Is ultrasound superior to fluoroscopy in distal radius volar fixation?

OBJECTIVES: In volar distal radius fixation, conventional and additional fluoroscopic views could not be sufficient to assess dorsal screw penetration. Ultrasound (US) has been suggested as a technique to improve this assessment. The objective was to determine the agreement between these two explorations in a clinical study. Quantify time-consuming of intraoperative US was the secondary objective. MATERIAL AND METHODS: A prospective descriptive study was performed. Thirty patients with a surgical distal radius fracture were treated with volar fixation by five consultant surgeons in a level I Trauma Centre. Final intraoperative fluoroscopic views: AP, lateral, 20º tilted lateral and Dorsal Tangential views (DTV) were performed assessing for dorsal screw protrusion. Then, ultrasound was performed to reassess dorsal cortex integrity. Those protruding screws were registered and changed. RESULTS: A total of 153 screws were examined. Four protruding screws were observed with no multiple protruding screws in the same fixation. Intraoperative ultrasound detected a dorsal screw protrusion in one fixation, assessed as correct by radiological projections. Almost perfect agreement was found between DTV and US examination k = 0.83 (p < 0.001). The mean surgical time was 63 ± 20.3 min while the addition of the ultrasound, supposed an average of 4 ± 1 min more. CONCLUSION: Ultrasound did not show a clinically significant improvement in the assessment dorsal screw penetration in distal radius fixation. A high agreement was observed between US and the described fluoroscopic views. The addition of intraoperative US was a non-significant time-consuming procedure.

Risk factors for infection in fixation of distal tibia fractures.

BACKGROUND: The aim of this study is to evaluate risk factors for infection as well as infection rates after open reduction and internal fixation for distal tibia fractures with a distal tibia locking plate and/or isolated screws. METHODS: This is a retrospective and descriptive study based on 55 patients treated in our Major Trauma Centre from January 2009 to December 2016. All patients were classified by age, sex, open or closed fracture, injury mechanism, comorbidities, fixation and time from injury to surgery. 22 extraarticular fractures AO/OTA 43-A and 33 intraarticular (14 cases 43-B and 19 43-C) were recorded. High energy trauma was related in 27 patients, while open fractures were observed in 10 patients. Splint until surgery was applied routinely while temporary external fixation (EF) was performed in 21 patients (7 extraarticular and 14 intraarticular). Patients were treated by 5 different consultant surgeons performing isolated screws (SC) in 20% of the surgeries, antero-medial locking distal tibia plate (AM) and anterolateral (AL) were used in 47% and 33% of the patients respectively. After assessing normality and homogeneity of the subgroups, statistical contrast tests were performed. RESULTS: Infection rate was 31.5%, mainly caused by S. aureus. We obtained a statistically significant correlation between greater age and infection rate. In the same way, a positive statistical trend between infection and AL plating was found. The use of EF followed by ORIF was not observed as a risk factor for infection compared with splint followed by internal fixation, however, the group of patients in which a splint was used, a positive relationship was found between the infection rate and shorter time until the definitive fixation. No statistically significant associations were found between extra/intraarticular fracture pattern, use of corticosteroids or open fractures and infection rate. CONCLUSION: Greater age was a predisposing factor for infection. The use of external fixation before definitive ORIF seems to be a safe procedure regarding risk infection, and if an external fixation is not used, we recommend longer waiting time until definitive ORIF. Screw fixation or antero-medial plates, if allowed by fracture pattern, can be an option to avoid infection.

An intact fibula may contribute to allow early weight bearing in surgically treated tibial plateau fractures.

PURPOSE: The role of the proximal tibiofibular joint (PTFJ) in tibial plateau fractures is unknown. The purpose of this study was to assess, with finite-element (FE) calculations, differences in interfragmentary movement (IFM) in a split fracture of lateral tibial plateau, with and without intact fibula. It was hypothesized that an intact fibula could positively contribute to the mechanical stabilization of surgically reduced lateral tibial plateau fractures. METHODS: A split fracture of the lateral tibial plateau was recreated in an FE model of a human tibia. A three-dimensional FE model geometry of a human femur-tibia system was obtained from the VAKHUM project database, and was built from CT images from a subject with normal bone morphologies and normal alignment. The mesh of the tibia was reconverted into a geometry of NURBS surfaces. The fracture was reproduced using geometrical data from patient radiographs, and two models were created: one with intact fibula and other without fibula. A locking screw plate and cannulated screw systems were modelled to virtually reduce the fracture, and 80 kg static body weight was simulated. RESULTS: Under mechanical loads, the maximum interfragmentary movement achieved with the fibula was about 30% lower than without fibula, with both the cannulated screws and the locking plate. When the locking plate model was loaded, intact fibula contributed to lateromedial forces on the fractured fragments, which would be clinically translated into increased normal compression forces in the fractured plane. The intact fibula also reduced the mediolateral forces with the cannulated screws, contributing to stability of the construct. CONCLUSION: This FE model showed that an intact fibula contributes to the mechanical stability of the lateral tibial plateau. In combination with a locking plate fixation, early weight bearing may be allowed without significant IFM, contributing to an early clinical and functional recovery of the patient.