Nonoperative Versus Operative Treatment of Z-Type Comminuted Clavicle Fractures in Adolescents: A Prospective Substratified Cohort Analysis.

OBJECTIVES: To compare the clinical, radiographic, and patient-reported outcomes of nonoperative and operative treatment of adolescents with comminuted "Z-type" midshaft clavicle fractures. DESIGN: Prospective observational cohort. SETTING: Eight tertiary care pediatric centers. PATIENT SELECTION CRITERIA: Patients aged 10-18 years who were treated either operatively or nonoperatively for a diaphyseal clavicle fracture between 2013 and 2017 were screened/enrolled at the time of injury. The current subcohort analysis was derived from a larger adolescent clavicle study population of 907 patients. OUTCOME MEASUREMENTS AND COMPARISONS: Complications and validated patient-reported outcome measures (PROs):(ASES, QuickDASH, Marx Shoulder Activity Score, EQ-5D, EQ-VAS, and patient satisfaction score) were compared between operative and nonoperative cohorts. RESULTS: Eighty-one patients (69 male [85.2%], 12 female; average age 15 years [11.1-18.7]; 78 with sports participation [96.2%]) were followed through bony healing and return to sports, while 59 patients (73%) completed 2-year follow-up with PROs, 26 of whom were treated nonoperatively and 33 treated operatively. All demographic and fracture characteristics were similar (P > 0.05) between the 2-year follow-up cohorts except for fracture shortening, which was greater in the operative cohort (23 vs. 29 mm, P = 0.01). After controlling for this potential confounder through both regression and propensity matched subgroup analysis, nonoperative versus operative cohorts showed no difference in rates of nonunion (0%), delayed union (0% vs. 2.3%, P = 1.0), symptomatic malunion (2.7% vs. 0%, P = 0.4), refracture (2.7% vs. 2.2%, P = 1.0), unexpected subsequent surgery (5.4% vs. 11.4%, P = 0.45), or clinically significant complications (5.4% vs. 16%, P = 0.17). There were no differences in any PROs between cohorts, both before and after controlling for the difference in fracture shortening (all P-values >0.05). CONCLUSIONS: In this prospective comparison of complications and 2-year PROs in adolescents with comminuted Z-type clavicle fractures, nonoperative and operative treatment yielded similar outcomes. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Articular Fragment Detachment and Separate Fixation for the Treatment of Comminuted Patellar Fractures with Coronal Split Articular Fragments: Articular Detachment Technique.

Background: Treatment of comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments is a challenge. To treat this difficult fracture, we perform articular fragment detachment and separate fixation for coronal split articular and inferior pole fragments. We aimed to evaluate the radiological and clinical outcomes of our technique in comminuted patellar fractures at least 1 year after surgery. Methods: Between January 2019 and June 2022, 15 patients diagnosed with comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments based on preoperative computed tomography underwent surgery using the articular detachment technique. The key point of this technique was anatomical reduction and subchondral fixation of the coronal split articular fragment to the superior main fragment after complete detachment of the coronal split fragment from the inferior pole. The remaining inferior pole was fixed using a separate construct. Postoperative articular gap, articular step-off, and complications, including resorption, reduction loss, and avascular necrosis of fixed articular fragments, were evaluated as radiological outcomes. Range of motion and the Lysholm scores were used to evaluate clinical outcomes. Results: Among the 15 patients, the coronal split articular fragments were fixed using Kirschner wires in 13 patients and headless screws in 2 patients. The inferior poles were fixed using separate vertical wiring in 13 patients and tension-band wiring in 2 patients. A postoperative articular gap was noted in 7 patients, with an average articular gap of 1.0 mm (range, 0.7-1.6 mm). No articular step-off was observed. Bone union and normal range of motion were achieved in all patients. On the 1-year postoperative lateral radiograph, resorption of the articular fracture site was seen in 5 patients. There was no loss of reduction or avascular necrosis of the coronal split articular fragments. The average postoperative Lysholm score at 1 year was 89.3 ± 4.1 (range, 82-95). Conclusions: The technique would be a reliable and safe option for the surgical treatment of comminuted patellar fractures accompanied by coronal split articular and inferior pole fragments in terms of anatomical reduction and stable fixation of articular fragments without risk of avascular necrosis.

OSTEOSYNTHESIS OF COMPLEX COMMINUTED HAND BONE FRACTURES BY APPLYING THE LACING METHOD (A CLINICAL CASE STUDY).

Complex comminuted hand injuries are an urgent medical and social problem of national health systems, which is especially sensitive for countries with a low level of socio-economic development. The work aims to substantiate the effectiveness and safety of the shoelace method of hand bone osteosynthesis in complex comminuted fractures (a clinical case study). Clinical case: A 42-year-old female patient was admitted to the clinic with complaints of the presence of a crushed wound on the 2nd finger of the left hand. The shoelace method was applied for hand bone osteosynthesis. The surgical intervention time was 24 minutes, and the time before returning to work or daily activities equaled 7.1 weeks. The time to bone fusion was less than 45 days. The shoelace osteosynthesis method in complex comminuted fractures of the hand bones has prospects for modern clinical practice with the possibility of improving the performance and safety indicators.

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).

Comprehensive comparison between conservative therapy and surgical management for completely displaced and comminuted mid-shaft clavicle fractures.

PURPOSE: It is still controversial whether complete displaced mid-shaft clavicle fractures should be treated with internal fixation or conservative therapy. This retrospective study aims to compare clinical outcomes of two treatment protocols. MATERIALS AND METHODS: 105 patients with displaced and comminuted mid-shaft clavicle fractures were included in this study, among which 55 patients were treated conservatively and 50 patients accepted surgical fixation and were followed up for over 20 months on average. Rate of union, malunion, time taken for union, functional outcome, self-reported satisfaction and complications were compared. RESULTS: Union rate of operative group (n=49, 98.0%) was higher than the non-operative group (n=48, 87.3%). Time taken for union in operative group (2.37±1.06 months) was shorter than the non-operative group (3.69±1.01 months). Malunion and asymmetric were only seen in the conservative group. Numbness of the shoulder was only reported in the operative group (n=23, 46.0%). Most of patients in the operative group (n=45, 90%) accepted a second operation to remove the implant. No statistically difference was found in self-reported satisfaction, Quick-DASH and Constant-Murley score. The operative group returned to work faster (1.47±0.89 to 3.34±1.37 months), regained full range of motion earlier (1.66±0.78 to 3.83±1.24 months) and regained strength faster (3.86±2.45 to 8.03±2.78 months) than the non-operative group. CONCLUSION: Complete displaced and comminuted mid-shaft clavicle fractures treated surgically have more reliable union and faster recovery when compared to conservatively treated fractures.

[Radial Head Replacement: Management of Elbow and Forearm Instability after Comminuted Radial Head Fractures Associated with Elbow Dislocation]. / Endoprotéza hlavice radia: resení nestability lokte a predloktí pri trístivých zlomeninách hlavice radia spojených s luxací lokte.

PURPOSE OF THE STUDY: This manuscript aims to identify an indication algorithm for the surgical treatment of radial head fractures associated with elbow dislocation. The study compares the mid-term functional outcomes of patients with multifragment radial head fracture treated by resection with the outcomes of patients treated with radial head replacement. MATERIAL AND METHODS: The cohort of 34 patients who sustained a radial head fracture at the mean age of 42.5 years (age range 20-81 years) was broken down into two groups by type of surgery. The EXT group consists of 20 patients with the radial head fracture treated by radial head resection. The END group includes 14 patients treated with the radial head replacement. In all patients, the radial head fracture was associated with elbow dislocation (type IV fracture according to the Mason-Johnston classification). The modified Kocher's surgical approach was used in all patients of both the groups. In the EXT group, resection of the fragmented radial head was performed. In the END group, the ExploR® Modular Radial Head System (Zimmer, Biomet, USA) was used, consisting of a CoCr (cobalt chromium) alloy head and a titanium stem. The pain and the range of motion of the elbow and forearm were evaluated after the completion of the outpatient rehabilitation (the mean follow-up period was 2.4 years). Simultaneously, the elbow joint stability was assessed. Radiographs were taken to detect heterotopic ossifications, proximalization of the radius, and any signs of prosthesis loosening. The frequency of reoperations was followed-up. The MEPS (Mayo Elbow Performance Score) was calculated. RESULTS: In the EXT group, the mean elbow flexion was 117.5° and the mean pronation/supination was 166.9°. In 50% of patients, the MEPS obtained was greater than 90 points, which means an excellent functional outcome. In 1 patient (5%), recurrent elbow dislocation occurred which was the reason for revision surgery (elbow transfixation with the Kirschner wires and medial collateral ligament suture). Revision surgery was also performed in 2 patients (10%) in whom not all the radial head fragments were removed. Moreover, also observed was elbow joint instability (2 patients) and temporary radial nerve paralysis (1 patient). In 1 case discrete proximalization of the radius developed. The patients in the END group showed the mean elbow flexion of 112° and the mean pronation/supination of 135°. The MEPS obtained from 69% of patients was greater than 90 points, which means an excellent outcome. The pain under load was reported by 3 patients (21%). In 5 patients (35%), the X-rays showed radiolucent zone around the stem of the prosthesis. Neither revision surgery, nor prosthesis removal has been performed yet in any patient. No instability, neurological complications or infections have been reported. In both EXT and END group heterotopic ossifications have developed in 4 patients. CONCLUSIONS: Radial head replacement compared to the radial head resection in the management of multifragment fractures associated with elbow dislocations increase the elbow and forearm stability. The group of patients with an implanted radial head prosthesis shows a higher percentage of patients achieving excellent functional outcome than the group of patients with radial head resection. KEY WORDS: radial head, elbow, fracture, dislocation, resection, prosthesis.

Treatment of Complex Central Talar Fractures with Lateral Plate Combination with Medial Screw Fixation.

OBJECTIVE: The treatment of talar neck and/or body fractures is known to be difficult and challenging, with significant impact on the long-term functional outcome for the patient. The optimal management, including the choice of surgical approaches and implants, are still under constant discussion. The purpose of the study was to investigate the clinical effects of lateral mini-plate combined with medial lag screws for the treatment of complicated central talar fractures. METHODS: The data of eight patients with complex central talus fractures treated between June 2019 and January 2021 were retrospectively analyzed. There were six males and two females, ranging in age from 15 to 66 years, with an average age of 37.4 years. There were three cases on the left and five cases on the right. All fractures were comminuted, including talar neck with talar body fracture in seven cases and talar body comminuted with subluxation of subtalar joint in one case. All patients were treated with the anteromedial combined anterolateral approach, lateral talar mini-plate fixation and medial lag screw fixation. Fracture reduction quality, union time, and complications were recorded, and functional outcomes were evaluated using the American Orthopedic Foot & Ankle Society (AOFAS) scoring system. RESULTS: The time from injury to surgery was 1-6 days, with an average of 3.38 days. The follow-up period was 34-53 months (mean 44.88 months). All fractures healed with a mean healing time of 16.75 weeks (13-23 weeks). Anatomical reduction was observed in six cases and near in two cases. After operation, there was no loosening or breakage of implant, loss of fracture reduction, and irritation of skin and soft tissue by internal fixation. The average AOFAS score was 87.38 (48-100), with excellent five cases, good two cases and poor one case, and the excellent and good rate was 87.5%. Superficial skin necrosis in one surgical incision healed after dressing exchange. No deep infection occurred. One case (1/8, 12.5%) developed avascular necrosis of the talus without collapse. Posttraumatic arthritis was found in four cases (4/8, 50%). CONCLUSION: The utilization of lateral mini-plates in combination with medial screws for treating complex central talar fractures results in satisfactory reduction and stable fixation, mitigating complications associated with poor reduction. However, due to the absence of an anatomical mini-plate, pre-contouring is necessary when applying the lateral plate. This demands a surgeon's thorough familiarity with the anatomical morphology of the talus and proficiency in surgical techniques. Posttraumatic arthritis is the most common complication of complex central talar fractures.

[Research progress in the treatment of distal humeral metaphyseal-diaphyseal junction fracture in children].

Objective: To summarize the research progress in the treatment of distal humeral metaphyseal-diaphyseal junction (DHMDJ) fractures in children and to provide reference for clinical practice. Methods: The characteristics and treatment methods of transverse and comminuted DHMDJ fractures in children were summarized and analyzed by referring to relevant literature at home and abroad. Results: DHMDJ fractures in children are not uncommon clinically, with high fracture line position, multi-directional instability, difficult closed reduction in treatment, and easy to cause complications such as coronal and sagittal deformity of the elbow. The Kirschner wire technique was effective for DHMDJ fractures with the fracture line at the middle and low levels, but was prone to iatrogenic ulnar nerve injury. Elastic stable intramedullary nail is suitable for higher-position transverse DHMDJ fractures. However, this technique requires a second operation to remove the internal fixator, and may cause iatrogenic epiphysis plate injury in children. External fixator is a new way to treat DHMDJ fractures, and it can show satisfactory results for transverse and comminuted DHMDJ fractures. However, at present, there are few relevant studies, and most of them focus on biomechanical studies, and the efficacy lacks high-quality clinical research support. Conclusion: The ultimate goal of DHMDJ fracture treatment in children is to restore the anatomical alignment of the fracture and prevent the loss of reduction. The choice of internal fixator depends on the location of the fracture line and the shape of the fracture to provide personalized treatment.

Arthroscopically Assisted Treatment of Isolated Comminuted Trapezium Fracture: A Report of Two Cases.

CASES: Two competitive athletes with isolated comminuted trapezium fractures, sustained during American football and rugby, presented with pain and swelling of the first metacarpal base. Computed tomography confirmed isolated comminuted trapezium fractures. Arthroscopic reduction of displacement with screw fixation below the articular surface was performed through a small incision. Both patients returned to their preinjury sports levels within 2 months postoperatively. CONCLUSION: Arthroscopic treatment of isolated comminuted trapezium fractures achieved accurate reduction of articular surface displacement and preserved trapeziometacarpal joint stability with minimal soft-tissue invasion. This facilitated an early return to contact sports for the affected athletes.

Study on the therapeutic effect of Kirschner wire tension band combined with anchor cross-stitch technique in the treatment of comminuted patellar inferopolar fractures.

PURPOSES: Fractures of the inferior patellar pole, unlike other patellar fractures, present challenges for traditional surgical fixation methods. This article introduces the clinical technique and outcomes of using Kirschner wire tension band combined with anchor screw cross-stitch fixation for comminuted inferior patellar pole fractures. METHODS: This retrospective case series study included 14 patients with comminuted inferior patellar pole fractures treated at our institution from September 1, 2020, to April 30, 2022. All patients underwent surgery using the Kirschner wire tension band with anchor screw cross-stitch technique. Follow-up assessments involved postoperative X-rays to evaluate fracture healing, as well as clinical parameters such as healing time, Visual Analog Scale (VAS) scores, range of motion (ROM), and Bostman scores. RESULTS: All patients were followed for an average of over 12 months, with no cases of internal fixation failure. Knee joint stability and function were excellent. X-rays revealed an average healing time of approximately 10.79 ± 1.53 weeks, hospitalization lasted 5.64 ± 1.15 days, surgery took approximately 37.86 ± 5.32 minutes, and intraoperative blood loss was 33.29 ± 8.15 ml. One patient experienced irritation from the internal fixation material. At the final follow-up, the Bostman score averaged 28.29 ± 0.83, knee joint flexion reached 131.07° ± 4.88°, all patients achieved full knee extension, and the VAS score was 0.36 ± 0.63. CONCLUSION: Kirschner wire tension band with anchor screw cross-stitch fixation for comminuted inferior patellar pole fractures delivered satisfactory clinical outcomes. This surgical method, characterized by its simplicity and reliability, is a valuable addition to clinical practice.

Comparison of 2 different fixation techniques of comminuted acetabular quadrilateral surface fractures using square bracket-shaped tubular plate or interfragmentary screws in addition to supra/infrapectineal plate fixation: An observational study.

The management of comminuted quadrilateral fractures remains challenging, and treatment options are constantly evolving. The purpose of the present study was to examine the outcomes of 2 different fixation techniques in the management of comminuted quadrilateral fractures. Twenty-two patients with comminuted quadrilateral acetabular fractures were surgically treated with interfragmentary lag screw (group 1) and square bracket-shaped tubular (SBST) plate technique (group 2), in addition to suprapectineal and infrapectineal pelvic reconstruction plate fixation between January 2016 and July 2019 at our clinic. 2 years follow-up control data of each group were compared in terms of radiological and functional results, and complications. According to the functional score comparison, the mean Merle d'Aubigne Postel scoring system (MAP) score was 15.2/15.6 (P = .632), and the mean Harris hip scoring (HHS) system score was 74.65/77.3 (P = .664) in groups 1 and 2, respectively. Radiological comparison was performed according to matta radiological criteria (MRC), and 2 excellent, 6 good, 2 poor, 4 excellent, 4 good, and 4 poor radiological results were observed in groups 1 and 2, respectively. intraarticular screw penetration was detected in 3 patients in group 1, while there was no articular implant penetration in group 2 (P = .001). We believe that satisfactory results can be obtained with the SBST plate technique, offering functional and clinical outcomes that are similar to those of the interfragmentary screw technique. The SBST plate technique is superior in terms of avoiding intraarticular screw penetration and related revision surgery.

Quadruple Disruption of Superior Shoulder Suspensory Complex With Proximal Humerus Open Fracture-Dislocation: A Case Report.

CASE: A 34-year-old man was a restrained passenger involved in a high-speed rollover motor vehicle crash. The patient sustained a type 5 AC joint separation, severely comminuted intra-articular glenoid fracture with extension to the coracoid process base, displaced open scapular body fracture, a posterior shoulder dislocation of the glenohumeral joint, and a 2-part proximal humerus fracture. CONCLUSION: To our knowledge, this is the first report describing this injury pattern involving the superior shoulder suspensory complex with an associated open proximal humerus fracture-dislocation.

Locking plate fixation in comminuted coronoid fractures with partial loss of the articular cartilage - Of basal-1 type according to the O'Driscoll classification.

BACKGROUND: We have attempted to restore the arc of motion by considering trochlear-coronoid articulation as a complete circle during fixation of the coronoid, even for comminuted coronoid fractures with partial loss of articular cartilage (CCFPLAC), using various kinds of locking plates. Herein, we report the radiological and clinical outcomes after fixation of the basal-1 type of CCFPLAC (O'Driscoll classification) using our method. METHODS: Thirty-one patients diagnosed with CCFPLAC were admitted between January 2012 and December 2020. Sixteen of these patients met the inclusion/exclusion criteria and were enrolled in this study. Surgically, the lost area (defect of articular cartilage) was never compressed or minimized, but the original height and shape of the coronoid were preserved as is. Provisionally, a few K-wires were used to maintain the original shape and position of the CCFPLAC, and various kinds of locking plates/screws were used to fix the fragment anatomically and firmly. If needed, the plate was bent to ensure stable compression of the coronoid according to its size. In a few cases, locking plates were adjusted by cutting extra screw holes. RESULTS: Among the 16 patients, the mean age was 46.2 years, and the male:female ratio was 10:6. The mean follow-up period was 3.63 years. 8, 6, and 2 patients were designated as group 1 (isolated CCFPLAC), 2 [CCFPLAC in type 4 (terrible triad) injury), and 3 (CCFPLAC in type 5 posterior olecranon fracture-dislocations), respectively. Complete union was achieved after a mean of 8.94 weeks. The mean flexion-extension and pronation-supination arcs were 127.19 ± 4.46° and 135.31.59 ± 8.06°, respectively, which were significantly different from those on the contralateral (normal) side (p < 0.001); however, the arcs were within the functional ranges for ordinary daily living. Additionally, the functional status was satisfactory in all patients. However, Mayo Elbow Performance Score and the degree of arthritis were statistically poor in group 2. CONCLUSIONS: CCFPLAC of the basal-1 type (O'Driscoll classification) can be treated satisfactorily if already designed and widely distributed locking plates are properly manipulated to maintain the original geometry of the coronoid according to the individual joint characteristics. LEVEL OF EVIDENCE: Level IV, Retrospective case series.

Retrograde intramedullary nailing of AO/OTA 33C femur fractures in patients with below-knee amputations: technical note and case series.

PURPOSE: Intra-articular distal femur fractures in patients with a lower extremity amputation can present a technical challenge for the treating surgeon in what may be otherwise considered a routine procedure in non-amputees. Difficulties with positioning, fracture reduction, limb contractures, and stump osteoporosis can present challenges with treatment. Here, we describe the surgical technique and outcome of a case series of amputee patients with AO/OTA 33C femur fractures. METHODS: Retrospective case series of five patients with a comminuted supracondylar distal femur fracture with intercondylar extension proximal to a below-knee amputation treated with retrograde intramedullary nail at a single Level 1 trauma center from January 1, 2021, to January 1, 2023. Baseline demographic and clinical data were recorded. Rate of bony union and complications were documented. RESULTS: Five patients (three females and two males) with a mean age of 48 years who were treated for a comminuted supracondylar distal femur fracture with intercondylar extension proximal to a below-knee amputation were identified. At the time of final follow-up (mean 109.3 days, range 29-183 days), all patients had healed their incisions and were progressing to return of function with their prosthesis. All patients were treated with the surgical technique described in this article, and no postoperative complications were reported. CONCLUSION: This is an effective and safe technique for surgical treatment of comminuted intra-articular distal femur fractures in patients with an ipsilateral below-knee amputation. We believe that this technique can be utilized by any orthopedic surgeon taking trauma call and can avoid unnecessary transfers or delays to care.

Comparative biomechanical analysis of reconstruction and cephalomedullary nails in the treatment of osteoporotic subtrochanteric fractures.

INTRODUCTION: This study aimed to compare the biomechanical properties of two types of intramedullary nails - reconstruction nails (RCN) and cephalomedullary nails (CMN) - each with different proximal fixations, in a model of an osteoporotic subtrochanteric femoral fracture. This study focused on assessing stiffness and load to failure of RCN and CMN nails to provide insight into their clinical applications in osteoporotic fracture treatments. MATERIALS AND METHODS: Ten synthetic osteoporotic femoral models were used to generate a comminuted subtrochanteric fracture model. Five femurs were fixed using an RCN, and the remaining five were fixed using a CMN. The constructs were subjected to axial compression to measure their structural stiffness, load to failure, and failure modes. RESULTS: The CMN group demonstrated a slightly higher load to failure (mean, 2250 N) than the RCN group (mean, 2100 N), which was statistically significant (p = 0.008). However, the stiffness in both groups was statistically similar (RCN, 250 N/mm; CMN, 255 N/mm; p = 0.69). Both groups showed a load to failure exceeding 1500 N, a typically exerted load on the femoral head by a 75 kg individual. The failure patterns differed, with CMN failures starting at the nail insertion area and RCN failures starting at the reconstruction screw area. CONCLUSION: The RCN offers stiffness comparable to that of the CMN; although its load to failure is slightly lower than that of the CMN, it still exceeds the physiological tolerance limit. These findings suggest that the RCN is a viable alternative for treating osteoporotic subtrochanteric fractures.

Locking vs. non-locking plate fixation in comminuted talar neck fractures: a biomechanical study using cadaveric specimens.

BACKGROUND: Talar neck fractures are rare but potentially devastating injuries, with early reduction and rigid fixation essential to facilitate union and prevent avascular necrosis. Even small degrees of malunion will alter load transmission and subtalar joint kinematics. Changes in fixation techniques have led to dual plating strategies. While locked plating has perceived advantages in porotic bone and comminution, its biomechanical benefits in talar neck fractures have not been shown. AIM: To compare the strength of locking vs. non-locking plate fixation in comminuted talar neck fractures. METHOD: Seven pairs of cadaveric tali were randomised to locking or non-locking plate fixation. A standardised model of talar neck fracture with medial comminution was created, and fixation performed. The fixed specimens were mounted onto a motorised testing device, and an axial load applied. RESULTS: Peak load to failure, deformation at failure, work done to achieve failure, and stiffness of the constructs were measured. No statistically significant difference was found between locking and non-locking constructs for all parameters. CONCLUSIONS: Both constructs provide similar strength to failure in talar neck fracture fixations. Mean peak load to failure did not exceed the theoretical maximum forces generated of 1.1 kN when weight-bearing. We would advocate caution with early mobilisation in both fixations.

"Sandwich" Structure in Reconstruction of Traumatic Comminuted Anterior Skull Base Fractures: Surgical Technique and Outcomes.

BACKGROUND: Comminuted fractures of the anterior skull base can easily cause dural damage, leading to cerebrospinal fluid leakage and retrograde infection. Skull base reconstruction is essential. This study aimed to present a novel and simple technique for repairing skull base defects using a self-made fascia-bone fragments-fascia "sandwich" structure made by fascia, fracture fragments, and sutures. METHOD: From 2018 to 2023, we performed self-made sandwich structures for skull reconstruction in 10 patients with anterior skull base comminuted fractures. After debridement, the intracranial bone fragments of the surgical patient were safely removed. In vitro, the bone fragments were spread between two layers of temporal or broad fascia to form a sandwich structure similar to the size of the bone defect, and the periphery was firmly sutured with sutures. The self-made structure was then filled to the defect and fixed with fibrin glue. The periosteum at the top of the forehead was also turned over to the repair area for covering and fixation. Meanwhile, a facial skin cosmetic suture was performed. Finally, we evaluate the feasibility and efficacy of this technique. RESULTS: All 10 patients underwent reconstructive surgery using the self-made fascia-fracture fragments-fascia sandwich structure. Five patients with open wounds on the face also underwent cosmetic revisions. No cerebrospinal fluid leakage occurred in all the patients at discharge as well as 3 months later. CONCLUSIONS: For patients with comminuted fracture of the anterior skull base, the fascia-bone fragments-fascia structure could repair the skull base and prevent the occurrence of cerebrospinal fluid leakage.

Comparative study of retrograde intramedullary nailing versus locking extramedullary plating in complete articular fractures with metaphyseal comminution of the distal femur.

INTRODUCTION: Fractures of the distal femur with metaphyseal comminution and complete intra-articular involvement (AO/OTA classifications 33C2 and 33C3) present challenges for reduction and fixation. However, an optimal fixation method remains unknown. This study aimed to compare the clinical and radiographic outcomes of locking extramedullary plating (LEP) and retrograde intramedullary nailing (RIN) for complete distal femoral intra-articular fractures with metaphyseal comminution. MATERIALS AND METHODS: Between January 2016 and May 2022, 80 patients (45 men and 35 women; average age, 56.7 years) diagnosed with AO/OTA 33C2 and 33C3 were treated with either LEP or RIN and followed up for at least one year. Post-operative evaluations included radiographic assessments of bone union rate, timing, and alignment. Clinically, the knee joint range of motion (ROM), lower extremity functional scale (LEFS), and Kellgren and Lawrence (KL) grade were analyzed. The complications were also compared. RESULTS: 36 underwent LEP and 44 underwent RIN. Bone union was observed in 69.4% and 63.6% of the patients in the LEP and RIN groups, respectively (p = 0.64). The average union time was 6.9 months for the LEP group and 6.6 months for the RIN group (p = 0.51). A tendency toward varus deformity was observed in the RIN group, although the difference was not statistically significant. No significant differences were observed in knee ROM, LEFS, or KL grade. Complications included non-union (33.8%; RIN, 11; LEP, 16), varus deformity (5%; RIN, 4; LEP, 0), infection (1.3%; RIN, 0; LEP, 1), heterotrophic ossification (1.3%; RIN, 0; LEP, 1), and wound dehiscence (2.5%; RIN, 2; LEP, 0). CONCLUSIONS: The surgical fixation methods, RIN and LEP, for complete distal femoral intra-articular fractures with metaphyseal comminution showed similar clinical and radiological outcomes. However, regardless of the type of fixation device used, there was a reduced rate of bone union owing to high energy and a less favorable prognosis.

Outcome determinants for coronal shear fractures of the distal humerus.

PURPOSE: Coronal shear fractures of the distal humerus involving the capitellum and trochlea are rare injuries. Internal fixation with headless compression screws provides a stable construct facilitating early mobilisation. Our study aimed to identify the key determinants of both radiological and functional outcomes of patients with distal humerus coronal shear fractures treated with internal fixation. METHODS: A retrospective analysis of 61 patients with distal humerus coronal shear fractures who were treated surgically was done. Demographics, fracture morphology, time to surgery, operative details such as surgical approach and implant used, quality of reduction, time to union, and associated complications from hospital records. Radiological outcomes were assessed using plain radiographs, and the functional outcomes were by Oxford Elbow Score (OES) and Mayo Elbow Performance Index (MEPI). RESULTS: Patients with anatomical reduction of the fracture had better functional outcomes and range of motion. The presence of posterior comminution of capitellum resulted in poorer outcomes (p = 0.03). Delayed presentation did not alter the outcome when the anatomical reduction was achieved. Myositis ossificans was noted in nine patients and non-union in five patients. Two patients developed avascular necrosis of the capitellum and arthritis of the elbow joint. CONCLUSION: Anatomical reduction and posterior comminution are the two key determinants of the functional outcome in these coronal shear fractures of the distal humerus. Early mobilisation following a stable fixation is crucial in achieving a good outcome.

Modified patient-specific surgical-guide-assisted precise treatment of unilateral comminuted zygomaticomaxillary complex fractures: A 5-year retrospective study.

Our study aimed to evaluate modified patient-specific surgical-guide-assisted precise treatment of unilateral comminuted zygomaticomaxillary complex (ZMC) fractures. The retrospective non-randomized study was conducted in a single hospital in China. All patients diagnosed with unilateral comminuted ZMC fractures between January 1, 2018 and December 31, 2022 were retrospectively reviewed. All patients underwent preoperative spiral computed tomography (CT). CT data were processed using software to DICOM format and transferred to Proplan CMF3.0 for preoperative virtual surgical planning and postoperative evaluation. All data were extracted from standardized electronic medical records. All statistical analyses were performed using SPSS version 20.0. The chi-square test and t-test were used for statistical analyses. The 54 included patients were divided into two comparable, equal cohorts of 27 patients, and followed up for at least 6 months. Fracture reduction was assisted using the modified patient-specific surgical guides in the guide group (23 males, four females; mean age 37.74 ± 12.07 years) and without the modified patient-specific surgical guides in the control group (20 males, seven females; mean age 37.44 ± 13.58 years). In the guide group, the mean eminence deviation between the affected and unaffected sides was 1.01 ± 0.92 mm, and the mean width deviation between the affected and unaffected sides was 1.29 ± 1.32 mm. In the control group, the mean eminence deviation between the affected and unaffected sides was 1.99 ± 1.69 mm, and the mean width deviation between the affected and unaffected sides was 2.68 ± 2.01 mm. The differences in facial protrusion (p = 0.001) and width (p = 0.003) symmetry between the affected and healthy sides of the two groups were statistically significant (p < 0.05). In conclusion, applying the modified patient-specific surgical guides to unilateral comminuted zygomaticomaxillary complex fracture reduction has the advantages of greater predictability and effectiveness, and improved bilateral ZMC symmetry. It should be noted that this approach would be especially beneficial for less-experienced surgeons.