Systematic review of humeral shaft fracture (OTA/AO 12) complicated with iatrogenic radial nerve injury.

OBJECTIVES: To compare the iatrogenic radial nerve injury (iRNI) rate of different implant (plate vs. intramedullary nail) and surgical approaches during humeral shaft fracture surgery. METHODS: The online PubMed database was used to search for articles describing iRNI after humeral fracture with a publication date from Jan 2000 to October 2023. The following types of articles were selected: (1) case series associating with adult humeral shaft fracture, preoperative radial nerve continuity, non-pathological fracture and non-periprosthetic fracture; (2) involving humeral shaft (OTA/AO 12) fractures. Articles where we were unable to judge surgical approach or fracture pattern (OTA/AO 12) were excluded. The data were analyzed by SPSS 27.0 and Chi-square test was performed to identify incidence of iRNI associated with different implant and surgical approaches. RESULTS: Fifty-four articles with 5063 cases were included, with 3510 cases of the plate, 830 cases of intramedullary nail and 723 cases of uncertain internal fixation. The incidences of iRNI with plate and intramedullary nail were 5.95% (209/3510) and 2.77% (23/830) (p < 0.05). And iRNI incidences of different surgical approaches were 3.7% (3/82) for deltopectoral approach, 5.74% (76/1323) for anterolateral approach, 13.54% (26/192) for lateral approach and 6.68% (50/749) for posterior approach. The iRNI rates were 0.00% (0/33) for anteromedial MIPO, 2.67% (10/374) for anterolateral MIPO and 5.40% (2/37) for posterior MIPO (p > 0.05). The iRNI rates were 2.87% (21/732) for anterograde intramedullary nail and 2.04% (2/98) for retrograde intramedullary nail (p > 0.05). In humeral bone nonunion surgery, the rate of iRNI was 15.00% (9/60) for anterolateral approach, 16.7% (2/12) for lateral approach and 18.2% (6/33) for posterior approach (p > 0.05). CONCLUSION: Intramedullary nailing is the preferred method of internal fixation for humeral shaft fractures that has the lowest rate of iRNI. Compared with anterolateral and posterior approaches, the lateral surgical approach had a higher incidence of iRNI. The rate of iRNI in MIPO was lower than that in open reduction and internal fixation. LEVEL OF EVIDENCE: Level IV.

Ulnar carpal translation following palmar locking plate fixation for distal radius fractures: a retrospective analysis.

BACKGROUND: Concomitant injuries to the radiocarpal ligaments may occur during episodes of distal radius fractures, which may not cause acute subluxation or dislocation but can lead to radiocarpal instability and progress over time. This study aimed to analyze the occurrence of ulnar carpal translation (UCT) after open reduction and internal fixation of distal radius fractures and evaluate the associated factors of UCT. METHODS: The retrospective study has been done now and includes patients treated between 2010 and 2020 who had undergone reduction and locking plate fixation of distal radius fractures. We assessed radiographs taken immediately after the operation and at 3 months post-operation, enrolling patients with UCT for evaluation. In addition to demographic data, we evaluated radiographic parameters, including fracture pattern, fragment involvement, and ulnar variance. We also assessed the palmar tilt-lunate (PTL) angle to determine associated rotatory palmar subluxation of the lunate (RPSL). RESULTS: Among the 1,086 wrists, 53 (4.9%) had UCT within 3 months post-operation. The majority of wrists with UCT exhibited normal to minus ulnar variance (49 wrists; mean: -1.1 mm), and 24 patients (45.3%) had concomitant RPSL. Fracture classification was as follows: 19 type A3 (35.8%), 5 type C1 (9.4%), 11 type C2 (20.8%), and 18 type C3 (34.0%). Radial styloid was involved in 20 wrists (37.7%), palmar rim in 18 wrists (34.0%), dorsal rim in 25 wrists (47.2%), and die-punch fractures in 3 wrists (5.7%). Concomitant ulnar styloid fractures were present in 29 wrists (54.7%). CONCLUSION: This study highlights the potential for UCT to occur following reduction and fixation of distal radius fractures, particularly in cases with a more severe fracture pattern and combined with ulnar minus variance. The high incidence of concomitant RPSL provides further evidence for the possibility of associated radiocarpal ligament insufficiency after distal radius fracture.

Subacromial osteolysis following hook plate fixation for acromioclavicular dislocation: a systematic review and meta-analysis.

BACKGROUND: Clavicular hook plates are extensively used in the treatment of acromioclavicular dislocation. Subacromial osteolysis is a typical complication following hook plate fixation. We performed a systematic review and meta-analysis to determine the incidence of subacromial osteolysis and analyzed the associated characteristics of subacromial osteolysis to guide surgeons. METHODS: PubMed, EMBASE, and Cochrane Library databases were comprehensively searched for relevant literature. We screened the literature based on the eligibility criteria, extracted relevant data, and assessed the quality of the included studies. Pooled odds ratios or mean differences with 95% confidence intervals (CIs) were calculated by a fixed-effects or random-effects model. Heterogeneity was evaluated by the chi-squared test and I2 statistics. A meta-regression analysis was performed to explore the potential source of heterogeneity. RESULTS: Thirty-two studies met the inclusion criteria. The total pooled incidence of subacromial osteolysis was 29% and the only covariate that could influence the incidence of subacromial osteolysis was the radiological measurement method (P = .017). Patients in the hook plate fixation with coracoclavicular ligament reconstruction group had lower odds of subacromial osteolysis (odds ratio, 2.54, 95% CI 1.54-4.18; P < .001). There were no significant differences in the Constant-Murley scores at the final follow-up between patients with and without subacromial osteolysis (standardized mean difference, -0.17; 95% CI, -0.50 to 0.15; P = .294). CONCLUSIONS: Subacromial osteolysis has a relatively high and variable incidence, and the primary factor influencing the reported incidence is the radiological assessment method. The current analysis suggests coracoclavicular ligament reconstruction as an effective surgical approach for decreasing the incidence of subacromial osteolysis. The presence or absence of subacromial osteolysis did not significantly impact the functional outcomes observed during the final follow-up period.

Pneumothorax After Superior Plating of Clavicle Fractures: Are the Concerns Warranted?

PURPOSE: The primary goal of this study was to determine the anatomic relationship between the clavicle and the apical lung segment. The secondary goal was to determine the incidence of pneumothorax (PTX) in patients who underwent clavicle ORIF to analyze the utility of postoperative chest radiographs. METHODS: Six hundred thirty-one patients with a midshaft clavicle fracture who underwent superior plating at a single institution were identified. Forty-two patients had a CT scan of the chest. Three points on the uninjured clavicle were defined: 2 cm from the medial end of the clavicle, the mid-point of the clavicle, and 2 cm from the lateral end of the clavicle. At each point, the distance from both the inferior cortex and the superior cortex of the clavicle to the apical lung segment was measured. All 631 patients who underwent Open Reduction and Internal Fixation had a postoperative chest radiograph to evaluate implant placement, restoration of clavicular length, and presence of PTX. RESULTS: From the lateral end of the clavicle, the mean distance of the lung was 60.0 ± 14.9 mm (20.1 to 96.1 mm) from the inferior cortex of the clavicle. At the mid-point, the mean distance of the lung was 32.3 ± 7.2 mm (20.4 to 45.5 mm) from the inferior cortex of the clavicle. At the medial end, the mean distance of the lung was 18.0 ± 5.5 mm (8.1 to 28.9 mm) from the inferior cortex of the clavicle. A review of postoperative radiographs for all 631 patients revealed none (0%) with a postoperative iatrogenic PTX. CONCLUSION: The risk of injury is minimal in all three zones. Postoperative chest radiographs after clavicle fracture repair to rule out PTX are unnecessary.

Flexor Pollicis Longus Reconstruction After Rupture Following Distal Radius Fixation With Volar Locking Plate: A Technique Guide.

Flexor pollicis longus rupture is an uncommon but potentially debilitating complication after volar locking plate fixation of distal radius fractures, occurring secondary to tendon attrition against the implant. This nature of tendon injury typically precludes primary repair. This paper will illustrate 2 reconstruction techniques, an interpositional tendon graft and a tendon transfer, that have been utilized successfully by the authors.

Surgical treatment of osteogenesis imperfecta: a summary of the incidence of femoral implant-related complications in children with Sillence type I, III and IV.

PURPOSE: This study explored the incidence of IRCs used in the procedures of the femur in children with osteogenesis imperfecta (OI) and investigated the independent risk factors of IRCs. METHODS: Three hundred eight-eight cases of surgical data about children with OI were included, who were treated with plate, elastic nail, Kirschner wire and telescopic rod. The choice of different procedures depended on the age of children, the status of femur and the availability of devices. Patient demographics and major IRCs were recorded to compare the outcomes of the four procedures. Then, Cox proportional hazard regression was used to analyse the independent risk factors of IRC, and subgroup analysis was applied to further verify the above results. RESULTS: The total incidence of IRC in the four groups was 90.1% (191/212) for plate, 96.8% (30/31) for Kirschner wire, 87.7% (57/65) for elastic nail and 30.0% (24/80) for telescopic rod. The incidence of IRC in the telescopic rod was lower than that in plate, elastic nail and Kirschner wire (P < 0.001). Cox proportional hazard regression analysis confirmed that procedure was the independent risk factor of IRC (HR, 0.191; 95% CI, 0.126-0.288; P < 0.001), fracture (HR, 0.193; 95% CI, 0.109-0.344; P < 0.001) and deformity (HR, 0.086; 95% CI, 0.027-0.272; P < 0.001). In addition, age of surgery was the independent risk factor of fracture (HR, 0.916; 95% CI, 0.882-0.952; P < 0.001) and deformity (HR, 1.052; 95% CI, 1.008-1.098; P = 0.019). Subgroup analysis confirmed that age of surgery, gender, classification, preoperative state and angle did not affect the effect of telescopic rod on reducing the risk of IRCs. CONCLUSIONS: In our cohort, lower incidence of IRCs was observed in telescopic rod group compared with plate, Kirschner wire and elastic nail. Procedure and age of surgery were independent risk factors of fracture. Likewise, procedure and age of surgery were independent risk factors of deformity, and procedure was independent risk factors of IRC.

Complications of operatively treated distal radial fractures.

Distal radial fractures represent the most common fractures of the upper extremity. Operative treatment is performed for approximately one-third of distal radial fractures in the adult population. Complications following operative treatment of distal radial fractures vary depending on the treatment modality and can be stratified into preoperative and postoperative complications. Complications can occur in the near, intermediate and long term. The most common complications seen are tendon irritation and rupture, chronic regional pain syndrome (CRPS), carpal tunnel syndrome, ulnar or radial neuropathy, compartment syndrome, malunion, inadequate fixation or loss of fixation, symptomatic hardware, post-traumatic arthritis, stiffness and infection. Careful planning, treatment and patient selection can help to mitigate these complications.Level of evidence: V.

Risk Factors of Failure in 228 Periprosthetic Distal Femur Fractures: A Multicenter Study.

OBJECTIVES: To identify risk factors of reoperation to promote union or to address deep surgical-site infection (DSSI) in periprosthetic distal femur fractures treated with lateral distal femoral locking plates (LDFLPs). DESIGN: Multicenter retrospective cohort study. SETTING: Ten level-I trauma centers. PATIENT SELECTION CRITERIA: Patients with Orthopaedic Trauma Association/Association of Osteosynthesis (OTA/AO) 33A or 33C periprosthetic distal femur fractures who underwent surgical fixation between January 2012 and December 2019 exclusively using LDFLPs were eligible for inclusion. Patients with pathologic fractures or with follow-up less than 3 months without an outcome event (unplanned reoperation to promote union or for deep surgical infection) before this time point were excluded. Fracture fixation constructs used medial plates, intramedullary nails, or hybrid fixation constructs were excluded from analysis. OUTCOME MEASURES AND COMPARISONS: To examine the influence of patient demographics, injury characteristics, and features of the fracture fixation construct on the occurrence of unplanned reoperation to promote union or to address a DSSI. RESULTS: There was an 8.3% rate (19/228) of unplanned reoperation to promote union. Predictive factors for the need for reoperation to promote union included increasing body mass index (odds ratio [OR] = 1.09; 95% confidence interval [CI]: 1.02-1.16; P = 0.01), increasing number of screws in the distal fracture segment (OR = 1.73; 95% CI: 1.06-2.95; P = 0.03), and decreasing proportion of proximal segment screws that are locking (OR = 0.17; 95% CI: 0.03-0.70; P = 0.02) There was a 4.8% rate (11/228) of reoperation to address DSSI. There were no statistically significant predictive factors identified as risk factors of the need for reoperation to address DSSI ( P > 0.05). CONCLUSIONS: 8.3% of periprosthetic distal femur fractures treated at 10 centers with LDFLPs underwent unplanned reoperation to promote union. Increasing patient body mass index and increasing number of screws in the distal fracture segment were found to be predictive factors, whereas increased locking screws in the proximal segment were found to be protective. 4.8% of patients in this cohort underwent reoperation to address DSSI. LEVEL OF EVIDENCE: Level III. See Instructions for Authors for a complete description of levels of evidence.

Fixation of femoral neck fracture with femoral neck system: a retrospective cohort study of 43 patients.

BACKGROUNDS: This study aimed to analyze the clinical outcomes of femoral neck fractures (FNF) in patients treated with a femoral neck system (FNS, DePuy Synthes), which is a recently introduced device. METHODS: This retrospective cohort study of 43 patients who underwent osteosynthesis using FNS for FNF between July 2019 and June 2021 with a minimum follow-up of 6 months. The researchers examined the patients' demographic factors and radiologically evaluated the fracture type and fixation status, bone union, and postoperative complications. RESULTS: Of 43 patients, 25 were female, and the patients' mean age and body mass index were 62.1 years and 22.5 kg/m2, respectively. According to the Association of Osteosynthesis/Orthopaedic Trauma Association (AO/OTA) classification, the most common fracture types were 31B1.1 and B1.2 (13 cases each), followed by B2.3, B2.1, and B2.2 (seven, five, and four cases, respectively). Radiological bone union was confirmed in 39 patients (90.7%), and the mean time to union was 3.6 months. Two cases of nonunion, one case of lag screw cut-out, and one case of osteonecrosis were confirmed; all four cases later underwent arthroplasty. The mean time to reoperation was 4.5 months. Meanwhile, five patients underwent implant removal after the bone union, and distal locking screw stripping was noted in three patients. All three patients required metal plate cutting to remove the implants. CONCLUSIONS: Osteosynthesis of FNF using the newly introduced FNS showed favorable clinical outcomes and no specific hardware-related complications were reported during the follow-up. However, attention must be paid to the issue regarding distal locking screw failure during hardware removal.

Outcomes of Humerus Nonunion Surgery in Patients With Initial Operative Fracture Fixation.

OBJECTIVES: To describe outcomes following humerus aseptic nonunion surgery in patients whose initial fracture was treated operatively and to identify risk factors for nonunion surgery failure in the same population. DESIGN: Retrospective case series. SETTING: Eight, academic, level 1 trauma centers. PATIENTS SELECTION CRITERIA: Patients with aseptic humerus nonunion (OTA/AO 11 and 12) after the initial operative management between 1998 and 2019. OUTCOME MEASURES AND COMPARISONS: Success rate of nonunion surgery. RESULTS: Ninety patients were included (56% female; median age 50 years; mean follow-up 21.2 months). Of 90 aseptic humerus nonunions, 71 (78.9%) united following nonunion surgery. Thirty patients (33.3%) experienced 1 or more postoperative complications, including infection, failure of fixation, and readmission. Multivariate analysis found that not performing revision internal fixation during nonunion surgery (n = 8; P = 0.002) and postoperative de novo infection (n = 9; P = 0.005) were associated with an increased risk of recalcitrant nonunion. Patient smoking status and the use of bone graft were not associated with differences in the nonunion repair success rate. CONCLUSIONS: This series of previously operated aseptic humerus nonunions found that more than 1 in 5 patients failed nonunion repair. De novo postoperative infection and failure to perform revision internal fixation during nonunion surgery were associated with recalcitrant nonunion. Smoking and use of bone graft did not influence the success rate of nonunion surgery. These findings can be used to give patients a realistic expectation of results and complications following humerus nonunion surgery. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Technical Factors Contributing to Nonunion in Supracondylar Distal Femur Fractures Treated With Lateral Locked Plating: A Risk-Stratified Analysis.

OBJECTIVE: To identify technical factors associated with nonunion after operative treatment with lateral locked plating. DESIGN: Retrospective cohort study. SETTING: Ten Level I trauma centers. PATIENT SELECTION CRITERIA: Adult patients with supracondylar distal femur fractures (OTA/AO type 33A or C) treated with lateral locked plating from 2010 through 2019. OUTCOME MEASURES AND COMPARISONS: Surgery for nonunion stratified by risk for nonunion. RESULTS: The cohort included 615 patients with supracondylar distal femur fractures. The median patient age was 61 years old (interquartile range: 46 -72years) and 375 (61%) were female. Observed were nonunion rates of 2% in a low risk of nonunion group (n = 129), 4% in a medium-risk group (n = 333), and 14% in a high-risk group (n = 153). Varus malreduction with an anatomic lateral distal femoral angle greater than 84 degrees, was associated with double the odds of nonunion compared to those without such varus [odds ratio, 2.1; 95% confidence interval (CI), 1.1-4.2; P = 0.03]. Malreduction by medial translation of the articular block increased the odds of nonunion, with 30% increased odds per 4 mm of medial translation (95% CI, 1.0-1.6; P = 0.03). Working length increased the odds of nonunion in the medium risk group, with an 18% increase in nonunion per 10-mm increase in working length (95% CI, 1.0-1.4; P = 0.01). Increased proximal screw density was protective against nonunion (odds ratio, 0.71; 95% CI, 0.53-0.92; P = 0.02) but yielded lower mRUST scores with each 0.1 increase in screw density associated with a 0.4-point lower mRUST (95% CI, -0.55 to -0.15; P < 0.001). Lateral plate length and type of plate material were not associated with nonunion. ( P > 0.05). CONCLUSIONS: Malreduction is a surgeon-controlled variable associated with nonunion after lateral locked plating of supracondylar distal femur fractures. Longer working lengths were associated with nonunion, suggesting that bridge plating may be less likely to succeed for longer fractures. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Fixation Strategies for Periprosthetic Fractures With Stable Implants.

The fixation of periprosthetic fractures remains challenging and controversial. It is important to achieve consensus opinions regarding the management of stable periprosthetic fractures with internal fixation. Key strategies to optimize surgical decision making and fixation and manage complications following these difficult injuries are addressed.

Comparison of the effectiveness of zero-profile device and plate cage construct in the treatment of one-level cervical disc degenerative disease combined with moderate to severe paraspinal muscle degeneration.

Objective: Recent evidence indicates that cervical paraspinal muscle degeneration (PMD) is a prevalent and age-related condition in patients with cervical disc degenerative disease (CDDD). However, the relationship between surgery selection and post-operative outcomes in this population remains unclear. Consequently, this study aims to investigate the disparities in clinical outcomes, radiological findings, and complications between two frequently utilized anterior cervical surgical procedures. The objective is to offer guidance for the management of PMD in conjunction with CDDD. Methods: A total of 140 patients who underwent single-level anterior cervical discectomy and fusion (ACDF) at our department were included in this study. The patients were divided into three groups based on the severity of PMD: mild (n=40), moderate (n=54), and severe (n=46), as determined by Goutalier fat infiltration grade. The subjects of interest were those with moderate-severe PMD, and their clinical outcomes, radiological parameters, and complications were compared between those who received a stand-alone zero-profile anchored cage (PREVAIL) and those who received a plate-cage construct (PCC). Results: The JOA, NDI, and VAS scores exhibited significant improvement at all postoperative intervals when compared to baseline, and there were no discernible differences in clinical outcomes between the two groups. While the PCC group demonstrated more pronounced enhancements and maintenance of several sagittal alignment parameters, such as the C2-7 angle, FSU angle, C2-7 SVA, and T1 slope, there were no statistically significant differences between the two groups. The incidence of dysphagia in the zero-profile group was 22.41% at one week, which subsequently decreased to 13.79% at three months and 3.45% at the final follow-up. In contrast, the plate cage group exhibited a higher incidence of dysphagia, with rates of 47.62% at one week, 33.33% at three months, and 11.90% at the final follow-up. Notably, there were significant differences in the incidence of dysphagia between the two groups within the first three months. However, the fusion rate, occurrence of implant subsidence, and adjacent segment degeneration (ASD) were comparable at the final follow-up. Conclusion: For patients with one-level cervical disc degenerative disease combined with paraspinal muscle degeneration, both the zero-profile technique and PCC have demonstrated efficacy in ameliorating clinical symptoms and maintaining the postoperative sagittal balance. Although no significant disparities were observed between these two technologies in terms of complications such as adjacent segment degeneration and implant subsidence, the zero-profile technique exhibited superior performance over PCC in relation to dysphagia during the early stages of postoperative recovery. To validate these findings, studies with longer follow-up periods and evaluations of multilevel cervical muscles are warranted.

Fracturas ipsilaterales proximales y diafisarias de fémur: ¿existe una mejor opción terapéutica?: revisión bibliográfica / Ipsilateral proximal and shaft femoral fractures: is there a better therapeutic option?: review / Fracturas ipsilaterais proximais e diafisárias do fémur: existe uma melhor opção terapêutica?: revisão bibliográfica

Introducción: Las fracturas ipsilaterales proximales de fémur ocurren en el 1 al 9% de las fracturas diafisarias. Existen múltiples tratamientos propuestos para dicha asociación lesional. El objetivo de este trabajo es revisar los diferentes métodos de tratamiento propuestos, y comparar sus resultados funcionales y principales complicaciones. Materiales y Métodos: Se utilizaron los buscadores electrónicos: PubMed, Lilacs, Cochrane y Ovid SP. La búsqueda llegó a un total de 1829 trabajos, de los cuales se seleccionaron 21 según criterios de inclusión y exclusión. Discusión: No existe un consenso acerca de cuál es el mejor método de fijación para esta asociación lesional. Esta ocurre en pacientes jóvenes por un mecanismo axial de alta energía cinética y la opción elegida debe buscar la reducción anatómica de la fracturas proximales de fémur. Las complicaciones como la pseudoartrosis de cuello femoral y la necrosis avascular son de difícil manejo en este grupo etario. Conclusión: Las fracturas ipsilaterales proximales y diafisarias de fémur son lesiones que presentan un problema diagnóstico y terapéutico. Hay un subdiagnóstico de las mismas y no existe un implante ideal, ni un consenso de cual es el mejor método de fijación.

Introduction: Ipsilateral proximal femoral fractures ocurred in 1 to 9% of femoral shaft fractures. There are multiple treatments proposed for these injuries. The objetive of the present work is revise the different treatment options and compare their functional results and main complications Materials and methods: A comprehensive literature search was carried out using: Pubmed, Lilacs, Cochrane and OVID SP. Initially there were identified a total of 1829 studies. Only 21 studies remained after inclusion and exclusion were applied. Discussion: There is no consensus about which is the best fixation option for these injuries. These occurred in young patients as a result of a high energy axial trauma, and the selected treatment must achieve anatomic reduction of the proximal femoral fracture. Complications such as femoral neck no-union and avascular necrosis are difficult to manage at this age. Conclusion: Ipsilateral proximal and shaft femoral fractures present diagnostic and therapeutic problems. There is an underdiagnosis of these injuries, and there is no ideal implant or consensus on which is the best fixation method.

Introdução: As fraturas proximais ipsilaterais do fêmur ocorrem em 1 a 9% das fraturas diafisárias. Existem vários tratamentos propostos para essa associação lesional. O objetivo deste trabalho é rever os diferentes métodos de tratamento propostos, e comparar os seus resultados funcionais e principais complicações. Materiais e Métodos: Foram utilizados os buscadores eletrônicos: Pubmed, Lilacs, Cochrane e Ovid SP. A busca chegou a um total de 1829 trabalhos, dos quais foram selecionados 21 segundo critérios de inclusão e exclusão. Discussão: Não há consenso sobre qual é o melhor método de fixação para esta associação lesional. Esta ocorre em pacientes jovens por um mecanismo axial de alta energia cinética e a opção escolhida deve procurar a redução anatômica da fratura proximal do fêmur. Complicações como a pseudoartrose do pescoço femoral e a necrose avascular são de difícil manejo neste grupo etário. Conclusão: As fraturas ...(SUPRIMIR LO PRECEDENTE)Conclusão: As fracturas ipsilaterais proximais e diafisárias do fémur são lesões que apresentam um problema diagnóstico e terapêutico. Há um subdiagnóstico das mesmas e não existe um implante ideal, nem um consenso de qual é o melhor método de fixação.

Errores de osteosíntesis en fracturas laterales de cadera tratadas con placa/tornillo deslizante / Failed internal fixation of intertrochanteric hip fractures with dynamic hip screws

Introducción: El uso de los sistemas placa/tornillo deslizante para fracturas intertrocantéricas ha demostrado ser un método de fijación eficaz, pero no está exento de fallas. El propósito de este estudio fue evaluar las causas de falla en los pacientes con fracturas laterales de cadera, tratados con placa/tornillo deslizante, puntualizando los defectos técnicos en la colocación. Materiales y Métodos: En nuestro centro, se trató a 177 pacientes por fractura lateral de cadera, a 151 de ellos se les practicó osteosíntesis con placa/tornillo deslizante. Se analizaron la adecuada reducción posoperatoria, la medición de la distancia punta a vértice, la posición del tornillo cefálico en la cabeza femoral y las posibles complicaciones. Resultados: La serie quedó conformada por 143 pacientes. El seguimiento promedio fue de 18 meses (rango 12-48). La tasa de fallas fue del 8,4% (n = 12): 7 (4,8%) por migración cefálica (cut-out) del tornillo proximal, 2 (1,4%) por migración medial (cut-through), 2 (1,4%) presentaron seudoartrosis y un caso (0,70%) de reducción inadecuada en varo. El porcentaje de una segunda operación fue del 7,7% (n = 11). La peor posición fue la superior/posterior con un 100% de migración (n = 4) (p <0,001, diferencia estadísticamente significativa). Conclusión: El posicionamiento superior/posterior del tornillo cefálico podría incrementar la posibilidad de migración y, en consecuencia, la tasa de falla del sistema. Nivel de Evidencia: IV

Objectives: The use of dynamic hip screws (DHS) for intertrochanteric fractures has proven to be an effective, but infalible, fixation method. The purpose of this study was to evaluate the reason behind fixation failure in patients with this type of hip fracture treated with a DHS. Materials and Methods: 177 patients were treated in our center for intertrochanteric hip fractures. A DHS was placed in 151 of them. Our analysis included quality of reduction after surgery, tip-apex distance, femoral head lag screw position, and possible complications. Results: The series included 143 patients. The average follow-up was 18 months (range 12-48). The failure rate was 8.4% (n = 12): 7 (4.8%) cases were due to intrapelvic migration of the lag screw ("cut-out") and 2 (1.4%) were due to medial perforation ("cut-through"), while 2 (1.4%) cases presented with pseudarthrosis and 1 (0.70%) with varus deformity after reduction. The revision rate was 7.7% (n = 11). Lag screws placed in a superior/posterior position had the highest failure rate (100% migration rate) (n = 4) (p <0.001, statistically significant difference). Conclusions: Superior/posterior positioning of the lag screw may increase the possibility of migration and, consequently, the failure rate of the DHS system. Level of Evidence: IV

Patología tendinosa en pacientes con placa bloqueada palmar de radio distal: incidencia y resultado clínico del tratamiento / Tendon pathology in patients with distal radius palmar locked plate: incidence and clinical outcome of their treatment

Introducción: El objetivo de este estudio es comunicar la incidencia de complicaciones tendinosas en pacientes con fracturas de radio distal tratados con placa bloqueada palmar y el resultado clínico del tratamiento mediante la sola extracción del implante. Materiales y Métodos: Se realizó una evaluación retrospectiva de 992 pacientes con fracturas de radio distal. Se incluyó a quienes se les extrajo la placa por irritación o rotura tendinosa. La evaluación final de los resultados, una vez extraído el implante, se efectuó con el puntaje DASH y una escala analógica visual de 0 a 10 para dolor en reposo, durante la actividad y para el resultado funcional. Resultados: Treinta y cuatro pacientes tuvieron complicaciones tendinosas: 20 tendinitis de flexores (2%), 13 tendinitis de extensores (1,3%) y una rotura de tendón flexor. Todos fueron tratados sólo con extracción del implante. En la escala analógica visual, los pacientes con tendinitis flexora obtuvieron un puntaje de 1 para dolor en reposo, de 1 para dolor durante la actividad y de 8 para resultado funcional, y un puntaje DASH de 13. La evaluación final promedio de los pacientes con tendinitis extensora fue: dolor en reposo 0, dolor durante la actividad 3, funcional 9 y DASH 15, respectivamente. Conclusiones: La incidencia de complicaciones tendinosas en el tratamiento de las fracturas de radio distal con placas palmares es baja. El tratamiento precoz mediante la sola extracción del implante lleva a la desaparición de los síntomas y evita la rotura tendinosa. Nivel de Evidencia: IV

Introduction: The aim of this paper is to report the incidence of tendon complications in patients with distal radius fractures treated with volar locking plates and the clinical results after plate removal. Methods: A total of 992 patients with distal radial fracture treated with volar locking plates were retrospectively evaluated. Cases with plate removal due to tendon irritation were included in this study. Clinical results were evaluated using DASH score and a visual analogue scale for pain at rest, during activity and functional result. Results: Thirty-four patients had tendon complications: 20 with flexor tendonitis (2%), 13 with extensor tendonitis (1.3%), and a flexor tendon rupture. All cases were treated only with implant removal. Final mean results were: visual analogue scale, 1 for pain at rest, 1 for pain during activity, and 8 for function; DASH score 13 in patients with flexor tendinitis; and 0, 3, 9, respectively, and DASH score 15 for those with extensor tenosinovitis. Conclusions: Tendon complications are infrequent in patients with distal radial fractures treated with volar locking plate. The early removal of the implant improves tendon irritation symptoms and prevents tendon rupture. Level of Evidence: IV

Heating produced by therapeutic ultrasound in the presence of a metal plate in the femur of canine cadavers / Aquecimento gerado pelo ultrassom terapêutico em presença de placa óssea metálica no fêmur de cadáveres caninos

The present study aimed to assess the heat generated by a therapeutic ultrasound (TUS) in a metal bone plate and adjacent structures after fixation to the femur of canine cadavers. Ten pairs of hind limbs were used, and they were equally distributed between groups that were subjected to 1- and 3-MHz frequencies, with each frequency testing 1- and 2-W/cm² intensities. The right hind limb was defined as the control group (absence of the metal plate), and the left hind limb was the test group (presence of the metal plate). Therefore, the control groups (CG) were denominated CGI, using TUS with 1-MHz frequency and 1-W/cm² intensity; CGII, using 1-MHz frequency and 2-W/cm² intensity; CGIII, using 3-MHz frequency and 1-W/cm² intensity; and CGIV, using 3-MHz frequency and 2-W/cm² intensity. For each control group, its respective test group (TG) was denominated TGI, TGII, TGIII and TGIV. The TUS was applied to the lateral aspect of the thigh using the continuous mode and a 3.5-cm² transducer in a 6.25-cm² area for 2 minutes. Sensors were coupled to digital thermometers that measured the temperature in different sites before (t0) and after (t1) of the TUS application. The temperatures in t1 were higher in all tested groups. The intramuscular temperature was significantly higher (P<0.05) in the groups used to test the 3-MHz frequency in the presence of the metal plate. The therapeutic ultrasound in the continuous mode using frequencies of 1 and 3 MHz and intensities of 1 and 2 W/cm2 for 2 minutes caused heating of the metal plate and adjacent structures after fixation to the femur of canine cadavers...

O objetivo deste estudo foi avaliar o aquecimento gerado pelo ultrassom terapêutico (UST) na placa óssea metálica e estruturas adjacentes após a fixação no fêmur de cadáveres caninos. Foram utilizados dez pares de membros pélvicos, distribuídos igualmente entre os grupos que utilizaram as frequências de 1 e 3 MHz. Cada frequência testou as intensidades de 1 e 2 W/cm², sendo que o membro pélvico direito foi definido grupo controle (ausência da placa óssea metálica) e o membro pélvico esquerdo o grupo teste (presença da placa óssea metálica). Portanto, os grupos controles foram denominados GCI, com UST na frequência de 1 MHz e intensidade de 1 W/cm²; GCII, com 1 MHz e 2 W/cm²; GCIII, com frequência de 3 MHz e intensidade de 1 W/cm²; e GCIV, com 3 MHz e 2 W/cm². Para cada grupo controle, seu respectivo grupo teste foi denominado GTI, GTII, GTIII e GTIV. O UST foi aplicado na face lateral da coxa, utilizando o modo contínuo, transdutor de 3,5cm², em uma área de 6,25cm², durante dois minutos. Foram utilizados sensores acoplados a termômetros digitais que mediram a temperatura em diferentes locais antes (t0) e após (t1) a aplicação do UST. Pode-se verificar que as temperaturas em t1 foram maiores em todos os grupos testados. Os grupos que testaram a frequência de 3 MHz demonstraram que a temperatura intramuscular foi significativamente maior (P<0,05) na presença da placa óssea metálica. O ultrassom terapêutico no modo contínuo de 1 e 3 MHz e intensidades de 1 e 2 W/cm2 durante dois minutos promove o aquecimento da placa óssea metálica e estruturas adjacentes após a fixação no fêmur de cadáveres caninos...

Estudo prospectivo e randomizado de pacientes com fraturas expostas da diáfise do fêmur submetidos a osteossíntese com placa e haste intramedular bloqueada a foco aberto / Prospective and randomized study of patients with open fractures of the femoral shaft, treated with plate or open intramedullary locked nail

Trata-se de um estudo prospectivo e randomizado de duas técnicas de osteossíntese no tratamento das fraturas expostas diafisárias do fêmur, realizado entre janeiro de 2002 a abril de 2004. Haste intramedular bloqueada fresada realizada a foco aberto e placa e parafusos foram empregadas no tratamento de 20 pacientes em cada grupo. De acordo com a classificação de Gustilo, 26 (65 por cento) foram tipo I, 10 (25 por cento) tipo II e 4 (10 por cento) tipo IIIA. Quanto ao mecanismo das fraturas, 21 por trauma contuso e 19 por ferimentos de arma de fogo.Três pacientes foram excluídos nas avaliação final. Houve complicação em 12 (32,4 por cento),sendo 4 no grupo de placas e 8 no grupo das hastes. O grupo de haste bloqueada apresentou 2 (10 por cento) infecções profundas, 2 infecções superficiais (10 por cento), 1 falha de consolidação (5 por cento).O grupo de placa e parafusos resultou em 1 infecção profunda associada à falha de consolidação (5,8 por cento), 1 infecção superficial (5,8 por cento). Pela classificação de resultados de Thorensen obteve-se bons e excelentes resultados em 28 (75,7 por cento) fraturas, 3 (7.5 por cento) casos regulares e 6 (15 por cento) casos ruins. A estabilização com placas e parafusos, trouxe menores taxas de complicações, quando comparadas com o uso de hastes fresadas a foco aberto,embora sem significado estatístico.

We assessed the complications and treatment outcomes in a prospective and randomized study of two osteosynthesis techniques in open femoral shaft fractures. Between January 2002 and April 2004, 40 patients with open fractures of the femoral shaft were assessed, with 20 being treated with open reamed intramedullary locked nail and 20 with plate. Twenty-six (65 percent) fractures were classified as Gustilo type -I open fractures; ten (25 percent) as type II and four (10 percent), as type IIIA. There were 21 blunt injuries and 19 gunshot injuries. Three patients were excluded from the final assessment. Complications were observed in 12 (32.4 percent) patients, 4 in the plate group and 8 in the nail group. Reamed intramedullary locked nail resulted in two deep infections (10 percent), two superficial infections (10 percent), and one nonunion (5 percent). With plate techniques, we had one deep infection associated to nonunion (5,8 percent) and one superficial infection (5.8 percent). Good and excellent outcomes were found in 28 fractures (75.7 percent), fair (7.5 percent) in three cases, and poor (15 percent) in six, according to Thorensen's criteria. In this study, the stabilization with plate results in lower complications rate when compared to the open intramedullary nail, although with no statistical significance.

Estudio epidemiológico de las fracturas cervicales y transtrocantéreas del fémur / Epidemiologic trial of trans-trochanteric and cervical fractures of the femur

Se realizó un estudió epidemiológico de fracturas cervicales y trans-trocantéreas del fémur del 1º de abril de 1992 al 31 de diciembre de 1993, para analizar los resultados de las técnicas quirúrgicas utilizadas en su tratamiento. De 200 casos revisados, 76 correspondieron a fracturas del cuello femoral, que fueron tratadas con prótesis de Thompson, Spotorno, y Müller. Los 124 casos restantes fueron de fracturas trans-trocantérea, que se trataron con placa angulada del 130 o 95 grados. En general el resultado fue satisfactorio, excepto por la iniciación tardía de la marcha en los casos operados con placa. Como complicaciones tardías, cinco pacientes con prótesis de Thompson sufrieron protrusión acetabular y ocho pacientes operados con placa angulada nunca lograron caminar