions were simple and wedge-type fractures, whereas all intraarticular fractures were comminuted. Number of screws, cortices and empty screw holes proximal and distal to the fracture, plate-span ratio (plate length divided by overall fracture length), plate-screw density (number of inserted screws divided by number of plate holes), fixation failures, delayed or nonunion, malalignment and leg length discrepancy were documented. Mean follow-up was 16 (range 12–26) months. On average, 4 screws with 6 cortices were used both proximally and distally in all fractures. Only in diaphyseal fractures, one screw hole close to the fracture was omitted. Average plate-screw density and plate-span ratio were 0.68 and 4, respectively. Mean union time was 3 months. There were no cases of delayed or nonunion on the final follow-up. Plate bending was observed in one patient who had fair result. The remaining 18 (94.8 %) patients showed good and excellent results. Satisfactory results can be achieved despite low plate-span ratio and high plate-screw density in simple and wedge-type diaphyseal fractures of the tibia. Additionally, plate-screw density can be higher at metaphysis in intraarticular fractures, in which essential point is a perfectly stable fixation that provides early motion.

The influence of different osteosynthesis configurations with locking compression plates (LCP) on stability and fracture healing after an oblique 45° angle osteotomy

BACKGROUND

Locking compression plates are used in various configurations with lack of detailed information on consequent bone healing.

STUDY DESIGN

In this in vivo study in sheep 5 different applications of locking compression plate (LCP) were tested using a 45° oblique osteotomy simulating simple fracture pattern. 60 Swiss Alpine sheep where assigned to 5 different groups with 12 sheep each (Group 1: interfragmentary lag screw and an LCP fixed with standard cortex screws as neutralisation plate; Group 2: interfragmentary lag screw and LCP with locking head screws; Group 3: compression plate technique (hybrid construct); Group 4: internal fixator without fracture gap; Group 5: internal fixator with 3mm gap at the osteotomy site). One half of each group (6 sheep) was monitored for 6 weeks, and the other half (6 sheep) where followed for 12 weeks.

METHODS

X-rays at 3, 6, 9 and 12 weeks were performed to monitor the healing process. After sacrifice operated tibiae were tested biomechanically for nondestructive torsion and compared to the tibia of the healthy opposite side. After testing specimens were processed for microradiography, histology, histomorphometry and assessment of calcium deposition by fluorescence microscopy.

RESULTS

In all groups bone healing occurred without complications. Stiffness in biomechanical testing showed a tendency for higher values in G2 but results were not statistically significant. Values for G5 were significantly lower after 6 weeks, but after 12 weeks values had improved to comparable results. For all groups, except G3, stiffness values improved between 6 and 12 weeks. Histomorphometrical data demonstrate endosteal callus to be more marked in G2 at 6 weeks.

DISCUSSION AND CONCLUSION

All five configurations resulted in undisturbed bone healing and are considered safe for clinical application.

Less invasive percutaneous wave plating of simple femur shaft fractures: A prospective series

In developing nations, fixation of femoral shaft fractures with intramedullary (IM) nails can pose significant challenges. Use of IM implants is commonly limited by availability, funds or patient's physique. Conversely, traditional compression plates are usually readily available at a much lower cost, making bridge plating of femur fractures a frequently used surgical technique. We hypothesised that less invasive percutaneous plate osteosynthesis (MIPPO) of femoral shaft fractures has a similar outcome compared to IM nailing. The study is designed as a prospective case series at a Level 1 university trauma centre. Fifty-seven patients with simple femur shaft fractures (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) type A) were enrolled between April 2001 and December 2005 and followed up for a minimum of 1 year or until fracture union. Primary outcome measures included union rate and time to union. Secondary outcome parameters were hardware failure, malalignment, infection and need for revision surgery. The mean age of the study cohort was 24.7 years. Fifty-four patients sustained associated systems injury. Primary union occurred in 54 patients in an average time of 13 weeks. Two patients presented with implant failure, and one patient displayed signs of delayed union. Six patients developed valgus deformities, whereas five patients displayed external rotation malalignment. One patient developed a superficial wound infection, and another presented with a deep infection. Bridge wave plating represents a safe and efficacious treatment alternative to IM nailing for simple femoral shaft fractures in countries where IM nails are limited by availability, costs and patient's physical characteristics.

Training in the practical application of damage control and early total care operative philosophy--perceptions of UK orthopaedic specialist trainees

INTRODUCTION

Despite improvements in the outcome of individuals sustaining significant injury, the optimum management of fractures in traumatised patients remains an area of debate and publication. There is, however, a paucity of studies regarding the specifics of acquired experience and training of junior orthopaedic surgeons in the practical application of these skills. Our null hypothesis is that, despite alteration in surgical training, the perceived confidence and adequacy of training of UK orthopaedic specialist trainees in the application of damage control orthopaedics (DCO) and early total care (ETC) philosophy is unaffected.

SUBJECTS AND METHODS

A web-based survey was sent to a sample of orthopaedic trainees. From 888 trainees, 222 responses were required to achieve a 5% error rate with 90% confidence.

RESULTS

A total of 232 responses were received. Trainees reported a high level of perceived confidence with both external fixation and intramedullary devices. Exposure to cases was sporadic although perceived training adequacy was high. A similar pattern was seen in perceived operative role with the majority of trainees expecting to be performing such operations, albeit under varying levels of supervision. In a more complicated case of spanning external fixation for a 'floating knee, trainees reported a decreased level of perceived confidence and limited exposure. One-third of trainees reported never having been involved in such a case. In contrast to nationally collated logbook data, exposure to and perceived confidence in managing cases involving ETC and DCO were similar.

CONCLUSIONS

Despite changes in the training of junior orthopaedic surgeons, trainee-reported confidence and adequacy of training in the practical application of DCO and ETC was high. Exposure to cases overall was, however, seen to be limited and there was a suggestion of disparity between current operative experiences of trainees and that recorded in the national trainee logbook.

Treatment of distal femoral fracture by minimally invasive percutaneous plate osteosynthesis: comparison between the dynamic condylar screw and the less invasive stabilization system

BACKGROUND

Treatment of distal femoral fractures by percutaneous plating without direct manipulation of the fracture fragments leads to good clinical outcome. Percutaneous plating has traditionally involved using a dynamic condylar screw (DCS) and the less invasive stabilization system (LISS) was reported. The biomechanical study showed that the LISS had the enhanced ability to withstand higher loads. However, there were no clinical comparison study of distal femoral fractures treated with DCS and LISS. The aim of this study was to outline any differences in clinical and radiological results between the DCS and the LISS for treating distal femoral fractures.

METHODS

Forty-five supracondylar or intercondylar femoral fractures were treated by minimally invasive percutaneous plating with the DCS or the LISS without bone graft. There were 26 patients with 26 fractures in the DCS group and 19 patients with 19 fractures in the LISS group. The data of the clinical and radiographic outcomes were compared between the two different fixation devices.

RESULTS

Complete union was achieved in 41 of the 45 patients (91.1%). The success rate was 96.2% in the DCS group and 94.7% in the LISS group (p = 0.672). The mean fusion time was 19.18 weeks in the DCS group and 19.38 weeks in the LISS group (p = 0.835). The average range of motion of the knee joint was 111.65 degrees in the DCS group and 116.26 degrees in the LISS group (p = 0.334). Early implant failure only occurred in the DCS group (11.5%, p = 0.252, odds ratio = 1.826 [95% CI: 1.387-2.404]). The total complication rate was 15.4% in the DCS group and 15.8% in the LISS group (p = 0.641). The mean loss of coronal fracture fragment angle was -0.77 degrees in the DCS group and -0.19 degrees in the LISS group (p = 0.125).

CONCLUSION

Minimally invasive percutaneous plating with the DCS or the LISS provides good outcome with few complications in the treatment of distal femoral fractures. Both systems minimize soft tissue trauma. LISS seems to have lower risk of early implant loosening than the DCS.

Distal Tibial Fracture Fixation with Locking Compression Plate (LCP) Using the Minimally Invasive Percutaneous Osteosynthesis (MIPO) Technique

BACKGROUND

Treatment of distal tibial fractures has always been a challenge. Distal tibia is more superficial, with less soft tissue coverage and blood supply. Therefore, operative treatment can lead to complications. We aim to see the results of the distal tibial fracture fixation with LCP using MIPO.

PATIENTS AND METHODS

Twenty-one consecutive patients were prospectively reviewed. AO types 43A, 43B and 43C were included. Fourteen male and seven female patients with a mean age of 51 years were included.

RESULTS

Mean time to union was 5.5 months (range 3-13 months). Seventeen fractures healed with good functional outcome. One patient had delayed union. One patient had nonunion and underwent revision; the fracture ultimately healed with good functional outcome. Two patients developed superficial wound infections but the fractures united completely.

DISCUSSION

The MIPO technique for distal tibia has shown good results with many additional advantages over the conventional methods. Early mobilization without risk of secondary displacement helps to prevent stiffness and contracture.

EPIDEMIOLOGICAL AND RADIOLOGICAL EVALUATION OF FEMORAL SHAFT FRACTURES: STUDY OF 200 CASES

OBJECTIVE

to evaluate epidemiological and radiological characteristics of the femoral shaft fractures, surgically treated from 1990 to 2005 at Hospital de Acidentados - Clínica Santa Isabel - in Goiânia, Goiás, aiming to contribute to better preventive and therapeutic measures planning to adopt on those fractures.

METHODS

200 patients' files and x-rays with femoral shaft fractures have been retrospectively evaluated. Patients below the age of 10 years were not included because the treatment for this group was conservative. 25 files have been discarded for not supplying all the necessary data to the study. The patients were assessed for sex, age, side of the fracture, bone exposure, mechanisms of trauma, classification of the fractures, associated trauma, time for bone healing and types of surgical devices. Statistic analyses were made by chi-squared, Fisher and Student's-t tests, adopting as a significance level p<0.05.

RESULTS

significant results (p < 0.05) were found in: 70% of men, 80% closed fractures and 65% of women above the age of 60. Fractures resulting from simple falls were more frequent in women, above 60 years old, with simpler traces, and the ones caused by projectiles of firearm in men, from 20 to 60 years, with unstable traces. Trampling accidents were prevalent among youngsters between 10 and 19 years old. Car accidents showed all the types of fractures, mostly associated to other traumas, reaching its peak incidence in the age group of 20-30 years. The treatment with Küntscher Nail resulted in a longer mean consolidation time, as well as fractures with unstable traces (B3,C1,C2,C3).

CONCLUSION

we found a bi-modal characteristic the femoral shaft fractures, consistently to literature data, where the high energy mechanisms (traffic accidents, high falls and wounds from firearms), have been more frequent in young adults, men, generating unstable traces of fractures, with more serious associated trauma, while the other group with low energy trauma (simple falls), was more frequently seen in elderly female individuals with less unstable fracture traces, without associated trauma.

Minimally invasive plate osteosynthesis (MIPO) in the treatment of the femoral shaft fracture where intramedullary nailing is not indicated

The aim of this study was to examine the results of minimally invasive plate osteosynthesis (MIPO) of the femoral shaft fracture in patients where intramedullary nailing is contraindicated and evaluate the proper number of the screws for stable fixation. This was a retrospective study of 36 closed femoral shaft fractures which underwent MIPO using a conventional 4.5 broad dynamic compression plate (DCP) with 14-18 holes fixed with three or four screws in the proximal and distal fragments. Thirty-three fractures had bony union in 21.0 weeks (range, 12-28 weeks), two had delayed union that required bone graft and union at 28 and 32 weeks. Malalignment occurred in five cases. Sixty-two fragments were fixed with three screws--40 in cluster and 22 in separated positions. Ten fragments were fixed with four screws--eight in cluster and two separated. Broken screws were found in three cases; all were in the group with three screws fixed in cluster group. MIPO of the femoral shaft fracture is an alternative treatment in the patient where intramedullary nailing is contraindicated. Malalignment is the common complication that must be carefully evaluated intraoperatively. We recommend using at least three separated screws in each fragment to reduce the risk of screw breakage.

Delayed union of multifragmentary diaphyseal fractures after bridge-plate fixation

Despite recent developments in fracture treatment, cases of non-union after long bone fractures are still encountered. This work aims at evaluating the active management of delayed union after the bridge-plate fixation of multifragmentary diaphyseal fractures by a limited surgical interference. Nineteen patients were included. All had revision surgery for delayed union of multifragmentary diaphyseal fractures after bridge-plate fixation. The period between primary and revision surgery was 12-20 weeks. Increasing stability was performed by adding more screws in all cases. Interfragmentary compression was performed in 16 patients. Axial compression of the fracture was applied in two patients, while one patient had the plate exchanged for a longer one. Bone grafting was added in nine patients. Union was achieved in all patients 8-16 weeks after re-operation. This work is a message for timely surgical interference in delayed union after bridge-plate fixation by a limited surgical procedure, before complete failure of the fracture stabilisation or non-union.

A short plate compression screw with diagonal bolts--a biomechanical evaluation performed experimentally and by numerical computation

INTRODUCTION

Decreasing the length of the side plate of the dynamic hip screw would theoretically allow a smaller surgical incision, a shorter surgical time, decreased operative blood loss and minimal periosteal stripping. A new design of a very short plate dynamic hip screw based on two diagonal screws has been developed. Our study compares the new design and the four-hole side plate in respect to mechanical properties and bio-mechanical outcomes utilizing the Finite Element Analysis method.

METHODS

Four pairs of fresh frozen cadaveric femora were extracted from male corpses aged 25-43 years (mean 34.8). One femur of each pair was fixated by means of the new system and the other by means of the conventional design. Mechanical loading was applied to all four pairs. The decline which occurred during the periodical loadings and the breakage loads of fixated bones were measured. Mechanical performance and probability of failure was assessed by conducting a mathematical analysis using the finite element method.

FINDINGS

The average deflection under excessive cyclic loading was 33% higher in the bones fixated with the very short plate-dynamic hip screw device than in those fixated with the conventional dynamic hip screw. The average load failure during the collapse-loading test was 3120N for the very short plate-dynamic hip screw as compared to 4160N for the regular device. Mechanical testing did not provide decisive results regarding failure. The mathematical analysis performed indicated that the maximal stress in the very short plate-dynamic hip screw reached values 3-4-fold higher than in the regular dynamic hip screw.

INTERPRETATION

Although the new design offers a minimally invasive approach to subtrochanteric femur fracture fixation, it was found to have insufficient biomechanical performance resulting in high probability of mechanical failure. The authors believe that the finite element method may have the potential to serve as an additional clinical tool for performing surgical preplanning and assist in decision making.

Femoral biologic plate fixation

New techniques of fracture fixation such as indirect reduction, careful soft tissue handling, and elastic fixation are being used in place of older methods of mechanical stabilization. These new techniques led to the concept of biologic plate fixation. We systematically reviewed the literature and provide an overall evaluation of femoral biologic fixation for fracture treatment. We analyzed 19 studies with 687 patients with 697 femoral fractures. Twenty-three percent of the fractures were subtrochanteric, 29% were diaphyseal, and 48% were supracondylar. Twenty-two percent were open fractures. The majority (81%) were comminuted and AO Types B and C. The overall union rate was 98.4%, with a mean time to union ranging from 10.7 to 24 weeks. Primary or secondary bone-grafting procedures were reported in all but one study with a frequency ranging from 0-55%. The most frequently recorded complications were malunion (0-29%) and reoperation (0-23%). The high union rate, low infection rate (2%), and occasional need for bone graft indicate biologic plate fixation is a viable alternative to modern nailing techniques, particularly in patients with polytrauma.

LEVEL OF EVIDENCE

Therapeutic study, Level III.

Low complication rate of LISS for femur fractures adjacent to stable hip or knee arthroplasty

Fractures of the femur after a knee or hip arthroplasty historically have been plagued with high complication rates. The Less Invasive Stabilization System (LISS) has theoretical advantages of improved biomechanics and limited insult to the bone's vascular supply. We theorized that the LISS would have a lower complication rate than historical controls for these fractures. Patients who were treated with a LISS at two Level I trauma centers from July 2001 to July 2003 were prospectively followed up. The inclusion criteria were an acute fracture of the femur treated with a LISS in a patient with a stable ipsilateral total knee prosthesis and/or hip pros- thesis. There were 24 patients in the study group. The injury mechanism was a low-energy fall for all patients. All patients were females with an average age of 79.5 years (range. 64-93 years). Ten patients had ipsilateral hip arthroplasties, nine patients had ipsilateral total knee arthroplasties, and five patients had knee and hip arthroplasties. Followup was at an average of 48 weeks (range, 17-101 weeks). Eighteen of the 19 fractures in the surviving patients with followup healed uneventfully for a complication rate of 5.2%. One fracture was complicated by hardware pullout and was revised to a longer LISS that healed uneventfully. We think our data show that our patients had a low complication rate compared with that of historical controls, and we suggest that the LISS may be an appropriate treatment alternative for femur fractures associated with stable hip or knee prostheses.

LEVEL OF EVIDENCE

Therapeutic, Level IV.

Results and technique of unstable pediatric femoral fractures treated with submuscular bridge plating

Twenty-seven patients underwent submuscular bridge plating for unstable pediatric femoral fractures with contraindications to fixation with flexible intramedullary nails. This report discusses the technique and results. A precontoured plate was tunneled proximally through a small distal incision in the subvastus plane to bridge the fracture. The plate was secured to the femur, with screws placed percutaneously proximal and distal to the fracture to reduce and stabilize the fracture. A retrospective review of radiographs and clinical follow-up was analyzed for postoperative alignment, any change in alignment or instrumentation failure, bony union, clinical exam, and complications. There were no intraoperative or postoperative complications. There has been no instrumentation failure or loss of reduction. Early callus was seen by 6 to 8 weeks and stable bony union by 12 weeks in all patients. Submuscular plating is a reasonable option for operative stabilization of comminuted and unstable pediatric femoral fractures.

Minimally invasive plate osteosynthesis (MIPO) of the humeral shaft fracture. Is it possible? A cadaveric study and preliminary report

Minimally Invasive Plate Osteosynthesis (MIPO) has gained popularity with satisfactory clinical outcomes in the treatment of long bone fractures. MIPO for humeral shaft fractures, however, could be a surgically dangerous procedure because of the risk of radial nerve injury. An anatomical study was performed to evaluate the feasibility of MIPO for the humeral shaft fractures, and to study the relationship between the radial nerve and the plate with the forearm in full pronation and in supination. The study was performed on ten arms from five fresh cadavers. Two separate incisions, one proximal and one distal, were made in each arm with the forearm in full supination. A 9-hole narrow DCP was inserted into a tunnel using an anterior approach and fixed with 2 screws each on the proximal and distal humerus. The tunnel was then explored to identify the relationship between the radial nerve and the plate. No radial nerve compression or entrapment by the plate was found. The distance measured from the closest part of the plate to the radial nerve was 2.0-4.9 mm (average 3.2 mm). When the forearm was pronated, the radial nerve moved closer to the plate by a distance of 0-3 mm. The results of this study showed that it is possible to treat humeral shaft fractures by the MIPO method using an anterior approach. To reduce the risk of radial nerve injury, the forearm must be kept in full supination during plate insertion, and excessive force should be avoided during retraction of the lateral half of the brachialis muscle together with the radial nerve in the distal incision. The results of using this MIPO approach for humeral shaft fractures in 4 patients were also reviewed.

Fractures of the distal tibia treated with closed reduction and minimally invasive plating

INTRODUCTION

The treatment of fractures of the distal tibia can be problematical because of the thin soft-tissue covering. Bridging slide-insertion plate osteosynthesis is performed by indirect, axially correct reduction of the fracture and stabilization without opening the soft tissue at the fracture site. Stripping of the periosteum is thus avoided, the fragments remain integrated into the soft tissue, and healing occurs spontaneously by way of callus formation.

MATERIALS AND METHODS

Seventy-one patients treated by slide-insertion plate osteosynthesis were followed up over at least 2 years. As would be expected in this anatomical region, the proportion of C fractures and fractures with concomitant soft-tissue damage was high. The majority of patients were treated by application of an external fixator on the day of the accident; the definitive osteosynthesis with the slide-insertion plate was performed at a later date after healing of the soft tissues.

RESULTS

In 68 patients, fracture healing was achieved within 2 years. In 80% of the cases, the final X-ray follow-up showed no or tolerable axis deviations (<5 degrees) in the varus/valgus plane or in the recurvation/antecurvation plane. A deviation >10 degrees requiring a correcting osteotomy was found in only 1 patient. Postoperative complications were rare occurrences. Five patients required an additional cancellous bone graft to deal with inadequate bone healing. System-related complications (instability, malalignment) due to intraoperative technical errors only had to be corrected in revision operations in 2 patients.

CONCLUSION

Closed reduction and minimally invasive plating offers the combined advantages of minimal soft-tissue damage with stable fracture fixation.

Minimally invasive percutaneous plating of distal femoral fractures using the dynamic condylar screw

BACKGROUND

In distal femoral fractures, conventional open reduction and internal fixation causes complications because of excessive soft-tissue stripping. To prevent this, minimally invasive percutaneous plating was performed in distal femoral fractures.

METHODS

Sixteen supracondylar or intercondylar femoral fractures were treated by minimally invasive percutaneous plating with the dynamic condylar screw without bone graft. Five (31%) were open fractures.

RESULTS

All fractures healed except one. The average time for fracture healing was 17 weeks (range, 14-22 weeks). Complications included one nonunion related to early full weight bearing. No patient showed malunion or deep infection. Results were evaluated by modified Neer rating, and all patients had excellent or good results. Intra-articular fractures showed less favorable range of motion and clinical scores than extra-articular fractures.

CONCLUSION

Minimally invasive percutaneous plating with the dynamic condylar screw can provide favorable results in the treatment of distal femoral fractures.

Oblique screws at the plate ends increase the fixation strength in synthetic bone test medium

OBJECTIVE

To test the hypothesis that oblique screws at the ends of a plate provide increased strength of fixation as compared to standard screw insertion.

DESIGN

Biomechanical laboratory study in synthetic bone test medium.

METHODS

Narrow 4.5-mm stainless steel low-contoured dynamic compression plates were anchored with cortical screws to blocks of polyurethane foam. The fixation strength in cantilever bending (gap closing mode) and torsion was quantified using a material testing system. Different constructs were tested to investigate the effect of the screw orientation at the end of the plate (straight versus oblique at 30 degrees), the plate, and bridging length as well as the number of screws.

RESULTS

An oblique screw at the plate end produced an increased strength of fixation in all tests; however, the difference was more significant in shorter plates and in constructs with no screw omission adjacent to the fracture site. Both longer plates and increased bridging length produced a significantly stronger construct able to withstand higher compression loads. Under torsional loading, the fixation strength was mainly dependent on the number of screws.

CONCLUSIONS

The current data suggest that when using a conventional plating technique, plate length is the most important factor in withstanding forces in cantilever bending. With regard to resisting torsional load, the number of screws is the most important factor. Furthermore, oblique screws at the ends of a plate increase fixation strength.

Advantages of submuscular bridge plating for complex pediatric femur fractures

Conventional treatments of pediatric femoral shaft fractures may result in an unacceptable rate of complications, especially in complex fractures. These fractures include high-energy injuries resulting in unstable fracture patterns, fractures in the proximal or distal third, and fractures occurring in large or multiply injured children. Our goal was to evaluate whether a minimally invasive submuscular bridge plating technique provides stability for early functional treatment (without protective casting or bracing) and predictable healing. Fifty-one patients with an average age of 10 years were studied. Sixty-seven percent had high-energy injuries and 55% had unstable fracture patterns. With an average followup of 14.2 months, all fractures united with excellent clinical results. Two (4%) significant complications occurred: fracture of one 3.5-mm LC-DCP Ti plate, and refracture of a pathologic fracture after early plate removal. Four patients (8%) had a leg-length discrepancy ranging from 23-mm short to 10-mm long. The average operative time was 106 minutes, with average fluoroscopy time of 84 seconds. Procedures were done by 15 surgeons in five university medical centers. This technique offers the advantage of adequate stability for early functional treatment and predictable healing with maintenance of length and alignment for all pediatric femoral shaft fractures.

Percutaneous plating for unstable tibial fractures

Twenty-four unstable tibial fractures were stabilized with a narrow limited contact-dynamic compression plate inserted using a percutaneous plating technique under fluoroscopic guidance. The major indication for this technique was a tibial fracture for which intramedullary nailing would be difficult. There were 16 proximal or distal metaphyseal fractures and 5 segmental fractures in adults and 3 mid-shaft fractures in adolescents who still had an open physis. Of the 24 fractures, 22 healed without a second procedure; the two failures included one that required an early bone graft for severe comminution and another with a superficial infection that healed after early removal of the plate. There were no other infections. There were three cases of screw breakage, but they did not require a further procedure. At the final follow-up, one patient had healed with 5 degrees varus alignment and another with 10 degrees external rotation. All the patients had good knee or ankle function. We are confident that the percutaneous plating technique to treat unstable tibial fractures for which intramedullary nailing would be difficult will prove to be an alternative stabilization method, as it avoids the risk of infection or soft tissue compromise.

Distal tibia metaphyseal fractures treated by percutaneous plate osteosynthesis

Twenty-one patients with fractures of the distal tibial metaphysis, some with minimal displacement in the ankle, were treated by percutaneous plate osteosynthesis with a narrow limited contact-dynamic compression plate. Using the classification by the Arbeitsgemeinschaft für Osteosynthesefragen and Orthopaedic Trauma Association, 17 fractures had no articular involvement, whereas four included intraarticular extension. At final followup (mean, 20 months), all the fractures healed without second procedures and the mean union time was 15.2 weeks. One patient had malalignment of the limb with 10 degrees internal rotation, but there were no angular deformities greater than 5 degrees or any shortening greater than 1 cm. All patients had excellent or satisfactory ankle function. There were no infections or any soft tissue compromise. Percutaneous plate osteosynthesis is a safe and worthwhile method of managing such fractures, which avoids some of the complications associated with conventional open plating methods.

Extraosseous blood supply of the tibia and the effects of different plating techniques: a human cadaveric study

OBJECTIVE

To describe the extraosseous blood supply of the tibia and how the blood supply of the distal tibia is influenced by different plating techniques.

DESIGN

Microdissection of cadaveric adult hip disarticulation specimens following sequential arterial injections of india ink and Ward's Blue Latex was performed. Readily identifiable arterioles measured approximately 0.5 mm in diameter. Their artery of origin was identified, and their position along the medial, lateral, and posterior aspects of the tibia was documented relative to the tibial plafond. Additionally, six matched pairs of limbs were used to assess the effects of different plating techniques on the extraosseous blood supply along the medial aspect of the distal tibia.

SETTING

University anatomy laboratory.

PATIENTS/PARTICIPANTS

Nine matched pairs ( = 18) of randomly obtained, adult cadaveric hip disarticulation specimens.

INTERVENTION

India ink followed by Ward's Blue Latex was injected into the superficial femoral artery at the level of the inguinal crease after cleansing of the arterial system. The skin, subcutaneous tissue, and muscles were dissected from the leg, exposing the arterial system and the extraosseous vessels of the tibia. MEAN OUTCOME MEASUREMENTS: The extraosseous blood supply of each aspect of the tibial diaphysis was determined. Each extraosseous arteriole was identified, and the locations of each documented relative to the tibial plafond. Changes in the filling of these vessels along the medial aspect of the distal tibia were documented in a separate group of specimens ( = 12), which had undergone two different plating techniques.

RESULTS

The proximal metaphysis of the tibia was found to have a rich extraosseous blood supply provided primarily from vessels from the popliteal artery, the anterior tibial artery (ATA) laterally, and the posterior tibial artery (PTA) medially. In comparison, the tibial diaphysis was found to have relatively few extraosseous vessels and a considerably hypovascular region, posteriorly. Branches of the ATA were found to supply the posterior aspect of the diaphysis with these branches passing through the interosseous membrane. The diaphysis also received a variable contribution from the PTA. The lateral aspect of the diaphysis was supplied by branches of the ATA. An anastomotic network of arteries from the ATA and PTA formed the rich extraosseous blood supply of the medial distal aspect of the tibia. Open plating of the medial aspect of the distal tibia caused a statistically significant ( < 0.05) greater disruption of the extraosseous blood supply of the metaphyseal region than did percutaneously applied plates. In each specimen, open plating prevented filling of each periosteal vessel in the region as opposed to percutaneous plates, which permitted filling of the extraosseous vessels up to the edge of the plate.

CONCLUSIONS

The proximal and distal metaphyseal areas of the tibia have a rich extraosseous blood supply provided primarily by branches of the ATA and the PTA. Open plating of the medial aspect of the distal tibia caused a greater disruption of this extraosseous blood supply than did percutaneously applied plates. Disruption of these extraosseous vessels following fracture and subsequent operative stabilization may slow healing and increase the risk of delayed union and nonunion. These findings support current efforts to develop less invasive methods and implants for operative stabilization of distal tibia fractures.

Treatment of multifragmentary fractures of the femur by indirect reduction (biological) and plate fixation

We present a retrospective review of the results of 43 multifragmentary femur fractures treated under the principle of indirect reduction (biological) and plate fixation. Fractures were caused by high-energy trauma in all patients. Sixteen were subtrochanteric, 14 diaphyseal and 13 supracondylar. There were 13 open fractures. In six of the patients with diaphyseal fractures, a plate was inserted through isolated proximal and distal incisions only, deep to the vastus lateralis. None of the fractures was treated with bone graft. The mean follow-up time was 28.3 months. Union was achieved in 41 patients within a mean period of 4.25 months. There was delayed union in one patient (subtrochanteric), non-union in two, infection in three, malunion in three, leg shortening in six and mild knee stiffness in seven. In eight patients with diaphyseal fractures in whom a single incision was performed, the average time for fracture healing was 4.14 months in seven and non-union developed in one. In six patients with diaphyseal fractures, in whom proximal and distal incisions were performed, the average time for fracture healing was 4 months. There was no difference (P>0.05) between single and double incision with reference to infection and time to union, but the indirect reduction methods must be meticulously implemented. The implants we used are cheaper and more easily supplied than many others. The success rate is high when the technique is correctly implemented. We believe that this is a treatment of choice in countries with low socioeconomic status, no efficient health insurance system and no intraoperative image intensification.

Associated injuries complicating the management of acetabular fractures: review and case studies

The treatment of acetabular fractures has evolved considerably in the past three decades. Associated injuries to the femoral head, proximal femur, or femoral shaft can complicate the initial management of the acetabular fracture, and mandate a careful treatment strategy for optimal treatment of both the acetabular fracture and associated injury. These injuries may have a large impact on the clinical outcome. The surgeon must consider surgical approaches, timing, and alternative modes of fixation. A discussion with case illustrations is provided.

Treatment of complex tibial periarticular fractures using percutaneous techniques

Open reduction and internal fixation typically is reserved for the treatment of patients with articular or periarticular tibia fractures, or other tibial injuries that are treated inadequately with intramedullary nailing. This approach can result in extensive dissection and tissue devitalization. By modifying the method of fixation, the plating of tibial fractures has been expanded using a percutaneous technique. Using this approach, the fracture is reduced indirectly and plates are placed through subcutaneous or submuscular tunnels through limited incisions. Between 1992 and 1998, 17 patients with tibial shaft fractures and associated severe soft tissue injury, were treated using a percutaneous plating technique. Followup was available in 14 patients. Six patients required bone grafting procedures for delayed union or nonunion, although four of these patients had significant bone loss related to their injury. There were no malunions. Three patients had superficial infections related to external fixator pin sites and one patient had osteomyelitis develop. Percutaneous plating of the tibia offers an alternative method for stabilizing complex fractures with severely compromised soft tissues, especially those injuries with periarticular extension. This technique is thought to cause no increase in the risk of infection or soft tissue damage and permits rapid mobilization of the limb and patient. When using this treatment for patients with significant bone loss, bone grafting should be considered.