Comparison of supraclavicular nerve injuries after clavicle mid-shaft surgery via minimally invasive plate osteosynthesis versus open reduction and internal fixation

INTRODUCTION

Only a few previous studies have evaluated the factors related to supraclavicular nerve (SCN) injury after clavicle mid-shaft fracture surgery. We analyzed the frequency and risk factors for SCN injury after clavicle mid-shaft fracture surgery via open reduction and internal fixation (ORIF) versus minimally invasive plate osteosynthesis (MIPO) MATERIALS AND METHODS: We retrospectively reviewed the cases from 59 patients who had undergone surgery for clavicle mid-shaft fractures between January 2018 and April 2019. Twenty-nine patients had undergone ORIF and 30 had undergone MIPO. The frequency of SCN injury in the two groups was evaluated, and preoperative patient demographics (age, sex, body mass index, smoking, alcohol, diabetes mellitus, and trauma mechanism), and radiological parameters (fracture displacement and shortening) were measured and evaluated as risk factors for SCN injury. When neurological symptoms, such as numbness, were present on the anterior chest wall or at the incision site, electromyography (EMG) was conducted.

RESULTS

Neurological symptoms were present in 12 patients. Numbness in the anterior upper chest around the incision site was present in eight and four patients who underwent ORIF and MIPO, respectively (p < 0.001). Furthermore, fracture displacement evaluated on preoperative three-dimensional computed tomography was significantly associated with the occurrence of SCN injury in patients who underwent MIPO (odds ratio, 1.038; 95% confidence interval, 1.001-1.077; p = 0.047). Although EMG was conducted in all patients with SCN injury, peripheral neuropathy was not found in any cases.

CONCLUSIONS

SCN injury, which is a possible complication of clavicle mid-shaft fracture surgery, occurred significantly less frequently in MIPO than in ORIF. In MIPO, greater preoperative fracture displacement was associated with a higher risk of SCN injury. Additional studies are required to reach a consensus regarding accurate methods to evaluate SCN injuries.

LEVEL OF EVIDENCE

IV, case series, treatment study.

Locking plate constructs benefit from interfragmentary lag screw fixation with decreased shear movements and more predictable fracture gap motion in simple fracture patterns

BACKGROUND

A mechanical characterisation of lag screw fixation plus locking plate - although clinically widely used as either "mixed fixation concept" or absolutely stable fixation - is so far missing. This study aimed to evaluate the influence of an interfragmentary lag screw on the resulting motion at the fracture site of locking plate constructs using a simple fracture at the distal femur.

METHODS

Human cadaver femora were in vitro loaded in torsion and axial bending-compression with and without lag screw fixation next to a locking plate fixation. In addition, two plate working lengths were tested. Interfragmentary movement was measured optically.

FINDINGS

Axial interfragmentary movement is reduced with lag screw (102 mm plate working length, 1000 N, mean): 0.28 mm versus 0.82 mm. With lag screw, the fracture gap stays closed with mean normal interfragmentary movement ≤0.03 mm. Fracture gap tends to open without lag screw: normal interfragmentary movement up to -0.29 mm. Reduction of shear interfragmentary movement was observed throughout all tested loads and groups. Mean true shear remains generally low with lag screw (≤0.42 mm) compared to without lag screw (≤1.46 mm). We also found that interfragmentary movement variance decreases with lag screw, especially for longer plate working length.

INTERPRETATION

An interfragmentary lag screw next to locking bridge plating reduces fragment motion in vitro for a simple fracture pattern and provides a sufficient tool to decrease detrimental shear movements. Prospective clinical trials with interfragmentary lag screw fixation should prove these findings in wide clinical use to treat simple fracture patterns.

Absolute or relative stability in minimal invasive plate osteosynthesis of simple distal meta or diaphyseal tibia fractures?

INTRODUCTION

Minimal invasive plate osteosynthesis in simple distal meta or diaphyseal tibia fractures can be applied using absolute (lag screw and neutralisation plate; LSN) or relative stability (bridge plate; BP). The primary aim of the study was to compare time to radiological union and time to full weight bearing in the two groups (LSN vs. BP). Reduction was performed either percutaneously or by a minimally open approach (mini open). Secondary aim was to analyse the number of complications between both groups.

METHODS

Retrospective single centre review of patients with a simple distal meta or diaphyseal tibia fracture operated with a Locking Compression Plate (LCP) between 2009 and 2015 in a Level one Trauma Centre. Postoperative radiographs were assessed in a standardised manner. Time to radiological fracture union and time to full weight bearing were observed. Callus index and postoperative complications were analysed.

RESULTS

Fifty-seven patients with a minimum follow-up of 6 months were analysed. Forty-eight patients had a shaft (AO/OTA Type 42) and nine a distal tibia fracture (AO/OTA Type 43). Forty patients were treated with using the LSN concept and 17 patients with the BP concept. Median time to radiological fracture union was statistically significant shorter (p=0.04) in the LSN group with 19 weeks compared to 27 weeks in the BP-group. Time to full weight bearing was 10 weeks in both groups. A total (including implant removal) of 35 reoperations were performed in the LSN-group and 18 in the BP-group. Wound healing disorders (deep surgical site infections) were seen less the LSN group in 3/40 (7.5%) compared to the BP-group with 3/17 (17.6%). In the LSN group, there was no statistical difference in time to union or weight bearing between a percutaneous or mini open approach.

CONCLUSION

Stable osteosynthesis of simple distal meta or diaphyseal tibia fractures leads to faster radiologic fracture healing without an increase in complications or number of revisions compared to bridge plating. If a percutaneous reduction is not feasible for the insertion of a lag screw, a mini-open approach does not lead to a delay in fracture healing.

Minimally invasive lateral plate placement for metadiaphyseal fractures of the humerus and its implications for the distal deltoid insertion- it is not only about the radial nerve. A cadaveric study

INTRODUCTION

Minimally invasive lateral placement of plates on the humerus may be associated with a risk of injury to the radial nerve. Whereas this potential complication has been investigated in several studies, there is no data regarding potential injuries to the distal insertion of the deltoid muscle when the plates are passed distally in a submuscular tunnel.

METHODS

Minimally invasive plate placement was performed on eight arms in fresh cadavers. A lateral deltoid split approach was made and the plates were introduced in an antegrade submuscular manner from proximal to distal. A lateral distal incison was made to adjust the position of the plate at the lateral aspect of the humerus without formal exploration of the radial nerve. The arms were dissected to identify the seven intramuscular tendons of the deltoid and their insertions at the humerus. The position of the plate and its relation to the intramuscular tendons of the deltoid was explored. Furthermore, potential injuries to the axillary and radial nerve were investigated. Damage to the brachialis muscle its interference with plate positioning were explored.

RESULTS

The distal deltoid insertion was affected in all eight examined arms. The two most anterior and two most posterior segments were intact in all. In two arms, the third intramuscular tendon was perforated. In three specimens, the insertion of the fourth segment was damaged. The fifth segment was partially disrupted in three arms. Overall, injuries to the intramuscular tendons were limited to one tendon in all arms. Partial brachial muscle entrapment underneath the plate was observed in four specimens. The axillary nerve was not damaged in any of the examined arms. The radial nerve was entrapped between plate and humeral shaft in one case.

CONCLUSIONS

Lateral plate placement in MIPO technique damages central parts of the distal deltoid muscle insertion. However, the most anterior and posterior tendons are not involved and the clinical significance on muscle function remains unclear. Introduction of the plate without prior distal incision and elevation of the brachial muscle may be associated with partial entrapment of the brachial muscle and a higher risk of injuring the radial nerve.

LEVEL OF EVIDENCE

Experimental study.

Clinic research on the treatment for humeral shaft fracture with minimal invasive plate osteosynthesis: a retrospective study of 128 cases

INTRODUCTION

Minimal invasive plate osteosynthesis (MIPO) is one of the most important techniques in the treatment for humeral shaft fractures. This study was performed to evaluate the efficacy of MIPO technique for the treatment for humeral shaft fractures.

MATERIALS AND METHODS

We retrospectively evaluated 128 cases with humeral shaft fractures that were treated with MIPO technique from March 2005 to August 2008. All the patients were followed up by routine radiological imaging and clinical examinations. Constant-Murley score and HSS elbow joint score were used to evaluate the treatment outcome.

RESULTS

The average duration of the surgery was 60 min (range 40-95 min) without blood transfusion. All fractures healed without infection. All cases recovered carrying angle except four cases with 10°-15° cubitus varus. After the average follow-up of 23 (13-38) months, satisfactory function was achieved according to Constant-Murley score and HSS elbow joint score. Constant-Murley score was 80 on average (range 68-91). According to HSS elbow joint score, there were 123 cases of excellent clinical outcome and five cases of effective outcome.

CONCLUSION

It seems to be a safe and effective method for managing humeral shaft fractures with MIPO technique.