Outcomes of young active patients with displaced clavicle fractures treated with Rockwood pin

PURPOSE

Various fixation techniques have been described for midshaft clavicle fractures in the literature. We hypothesized that use of the Rockwood pin for fixation of displaced midshaft clavicle fractures would result in favorable outcomes in a young active cohort.

METHODS

Patients aged 10-35 years who underwent Rockwood clavicle pin fixation at a single institution were identified. Preoperative and postoperative radiographs were reviewed and assessed for fracture characteristics, postoperative alignment, and radiographic union. Postoperative outcome scores were obtained.

RESULTS

A total of 39 patients (age 17.3 ± 3.9 years) with clavicle fracture treated with Rockwood pin were identified. Radiographic review demonstrated that 88% of fractures were 100%, or more, displaced, and surgery achieved near-anatomic reduction in 92% of cases. Average time to radiographic union was 2.3 ± 0.8 months, and average time to clinical union was 2.5 ± 0.3 months. One patient required revision for nonunion (3%). Complete outcome responses were obtained for 24 patients, with an average 40 ± 27.7 months of follow-up. Mean Total Clavicle Functional score was 2.75 ± 3.6 for minor patients. For adult patients, Nottingham Clavicle score was 90.7 ± 10.7, mean American Shoulder and Elbow Society score was 92.4 ± 11.2, and mean Single Assessment Numerical Evaluation score was 88.8 ± 21.5. 77% of adults reported no long-term functional limitation; 54% reported a bump at the prior fracture site, but 100% reported satisfaction with shoulder appearance.

CONCLUSIONS

In our cohort of young active patients, treatment with Rockwood pin allowed for anatomic reduction, healing with a low nonunion rate, and favorable patient reported outcomes.

Outcomes of early versus delayed weight-bearing with intramedullary nailing of tibial shaft fractures: a systematic review and meta-analysis

PURPOSE

Early weight bearing (EWB) is often recommended after intramedullary nailing of tibial shaft fractures, however, the risks and benefits have not been critically evaluated in a systematic review or meta-analysis. Therefore, the aims of this study were to perform a systematic review and meta-analysis comparing EWB and delayed weight-bearing (DWB) after intramedullary nailing of tibial shaft fractures and assess the relationship between weight-bearing, fracture union and healing.

METHOD

This review included studies comparing the effects of EWB, defined as weight-bearing before 6 weeks, and DWB on fracture union and healing. PubMed, Embase, CINAHL, and the Cochrane Library were searched from inception to 9 May 2021. Risk of bias was assessed using the Down's and Black Checklist and Cochrane Risk of Bias Tool 2.0. Data were synthesised in a meta-analysis, as well as narrative and tabular synthesis.

RESULTS

Eight studies were included for data extraction and meta-analysis. The analysis produced mixed results and found a significant decrease in mean union time (-2.41 weeks, 95% confidence interval: -4.77, -0.05) with EWB and a significant Odd's Ratio (OR) for complications with DWB (OR: 2.93, 95% CI: 1.40, 6.16). There was no significant difference in rates of delayed union, non-union, re-operation and malunion.

CONCLUSION

The included studies were of moderate risk of bias and demonstrated shorter union time and fewer complications with EWB. However, current evidence is minimal and has significant limitations. The role of EWB in high-risk patients is yet to be examined. Further well-designed, randomised studies are required on the topic.

Outcomes and complications after dual plate vs. single plate fixation of displaced mid-shaft clavicle fractures: A systematic review and meta-analysis

INTRODUCTION

Open reduction and internal fixation (ORIF) of displaced midshaft clavicle fractures is associated with higher union rates and earlier functional recovery. However, ORIF with plate fixation is associated with complications including implant irritation and implant failure. Dual plate fixation provides fixation in orthogonal planes, and uses a lower profile fixation technique in comparison to pre-contoured and surgeon-contoured small-fragment locking plates, which may be more prominent. The objective of this study was to conduct a systematic review to summarize outcomes and complications associated with surgical fixation of displaced acute midshaft clavicle fractures with dual plate fixation.

METHODS

Using a predetermined study protocol in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, the databases MEDLINE, EMBASE, and CENTRAL were searched from inception to 2020 to identify studies reporting outcomes in acute midshaft clavicle fractures treated with dual plate fixation. All clinical studies which reported on outcomes of dual plating in patients with acute midshaft clavicle fractures were included. Baseline demographics, plate fixation constructs, fracture union rates, implant removal rates, maintenance of reduction, symptomatic implant rates, wound complications, and functional outcomes were extracted. All extracted data were recorded, and descriptive statistics were summarized. Meta-analysis was performed on fracture union rates and implant removal rates using random-effects modeling using Mantel-Haenszel weighting.

RESULTS

Our literature search identified 2226 unique abstracts, of which eight studies met our study inclusion criteria following review. A total of 278 patients made up of 79.8% male with an average age of 36.0 years were included. The overall dual plate implant removal rate was 4.2% with excellent rates of union reported. Moreover, single plate fixation was associated with a 3.9-fold increased implant removal rate compared to dual plate fixation.

CONCLUSION

Results from this systematic review demonstrate that ORIF of displaced midshaft clavicle fractures using a dual plate fixation technique is a viable option to reduce the incidence of implant removal, without negatively impacting the rate of fracture union.

LEVEL OF EVIDENCE

Therapeutic Level III.

Cigarette smoke inhalation impairs angiogenesis in early bone healing processes and delays fracture union

Aims

Cigarette smoking has a negative impact on the skeletal system, causes a decrease in bone mass in both young and old patients, and is considered a risk factor for the development of osteoporosis. In addition, it disturbs the bone healing process and prolongs the healing time after fractures. The mechanisms by which cigarette smoking impairs fracture healing are not fully understood. There are few studies reporting the effects of cigarette smoking on new blood vessel formation during the early stage of fracture healing. We tested the hypothesis that cigarette smoke inhalation may suppress angiogenesis and delay fracture healing.

Methods

We established a custom-made chamber with airflow for rats to inhale cigarette smoke continuously, and tested our hypothesis using a femoral osteotomy model, radiograph and microCT imaging, and various biomechanical and biological tests.

Results

In the smoking group, Western blot analysis and immunohistochemical staining revealed less expression of vascular endothelial growth factor (VEGF) and von Willebrand factor (vWF). The smoking group also had a lower microvessel density than the control group. Image and biochemical analysis also demonstrated delayed bone healing.

Conclusion

Cigarette smoke inhalation was associated with decreased expression of angiogenic markers in the early bone healing phase and with impaired bone healing.

Cite this article:Bone Joint Res. 2020;9(3):99–107.

Application of the Radiographic Union Scale for Tibial fractures (RUST): Assessment of healing rate and time of tibial fractures managed with intramedullary nailing

INTRODUCTION

Tibial fractures are devastating injuries and a cause of significant morbidity. There is limited information describing the length of time it takes for these injuries to heal. The aim of this study was to define the normal distribution of healing times of a consecutive series of tibial fractures treated with intramedullary (IM) nailing by applying the Radiographic Union Scale for Tibial fractures (RUST).

METHODS

880 radiographs from 217 patients were assessed with RUST. Patients requiring more than one standard deviation from the mean were defined to have a delayed union.

RESULTS

16 patients (7%) developed non-unions and 30 patients (14%) had delayed union. Of the 201 patients who achieved union, the mean time to healing was 18.7 (SD 6.9) weeks, with a wide range from 7 to 52 weeks. In the union group, the rate of healing was greatest in the 8 to 12-week period. In contrast, in the delayed union group there was a lower peak rate of change, which was reached at a later time point.

DISCUSSION

Our data indicates that 7% of patients with tibial fractures treated with IM nailing develop non-unions and over 10% of those progressing to union will take longer than 26 weeks. The data on healing rates is important to surgeons and orthopaedic multidisciplinary staff in guiding management. It can also be of help for patients planning their finances and for giving estimates for personal injury claims.

LEVEL OF EVIDENCE

IV, Retrospective cohort study.

Hangman's fracture: Management strategy and healing rate in a prospective multi-centre observational study of 34 patients

BACKGROUND

Hangman's fractures account for 15% to 20% of all cervical spine fractures. The grading system developed by Effendi and modified by Levine and Edwards is generally used as the basis for management decisions. Nonetheless, the optimal management remains controversial. The objective of this study was to describe the treatments used in France in patients with hangman's fractures. The complications and healing rates were analysed according to the fracture type and treatment used.

HYPOTHESIS

Among patients with hangman's fracture, those with disc damage must be treated surgically.

MATERIAL AND METHODS

A prospective, multi-centre, observational study was conducted under the aegis of the French Society for Spine Surgery (SociétéFrançaisedeChirurgieRachidienne, SFCR). Patients were included if they had computed tomography (CT) evidence of hangman's fracture. Follow-up data were collected prospectively. Fracture healing was assessed on CT scans obtained 3 and 12 months after the injury. The type of treatment and complications were recorded routinely.

RESULTS

We included 34 patients. The fracture type according to Effendi modified by Levine and Edwards was I in 68% of patients, II in 29% of patients, and III in a single patient (3%). The treatment was non-operative in 21 (62%) patients and surgical in 11 (32%). All 28 patients re-evaluated after 1 year had evidence of fracture healing. The remaining 6 patients were lost to follow-up.

CONCLUSION

Hangman's fracture is associated with low rates of mortality and neurological complications. Non-operative treatment is appropriate in Type I hangman's fracture, with a 100% healing rate in our study. Types II and III are characterised by damage to the ligaments and discs requiring either anterior C2-C3 fusion or posterior C1-C3 screw fixation.

LEVEL OF EVIDENCE

III.

Working length and proximal screw constructs in plate osteosynthesis of distal femur fractures

BACKGROUND

The study purpose is to evaluate the working length, proximal screw density, and diaphyseal fixation mode and the correlation to fracture union after locking plate osteosynthesis of distal femoral fractures using bridge-plating technique.

METHODS

A four-year retrospective review was performed to identify patients undergoing operative fixation of distal femur fractures with a distal femoral locking plate using bridge-plating technique for the metadiaphyseal region. Primary variables included fracture union, secondary surgery for union, plate working length, and diaphyseal screw technique and configuration. Multiple secondary variables including plate metallurgy and coronal plane fracture alignment were also collected.

RESULTS

Ninety-six patients with distal femur fractures with a mean age 60 years met inclusion criteria. None of the clinical parameters were statistically significant indicators of union. Likewise, none of the following surgical technique parameters were associated with fracture union: plate metallurgy, the mean working length, screw density and number of proximal screws and screw cortices. However, diaphyseal screw technique did show statistical significance. Hybrid technique had a statistically significant higher chance of union when compared to locking (p=0.02). All proximal locking screw constructs were 2.9 times more likely to lead to nonunion.

CONCLUSIONS

Plating constructs with all locking screws used in the diaphysis when bridge-plating distal femur locking plates were 2.9 times more likely to incur a nonunion. However, other factors associated with more flexible fixation constructs such as increased working length, decreased proximal screw number, and decreased proximal screw density were not significantly associated with union in this study.

A novel nail providing more biomechanical rotational and axial stability than conventional interlocking nail in femur complex fracture model

PURPOSE

Inter-fragmentary rotational and axial instabilities are major challenges in nailing of complex or comminuted fractures. We aimed to compare the inter-fragmentary rotational and axial stability of novel anti-rotation interlocking nail and the conventional interlocking nail in complex or comminuted femur shaft fractures.

METHODS

Twenty composite femurs were divided into two groups, 30 mm was resected from the mid-portion of all composite femurs. The inter-fragmentary rotational and axial stabilities were assessed.

RESULTS

Between 10-N m external and 6-N m internal rotation torques, mean maximum inter-fragmentary rotational arc motion in the novel nails was 1.63 mm and 291 % less than that of the conventional nails (6.38 mm, P = 0.000). Between 150 N distraction and 2300 N compression, mean axial motion in the novel nails was 0.8 mm and 257 % less than that of the conventional nails (2.86 mm, p = 0.000).

CONCLUSION

An anti-rotational novel nail is superior to the conventional interlocking nail in terms of maximum inter-fragmentary rotational and axial stabilities in complex and comminuted femur shaft fractures.

Role of common biochemical markers for the assessment of fracture union

The progress of fracture union requires close monitoring. Whereas, clinical examination and radiographic studies assess the outcome, biochemical markers like serum alkaline phosphatase and urinary hydroxyproline reflect the actual status of bone resorption and bone formation over a short time frame. 36 patients of long bone fracture were randomly allocated for the study. When the patient reported to the Department of Orthopedics after fracture, serum and urinary samples were collected and X-ray of the affected part were taken. Subsequent samples were collected and X-ray taken just after management (either operative or conservative), after 3rd, 5th, 8th and 12th week, respectively after onset of fracture. According to the course of callus formation the patients were divided into two groups that progressed to proper union or malunion. The levels of serum alkaline phosphatase, urinary total and free hydroxyproline levels were measured and statistically analysed and compared. A statistically significant positive correlation between total urinary hydroxyproline excretion and serum alkaline phosphatase indicate progress towards satisfactory union. Thus, serial monitoring of biochemical markers of bone turnover can be used as an adjunct to clinical and radiological evidence of fracture healing.