Pins and Rubbers Traction System for Treatment of Intraarticular Fractures of Distal Interphalangeal Joint.

Background: The pins and rubber traction system (PRTS) has proven effective in managing intra-articular fractures of the proximal interphalangeal joint. However, there is scant evidence in the literature regarding its efficacy in treating distal interphalangeal joint (DIPJ). This study aims to investigate the outcomes of PRTS in the treatment of comminuted intra-articular fractures of the DIPJ. Methods: We conducted a retrospective review of patients with comminuted intra-articular fractures of the DIPJ treated with PRTS between 2017 and 2021. At the final follow-up, we measured and compared the active range of motion (ROM) in both affected and non-injured contralateral fingers. The subjective evaluation utilised the Quick Disabilities of the Arm, Shoulder and Hand (Quick-DASH) questionnaire and the Visual Analogue Scale (VAS). Results: Ten patients with a mean follow-up of 13.2 months (range: 12-17) were included in the study. Fracture locations included the base of the distal phalanx in two patients, the condyle of the middle phalanx in seven and both in one patient. At the final follow-up, the average VAS score was 0.5 (range: 0-2). The average active motion of the DIPJ was 61° (range: 50°-70°) for the injured side and 76° (range: 75°-80°) for the opposite side. The mean range of DIPJ movement was 80% (range: 68%-87%) of the non-injured side. Extension deficits were observed in five patients, with a median deficit value of 10° (range: 5°-10°). The average Quick-DASH score was 2.9 (range: 0-11.3). Conclusions: The PRTS can be considered as an effective surgical technique in managing comminuted intra-articular fractures of the DIPJ. Level of Evidence: Level IV (Therapeutic).

Posterior Pedicle Screw Fixation With Indirect Decompression Versus Direct Decompression in Treating Thoracolumbar Burst Fracture: A Systematic Review and Meta-Analysis.

OBJECTIVE: To compare the safety and efficacy between posterior pedicle screw fixation with direct versus indirect decompression in treating patients with thoracolumbar burst fracture. METHODS: This study was conducted on the basis of PRISMA statement. We systematically searched the PubMed and Embase databases up to July 3, 2023. Relevant studies comparing indirect decompression and direct decompression were recruited. Weighted mean differences (WMDs), odds ratios (ORs) and 95% confidence intervals (CIs) were analyzed for continuous and dichotomous data, respectively. P < 0.05 was considered statistically significant. RESULTS: The operation time (WMD: -37.14, 95% CI: [-42.64, 31.64], P < 0.00001, I2 = 0%) and intraoperative blood loss (WMD: -316.82, 95% CI: [-469.80, -163.85], P < 0.0001, I2 = 99%) of indirect decompression group were significantly lower. Percentage of anterior vertebral body height (WMD: 3.98, 95% CI: [2.36, 5.60], P < 0.00001, I2 = 32%) and encroachment rate of the spinal canal (WMD: 1.48, 95% CI: [0.56, 2.40], P = 0.002, I2 = 35%) of indirect decompression group were significantly higher. No statistical difference was identified in grades of neurologic recovery and Cobb angle. CONCLUSIONS: Posterior pedicle screw fixation with indirect decompression was safe and effective for thoracolumbar burst fracture with or without neurologic deficits when posterior longitudinal ligament was intact.

Does ligamentotaxis reduce the risk of avascular necrosis of the talus after lateral subtalar dislocation.

Lateral subtalar dislocations are rare and severe injuries caused by high-energy trauma, and they require urgent treatment. We reported two cases of lateral subtalar dislocation, which were treated with different methods. In case of open lateral subtalar dislocation, we used the method of distractional external fixation; the final outcome was good, without avascular necrosis of the talus. The case of closed subtalar dislocation has been treated with open reduction and K-wires fixation. The final outcome was poor, with avascular necrosis of the talus. Our opinion is that ligamentotaxis of the ankle and subtalar joint with unilateral external fixation unloads the talus and reduces the possibility of the development of avascular necrosis of the talus.

Indirect Spinal Canal Decompression Using Ligamentotaxis Compared With Direct Posterior Canal Decompression in Thoracolumbar Burst Fractures: A Prospective Randomized Study.

Background: There is still no standard of care to manage thoracolumbar burst fractures. With all the recent advances, posterior approaches are still one of the mainstays of treatment. On the other hand, while spinal canal decompression in neurological impaired patients is an important goal of treatment, its technique remains controversial.This study compared the effects of direct laminectomy decompression against ligamentotaxis/indirect canal decompression on neurological and radiographic improvements. Methods: A prospective double-blind randomized clinical trial was conducted on 60 thoracolumbar burst-fracture patients meeting our inclusion and exclusion criteria. They were randomized into 2 treatment arms: (1) direct decompression using laminectomy and (2) indirect decompression using ligamentotaxis/distraction. Each patient was observed for 6 months, and their neurological and radiographical data were collected prospectively. Statistical analysis was done by the Student t test, Friedman test, Mann Whitney-U test, Wilcoxon ranked test, and 1-way analysis of variance. Results: Among 60 patients enrolled in our study, each treatment arm had an improvement in Frankel scores but there was no difference between the groups at any given time. After 6 months of surgery, local sagittal kyphosis improved in both groups (from 32.2 to 7.43 and 29.93 to 8.77 for the indirect and direct groups, respectively), as well as anterior vertebral height ratio (from 57.73 to 70.7 and 62.17 to 66.27 for the indirect and direct group, respectively) and posterior vertebral height ratio (from 61.17 to 74.87 and 64 to 67.5 for the indirect and direct group, respectively). For between-group comparisons after 6 months, there was a significant difference only for posterior vertebral height ratio (P = 0.040). Conclusion: Posterior approaches with ligamentotaxis have shown to be safe and may present the same outcome as direct decompression techniques using wide laminectomy.

In-Fracture Pedicular Screw Placement During Ligamentotaxis Following Traumatic Spine Injuries, a Randomized Clinical Trial on Outcomes.

Objective: To investigate the efficacy and safety of two different techniques for spinal ligamentotaxis. Spine ligamentotaxis reduces the number of retropulsed bone fragments in the fractured vertebrae. Two different ligamentotaxis techniques require clinical evaluation. Methods: This was a randomized clinical trial. The case group was defined as one pedicular screw insertion into a fractured vertebra, and the control group as a no-pedicular screw in the index vertebra. Spine biomechanical values were defined as primary outcomes and complications as secondary outcomes. Results: A total of 105 patients were enrolled; 23 were excluded for multiple reasons, and the remaining were randomly allocated into the case (n=40) and control (n=42) groups. The patients were followed up and analyzed (n=56). The postoperative mid-sagittal diameter of the vertebral canal (MSD), kyphotic deformity correction, and restoration of the anterior height of the fractured vertebrae showed equal results in both groups. Postoperative retropulsion percentage and pain were significantly lower in the case group than in the control group (p=0.003 and p=0.004, respectively). There were no group preferences for early or long-term postoperative complications. Conclusions: Regarding clinical and imaging properties, inserting one extra pedicular screw in a fractured vertebra during ligamentotaxis results in better retropulsion reduction and lower postoperative pain.

Reverse Cortical Sign in Lumbar Burst Fracture.

"Reverse cortical sign" is a rare entity described in lumbar burst fracture that corresponds to the fracture fragment of the posterior wall of vertebral body, which has rotated 180 degrees with the cortical surface facing anteriorly and the cancellous surface facing posteriorly in the canal. Identifying this sign is crucial in deciding the line of management as it is a contraindication for ligamentotaxis. The advent of computed tomography scans with axial and sagittal reconstruction has allowed us to better describe these rare entities. We present a lumbar burst fracture with a reverse cortical sign describing its appearance in axial computed tomography scans, sagittal reconstruction, and magnetic resonance imaging.

Are external fixators as effective as volar plates in multi-fragmented radius distal intra-articular fractures (AO type C)?

INTRODUCTION: This study aimed to compare the radiological and clinical results of VP and EF applications in multi-fragmented radius distal intra-articular fractures (AO type C) in our clinic. METHODS: We retrospectively analysed 80 patients who underwent surgery for radius distal fracture (AO type C) between 2014 and 2020. Group 1 comprised patients who were treated with VP, and Group 2 comprised patients who were treated with EF. Radiological evaluation was performed by measuring radial inclination, radial length, volar tilt, intra-articular step-off and ulnar variance by two-way radiography. The clinical findings were evaluated using the Gartland and Werley scoring system, and complications were noted. RESULTS: There were no statistically significant differences between the two groups in terms of age, gender, side, fracture subtypes and follow-up time (p > 0.05). There were no statistically significant differences between the two groups in radiological parameters (based on cut-off values) (p > 0.05). The clinical evaluation did not reveal a statistically significant difference between the two groups (p = 0.613). CONCLUSION: EF is as successful as VP in providing radiological cut-off values. EF treatment can be used as an effective and safe alternative method for multi-fragmented radius distal intra-articular fractures.

Revision of Failed Sacroiliac Joint Posterior Interpositional Structural Allograft Stabilization with Lateral Porous Titanium Implants: A Multicenter Case Series.

Background: Distraction arthrodesis (DA) and stabilization of the sacroiliac (SI) joint by placing standalone structural allograft (SA) into the joint from a posterior trajectory has recently been introduced as a surgical procedure for chronic SI joint pain refractory to non-operative care. Methods: Retrospective case series of patients with recurrent and/or persistent pain after placement of one or more interpositional/intraarticular standalone SAs between the ilium and sacrum using a posterior procedure to treat SI joint pain/dysfunction. Patients subsequently underwent surgical revision with porous titanium fusion implants using a lateral transfixing procedure. The demographic, clinical, and radiographic features of these cases are described. Results: Data were available for 37 patients. The average (SD) age was 57 (13) years, 62% were female, and the average BMI was 31 (5.4). On average, two SA implants were placed per joint; 46% of cases were bilateral. At follow-up, two common themes were identified: lucencies around the implants and suboptimal implant position. None of the cases showed radiographic fusion of the SI joint prior to revision. One patient had an inflammatory reaction to the SA. All patients presented for revision due to either continued (49%) or recurrence (51%) of pain. In one revision case, the SA was forced ventrally, resulting in a sacral fracture, which was treated conservatively without sequelae. Conclusions: The popularity of standalone SA for SI joint stabilization/fusion with a posterior procedure is increasing. This case series demonstrates that clinical failures from this procedure may require surgical revision. The proposed fusion strategy (DA) for these products is unproven in the SI joint, and, therefore, properly conducted prospective randomized clinical trials with long-term clinical and radiographic follow-up are important to establish the safety and efficacy of this approach. In the meantime, the placement of lateral titanium implants appears to be an effective revision strategy.

The flexibility and convenience of using a standard orthopaedic table in peri-articular knee fractures: Allowing ligamentotaxis and improving imaging accessibility.

Tibial plateau and distal femoral fractures are common injuries presenting a significant operative challenge. Complexity of the fracture often needs multi-planar surgical access. A combined two-staged procedure is frequently suggested both in supine and prone position to address this issue. However, this will significantly increase the operative time and eventually impact the outcome, in addition to the complications associated with prone positioning. In this study we used a standard orthopaedic table to position these patients in order to grant access to the postro-medial and a postro-lateral structures while the patient stays in supine setup, at the same time, giving the flexibility to change the alignment from valgus to varus and vice versa. This facilitates fracture reduction while addressing the anatomical structure of the knee. A further advantage is the unobstructed imaging access throughout the surgical fixation. This facilitates the reduction in operative time hence leading to a better outcome in these difficult fractures. We tested this positioning technique in more than 40 patients over a 4-year period at two different centres in the United Kingdome. We found that this approach is safe, reproducible and relatively easy to set up in the two centres.

Percutaneous Spine Fusion Combined with Whole-Body Traction in the Acute Surgical Treatment of AO A- and C-Type Fractures: A Technical Note.

BACKGROUND: A diminished level of pain following the operation and shortened hospitalization are the distinct advantages of minimally invasive spine surgery (MISS). However, manipulating the spine with additional MISS tools (e.g., distraction and compression devices) is often cumbersome. Our paper draws attention to a cost-free, fast, indirect decompression method that can be used in the acute treatment of thoracolumbar spine fractures. The presented method involves ligamentotaxis by whole-body traction in the operating room combined with percutaneous spine fixation. METHODS: Fifteen patients with thoracolumbar injuries A type and C type (without distraction) by AO classification were operated sequentially with the combination of whole-body traction and percutaneous minimally invasive spine fixation. Data were analyzed retrospectively. RESULTS: A total of 139 screws were implanted into 70 segments in 6 female and 9 male patients. The average clinical follow-up was 16 months. Average preoperative traumatic kyphosis was 17 degrees, and an average postoperative kyphosis was 1.8 degrees. The fractured vertebrae's height gain was an average of 11.0 mm (range 3.9-21.9 mm) ventrally and an average of 5.4 mm (range 1-11.2 mm) dorsally after the surgeries. The spinal canal space narrowing showed an average 6.5 mm improvement postoperatively. Operative time averaged 2 hours and 34 minutes, and blood loss averaged 250 mL (range 150-400 mL). No neurologic complications and wound healing problems were observed. CONCLUSIONS: The combination of MISS and whole-body traction provided successful anatomical correction in thirteen of the fifteen cases of compression type thoracolumbar fractures without extensive surgical exploration.

Ilizarov ligamentotaxis versus volar locked plating in the management of AO type C2/C3 distal radius fractures-a prospective non-randomised comparative trial.

PURPOSE: The aims of this study were to compare radiological and functional outcomes of Ilizarov ligamentotaxis and locked volar plating in comminuted intra-articular distal radius fractures (AO type C2/C3) using a non-randomised superiority trial. METHODS: A total of 72 patients with AO C2/C3 distal radius fractures were allotted into Ilizarov ligamentotaxis (n = 30) and locked volar plating (n = 42) groups based on patient preference. Primary outcome was the ability to achieve and stably maintain acceptable radiological parameters (post-operative, 6 weeks, 3 months, 12 months), and secondary outcome was functional scoring (at 12 months). RESULTS: All patients completed the study. All fractures united uneventfully. Plating was superior to Ilizarov in restoring ulnar variance (100% versus 80%, p value 0.004), but Ilizarov was superior to plating in restoring volar tilt (as opposed to neutral tilt, 83.3% versus 47.8%, p value 0.002). Both groups were comparable in restoring radial height, radial inclination and intra-articular reduction and stably maintaining all five parameters over long term. There was a statistically significant difference between the two groups with regard to mean ulnar variance (plating superior) and volar tilt (Ilizarov superior) at all stages of follow-up, whereas radial height and radial inclination were comparable at all points. There was no significant change of all radiological parameters over a follow-up period. At the end of one year, DASH score was slightly better (not clinically appreciable) in the Ilizarov group (8.47 versus 13.61, p value 0.03), but Gartland and Werley scores were comparable between both groups. Mean duration of external fixation in the Ilizarov group was 43.07 ± 8.94 days. Apart from five cases of pin site infections, there were no complications. CONCLUSION: Ilizarov ligamentotaxis is a comparable option to locked volar plating in achieving radiological restoration and clinical function in comminuted intra-articular distal radius fractures, AO types C2 and C3. Restoration of ulnar variance needs utmost care while performing Ilizarov ligamentotaxis. Ilizarov comes with the disadvantages of reduced patient preference, pin site infections, need for removal of external fixator and slightly slower return to activity. TRIAL REGISTRATION NUMBER:  CTRI/2018/08/015549 LEVEL OF EVIDENCE: Level III, Non-randomised prospective trial.

Simplified Kirschner­wire-based dynamic external fixator for unstable proximal interphalangeal joint fractures.

PURPOSE: Ligamentotaxis is a well-established treatment modality for treating challenging articular fractures. Many devices have been evolved to apply this principle to complex proximal interphalangeal joint (PIPJ) fractures. Although they gave satisfactory results, these devices were sometimes costly, complex and cumbersome. The aim of this study was to evaluate the short-term functional and radiological outcomes of treating complex intra-articular PIPJ fractures using a simplified, preloaded Kirschner­wire (K­wire)-based dynamic external fixator. METHODS: Twenty consecutive patients with intraarticular PIPJ fractures, who fulfilled the study selection criteria, have been treated during 2018 and included in this prospective study after the approval of the responsible institutional ethics committee. Plain radiographs were used for assessing fracture reduction, congruity and healing. The visual analogue sore (VAS) and the Michigan Hand Outcome Questionnaire (MHQ) were used for functional evaluation. PIPJ range of motion (ROM) and hand grip-strength were also assessed. RESULTS: At the final follow-up, all patients had no residual pain. The average PIPJ-ROM was 76.4 ± 23.51°, and the average grip-strength was 85 ± 13.95% as compared to the healthy side. The mean normalized MHQ score was 83 ± 12.63 points, with 4, 13, and 3 patients had excellent, good, and fair results retrospectively. Complications included pin tract infection (one case), stress fracture related to the applied wires (one case), and flexion contractures (four cases; three of them were symptomatic). CONCLUSIONS: The used fixator technique is simple, reliable, available, reproducible, time-saving and cost-effective for managing complex PIPJ fractures while allowing early joint mobilization, which proven effective in achieving high satisfactory functional results.

Predictors of indirect neural decompression in minimally invasive transpsoas lateral lumbar interbody fusion.

OBJECTIVE: An advantage of lateral lumbar interbody fusion (LLIF) surgery is the indirect decompression of the neural elements that occurs because of the resulting disc height restoration, spinal realignment, and ligamentotaxis. The degree to which indirect decompression occurs varies; no method exists for effectively predicting which patients will respond. In this study, the authors identify preoperative predictive factors of indirect decompression of the central canal. METHODS: The authors performed a retrospective evaluation of prospectively collected consecutive patients at a single institution who were treated with LLIF without direct decompression. Preoperative and postoperative MRI was used to grade central canal stenosis, and 3D volumetric reconstructions were used to measure changes in the central canal area (CCA). Multivariate regression was used to identify predictive variables correlated with radiographic increases in the CCA and clinically successful improvement in visual analog scale (VAS) leg pain scores. RESULTS: One hundred seven levels were treated in 73 patients (mean age 68 years). The CCA increased 54% from a mean of 0.96 cm2 to a mean of 1.49 cm2 (p < 0.001). Increases in anterior disc height (74%), posterior disc height (81%), right (25%) and left (22%) foraminal heights, and right (12%) and left (15%) foraminal widths, and reduction of spondylolisthesis (67%) (all p < 0.001) were noted. Multivariate evaluation of predictive variables identified that preoperative spondylolisthesis (p < 0.001), reduced posterior disc height (p = 0.004), and lower body mass index (p = 0.042) were independently associated with radiographic increase in the CCA. Thirty-two patients were treated at a single level and had moderate or severe central stenosis preoperatively. Significant improvements in Oswestry Disability Index and VAS back and leg pain scores were seen in these patients (all p < 0.05). Twenty-five (78%) patients achieved the minimum clinically important difference in VAS leg pain scores, with only 2 (6%) patients requiring direct decompression postoperatively due to persistent symptoms and stenosis. Only increased anterior disc height was predictive of clinical failure to achieve the minimum clinically important difference. CONCLUSIONS: LLIF successfully achieves indirect decompression of the CCA, even in patients with substantial central stenosis. Low body mass index, preoperative spondylolisthesis, and disc height collapse appear to be most predictive of successful indirect decompression. Patients with preserved disc height but severe preoperative stenosis are at higher risk of failure to improve clinically.

Distal femoral fine wire traction assisted retrograde nailing of the femur.

Here we describe the surgical technique for using distal femoral fine wire traction during retrograde femoral nailing and present case examples. This technique allows for hands-free distraction across the fracture site to restore length and alignment, while not interfering with the preparation and insertion of the retrograde femoral nail. Distal femoral fine wire traction is a useful adjunctive technique to restore length and effect an indirect reduction in femur fractures being stabilized with a retrograde nail.

Mid-Term Outcomes of Unstable Complex Proximal Interphalangeal Joint Fracture Management Using the Ligamentotaxor® Device: A Case Series of 33 Cases.

Background and objective Fractures of the proximal interphalangeal joint (PIPJ) of the hand have always been difficult to treat, often leading to less than satisfactory outcomes. The use of dynamic external fixator devices to treat these fractures is well established and it is based on the philosophy of minimal soft tissue injury and early joint mobilization. There has been a wide variety in their designs, surgical technique, and reported outcomes. This study aimed to report the long-term outcome following the use of the Ligamentotaxor® device (Ligamentotaxor1, ArexTM, Palaiseau, France) in treating fractures of the PIPJ of the hand. Methods Between 2009 and 2018, 33 patients treated in our institution with Ligamentotaxor® for fractures of the PIPJ were followed up for a minimum period of 12 months. Radiographs and clinical records were reviewed for clinical and functional outcomes including finger range of motion (ROM), union, Quick Disability of the Arm, Shoulder, and Hand (QuickDASH) score, and any complications. Results A total of 33 patients completed a minimum follow-up of 12 months (mean: 27.5 months). All fractures showed radiological union at a mean of 33 days. Surgery was performed within a mean of 8.9 days and surgical operating time averaged 23.7 minutes. Devices were removed at a mean of 33 days. At the end of the follow-up, the mean range of flexion was 66 degrees and the mean extension lag was six degrees. The mean QuickDASH score was 8.72. Of note, 85% of the patients experienced no limitations in their daily activities, while 35% reported pain on exertion. One patient had a pin tract infection. Four patients had cold intolerance and persistent swelling. Conclusion The results of the use of Ligamentotaxor® in this series are comparable to those of other dynamic external fixator devices reported in the literature. Thanks to its quick and easy surgical technique, the device provides an appealing option for the management of PIPJ fractures.

Necessity of Direct Decompression for Thoracolumbar Junction Burst Fractures with Neurological Compromise.

BACKGROUND: Surgical management of burst fractures is controversial, with many different operative options. From a posterior approach, decompression of the spinal cord can be performed through both indirect and direct methods, the former relying on ligamentotaxis. It is unclear whether indirect decompression with ligamentotaxis is as effective as direct decompression. METHODS: Prospective, randomized controlled data were retrospectively analyzed to include only burst fractures of the thoracolumbar junction. Patients were treated with either direct decompression, involving wide posterior decompression in addition to operative stabilization, or indirect decompression, where decompression was performed solely through ligamentotaxis. Patients were followed up at 6 months with clinical assessment and imaging. Additional clinical assessment was performed at 1 year. For all analyses, P < 0.05 was significant. RESULTS: The study included 46 patients, with 18 patients in the direct decompression subgroup and 28 patients in the indirect decompression subgroup. The average age of the full cohort was 35.1 ± 13.1 years (range, 16-60 years). Most patients had L1 fractures (21/46; 46%), with an AOSpine classification type A4 fracture morphology (17/46; 37%), and were American Spinal Injury Association grade B (18/46; 39%). Both treatments resulted in similar increases in canal diameter and decreases in dural sac compromise (P > 0.5) at 6-month follow-up. Both treatments resulted in similar grades of neurological improvement (P = 0.575) at 1 year. CONCLUSIONS: There were no significant differences in clinical and imaging outcomes when comparing direct decompression with ligamentotaxis. Ligamentotaxis alone may be effective in carefully selected cases.

Acute burst fracture in Kummell's disease with acute onset neurological deficit: a case report on role of spinal stability and technical notes on "pivot ligamentotaxis".

BACKGROUND: Kummell's Disease has insidious progression. Neurological deficit is usually slow in onset and progression and only few cases of acute neurological deficit have been reported. We came across a case of Kummell's disease which progressed to burst fracture, developed neurological deficit within two weeks. We managed patient with "pivot ligamentotaxis" and Polymethylmethacrylate augmented, posterior compressed, short segment percutaneous pedicle screw fixation. CASE PRESENTATION: Eighty-three years old woman following fall was on conservative management at another hospital. She had no neurological deficit. A week later her back pain aggravated and two weeks later developed bilateral buttock pain, bilateral lower limb weakness and diminished sensation in the sacral area. Radiological investigations (X-rays, Magnetic resonance imaging and Computed tomography) showed L1 vertebral body fracture with vacuum cleft and fracture fragment retropulsed into the spinal canal. A diagnosis of Kummell's disease with burst fracture of L1 vertebra & neurological deficit was made. Patient was managed with Polymethylmethacrylate augmented, posterior compressed, short segment percutaneous pedicle screw fixation. The reduction of the retropulsed fragment was achieved by virtue of "Pivot ligamentotaxis". The patient got relieved of the symptoms (Preoperative VAS 8 and postoperative VAS 3) and was allowed brace assisted ambulation on first postoperative day. CONCLUSION: This study reports acute occurrence of the burst fracture in unstable vertebra inflicted by Kummell's disease and role of spinal stability in recovery. We achieved closed reduction of the fracture fragments and relief of the cord compression by posterior compression with "pivot ligamentotaxis".

A Bridging: Distraction External Fixation for a Severely Comminuted Fracture of the Middle Phalanx. A Case Report.

Severely comminuted fractures of the middle phalanx of the digits are known to be demanding cases for hand surgeons. The restoration of the length and axis of the phalanx, such as the anatomic reduction of the articular surface in case of intra-articular association are basic principles that have to be followed. A simple and cheap device consisting of two Kirschner wires and a nylon suture can work as an external fixation system based on the principle of ligamentotaxis. As a result, the anatomic reduction of the fracture with minimal soft tissue damage and simple surgical equipment is feasible.

Arthroscopic repair of glenoid rim fractures: a ligamentotaxis surgical technique.

PURPOSE: Glenoid fractures occur as a result of direct impact of the humeral head against the glenoid rim following high-energy trauma. They frequently involve one-third of the glenoid surface with an oblique fracture rim from 2 to 6-7 o'clock, and they must not be confused with bony Bankart lesions. In medium-age patients, they are frequently associated with acute cuff tear while in older patients with chronic cuff tear: These conditions increase the instability of the shoulder if not treated. With this study, we reported the results of the arthroscopic ligamentotaxis technique treatment of acute antero-inferior glenoid fractures type IA of Ideberg with a cuff repair associated. MATERIALS AND METHODS: Eleven patients with IA Ideberg glenoid fracture were treated with ligamentotaxis technique. Mean age: 56 years (45-70); 80% dominant side; male/female: 1.2. Mean extension area of glenoid fracture: 25%. The fragment was fixated reinserting the labro-ligamentous complex with a single 2 o'clock anchor. In six patients (55%), a rotator cuff tear was present, repaired during the surgical intervention. Radiological assessment: X-rays and CT with PICO method to measure the glenoid area involved. Clinical assessment: VAS, constant score, Dash score and Rowe score. RESULTS: After 30 months of follow-up (12-50), no differences in flexion, abduction, rotations and pain were reported compared to the contralateral side (p > 0.05). The mean normalized constant was 101 (60-123), and the mean Rowe was 93 (65-100). X-rays showed good healing without articular surface depressions or step in all cases. Two patients had a progression of gleno-humeral arthritis. CONCLUSION: Acute antero-inferior glenoid rim fractures are uncommon but they are increasing in over 55 years population (frequently associated with cuff tear). Correct classification and treatment are necessary to achieve good results. The X-ray assessment includes the Neer's trauma series and the CT study with PICO measurement of glenoid fragment size. Wrong treatment can lead to chronic instability, degenerative joint disease and poor results. The arthroscopic repair with ligamentotaxis is a good solution and permits the treatment of the associated rotator cuff tear. Arthroscopic technique imposes a long learning curve. CT can be used to confirm the anatomic reduction and the healing of the fracture but since it uses X-rays it must be reserved to comminuted fractures.