Stellenwert und Vorteil neuer winkelstabiler Implantate bei Schaftfrakturen (LCP vs. Nagel)

Plate Positioning in Periprosthetic or Interprosthetic Femur Fractures With Stable Implants-A Biomechanical Study

BACKGROUND

Angular stable plate fixation is a widely accepted treatment option for interprosthetic or periprosthetic femoral fractures with stable implants. This biomechanical study tries to establish a safe distance of the plate from the tip of a femoral prosthesis.

METHODS

A total of 38 composite femurs were reamed to an inner diameter of 23 mm to create an osteoporotic bone model. A Weber hip stem was cemented into each and a distal femoral NCB plate applied with the distance to the stem varying from 8 cm apart to 6 cm overlap in 2-cm steps. Each specimen was tested in cyclic axial loading (400 N-1500 N) and then cyclic torsion (0.6 Nm-50 Nm). Peak strain on the femur around the tip of the plate was measured with a 3D image correlation system and averaged over 26 cycles (excluding the first 3 and the last cycles). Finally, each femur was axially loaded to failure.

RESULTS

Strain increased with decreasing overlap or gap. Seven specimens failed early between 2-cm overlap and 2-cm gap. Results were divided into a far group with a distance of >4 cm and a close group of <4 cm. Strain was significantly higher in the close group for axial (P < .001) and torsional (P < .001) loading. Failure load was significantly lower in the close group (P = .002).

CONCLUSION

A minimal gap and/or overlap of at least 6 cm is recommended in osteoporotic bone to avoid stress risers.

Plate fixation versus intramedullary nailing for displaced extra-articular distal tibia fractures: a system review

PURPOSE

The optimal surgical procedure for displaced extra-articular distal tibia fractures remains debated at present. The objective of this systematic review is to compare the complications and functional outcomes of this type of fracture after plate fixation and intramedullary nailing .

METHODS

A computer-aided search of PubMed, Embase and Cochrane was carried out on July, 2012. Two independent reviewers screened and assessed abstracts. Every study published in English about the comparison between plate fixation and intramedullary nailing for displaced extra-articular distal tibia fractures was included. The outcomes were pooled or summarized separately per study according to heterogeneity between studies. Pooled risk ratios (RR) with 95 % confidence intervals (95 % CIs) were calculated by Mantel-Haenszel method using either the fixed effects model or random effects model.

RESULTS

Eight studies, with 270 patients in the intramedullary nailing and 217 patients in the plates fixation group, met the inclusion criteria. Functional outcome, days of hospital stay and time for bone union were comparable between intramedullary fixation and plate fixation. Total complication rate was significant higher for intramedullary nailing compared with plate fixation (44.5 vs. 25.8 %, P < 0.001). Similarly, the rate of minor complications was higher for intramedullary nailing than that for plate fixation (35.9 vs. 21.2 % P < 0.001). Major complication rate was 8.52 % for intramedullary nailing and 4.6 % for plate fixation, but the difference had no statistical significance (P = 0.06). Our pooled estimates showed a decreased risk of total complication in plate fixation (RR, 2.38; 95 % CI, 1.13-5.03; P = 0.02). Among these complications, malunion and anterior knee pain were more common in intramedullary nailing than in plate fixation (20.1 vs. 4.5 %, P < 0.001; 4.2 vs. 0.45 %, P = 0.02, respectively). Meanwhile, significantly less wound problems happened in intramedullary nailing than in plate fixation (2.9 vs. 7.5 %, P = 0.03). In addition, locking plate fixation with mini-invasive technique tended to have a lower complication rate than conventional plate fixation, although the difference was not significant (21 vs. 28.4 %, P = 0.26).

CONCLUSIONS

The results of this systematic review suggested that plate fixation, especially minimally invasive percutaneous plating osteosynthesis technique would be preferred for extra-articular distal tibia fractures because of its low complication rate. Nevertheless, intramedullary fixation should be taken priority for distal tibia fractures with serious soft tissue injuries.

Minimally invasive plate osteosynthesis using a locking compression plate for distal femoral fractures

PURPOSE

To evaluate treatment outcomes of minimally invasive plate osteosynthesis (MIPO) for distal femoral fractures in 31 patients.

METHODS

22 male and 9 female consecutive patients aged 21 to 65 (mean, 42) years underwent minimally invasive plate osteosynthesis using a locking compression plate (LCP) for distal femoral fractures. The causes of injury were vehicular accidents (n=24), falls (n=6), and assault (n=1). According to the AO classification, the fractures were classified as types A1 (n=10), A2 (n=7), and A3 (n=14). Most fractures were closed; 3 were Gustilo type-II fractures. Clinical and functional outcomes were assessed using the Knee Society Scores.

RESULTS

The mean operating time was 70 (range, 60-100) minutes. The mean length of hospital stay was 9 (6-14) days. The mean time to union was 3.7 (range, 2.8-4.6) months. The mean follow-up period was 18 (14-26) months. At the one-year follow-up, 29 of the patients had good or excellent outcomes. No patient had angular or rotational deformity of >10º. One osteoporotic woman with a type-A1 fracture had implant failure at 10 weeks and underwent revision surgery. Another patient with a type-A1 fracture had persistent pain on the lateral aspect of the distal thigh and underwent implant removal at 22 months. No patient developed deep infection, malunion or nonunion.

CONCLUSION

MIPO using a LCP achieves favourable biological fixation for distal femoral fractures with few complications. Bone grafting is not needed even in cases of metaphyseal comminution. Proper patient selection and preoperative planning are essential to prevent complications.

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.

Locking compression plate with minimally invasive plate osteosynthesis in diaphyseal and distal tibial fracture: a retrospective study of 32 patients

With the introduction of Locking Compression Plates (LCP), Minimally Invasive Plate Osteosynthesis (MIPO) has become widely used. The plates act as internal fixators in a bridging manner, thus resulting in secondary bone healing. We retrospectively evaluated the healing pattern and the clinical evolution of diaphyseal and distal tibial shaft fractures over two and a half years in 32 patients (6 females, 26 males). Fractures were classified according to AO classification and included all 42A-C, 43A-B and 43C1-2 types. For open fractures, Gustillo Anderson classification was used. Plates consisted of the 4.5mm LCP and 3.5mm LCP-Pilon form plate. Clinical and radiological assessment was performed at 6 weeks, and at 3, 6, 9, and 12 months. Two patients were lost to follow-up. Fracture healing was defined as callus bridging of one cortex, seen on both lateral and posterior-anterior X-ray, and full, painless weight bearing. Ten patients at 3 months, 23 at 6 months, and 27 at 9 months met the criteria for a healed fracture. Plate bending was observed in one patient and called for re-operation at 5 months. Two patients required re-operation at 13 months secondary to pseudoarthrosis. Though MIPO seems more advantageous for soft tissue and bone biology, prolonged healing was observed in simple fracture patterns when a bridging plate technique was used.