The Role of Arthroscopy in Contemporary Glenoid Fossa Fracture Fixation

Glenoid fossa fractures are rare injuries accounting for 10 to 29% of all intra-articular scapula fractures. They are usually the result of high-energy trauma, and concomitant injuries are not uncommon. Patients with glenoid fractures are admitted with shoulder pain and restricted range of motion. Although shoulder plain radiographs could establish the diagnosis, a computed tomography scan is necessary to adequately define the fracture pattern and characteristics. The most commonly used classification system is that of Ideberg (modified by Goss), which includes five glenoid fossa fracture types according to the location, extension, and complexity of the lesion. Articular surface displacement and step-off are the most important factors that should be taken under consideration when deciding for conservative or surgical management. Operative treatment includes open reduction and internal fixation through a posterior or anterior approach depending on fracture morphology and displacement. However, open surgical techniques are related to extensive soft-tissue disruption, risk of neurovascular injury, and inadequate exposure of the entire glenoid cavity. Introduction of arthroscopy could facilitate better visualization of the glenoid articular surface and improved fracture reduction. However, it is a technically demanding procedure with many challenges and pitfalls. The aim of this review is to summarize the current evidence regarding the treatment of glenoid fossa fractures and present the beneficial effect of arthroscopy in improving the quality of fracture fixation and overall functional outcomes.

Pediatric Knee Injury: A Unique Case of Intra-articular Osteochondral Fracture Following Penetrating Trauma

Penetrating injuries to the musculoskeletal system pose common challenges for orthopedic surgeons in emergency departments (EDs). The complexity escalates when a joint is affected, increasing the risk of severe complications such as infection and post-traumatic arthritis. Given the potential importance of these injuries, early diagnosis and a meticulous treatment plan are crucial. In this paper, we present a unique case of penetrating trauma, resulting in an intra-articular defect on the lateral femoral condyle of an adolescent girl. This case underscores the importance of tailored interventions in managing complex musculoskeletal injuries.

AO/OTA type C3 distal humeral fractures in patients aged 75 years and older: Is ORIF with double precontoured anatomical locking plates a reliable treatment?

INTRODUCTION

The incidence of osteoporotic distal humeral fractures (DHF) is on the rise. Their operative management is demanding. Fixation with non-locking reconstruction plates was associate with a high number of complications. Elbow arthroplasty (total or hemi) has been proposed as an alternative treatment, in spite of lifetime activity restrictions, and risk of complications, unknown implant survival and problematic revision surgery. Precontoured anatomical locking plates have increased the strength of the fixation in complex fractures.

HYPOTHESIS

double plating ORIF with precontoured anatomical locking plates is a safe and reliable treatment option for the management of AO/OTA type C3 DHF in patients aged 75 and older.

PATIENTS AND METHODS

A retrospective case series study of patients aged 75 years old and older with an AO/OTA type C3 DHF treated with ORIF with double precontoured anatomical locking plates between 2007 and 2021. Pathologic fractures were excluded. Patients' demographic, surgical, clinical, and radiological data were reviewed.

RESULTS

A total of 27 women and 3 men, mean age of 80.1 years (range 75-93 years), were included. Mean Charlson index was 5 (range 3-8). Out of 30 patients, 19 had already died. Mean survival time after the surgical treatment was 72.3 months. Mean Mayo elbow performance score was 88.9 (range 60-100); 23 patients scored excellent or good. All fractures healed with no cases of delay union or non-union, hardware failure or loss of reduction. No patient needed a revision surgery to arthroplasty. The total number of complications was 12 (40%), mainly ulnar neuropathy (5) and cerclage removal (4).

CONCLUSION

ORIF with double pre-contoured locking plates may be a safe and reliable treatment for type C3 DHF in patients aged 75 years and older, with a good functional outcome. Complications are expected but not related to loss of reduction, fixation failure or revision to elbow arthroplasty.

Computed Tomography Evaluation of Distal Screw Penetration in Volar Locking Plate Fixation for Intra-Articular Distal Radius Fractures

PURPOSE

Volar locking plate fixation for distal radius fractures (DRFs) is a technically demanding procedure with a risk of distal screw penetration through the dorsal cortex or the articular surface. This study aimed to investigate the incidence and details of distal screw penetration after volar locking plate fixation for intra-articular DRFs using a CT scan and to evaluate the relationship between the incidence of screw penetration and fracture comminution severity and the clinical complications of screw penetration.

METHODS

This was a retrospective case series of 91 adult patients (mean age, 63 years; 27 men) who underwent volar locking plate fixation for intra-articular DRFs from 2015 to 2018. The positioning of the distal screws was evaluated using a postoperative CT scan, and radiological outcomes were compared between the AO C1 and C3 groups. At the final follow-up, tendon rupture and arthritis severity were assessed as clinical complications of dorsal and intra-articular screw penetration.

RESULTS

Distal screw penetration was observed in 44 wrists (48%), dorsal cortex screw penetration in 34, intra-articular screw penetration in 13, and both dorsal cortex and intra-articular screw penetration in three. The incidence of intra-articular screw penetration was significantly higher in the C3 group than in the C1 group. No tendon rupture was observed. Multivariable analysis revealed that intra-articular screw penetration was significantly related to high severity of arthritis.

CONCLUSIONS

Approximately half of the study patients with intra-articular DRFs had distal screw penetration. The incidence of intra-articular screw penetration was associated with the severity of fracture comminution, and the intra-articular screw penetration was associated with the incidence of early radiocarpal arthritis. Intra-articularly penetrating screws should be replaced as soon as they are discovered, regardless of the length of penetrated screw or absence of patients' subjective symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Redefining radiocarpal fracture-dislocations with injury specific management and a clinical classification system: a retrospective review

BACKGROUND

Unlike articular shear fractures of the distal radius, radiocarpal fracture-dislocations defined as complete dislocation of the lunate from its articular facet of the radius are relatively uncommon. The management principles of these fractures have not been defined and there is no consensus on approach to management of these injuries. The aim of this study is to review our series of radiocarpal fracture-dislocations and propose a radiographic classification to guide surgical management.

METHODS

This study is reported based on STROBE guidelines. A total of 12 patients underwent open reduction and internal fixation. All the fracture-dislocations were dorsal and satisfactory objective outcomes achieved were comparable to literature. Injury morphology-specific management approach was used based on the size of dorsal lip fragment and the volar teardrop fragment attached to the short radiolunate ligament assessed by preoperative CT scans.

RESULTS

All patients with known outcome (n = 10) went on to resume their prior occupation and hobbies that included high-demand activities and manual labour at mean follow-up of 27 weeks. Average wrist flexion was 43° and wrist extension was 41° while radial and ulnar deviation were 14° and 18° respectively. Average forearm pronation was 76° and supination was 64° at final follow-up.

CONCLUSION

We describe four injury patterns of radiocarpal fracture-dislocations based on preoperative CT scans that guide fixation. We believe that early recognition of radiocarpal fracture-dislocations and appropriate management can yield satisfactory outcomes.

Biomechanical guidance can improve accuracy of reduction for intra-articular tibia plafond fractures and reduce joint contact stress

Articular fracture malreduction increases posttraumatic osteoarthritis (PTOA) risk by elevating joint contact stress. A new biomechanical guidance system (BGS) that provides intraoperative assessment of articular fracture reduction and joint contact stress based solely on a preoperative computed tomography (CT) and intraoperative fluoroscopy may facilitate better fracture reduction. The objective of this proof-of-concept cadaveric study was to test this premise while characterizing BGS performance. Articular tibia plafond fractures were created in five cadaveric ankles. CT scans were obtained to provide digital models. Indirect reduction was performed in a simulated operating room once with and once without BGS guidance. CT scans after fixation provided models of the reduced ankles for assessing reduction accuracy, joint contact stresses, and BGS accuracy. BGS was utilized 4.8 ± 1.3 (mean ± SD) times per procedure, increasing operative time by 10 min (39%), and the number of fluoroscopy images by 31 (17%). Errors in BGS reduction assessment compared to CT-derived models were 0.45 ± 0.57 mm in translation and 2.0 ± 2.5° in rotation. For the four ankles that were successfully reduced and fixed, associated absolute errors in computed mean and maximum contact stress were 0.40 ± 0.40 and 0.96 ± 1.12 MPa, respectively. BGS reduced mean and maximum contact stress by 1.1 and 2.6 MPa, respectively. BGS thus improved the accuracy of articular fracture reduction and significantly reduced contact stress. Statement of Clinical Significance: Malreduction of articular fractures is known to lead to PTOA. The BGS described in this work has potential to improve quality of articular fracture reduction and clinical outcomes for patients with a tibia plafond fracture.

[Effectiveness comparison of two surgical methods in treatment of intra-articular displaced calcaneal fractures in older children]

Objective

To compare the effectiveness of open reduction and internal fixation with plate and closed reduction and internal fixation with Kirschner wire (K-wire) in the treatment of intra-articular displaced calcaneal fractures in older children.

Methods

A clinical data of 35 older children (37 feet) with intra-articular displaced calcaneal fractures who were admitted between November 2014 and November 2020 and met the selection criteria were retrospectively analyzed. Among them, 19 cases (20 feet) underwent open reduction and internal fixation with plate (plate group), and 16 cases (17 feet) underwent closed reduction and internal fixation with K-wire (K-wire group). There was no significant difference in gender, age, cause of injury, side and type of fracture, and time from injury to admission, and preoperative calcaneal Gissane angle and Böhler angle ( P>0.05). The postoperative calcaneal Gissane angle, Böhler angle, complications, and fracture healing were compared between the two groups. The ankle function was evaluated based on the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scoring system.

Results

Incision necrosis occurred in 1 foot in the plate group after operation, which healed after symptomatic treatment; the other incisions in the two groups healed by first intention. All children were followed up 12-39 months (mean, 19 months). X-ray films showed that the fractures in both groups healed; the healing time was (2.65±0.71) months in the plate group and (2.24±1.38) months in the K-wire group respectively, with no significant difference ( t=1.161, P=0.253). At last follow-up, the calcaneal Gissane angle and Böhler angle returned to normal; and the difference between pre- and post-operation in the two group was significant (P<0.05), but there was no significant difference between the two groups in the difference between before and after operation ( P>0.05). In the plate group, the plate was removed at 11-22 months after operation (mean, 16.8 months). At last follow-up, the AOFAS ankle-hindfoot score in the plate group was 91.2±5.1, which was significantly higher than that in the K-wire group (86.9±6.1) ( t=2.316, P=0.027). The ankle function was rated as excellent in 15 feet, good in 4 feet, and fair in 1 foot in the plate group, and excellent in 14 feet and good in 3 feet in the K-wire group, and the difference between the two groups was not significant ( Z=1.712, P=0.092).

Conclusion

For intra-articular displaced calcaneal fracture in older children, the open reduction and internal fixation with plate and closed reduction and internal fixation with K-wire can achieve good effectiveness, but the former has better recovery of ankle function.

Comminuted Dorsal Ulnar Fragment in Distal Radius Fractures Treated Using the Integrated Compression Screw With a Mini-Plate

Stabilization for displaced dorsoulnar fragments in distal radius fractures is challenging to treat with conventional volar locking plates alone. The integrated compression screw combined with a volar locking plate has been introduced as an additional tool to stabilize the dorsoulnar fragment and has been reported to work effectively. However, the compression screw is unable to stabilize a comminuted dorsal ulnar fragment; therefore, it is necessary to consider using an additional dorsal plate. We have developed a modified surgical technique to stabilize a comminuted dorsal intra-articular fragment by combining the integrated compression screw with a mini-plate as a washer or a buttress.

Compartment Syndrome Secondary to Knee Lipohemarthrosis

When treating patients presenting with knee trauma or intra-articular fracture, clinicians should maintain a high index of suspicion for lipohemarthrosis. Diagnosis of lipohemarthrosis can be accomplished via visualization of a fat-fluid level. Increased fluid and pressure build-up within the joint space may lead to compartment syndrome, which requires emergency compartment fasciotomy. In this paper, we discuss the importance of identifying lipohemarthrosis in patients presenting with intra-articular fracture, as well as the necessity of frequent patient re-evaluations in order to monitor the onset of compartment syndrome.

Single volar locking plating for the intra- and extra-articular distal radius fractures with dorsal metaphyseal comminution

BACKGROUND

Volar locking plating remains a popular method for the surgical management of distal radius fractures. Dorsal metaphyseal comminution (DMC) is a common fracture pattern which weakens the stability during fracture fixation. In this study, we aimed to compare the radiographic and functional outcome of the intra- and extra-articular distal radius fractures with DMC following single volar locking plate fixation.

MATERIALS AND METHODS

Patients suffered from a distal radius fracture with DMC were reviewed in the clinical database of the authors' institution between Jan 2016 and Jan 2020. The included patients were classified into the extra-articular (A3) group or the intra-articular (C2 and C3) group according to the AO/OTA system. The radiological parameters, wrist range of motion, and functional outcomes were evaluated following open reduction and volar locking plate fixation.

RESULTS

A total of 130 patients were included in this study with a mean follow-up length of 17.2 months. Compared with the A3 fracture group, no significant fracture re-displacement or reduced wrist ROMs was observed in the C2 fractures after 12-month's follow-up. However, significantly decreased volar tilt (P = 0.003) as well as the extension/flexion ROMs were observed in the C3 fractures comparing to the A3 fractures. Most of the patients achieved an excellent (n = 75) or good (n = 51) Gartland and Werley wrist score. Four patients with C3 fractures resulted in a fair functional outcome due to a significant loss of volar tilt during follow-up.

CONCLUSIONS

The single volar locking plate fixation provided sufficient stability for distal radius fractures with DMC, and resulted in similar radiological and functional outcomes in the intra-articular distal radius fractures with a simple articular component (C2 fractures) as those in the extra-articular fractures. Considering the intra-articular fractures with multifragmentary articular component (C3 fracture), despite of the subsequent loss of volar tilt, the majority of the patients achieved good to excellent wrist function following single volar locking plating.

TRIAL REGISTRATION

This study has been registered on the ClinicalTrials.gov.

Elevation of Pro-Inflammatory Cytokine Levels Following Intra-Articular Fractures-A Systematic Review

Introduction: Intra-articular fractures are a major cause of post-traumatic osteoarthritis (PTOA). Despite adequate surgical treatment, the long-term risk for PTOA is high. Previous studies reported that joint injuries initiate an inflammatory cascade characterized by an elevation of synovial pro-inflammatory cytokines, which can lead to cartilage degradation and PTOA development. This review summarizes the literature on the post-injury regulation of pro-inflammatory cytokines and the markers of cartilage destruction in patients suffering from intra-articular fractures. Methods: We searched Medline, Embase, and Cochrane databases (1960-February 2020) and included studies that were performed on human participants, and we included control groups. Two investigators assessed the quality of the included studies using Covidence and the Newcastle-Ottawa Scale. Results: Based on the surveyed literature, several synovial pro-inflammatory cytokines, including interleukins (IL)-1β, IL-2, IL-6, IL-8, IL-12p70, interferon-y, and tumor necrosis factor-α, were significantly elevated in patients suffering from intra-articular fractures compared to the control groups. A simultaneous elevation of anti-inflammatory cytokines such as IL-10 and IL-1RA was also observed. In contrast, IL-13, CTX-II, and aggrecan concentrations did not differ significantly between the compared cohorts. Conclusions: Overall, intra-articular fractures are associated with an increase in inflammation-related synovial cytokines. However, more standardized studies which focus on the ratio of pro- and anti-inflammatory cytokines at different time points are needed.

Two-Stage Surgical Procedure in Intra-articular Distal Tibiofibular Fractures with Soft Tissue Injury: in Which Stage Should the Fibular Plate be Applied at Initial Surgery?

Introduction:

The selection of the stage where fibular plate was performed in two-stage surgery of the intra-articular distal tibiofibular fractures with soft tissue injury is still controversial. The aim of the study was to compare the complications, radiological and functional outcomes between the patients who had fibular plate at initial or second phase during surgical management of such fractures.

Materials and Methods:

In this study, medical records of 47 patients who underwent a two-stage surgical procedure for intra-articular distal tibia fractures accompanying soft tissue injury were retrospectively examined. Delta frame was applied in all cases within 24 hours following admission to the emergency department in accordance with AO principles. Those cases where fibular plate was applied during the initial stage and the second stage were classified as Group 1 and Group 2 in order to compare recorded data between the two groups.

Results:

According to the results of the study, there were 25 cases in Group 1 and 22 cases in Group 2 in which fibular plate was applied at the first stage and the second stage, respectively. The mean follow-up was found as 27.7±7.0 months in Group 1 and 28.2±6.2 months in Group 2 (p=0.778). No difference was found between the two groups in terms of the age, sex, hospital stay, the time between two surgical procedures, tibiofibular angle and AOFAS scoring (p>0.05).These two groups were also similar in mechanism of injury, Denise-Weber or AO classification, rates of tibiofibular malalignment on post-operative CT, fibular rotation, intra-articular tibial step-off, tibial varus-valgus duration of union, rate of infection, fibular angulation and the presence of the flap/graft/debridement (p>0.05).

Conclusion:

In conclusion, two-stage surgical procedure in intra-articular distal tibiofibular fractures may be an effective method decreasing soft tissue complications. The timing of the open reduction and internal fixation of the fibula at different stages may not necessarily have an impact on the success of the post-operative tibial reduction, the total duration of surgery, syndesmosis malalignment or soft tissue complications.

Three-dimensional analysis of displacement characteristics of dorsally angulated intra-articular distal radial fractures

Understanding the complex fragmentation of intra-articular distal radial fractures contributes to achieving anatomical reduction during surgery. This study aimed to clarify three-dimensional displacement patterns of intra-articular fragmentation in dorsally angulated, intra-articular distal radial fractures. We identified five characteristic intra-articular fragments: a key fragment, dorsal ulnar corner, dorsal wall, radial column and anterior radial column. The key fragment was displaced with radial deviation, pronation and extension and with dorsal, proximal and radial translations. The dorsal ulnar corner displacement resulted in a gap, a step-off and a deepened concavity for the lunate facet and sigmoid notch. The dorsal wall displacement resulted in a deepened concavity, a gap and a step-off of the dorsal scaphoid facet. The displacements of the radial column and anterior radial column caused a step-off between the scaphoid and lunate facets. The five characteristic intra-articular fragments each created a characteristic gap and step-off in the articular surface. Level of evidence: IV.

Conservative Treatment of an Intra-Articular Shear Fracture of the Ulnar Head

Background  Isolated intra-articular fracture of the ulnar head is rare. Case Description  A 59-year-old woman experienced an ulnar head fracture involving the distal radioulnar joint after a fall at ground level. The intra-articular fragment of the ulnar head was rotated into anatomical alignment with an above-elbow cast in 90° of supination for 4 weeks. A below-elbow night splint was retained for 2 additional weeks. Twelve months post-injury, full active motion and bone union were achieved. Literature Review  Only three studies have reported treatment of isolated intra-articular ulnar head fractures, and in all cases open reduction and internal fixation were performed. Clinical Relevance  Our report demonstrated good results for the conservative treatment of an intra-articular ulnar head shear fracture, with early recovery of forearm rotation and wrist function.

Minimally invasive treatment of calcaneal fracture

Objective

This study was performed to analyze the outcomes of calcaneal fractures using a minimally invasive internal fixation method with a thin plate and bone grafting.

Methods

This retrospective analysis included 21 patients treated using our minimally invasive approach. The outcome measures were the change in the Bohler and Gissane angles and the calcaneus width after fixation. The clinical outcomes were evaluated by the Maryland foot scoring system and assessment of soft tissue complications.

Results

The follow-up time was 12 to 18 months. The Bohler angle, Gissane angle, and width of the calcaneus were significantly different between the preoperative and postoperative periods. The rate of excellent and good outcomes was 85.7% according to the Maryland foot scoring system. The incidence of soft tissue complications was 14.3%.

Conclusion

Treatment of calcaneal fractures using a minimally invasive internal fixation method with a plate and bone grafting provides good to excellent clinical outcomes with few soft tissue complications.

Prolonged surgical duration, higher body mass index and current smoking increases risk of surgical site infection after intra-articular fracture of distal femur

BACKGROUND

This study aimed to investigate incidence of surgical site infection (SSI) following the surgery of intra-articular fractures of distal femur.

METHODS

Between July 2014 and December 2017, inpatient medical records of consecutive patients who had intra-articular fractures of distal femur treated by open reduction and plate/screw fixation were inquired to identify whether they had a SSI. After discharge, patients who had a SSI and were readmitted for treatment of SSI were also allocated to the case group. Univariate and multivariate logistic regression analyses were performed to determine whether some clinical factors were independently associated with SSI, after adjustment for confounding variables.

RESULTS

During the study period, 434 patients were evaluated and 21 patients were confirmed to develop a SSI, indicating the accumulated incidence of 4.8% within 1 year. A total of six deep and 15 superficial SSIs were identified, with respective incidence being 1.4% and 3.4%. The most common causative pathogen was Staphylococcus aureus (8, 50.0%), followed by mixed bacteria (5, 31.3%). Open fracture, prolonged surgical duration, increased body mass index and current smoking were identified as independent risk factors for development of SSI (P < 0.05).

CONCLUSIONS

It should be noted that it was likely difficult to modify these risk factors, but they do prove useful for preoperative counselling of patients and their relatives regarding their own risk profile of SSI, and the perioperative medical optimization.

Intraoperative computed tomography with an integrated navigation system versus freehand technique under fluoroscopy in the treatment of intra-articular distal radius fractures

Volar locking plate (VLP) fixation for distal radius fractures (DRF) is a technically demanding procedure, where accurate placement of the distal screws for subchondral articular support is essential. The purpose of this retrospective, case-control study was to compare a computed tomography (CT) navigation system for VLP fixation of intra-articular DRF with conventional freehand fluoroscopy guided surgery. Twelve consecutive patients with DRF, AO type C3.1, underwent VLP fixation using intraoperative CT navigation (navigated group) and 16 consecutive patients had conventional freehand fluoroscopy guided surgery (non-navigated group). Follow-up was done mean 12 (range, 4-18) months after surgery. Radiological outcomes included evaluation of placement for the distal fixation screws and radiological parameters such as; radial inclination, palmar tilt, ulnar variance, fracture-gap, and step-off. Clinical outcomes included grip strength, wrist range of motion, Mayo wrist score, and the Disabilities of the arm, shoulder and hand (DASH) questionnaire. Dorsal cortical and articular screw penetrations were significantly more common in the non-navigated group compared with the navigated group. At the final follow-up, a significantly larger intra-articular fracture gap was observed in the non-navigated group compared to the navigated group. There were no significant differences in clinical outcomes between the two treatment groups. Our results suggest that CT navigation guided surgery for VLP fixation of type C3 DRF, compared with conventional freehand fluoroscopy guided surgery, provides a more accurate placement of the distal screws which minimize the risk for intra-articular and dorsal cortical screw penetration.

Displaced medial end clavicular fractures treated with an inverted distal clavicle plate contoured through 90 degrees

BACKGROUND

This study assessed whether treating medial end clavicular fractures using an inverted distal clavicle locking plate, twisted through 90° around its axis, would allow for a less invasive surgical approach and improve screw trajectory insertion.

MATERIALS AND METHODS

We searched the databases of the 2 senior authors for patients who had sustained an acute, displaced fracture of the medial end of the clavicle and had undergone operative fixation using an inverted distal clavicle plate contoured through 90°. Through an inferior incision, a contoured locking plate was positioned on the anterior surface of the medial end of the clavicle. Up to 8 unicortical screws were inserted from anterior to posterior through the medial end of the plate. The lateral end was contoured and fixed to the superior clavicular surface. The patients were assessed preoperatively and at 1 month, 4 months, and final follow-up. Preoperative and postoperative plain x-ray images and computed tomography scans were reviewed.

RESULTS

The study included 8 patients (average age, 31.3 years; range, 15-59 years) with displaced fractures who underwent fixation. The median follow-up time was 30.5 months (range, 24-45 months). All patients reached clinical and radiographic union at 4 months. The mean 11-item version of the Disabilities of the Arm, Shoulder, and Hand score was 0.6 (range, 0-2.3). All of the patients had returned to their preinjury level of sport and activity. None of the patients had a complication.

CONCLUSION

Contouring an inverted distal clavicle plate through 90° may improve fixation options by allowing access to the anterior clavicle when treating medial clavicular fractures.

[An Experience of Using a Distraction Plate for an Elderly Patient with a Highly Communited Intraarticular Distal Radius Fracture]

We performed open reduction and internal fixation using a distraction plate in two cases of elderly patients with highly communited intraarticular open distal radius fractures. There was no corrective loss of intraarticular fracture fragment in either case. The implant was removed in one case because bone union was achieved. The plate was retained in the other case, without the hope of implant removal. Neither case complained of any marked disturbance of activities of daily living (ADL), and there was no pain at the time of the final follow up period. However, there is a high possibility of limitation of the range of motion (ROM) of the wrist after implant removal, therefore we need to judge the indications carefully.

[Preliminary effectiveness of carpal arthroscopic adjuvant treatment of intra-articular fractures of distal radius]

Objective

To investigate the early-term effectiveness of carpal arthroscopy in the treatment of intra-articular fractures of distal radius.

Methods

The clinical data of 50 cases of intra-articular fractures of distal radius between January 2015 and December 2017 were retrospectively analyzed. According to the different methods of intraoperative assisted treatment, the patients were divided into the trial group (11 cases with carpal arthroscopy assisted treatment) and the control group (39 cases with traditional open reduction). There was no significant difference between the two groups in general data such as gender, age, affected side, cause of injury, time from injury to operation, and preoperative displacement ( P>0.05), which were comparable. Six patients in the trial group had triangular fibrocartilage complex (TFCC) injury and received one-stage repair. Postoperative X-ray films were taken to estimate the fracture reduction. Patient-Rated Wrist Evaluation (PRWE) wrist function score and modified Mayo score were used at 3 months after operation to evaluate the function of the wrist. The range of wrist flexion, extension, pronation, and supination motion of the two groups were recorded and compared at 3 months after operation. Patients in the trial group were further divided into the reduction group after arthroscopic exploration (group A, 6 cases) and the simple cleaning group after arthroscopic exploration (group B, 5 cases), and their wrist motions were compared.

Results

The operation time of the trial group was greater than that of the control group ( t=11.08, P=0.00). There was no significant difference in intraoperative blood loss and fracture reduction between the two group ( P>0.05). X-ray film at 1 day after operation showed that the degree of fracture displacement was significantly decreased when compared with preoperative one in each group ( P<0.05), but no significant difference was found between the two groups at 1 day after operation ( t=0.19, P=0.85). Patients in both groups were followed up 8-20 months, with an average of 12 months. There was no significant difference in fracture healing time between the two groups ( t=0.52, P=0.60). At 3 months after operation, the PRWE score, modified Mayo score, and wrist motions in the trial group were all better than those in the control group ( P<0.05). There was no significant difference in wrist motions between group A and group B ( P>0.05).

Conclusion

Carpal arthroscope assisted treatment of intra-articular fractures of distal radius can achieve good reduction and postoperative function. Meanwhile, TFCC, ligament, articular cartilage, and other injuries can be repaired in one stage.

Effects of knockout of the receptor for advanced glycation end-products on bone mineral density and synovitis in mice with intra-articular fractures

Our group employed the mouse closed intra-articular fracture (IAF) model to test the hypothesis that the innate immune system plays a role in initiating synovitis and post-traumatic osteoarthritis (PTOA) in fractured joints. A transgenic strategy featuring knockout of the receptor for advanced glycation end-products (RAGE ^-/- ) was pursued. The 42 and 84 mJ impacts used to create fractures were in the range previously reported to cause PTOA at 60 days post-fracture. MicroCT (μCT) was used to assess fracture patterns and epiphyseal and metaphyseal bone loss at 30 and 60 days post-fracture. Cartilage degeneration, synovitis, and matrix metalloproteinase (MMP-3, -13) expression were evaluated by histologic analyses. In wild-type mice, μCT imaging showed that 84 mJ impacts led to significant bone loss at 30 days (p < 0.05), but recovered to normal at 60 days. Bone losses did not occur in RAGE^-/- mice. Synovitis was significantly elevated in 84 mJ impact wild-type mice at both endpoints (30 day, p = 0.001; 60 day, p = 0.05), whereas in RAGE^-/- mice synovitis was elevated only at 30 days (p = 0.02). Mankin scores were slightly elevated in both mouse strains at 30 days, but not at 60 days. Immunohistochemistry revealed significant fracture-related increases in MMP-3 and -13 expression at 30 days (p < 0.05), with no significant difference between genotypes. These findings indicated that while RAGE ^-/- accelerated recovery from fracture and diminished synovitis, arthritic changes were temporary and too modest to detect an effect on the pathogenesis of PTOA. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2439-2449, 2018.

CXCL10 is upregulated in synovium and cartilage following articular fracture

The objective of this study was to investigate the expression of the chemokine CXCL10 and its role in joint tissues following articular fracture. We hypothesized that CXCL10 is upregulated following articular fracture and contributes to cartilage degradation associated with post-traumatic arthritis (PTA). To evaluate CXCL10 expression following articular fracture, gene expression was quantified in synovial tissue from knee joints of C57BL/6 mice that develop PTA following articular fracture, and MRL/MpJ mice that are protected from PTA. CXCL10 protein expression was assessed in human cartilage in normal, osteoarthritic (OA), and post-traumatic tissue using immunohistochemistry. The effects of exogenous CXCL10, alone and in combination with IL-1, on porcine cartilage explants were assessed by quantifying the release of catabolic mediators. Synovial tissue gene expression of CXCL10 was upregulated by joint trauma, peaking one day in C57BL/6 mice (25-fold) versus 3 days post-fracture in MRL/MpJ mice (15-fold). CXCL10 protein in articular cartilage was most highly expressed following trauma compared with normal and OA tissue. In a dose dependent manner, exogenous CXCL10 significantly reduced total matrix metalloproteinase (MMP) and aggrecanase activity of culture media from cartilage explants. CXCL10 also trended toward a reduction in IL-1α-stimulated total MMP activity (p = 0.09) and S-GAG (p = 0.09), but not NO release. In conclusion, CXCL10 was upregulated in synovium and chondrocytes following trauma. However, exogenous CXCL10 did not induce a catabolic response in cartilage. CXCL10 may play a role in modulating the chondrocyte response to inflammatory stimuli associated with joint injury and the progression of PTA. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1220-1227, 2018.

Intra-articular distal radius fractures in elderly patients: a randomized prospective study of casting versus volar plating

We compared outcomes in elderly patients with intra-articular distal radius fractures treated by closed reduction and plaster immobilization or open reduction and internal fixation with a volar plate. Ninety-seven patients older than 60 years were randomly allocated to conservative (47 patients) or surgical (50 patients) treatment. Over a 2-year period, we assessed patient-rated wrist evaluation score, DASH (disability arm, shoulder and hand) questionnaire, pain, wrist range of motion, grip strength, and radiological parameters. The functional outcomes and quality of life were significantly better after volar plating fixation compared with conservative treatment. We found that restoration of the articular surface, radial inclination, and ulnar variance affected the outcomes, but the articular step-off did not. Twenty-five per cent of the patients with conservative treatment had secondary loss of reduction. We conclude that surgical plating leads to better outcomes than conservative treatment for elderly patients with intra-articular distal radius fractures.

LEVEL OF EVIDENCE

I.

Management of Intra-Articular Distal Radius Fractures: Volar or Dorsal Locking Plate-Which Has Fewer Complications?

BACKGROUND

The aim of this study was to compare the functional outcomes and complications of volar and dorsal plating for the management of intra-articular distal radius fractures, with special regard to indications for dorsal plating. Furthermore, we examine the rationale for choosing dorsal plating and its frequency of use.

METHODS

Clinical assessments included range of motion measurements at the wrist; grip strength; the Quick Disabilities of the Arm, Shoulder, and Hand score; and the Gartland and Werley score. Clinical results were compared with those achieved using a volarly placed locking plate system. According to Lutsky's plate theory, the rationale for choosing dorsal plating was based on 4 types of pathologic fractures.

RESULTS

Of 112 patients, 38 patients were treated with open reduction internal fixation via a dorsal approach and 68 patients were treated using a volar approach. Except for wrist flexion, there were no other statistical differences in the clinical results between groups for both subjective and objective parameters. There were no statistically significant differences in the complication rates between the volar and dorsal plated groups. One serious complication occurred after volar plating. The most common reason for choosing dorsal plating was irreducible dorsal die-punch fractures.

CONCLUSIONS

The treatment of displaced intra-articular distal radius fractures with a dorsally versus a volarly placed interlocking plate system demonstrated similar clinical results. Postoperative complications were not readily observed in the patients treated with a dorsal locking plate. Certain fracture patterns are more appropriately stabilized using a dorsal plate fixation.

A Protocol for Percutaneous Transarticular Fixation of Sanders Type II and III Calcaneal Fractures With or Without an Added Mini-Open Approach

Intra-articular fracture of the calcaneus is one of the most displeasing fractures if not properly managed. Open reduction and internal fixation have been associated with a high incidence of postoperative soft tissue complications. Closed reduction and percutaneous fixation have resulted in a greater incidence of postoperative subtalar osteoarthritis with improper reduction of the articular surface. In the present study, a mini-open approach was used in cases of failure of articular surface restoration with closed reduction. A total of 64 feet in 57 consecutive patients with an intra-articular calcaneal fracture underwent the proposed minimally invasive surgical protocol. Of the 57 patients, 7 (12.3%) had bilateral fractures. According to Sanders classification, 33 (51.6%) fractures were type II and 31 (48.4%) were type III. Seven (12.3%) patients had wedge fractures of the dorsolumbar spine without neurologic manifestations. The postoperative evaluation included radiographs and completion of the Maryland Foot Score and visual analog scale for pain. The mean follow-up period was 16 (range 12 to 36) months. The mean operative time was 42 (range 35 to 60) minutes. The mean period until union of the fracture was 12 (range 10 to 16) weeks. The clinical results according to the Maryland Foot Score revealed 52 (81%) with satisfactory (27 excellent and 25 good) and 12 (19%) with unsatisfactory (10 fair and 2 poor) results. The mean visual analog scale score was 1.5 ± 0.3 when radiographic fracture healing was observed. Six patients (9.4%) developed superficial pin tract infections that responded to local care and parenteral antibiotic therapy and resolved completely after removal of the Kirschner wires. In conclusion, the presented surgical protocol combining closed reduction with or without an added mini-open approach and percutaneous fixation improves the functional outcome and minimizes the incidence of complications.

The Effect of Displaced Dorsal Rim Fragment in a Distal Radius Fracture

Background In intra-articular fracture of distal radius, the intra-articular fragments can be divided into some specific fragments. In particular, the poor outcomes have been well documented for reduction loss of the volar lunate facet, but the effect of a displaced dorsal rim fracture has rarely been addressed. Materials and Methods The records of 26 patients with dorsal rim fragment displaced by more than 2 mm after volar locking plate (VLP) fixation for a dorsally displaced distal radius fracture (DRF) treated from March 2006 to March 2009 were retrospectively reviewed. Clinical assessments including grip strengths, wrist range of motions, and Disabilities of Arm, Shoulder, and Hand (DASH) scores were performed at 12 months postoperatively. Widths of the distal ends of dorsal rims were determined by preoperative computed tomography (CT). Dorsal rim fragment displacements were measured in immediate postoperative plain lateral radiographs. Radial inclination, volar tilt, and ulnar variance were measured on immediate postoperative wrist radiographs. Arthritic changes of radiocarpal joints were graded using radiographs obtained at 12 months postoperatively. Description of Technique DRFs were fixed using a VLP in the usual manner. Although DRF displacement was noticed after plate fixation, no further procedure was performed. The sizes of articular portions of dorsal rim fragments were measured arthroscopically in 5 of the 26 patients at the time of plate fixation. Results At 12 months postoperatively, mean grip strength, wrist flexion arc, and mean wrist extension arc were 86 ± 13, 87 ± 11, and 91 ± 10%, respectively, of contralateral sides. Mean forearm supination and pronation were 96 ± 8 and 99 ± 5%, respectively, of contralateral sides. Mean DASH score was 11 ± 10 points. Preoperatively, mean width of the distal end of dorsal rim fragments and mean displacements of dorsal rim fragments were 2.0 ± 0.6 and 3.0 ± 0.9 mm, respectively. Mean width of the articular portions of dorsal rim fragment by arthroscopic examination was 1.0 ± 0.4 mm. Mean radial inclination was 21 ± 4.8 degrees, mean volar angulation was 4.8 ± 3.9 degrees, and mean ulnar variance was 0.6 ± 1.8 mm at immediate postoperatively. Two patients showed grade I arthritic changes at 12 months postoperatively. Conclusions The articular portions of dorsal rim fragments measured arthroscopically were smaller than determined by CT. Furthermore, the study shows that displaced dorsal rim fragments in dorsally displaced DRFs treated by VLP do not adversely affect wrist clinical outcomes.

Therapeutic opportunities to prevent post-traumatic arthritis: Lessons from the natural history of arthritis after articular fracture

An estimated 12% of patients seeking surgical intervention for symptomatic arthritis have an etiology of post-traumatic arthritis (PTA). The onset of PTA is rapid in the setting of articular fracture (AF). The investigation began with development of a murine model of a closed AF that develops PTA. In the process of characterizing this model a technique was developed for assessing quantitative synovial fluid biomarker concentrations. The work began with observations of the natural history of PTA development in the C57BL/6 strain of mice. A species of mice (MRL/MpJ) was found that is protected from PTA after AF. Further work identified key differences between mouse strains that did and did not develop PTA. This knowledge led to an intervention based on anti-cytokine (interleukin 1 receptor antagonist, (IL-1Ra) delivery in the C57BL/6 strain of mice that successfully prevented PTA following AF. This success in preventing PTA in the murine model has elucidated several important clinical implications: 1) Pro-inflammatory cytokines play an important role in the development of PTA after joint injury, 2) Pharmacologic intervention can lessen the severity of PTA after an AF, and 3) The murine AF model of joint injury provides a novel means of studying mechanisms of PTA development.

Superior peroneal retinacular injuries in calcaneal fractures

Calcaneal fractures are injuries that occur generally as the result of high-energy mechanisms, and, as such, the presence of concurrent injuries should be suspected. The presence of peroneal tendon and superior retinacular injuries has been underreported. We sought to report the incidence of peroneal tendon pathologic features in our population of patients with calcaneal fractures, with emphasis on the method of identification. Furthermore, we sought to identify whether specific fracture patterns were more commonly associated with this pathologic finding. Of the 97 cases, 13 (13.4%) required repair of the superior peroneal retinaculum, 11 of which demonstrated the Sanders A fracture line. Our findings have demonstrated an incidence of pathologic features, in particular, with the presence of the Sanders A fracture line, that warrants attention to potentially help improve the outcome of these devastating injuries.

Intra-articular osteotomy for malunited articular fractures of the distal end of the humerus

BACKGROUND

The precarious anatomy of the articular surface of the distal humerus, as well as its meager subchondral bony support and limited soft-tissue attachments, presents enormous challenges for the operative correction of post-traumatic intra-articular deformities. This study presents 8 patients who underwent articular osteotomy with a mean follow-up period of 10.6 years, with an emphasis on functional, patient-rated, and radiographic outcomes.

METHODS

Eight patients (mean age, 39 years; range, 17-60 years) were followed up for a mean period of 10.6 years. The original fracture was a type C variant in 4 patients, a type B unicondylar fracture in 2, and a type B articular shearing fracture in 2. The initial injury was treated operatively in 5 patients and nonoperatively in 3. The osteotomy and reconstruction were performed on average 8 months after injury (range, 6-11 months). The mean preoperative elbow arc of motion was 37°. Two patients had ulnar nerve dysfunction.

RESULTS

All the osteotomies healed after the index procedure without evidence of avascular necrosis. Two patients required a second procedure for stiffness. At follow-up, the mean arc of elbow motion improved to 104° (P = .001), with a mean flexion contracture of 26°. The mean Disabilities of the Arm, Shoulder and Hand score at follow-up was 13 (range, 1-37); the mean patient satisfaction rating on a Likert scale (from 0 to 10) was 9.1; and the mean Mayo Elbow Performance Index score was 83 points (range, 70-100 points). Grade II osteoarthritic changes were seen in 3 patients, grade I in 3, and grade 0 in 2.

CONCLUSIONS

In selected patients with a defined intra-articular malunion, the results of our experience support corrective osteotomy.

Effects of cartilage impact with and without fracture on chondrocyte viability and the release of inflammatory markers

Post-traumatic arthritis (PTA) frequently develops after intra-articular fracture of weight bearing joints. Loss of cartilage viability and post-injury inflammation have both been implicated as possible contributing factors to PTA progression. To further investigate chondrocyte response to impact and fracture, we developed a blunt impact model applying 70%, 80%, or 90% surface-to-surface compressive strain with or without induction of an articular fracture in a cartilage explant model. Following mechanical loading, chondrocyte viability, and apoptosis were assessed. Culture media were evaluated for the release of double-stranded DNA (dsDNA) and immunostimulatory activity via nuclear factor kappa B (NF-κB) activity in Toll-like receptor (TLR) -expressing Ramos-Blue reporter cells. High compressive strains, with or without articular fracture, resulted in significantly reduced chondrocyte viability. Blunt impact at 70% strain induced a loss in viability over time through a combination of apoptosis and necrosis, whereas blunt impact above 80% strain caused predominantly necrosis. In the fracture model, a high level of primarily necrotic chondrocyte death occurred along the fracture edges. At sites away from the fracture, viability was not significantly different than controls. Interestingly, both dsDNA release and NF-κB activity in Ramos-Blue cells increased with blunt impact, but was only significantly increased in the media from fractured cores. This study indicates that the mechanism of trauma determines the type of chondrocyte death and the potential for post-injury inflammation.

Pediatric and adolescent intra-articular fractures of the calcaneus

Calcaneal fractures in childhood are very rare, whereas particularly intra-articular displaced fractures are not typical in skeletally immature children. Various techniques of osteosynthesis have been described. This study aimed to determine clinical and radiological outcome after surgical treatment of intraarticular calcaneal fractures. Fourteen intraarticular fractures of the calcaneus were included in this retrospective study. Eleven children (2 girls and 9 boys) aged 6-16 years (average age 11.5 years) underwent surgical treatment. One child sustained a Type II open fracture of both calcanei. All injuries occurred after a high-energy trauma; 3 patients had multiple additional fractures. The clinical and radiological postoperative follow up was an average 44 months. In 4 cases, a reduction through a minimally invasive approach and fixation with K-wires or screws could be achieved. Eleven fractures were treated with open reduction and internal fixation with plate osteosynthesis, K-wires or screws. In one case with open fractures of both heel bones, an additional external fixator was applied. The surgical treatment approach adopted enabled the pre-operative Böhler’s angle (average 16°) to be improved to an average 30°. In all cases, except for the patient with open fractures, a good functional result and outcome could be achieved. In calcaneal fractures in childhood, anatomical reduction is the determining factor, as in fractures in adults, whereas the surgical technique seems to have no influence on clinical outcome in children. The wound healing problems that have often been described were not observed in this age group.

A novel impaction technique to create experimental articular fractures in large animal joints

OBJECTIVE

A novel impaction fracture insult technique, developed for modeling post-traumatic osteoarthritis in porcine hocks in vivo, was tested to determine the extent to which it could replicate the cell-level cartilage pathology in human clinical intra-articular fractures.

DESIGN

Eight fresh porcine hocks (whole-joint specimens with fully viable chondrocytes) were subjected to fracture insult. From the fractured distal tibial surfaces, osteoarticular fragments were immediately sampled and cultured in vitro for 48 h. These samples were analyzed for the distribution and progression of chondrocyte death, using the Live/Dead assay. Five control joints, in which "fractures" were simulated by means of surgical osteotomy, were also similarly analyzed.

RESULTS

In the impaction-fractured joints, chondrocyte death was concentrated in regions adjacent to fracture lines (near-fracture regions), as evidenced by fractional cell death significantly higher (P < 0.0001) than in central non-fracture (control) regions. Although nominally similar spatial distribution patterns were identified in the osteotomized joints, fractional cell death in the near-osteotomy regions was nine-fold lower (P < 0.0001) than in the near-fracture regions. Cell death in the near-fracture regions increased monotonically during 48 h after impaction, dominantly within 1 mm from the fracture lines.

CONCLUSION

The impaction-fractured joints exhibited chondrocyte death characteristics reasonably consistent with those in human intra-articular fractures, but were strikingly different from those in "fractures" simulated by surgical osteotomy. These observations support promise of this new impaction fracture technique as a mechanical insult modality to replicate the pathophysiology of human intra-articular fractures in large animal joints in vivo.

Acute joint pathology and synovial inflammation is associated with increased intra-articular fracture severity in the mouse knee

OBJECTIVE

Post-traumatic arthritis is a frequent cause of disability and occurs most commonly and predictably after articular fracture. The objective of this investigation was to examine the effect of fracture severity on acute joint pathology in a novel murine model of intra-articular fracture.

DESIGN

Low and high energy articular fractures (n=25 per group) of the tibial plateau were created in adult male C57BL/6 mice. The acute effect of articular fracture severity on synovial inflammation, bone morphology, liberated fracture area, cartilage pathology, chondrocyte viability, and systemic cytokines and biomarkers levels was assessed at 0, 1, 3, 5, and 7 days post-fracture.

RESULTS

Increasing intra-articular fracture severity was associated with greater acute pathology in the synovium and bone compared to control limbs, including increased global synovitis and reduced periarticular bone density and thickness. Applied fracture energy was significantly correlated with degree of liberated cortical bone surface area, indicating greater comminution. Serum concentrations of hyaluronic acid (HA) were significantly increased 1 day post-fracture. While articular fracture significantly reduced chondrocyte viability, there was no relationship between fracture severity and chondrocyte viability, cartilage degeneration, or systemic levels of cytokines and biomarkers.

CONCLUSIONS

This study demonstrates that articular fracture is associated with a loss of chondrocyte viability and increased levels of systemic biomarkers, and that increased intra-articular fracture severity is associated with increased acute joint pathology in a variety of joint tissues, including synovial inflammation, cortical comminution, and bone morphology. Further characterization of the early events following articular fracture could aid in the treatment of post-traumatic arthritis.

Cartilage viability and catabolism in the intact porcine knee following transarticular impact loading with and without articular fracture

Posttraumatic arthritis commonly develops following articular fracture. The objective of this study was to develop a closed joint model of transarticular impact with and without creation of an articular fracture that maintains the physiologic environment during loading. Fresh intact porcine knees were preloaded and impacted at 294 J via a drop track. Osteochondral cores were obtained from the medial and lateral aspects of the femoral condyles and tibial plateau. Chondrocyte viability was assessed at days 0, 3, and 5 postimpact in sham, impacted nonfractured, and impacted fractured joints. Total matrix metalloproteinase (MMP) activity, aggrecanase (ADAMTS-4) activity, and sulfated glycosaminoglycan (S-GAG) release were measured in culture media from days 3 and 5 posttrauma. No differences were observed in chondrocyte viability of impacted nonfractured joints (95.9 ± 6.9%) when compared to sham joints (93.8 ± 7.7%). In impacted fractured joints, viability of the fractured edge was 40.5 ± 27.6% and significantly lower than all other sites, including cartilage adjacent to the fractured edge (p < 0.001). MMP and aggrecanase activity and S-GAG release were significantly increased in specimens from the fractured edge. This study showed that joint impact resulting in articular fracture significantly decreased chondrocyte viability, increased production of MMPs and aggrecanases, and enhanced S-GAG release, whereas the same level of impact without fracture did not cause such changes.

Is elevated contact stress predictive of post-traumatic osteoarthritis for imprecisely reduced tibial plafond fractures?

Despite the widely held belief that residual incongruities from intra-articular fractures subject the joint to contact stresses that predispose to post-traumatic osteoarthritis (PTOA), objective evidence has been lacking. This study tested the hypothesis that a metric of elevated contact stress exposure would predict the onset of PTOA. The ankles of 10 tibial plafond fracture patients were treated initially using a spanning fixator, with subsequent screw fixation of the articular surface. Following up on an earlier report of finite element computed post-operative contact stress distributions in these patients' ankles, Kellgren-Lawrence (KL) scores were assessed from minimum 2-year follow-up radiographs to characterize the presence/severity of PTOA. At that time point, seven patients had developed PTOA (KL ≥ 2). Five different metrics of contact stress exposure were calculated, all of which exhibited excellent concordance with KL scores, ranging from 88% to 95%. When time of stress exposure was included, one metric was able to predict PTOA development (KL ≥ 2) with 100% reliability, and all metrics exhibited >94% prediction reliability. These findings, albeit in a small population, support the existence of a contact stress exposure threshold above which incongruously reduced tibial plafond fractures are highly likely to develop PTOA.

Controversies in the management of intra-articular fractures of distal humerus in adults

BACKGROUND

The surgical approach, type of olecranon osteotomy, method of stabilization of osteotomy, type of fracture stabilization, orthogonal vs parallel plate fixation, need for transposition of ulnar nerve, place for primary total elbow replacement, and type of rehabilitation schedule after surgical fracture treatment are the controversial issues in the treatment of complex intra-articular distal humerus fractures (C2 and C3) in adults. Severe comminution, bone loss, and osteoporosis at the site of distal articular fractures of humerus often lead to unsatisfactory results due to inadequate fixation. We hereby report the outcome of a series of intracondylar fractures of the humerus treated by open reduction and internal fixation and discuss the controversies in light of published literature.

MATERIALS AND METHODS

One hundred and eighty-four patients of intra-articular fractures of distal humerus (C2 and C3) were operated by posterior transolecranon approach between January 1980 and December 2008. Initially, in the first part Chevron intra-articular osteotomy (n=108) was performed out of which 94 have been published in another publication. In later second part (1993 onward), extra-articular olecranon osteotomy (n=76) was routinely performed. Both columns were stably fixed by orthogonal methods; (n=174) however, during the last 2 years, in 10 patients with severe comminution with bone loss, stabilization was achieved by parallel plating. The osteotomy was routinely stabilized by tension band wiring with two parallel K-wires introduced up to the anterior ulnar cortex. The results were evaluated by the staging system of Caja et al. at a minimum follow-up of 2 years.

RESULTS

In the first part of the study (n=94), there was delayed union in 4% (n=4), with the fracture taking more than 20 weeks for union. There was delayed union of ulnar osteotomy (n=3) and failure of one tension band wiring, requiring revision. Some loss of motion was seen in 20% of cases and these patients did not achieve full flexion and extension. However, all these patients had useful range of function, with 20°-110° of flexion and full pronation-supination. As per the staging system of Caja et al., the results were in the range of excellent to good in 72% cases (n=67), fair in 19% (n=18), and poor in 9% patients (n=9). In the second part of study (n=90) dual plate fixation of both columns by orthogonal methods (n=80) and parallel plate fixation in 10 patients was performed. The results were excellent to good in 78 patients (86%).

CONCLUSIONS

The high rate of union can be achieved in complex intra-articular fractures of distal humerus if the proper principles of stable fracture fixation are followed, i.e., a posterior transolecranon approach and dual fixation of both columns and restoration of the continuity of articular surface. The stability achieved by this technique permits institution of early intensive physiotherapy to restore elbow function.