Nonvascularized fibular graft with locking screw fixation for metaphyseal bone loss of distal femur: biomechanical assessment validated by a clinical case series.

BACKGROUND: The optimal modality to surgically treat significant bone loss of distal femur remains inconclusive. The objectives of the present study were to assess the mechanical performance of nonvascularized fibular graft (NVFG) with locking screw fixation in distal femur fixation construct by finite element analysis and to retrospectively describe the outcomes of the present technique in clinical cases. METHODS: Four constructs which the fractured femur was stabilized by LCP-DF alone, dual plating, LCP-DF combined with NVFG, and LCP-DF combined with NVFG (LCP-DF-NVFG-S) with locking screw were assessed the biomechanical performance under physiological loads. For the clinical case series, 12 patients with open intercondylar fracture with metaphyseal bone loss of distal femur were operated by LCP-DF-NVFG-S. The collected data included fracture consolidation, length of NVFG, perioperative complications and objective clinical results. RESULTS: LCP-DF-NVFG-S demonstrated lower implant equivalent von Mises stress (EQV) stress and better fracture stability than other constructs. A locking screw presented its essence in maintaining the NVFG in the required position and subsequently enhancing the fracture stability. In regard to the clinical series, all fractures were consolidated with an average duration of 27.8 weeks (range 20-32). An average NVFG length was 7.8 cm (range 6-12). No perioperative complication was demonstrated. By the Knee Society score, 1 was considered to be excellent, 9 to be good and 2 to be poor. CONCLUSION: Based on the results of mechanical assessment and case series, LCP-DF-NVFG-S can be an effective technique in the management of metaphyseal bone loss of distal femur.

Concurrent plate fixation and pedicled flap coverage for open fractures complicated by soft tissue loss of the tibia in pediatric cohort: a clinical series.

BACKGROUND: The optimal treatment of open fractures complicated by soft tissue loss of pediatric tibial fractures remains inconclusive. The author described a protocol of concurrent plate fixation and pedicled flap coverage and retrospectively reviewed the outcomes of such injuries. METHODS: A total of 25 pediatric cases with Gustilo lllB open tibial fracture were treated by single-stage plate fixation and pedicled flap reconstruction. The reviewed information consisted of time to fix and flap, type of plate, type of pedicled flap, fracture union time, postoperative complication and the clinical outcomes by objective scoring system. RESULTS: Fix and flap was undergone between 7 and 12 days after injury with the average time of 8.2 days. Regarding the type of plate, narrow LCP was applied in 8, 3.5 mm precontoured LCP in 10, 5.0 mm precontoured in 2 and double LCP in 5. According to soft tissue reconstruction, the medial gastrocnemius flap was selected in 6 cases, myocutaneous medial gastrocnemius flap in 2, soleus flap in 3, hemisoleus flap in 5, reverse sural flap in 6 and combined medial gastrocnemius and hemisoleus flaps in 3. No flap-related complication was demonstrated. All cases established fracture union in between 12 and 24 weeks with an average time to union of 17.7 weeks. According to postoperative complications, infected plate occurred in 2 cases and implant irritation in 5. According to Puno functional score, excellent results were presented in 7 cases and good results in 18 cases. CONCLUSION: Single-stage plate fixation and pedicled flap coverage are a reliable regimen for pediatric open fractures complicated by soft tissue loss of the tibia.

The application of inverted lateral clavicle locking compression plate for medial clavicle fractures: biomechanical study and clinical implementation.

BACKGROUND: There has been no absolute consensus on the optimal implant for fixation of medial clavicle fracture. The purpose of the present study was to test the biomechanical efficacy of inverted lateral clavicle locking compression plate (LCP-LC) in fixation of this specific fracture location by finite element analysis. METHODS: Transverse and comminuted medial clavicle fracture simulated models stabilized by three different devices including inverted LCP-LC, superior clavicle LCP (LCP-SC), and dual reconstruction (LCP-RP) with LCP-SC were investigated biomechanical performance under three loading conditions, i.e., axial compression, inferior bending, and axial torsion. RESULTS: EQV stress exhibited on implant and elastic strain at fracture site under inferior bending was greater than other loading cases. LCP-SC construct represented the greatest EQV stress and elastic strain. The inverted LCP-LC construct demonstrated lower EQV stress than the LCP-SC construct and was comparable to dual plating. Under axial compression and axial torsion, elastic strain produced from the inverted LCP-LC construct was comparable to dual plating, but greater than dual plating when subjected to inferior bending. CONCLUSION: By the results of FE analysis, inverted LCP-LC could be a potential application for fixation of clavicle fracture with short medial fragment.

Comparative study of mechanical performance of various fixation constructs in multifragmentary distal humeral shaft fracture: a finite element analysis.

BACKGROUND: There has been no scientific mechanical assessment demonstrating the optimal fixation technique in multifragmentary fractures of the distal humeral shaft. The purpose of the present study was to compare the biomechanical performance of 5 fixation constructs as used in minimally invasive plating osteosynthesis (MIPO) for distal humeral shaft fractures. METHODS: Three-dimensional (3D) humerus model with 20 mm distal humeral shaft fracture gap simulating multifragmentary fracture was created from computed tomography data and virtually fixed by 5 fixation techniques as MIPO, i.e., anterior narrow dynamic compression plate (DCP), anterior narrow locking compression plate (LCP), anterior reversed proximal humeral internal locking system (R-PHILOS), extra-articular distal humerus locking compression plate (LCP-EADH), and anteromedial LCP. All constructs were biomechanically tested under 6 loading conditions by means of finite element analysis, i.e., 250-N axial compression, 7.5-N m internal rotation, 7.5-N m external rotation, 10-N m posterior bending, 10-N m valgus rotation, and 10-N m varus rotation. In addition, A 3D model of each construct was fabricated as 3D printed models. Fixations were applied to the 3D printing model which were later mechanically tested to validate the FE results. RESULTS: EQV stress exhibited on anterior narrow LCP and anterior R-PHILOS were comparable which were lower than other constructs under axial compression and valgus-varus bending. Anterior R-PHILOS produced lower EQV stress than other constructs under internal-external rotation and posterior bending. On the whole, R-PHILOS demonstrated a comparable fracture displacement to those LCP with anterior or anteromedial approaches, that achieved the lowest displacement values. In addition, the experimental mechanical test values shared a correlation with the FE model results. CONCLUSION: Overall, the anterior R-PHILOS was considered as a potential candidate for multifragmentary distal humeral shaft fractures. It demonstrated efficacious biomechanical performance in terms of implant stress and distal fragment displacement.

Simultaneous internal fixation and latissimus dorsi pedicle flap coverage: A reliable regimen for open fractures with accompanying sizable soft tissue loss of the upper extremities.

BACKGROUND: The optimal treatment protocol for open fractures with accompanying sizable soft tissue defect of the upper extremities has not been specifically delineated. The authors described the concurrent use of internal fixation and latissimus dorsi (LD) pedicle flap coverage in managing such complex fractures. METHODS: Twenty patients with open fractures accompanied by large soft tissue defect of the upper extremities (8 clavicle fractures and 12 humeral fractures) were treated by fix & LD pedicle flap. The dimension of the defect, time to fix & flap, post-operative complications, time to union and clinical measurements were recorded. RESULTS: The mean size of the defect was 132.45 cm2 (range 6-12 x 2-20 cm2). The average time to fix & flap was 9.9 days (range 7-14). Fractures union was achieved in all patients with an average duration of 18.5 weeks (range 14-28). Regarding post-operative complications, distal flap necrosis occurred in 3 patients, retained seroma in 3 and heterotopic ossification in 1. By the Mayo Elbow Performance (MEP) score, 3 cases were considered to be excellent, 6 were good, 7 were fair and 4 were poor. By the University of California-Los Angeles (UCLA) shoulder score, 2 cases were considered to be excellent, 7 were good, 7 were fair and 4 were poor. The average Disabilities of Arm, Shoulder and Hand (DASH) score was 31.29 (range 12.5-58.3). CONCLUSION: Fix & LD pedicle flap is a reliable regimen for open fractures with sizable soft tissue defect of the clavicle and humerus.

Minimally invasive plate osteosynthesis via posterior approach for type B and C fractures of distal humeral shaft: surgical tactics and a clinical series.

The optimal technique and implant for fixation of multifragmentary fractures of the distal humeral shaft remain inconclusive. We describe the use of minimally invasive plate osteosynthesis (MIPO) via posterior approach and extra-articular distal humerus locking compression plate (LCP-EADH) fixation for 18 such fractures. All fractures were united with a mean union time of 17.6 weeks (range 12-20). Transient radial nerve palsy was demonstrated in 2 patients. Six patients had 5° varus angulation and 1 had 5° valgus angulation. Triceps power was Grade 5 in all patients. The mean arc of elbow motion was 127.5 degrees (range 115-140). Six patients had an excellent MEP score and 12 had a good MEP score. As the results, posterior MIPO and LCP-EADH fixation could be an alternative for multifragmentary fractures of the distal humeral shaft, particularly for fractures with a very short distal fragment.

The utility of reverse distal femur locking compression plate in minimally invasive osteosynthesis for type C subtrochanteric fractures of the femur: technical description and a clinical series of 50 cases.

BACKGROUND: Establishing fracture consolidation and avoiding postoperative complications of comminuted subtrochanteric fractures of the femur are technically challenging. The authors delineated a technical description of minimally invasive plate osteosynthesis (MIPO) by using a reverse distal femur locking compression plate (LCP-DF) and retrospectively reviewed the outcomes of these particular fractures. METHODS: Fifty patients with 51 type C subtrochanteric fractures of the femur were operated on by MIPO and reverse LCP-DF fixation. The collected data included postoperative complications, union times, and clinical outcomes. RESULTS: All fractures were united with a mean union time of 19.4 weeks (range 16-22). Regarding postoperative complications, asymptomatic valgus angulation occurred in five patients and trochanteric pain in six. According to Harris hip score, nine patients were determined to be excellent, 36 to be good and five to be fair. CONCLUSION: MIPO by reverse LCP-DF is reliable and effective for type C subtrochanteric fractures of the femur particularly in situations where intramedullary nailing is not feasible.

Utilizing the various forms of the gastrocnemius muscle in fix & flap protocol: a reliable remedy for open proximal tibial fractures with accompanying soft tissue defect.

BACKGROUND: Open proximal tibial fractures accompanied by soft tissue loss are substantially challenging to accomplish both bony consolidation and wound healing. The authors retrospectively delineated the utility of the various forms of the gastrocnemius muscle in fix & flap regimen for management of such complicated injuries. METHODS: Thirty-one patients with open fracture accompanied by soft tissue loss of proximal tibia were managed by the protocol of fix & gastrocnemius flap. The collected data included implant for fixation, form of the gastrocnemius flap, postoperative complications, union time, and clinical assessment. RESULTS: According to fixation devices, lateral anatomical locking compression plates were selected in 28 cases, dual plates in 1, and interlocking nails in 2. According to the forms of the gastrocnemius flap, medial gastrocnemius flap was utilized in 22 cases, medial hemigastrocnemius flap in 2, medial myocutaneous gastrocnemius flap in 2, lateral gastrocnemius flap in 3, and combined medial and lateral gastrocnemius flaps in 2. All flaps completely survived without any flap-related complications. Fracture consolidation was established in all patients with an average period of 19.9 weeks (range 16-26). Surgical site infection occurred in 3 cases, and delayed union in 1. By functional score of Puno, 3 cases were determined to be excellent, 27 to be good, and 1 to be fair. CONCLUSION: Concurrent use of internal fixation and gastrocnemius flap reconstruction is a reliable and efficient protocol in managing open fractures with accompanying soft tissue defect of proximal tibia.

Minimally invasive plate osteosynthesis without floating segment fixation for segmental fracture of femur.

Segmental fractures of the femur are technically difficult to manage by intramedullary nailing, the gold standard treatment. We specifically describe minimally invasive plate osteosynthesis (MIPO) without floating segment fixation for this particular fracture pattern. Twenty patients with segmental fractures of the femur were operated on by the MIPO technique. Data were collected on operative time, postoperative complications, union times, and clinical outcomes. The mean operative time was 63.5 minutes (range 50-90). There were no peri-operative complications. All fractures were united with a mean union time of 16.1 weeks (range 12-20). Regarding postoperative malalignment, limb shortening was demonstrated in 4 patients, valgus angulation in 2 and varus angulation in 3. One patient had a bent plate with 7°varus angulation. According to the Thoresen score, 13 were determined to be excellent values, 6 to be good and 1 to be fair. MIPO without floating segment fixation is a safe and effective alternative for segmental fractures of the femur especially in circumstances that are unsuitable or unfeasible for intramedullary nailing.

Simultaneous internal fixation and soft tissue coverage by soleus muscle flap and variances: a reproducible strategy for managing open fractures of tibial shaft.

BACKGROUND: The role of internal fixation and local muscle flaps for open tibial fractures is still not specifically determined. We describe the integration of internal fixation and soleus muscle flap for open fractures complicated with soft tissue loss of the tibial shaft. METHODS: Twenty-seven patients with Gustilo IIIB open fractures of the tibial shaft were operated on by internal fixation and soft tissue coverage by soleus muscle flaps and variances. Data were collected on types of implants, types of flaps, union time, postoperative complications, and objective clinical measurement. RESULTS: Regarding implants for fixation, plates and screws were selected in 22 patients, and intramedullary nails in 5. Proximally based soleus flap was used in 17 patients, hemisoleus in 6, and reversed hemisoleus in 4. All flaps survived and all fractures were united with a mean union time of 21.8 weeks (range 14-30). One patient had unplanned reoperations due to delayed union and equinus deformity of the ankle. All patients had good-to-excellent Puno functional score results. CONCLUSION: Internal fixation and soft tissue coverage, frequently referred to as 'fix and flap', by a local soleus muscle flap is safe and effective for open fractures accompanied with small-to-medium size soft tissue defect of the tibial shaft.

Single lag screw and reverse distal femur locking compression plate for concurrent cervicotrochanteric and shaft fractures of the femur: biomechanical study validated with a clinical series.

BACKGROUND: The optimal surgical management of concurrent cervicotrochanteric and shaft fractures of the femur has not been consensual. The authors investigated the reliability of combined single lag screw and reverse distal femur locking compression plate (LCP-DF) by finite element (FE) study and retrospectively described the present technique for these dual fractures. METHOD: Intact femurs were derived from CT data, and the implant models were created by using CAD software. The fractured femur and implant models were virtually aligned based on the surgical techniques before converting to the FE model. In the FE model, applied boundary conditions included body weight, muscle forces, and constraint of the joints. Regarding clinical series, three patients with these dual fractures of the femur and 2 with cervicotrochanteric fractures with subtrochanteric extension were operated on by the proposed technique. The collected data include operative time, postoperative complications, union times, and clinical outcomes. RESULTS: Equivalent von Mises stress exhibited on dynamic hip screws with an anti-rotational screw was higher than the other techniques, close to the yield stress of the material. Multiple screw fixation produced better stability for transcervical fractures whereas the proposed technique of combined single lag screw and reverse LCP-DF provided better stability for intertrochanteric fractures. No significant difference in cortical bone stress was found between multiple screw construct and the proposed technique. The proposed technique presented a lower risk of secondary fractures, as the strain energy density (SED) in cancellous bone was lower than multiple screw construct. Regarding clinical series, all fractures were united with a mean union time of-16.1 weeks (range 12-20). There were no any postoperative complications. Regarding the Harris score, 1 was determined to be excellent value, and 4 to be good. CONCLUSION: By the FE results, a combination of a single lag screw and reverse LCP-DF is an effective technique for fixation of cervicotrochanteric fractures. Empowered by the clinical results, this proposed technique could be an alternative for concurrent cervicotrochanteric and shaft fractures of the femur especially when either single-system or dual-system devices seem not to be suitable.

Combined medial gastrocnemius and hemisoleus flap: a reproducible alternative for open tibial fractures complicated with large or double soft tissue defects.

BACKGROUND: Utilization of combined local muscle flaps for Gustilo type IIIB open tibial fractures has not been clearly delineated. We describe a combination of medial gastrocnemius and hemisoleus flaps for managing open tibial fractures accompanying large or double soft tissue defects. METHODS: Twelve patients with Gustilo IIIB open fractures of the tibial shaft with large (9) or double (3) defects were operated on by fracture stabilization and combined medial gastrocnemius and hemisoleus flap coverage. Data were collected on types of implants, types of flaps, union time, postoperative complications, and Puno functional scores. RESULTS: Regarding implants for fixation, an intramedullary nail was used in three patients, plate and screws in five, combined plate and intramedullary nail in one, and definitive external fixation was used in three. Regarding soft tissue coverage, combined medial gastrocnemius and hemisoleus flaps were used in ten patients, combined hemigastrocnemius and hemisoleus in one, and combined medial gastrocnemius and reversed hemisoleus in one. All flaps survived, and all fractures were united with a mean union time of 19.7 weeks (range 16-24). Tip necrosis of the hemisoleus flap occurred in two patients. Regarding Puno functional score, one was determined to be excellent, nine was good and two was fair. CONCLUSION: Combined medial gastrocnemius and hemisoleus flaps are reliable and effective for open tibial fractures complicated with large or double soft tissue defects.

Concurrent internal fixation and soft tissue reconstruction by distally based sural flap: a practicable scheme for complex distal tibial fractures.

BACKGROUND: It is difficult to establish both fracture union and wound healing of open fractures complicated with soft tissue defects of the distal tibia. We describe the simultaneous use of internal fixation and soft tissue coverage by a distally based sural flap (DBSF) for these complex injuries. METHODS: Seventeen patients with Gustilo IIIB open fractures of the distal tibia were operated on by internal fixation and DBSF coverage. Data were collected on the size of the defect, time to fixation and soft tissue coverage or 'fix & flap', types of implant, time to union, postoperative complications and objective clinical measurement. RESULTS: The average size of the soft tissue defect after debridement was 6.4 × 8.4 cm2 (range 4.0-9.0 × 6.0-12.0). The mean time to fix & flap was 8.1 days (range 7-10). A medial precontoured plate was used in 8 patients and an anterolateral precontoured plate in 9. All fractures were united in a mean duration of 22.6 weeks (range 20-28). One patient had partial flap necrosis. Using the Puno functional score, 2 patients had excellent functional outcomes and 15 patients had good functional outcomes. CONCLUSION: Concurrent Internal fixation and soft tissue reconstruction by DBSF is effective and reproducible for Gustilo type III open fractures of the distal tibia even in cases of more than 50 cm2 soft tissue defects.

Anterior minimally invasive plating osteosynthesis using reversed proximal humeral internal locking system plate for distal humeral shaft fractures.

OBJECTIVE: To describe the surgical application of anterior minimally invasive plating osteosynthesis (MIPO) using reversed proximal humerus internal locking system (PHILOS) plate for multifragmentary distal humeral shaft fractures. METHODS: Twelve patients with distal humeral shaft fractures (type 12B, n = 6 and type 12C, n = 6) were operated on by anterior MIPO and reversed PHILOS plate fixation. The amount of intact bone in the distal fragment was measured by fracture-to-coronoid distance (FCD). Data of the postoperative alignment, complications, union time, and clinical outcomes were collected. RESULTS: The mean time for fractures to unite in all patients was 14.8 weeks (range 12-22). There was no perioperative complication. The mean FCD was 4.8 cm (range 2.1-8.1). The mean coronal angulation was 3.4° (range 0-9), and the mean sagittal angulation was 1° (range 0-5). All patients had excellent UCLA shoulder score and MEP score results, and the mean range of elbow motion was 140° (range 130-145). CONCLUSION: Anterior MIPO using reversed PHILOS plate is safe and effective for multifragmentary fractures of the distal humeral shaft even in a fracture with a length of intact bone above the coronoid fossa of only 2 cm.

Dual plating for fixation failure of the distal femur: Finite element analysis and a clinical series.

BACKGROUND: The optimal technique for managing distal femur fixation failure remains inconclusive. The author studied the efficacy of a combined proximal humerus locking compression plate (LCP-PH) and 3.5 mm reconstruction plate (LCP-RP) by finite element (FE) analysis and retrospectively described the clinical outcomes of the present technique in such difficult circumstances. METHODS: Biomechanical study setting included FE models of the distal femur with remaining holes from previous distal femur LCP (LCP-DF) fixation stabilized with three different constructs i.e., LCP-DF alone, LCP-DF-and-LCP-RP, as well as LCP-PH-and-LCP-RP. All settings were analyzed by using FE under physiological loads. Regarding the clinical series, the outcomes of 8 LCP-DF fixation failures operated on by the present technique were retrospectively reviewed. RESULTS: High Implant stress of 911.2 MPa and elastic strain at fracture site of 200.8 µÉ› were found when stabilized with LCP-DF. The constructs of LCP-DF-and-LCP-RP, and LCP-PH-and-LCP-RP presented lower implant stress compared to LCP-DF, 511.5, and 617.5 MPa, respectively. The elastic strain of both dual plating constructs was also 4-5 times lower than LCP-DF and differed from each other by approximately 10 µÉ›. Regarding the clinical series, bony consolidation was achieved in all cases with a mean duration of 28.5 weeks (range 24-36). An average ROM of the affected knee was 115° (range 105-140). Regarding the KSS, 1 was determined to be excellent and 7 to be good. CONCLUSION: By the biomechanical analysis and the clinical results, the construct of LCP-PH-and-LCP-RP could be an effective technique for revision surgery of LCP-DF fixation failure.