Traumatic Floating Clavicle: A Case Report and Updated Literature Review.

Traumatic floating clavicle or bipolar dislocation is a rare injury. Herein, we present a case of ipsilateral sternoclavicular and acromioclavicular joint dislocation after a motorcycle accident. The patient was a 43-year-old man who presented with right shoulder pain and limited range of motion. The radiograph revealed superior displacement of the acromioclavicular joint dislocation and suspected ipsilateral sternoclavicular joint dislocation and a CT scan confirmed injuries to both the medial and lateral ends of the clavicle. Due to the patient being active and young, we considered operative treatment. The sternoclavicular joint was stabilized with FiberTape® suture (Arthrex, Naples, FL), and the acromioclavicular joint with Dog Bone™ Button (Arthrex) and suture cerclage. At the one-year follow-up, the patient reported excellent outcomes without complications. We also summarize the literature on this particular injury, including its characteristics, surgical options, and treatment outcomes.

Lateral minimally invasive plate osteosynthesis (MIPO) with long PHILOS for proximal metaphyseal-diaphyseal humeral fracture: surgical techniques and a clinical series.

The minimally invasive plate osteosynthesis (MIPO) for proximal metaphyseal-diaphyseal humeral fracture is an effective alternative treatment with satisfactory outcomes. In this study, we described the surgical techniques and clinical results using MIPO via a lateral approach and long PHILOS plate fixation in 23 patients. All fractures were successfully united within a mean union time of 13.5 weeks (range 9-18). There was no iatrogenic radial nerve palsy. The deltoid power was grade 5 in all patients, except for 2 patients who had associated brachial plexus injury and gunshot injury at the deltoid muscle. The mean Constant-Murley score was 85.6 (range 16-98) and DASH score was 12.1 (range 1.7-85). Based on these findings, the lateral MIPO with long PHILOS plate fixation could be an alternative for the proximal metaphyseal-diaphyseal fractures of the humeral shaft.

Comparison of single versus double coracoclavicular loop stabilization technique for the management of unstable distal clavicular fractures: a randomized controlled trial.

PURPOSE: The coracoclavicular (CC) loop stabilization technique is proposed for unstable distal clavicular fractures. This study aims to compare single and double CC loop stabilizations and evaluate differences in functional and radiographic outcomes between them. METHODS: We conducted a prospective randomized controlled trial involving 46 patients who sustained unstable distal clavicular fractures between April 2017 and 2019. The participants were randomly assigned to one of two groups: the single CC loop stabilization group (n = 23) or the double CC loop stabilization group (n = 23). We assessed their Constant score, American Shoulder and Elbow Surgeons score (ASES), and pain level. Additionally, we recorded data on time to union, CC distance, and any complications. RESULTS: The single CC loop group demonstrated a shorter operative time and significantly higher Constant score than the double CC loop group at 1 month (77.32 ± 5.65 vs. 71.91 ± 8.33; p = 0.016) and 3 months (86.17 ± 4.05 vs. 81.13 ± 6.34; p = 0.009) postoperatively. However, there was no differences in the ASES score, time to union or CC distance restoration between two groups. Implant irritation was observed in the double CC loop group (26.1%), but there were no cases requiring revision surgery. CONCLUSIONS: Both single and double CC loop stabilization demonstrated favorable outcomes, including a high union rate and minimal complications. Single CC loop stabilization showed slightly better early functional outcomes, reduced implant-related irritation, and shorter operative times.

Locating an iliac cortical window for reduction of an acetabular dome impaction: A computed tomography and cadaveric study.

This study aimed to determine the optimal location of the iliac cortical window (ICW) for the direct reduction of acetabular dome impactions using a reference bony landmark. Methods: In the first part of the study, computed tomography scans of 10 normal acetabula, the femoral head weight bearing area, were projected through the superior iliac cortical surface perpendicular to the plane of the true pelvis to show the area that corresponds to the acetabular dome. A line connecting each pair of anterior inferior iliac spines (AIIS) was drawn then reflected in the superior surface of the acetabulum and a reference point (RP) was marked on the line halfway between the AIIS and the pelvic brim. A 12-point 1-cm interval grid with horizontal and vertical axes labeled A, B, C and 1 to 4, respectively, overlying the acetabular surface projection was created to identify the location of the acetabular dome. In the second part of the study, the 12-point grid was marked on eight fresh cadavers (16 acetabula) and the same acetabular dome reference point was identified. K-wires were drilled into the acetabula using a parallel drill guide at each of the twelve grid points. An arthrotomy was carried out and the locations of the K-wires which penetrated the acetabular dome were recorded. Results: The average distance from the AIIS to the medial pelvic brim in the CT scans and cadaveric study were 47.7 and 45.9 mm, respectively. The K-wires at grid points B2 and C1 had a 100% correlation to the dome area. The A2, B1, and C2 grid points had a correlation with the dome area of >80%. The remaining grid points had joint penetrations ranging from 6.25% to 62.5%. Conclusion: The proposed RP, which can be easily identified intraoperatively, and the area 1 cm2 around the RP (except in the posterior direction) can be used as reliable reference landmarks and for identification of the location of the ICW for the reduction of an acetabular dome impaction.

Efficacy and Safety of Antibiotic Impregnated Microporous Nanohydroxyapatite Beads for Chronic Osteomyelitis Treatment: A Multicenter, Open-Label, Prospective Cohort Study.

Chronic osteomyelitis is still a serious health problem that causes disabling conditions and has an impact on the quality of life. The objective of this study was to determine the clinical efficacy and safety of localized antibiotics delivery via impregnated microporous nanohydroxyapatite (nHA-ATB) beads for chronic osteomyelitis treatment. A total of 62 patients were enrolled in this study. After radical surgical debridement, the bone defect was filled with three types of antibiotics (vancomycin or gentamicin or fosfomycin) impregnated HA beads. The follow-up period was 48 weeks. It was found that the success rate was approximately 98% with a re-infection in only one patient. Quality of life of all patients after treatment improved significantly over time. Systemic exposure to vancomycin and gentamicin after beads implantation was limited and high local antibiotics concentrations were found in wound drainage fluid at 24, 48 and 72 h. Blood biochemistry measurements did not show any nephrotoxic or hepatotoxic effects. 20 adverse events were reported, but 90% of the events were resolved without having to remove the beads and the patients recovered. Satisfactory outcomes were observed in terms of success rate, quality of life and adverse effect. nHA-ATB beads impregnated by vancomycin or gentamicin or fosfomycin could potentially be employed as an alternative product of choice for localized antibiotics delivery in chronic osteomyelitis treatment.

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.

Traction-Internal Rotation Radiograph Can Improve Agreement in AO/OTA Classification System for Intertrochanteric Fracture.

Purpose: The objective of our study was to evaluate the inter- and intra-observer reliability of the standard anteroposterior of both hips, traction-internal rotation, and the combination of the two radiographs for intertrochanteric fracture. Methods: In one hundred cases, three sets of radiographs of intertrochanteric fracture were prepared. Two senior and two junior orthopedic trauma surgeons were asked to classify the radiograph according to AO/OTA classification. The standard both hips radiograph, traction-internal rotation radiograph and combination of both techniques were evaluated. All radiographs were evaluated at two different points in time for all observers. The inter- and intra-observer reliability were analyzed with the Kappa agreement index. Results: Inter-observer agreement for standard radiographs was "substantial" in one while "moderate" in five among observers. After adding the traction radiograph to the standard radiograph, the agreement was improved to "substantial" in 4 while the rest was "moderate."Intra-observer agreement for standard radiographs was "substantial" in two observers and "moderate" in two observers. Adding traction to standard radiographs resulted in "substantial" in three observers and "moderate" in one observer.Overall pattern stability was changed in 19% after adding the traction film. Thirty-four percent of the fracture which initially diagnosed as A2.1 was changed from stable to unstable fracture patterns after adding the traction film. Conclusions: Adding traction-internal rotation radiograph to the standard radiograph is a useful method for improving agreement to classify intertrochanteric fracture regarding AO/OTA classification. This may be helpful in determining fracture classification.

The radiographic relationship between the cortical overlap view (COV) and the tip of the greater trochanter.

For proximal femoral nailing, choosing the proper entry point with the aid of C-arm imaging is crucial. Therefore, obtaining accurate radiological views that facilitate sound identification of the tip of the greater trochanter (GT) is of utmost importance. The aim of this study was to define a radiological view characterised by reproducible radiographic landmarks which will allow the reliable identification of the tip of the GT in the anteroposterior view. Anatomical and radiographic features of 16 cadaveric femurs were analysed. The cortical overlap view (COV), characterised by the radiological overlap of the density line of the piriform fossa and the intertrochanteric crest, was identified. It marks the rotation of the proximal femur at which the GT can be accurately identified and used to determine the desired entry point for a proximal femoral nail. Trainees and fully qualified orthopedic trauma surgeons were asked to identify the correct COV in radiological imaging series. Mean internal rotation of the femur to achieve a COV was 17.5° (range 12.8°-21.8°). In the COV the tip of the GT is the highest visible point and the mean distance from the cortical overlap line to the tip of the GT is 4.45 mm. Intra- and inter-rater reliability was high with ICC(2,k) = 0.932 and ICC(2,k) = 0.987 respectively. Trainees achieved higher rates of correct COV identification than specialists. There was no significant correlation between the internal rotation of the femur to achieve the COV and femoral antetorsion. In conclusion, the COV is a highly reproducible radiological view that is characterised by radiographic landmarks easy to recognise. It allows for accurate identification of the tip of the GT, which can be used by the surgeon as a reference to determine the desired entry point for an intramedullary nail.

The nail-shaft-axis of the of proximal femoral nail antirotation (PFNA) is an important prognostic factor in the operative treatment of intertrochanteric fractures.

INTRODUCTION: Due to the world's aging population, intertrochanteric fractures are frequent. Considering age and comorbidities of most of these patients, it is indispensable to enable early postoperative mobilization of these patients. Intramedullary osteosynthesis with PFN-A is widely used and, in general, considered safe and reliable for the operative treatment of intertrochanteric fractures. However, implant -related complications are reported in 6-21% of all cases. In this study, we are analyzing complication rates and risk factors for implant-related complications. MATERIALS AND METHODS: All intertrochanteric fractures admitted to our hospital and treated with PFN-A between January 2012 and January 2016 were analysed retrospectively. Radiological analyses of the CCD and the lateral offset on the uninjured side was compared to the CCD initially postoperatively and during follow-up on the operated side. Furthermore, we analysed the tip-apex distance (TAD), blade position in the femoral head and introduced the nail-shaft axis as a new parameter. RESULTS: Within 101 intertrochanteric fractures included, 16 implant-related complications were encountered (15.84%). Analyses of risk factors for secondary varus displacement of greater than 10° within the follow-up and thus risk for cut-out in the osteosynthesis revealed that etasblished risk factors such as a TAD > 25 mm, reduction in varus and an improper position of the blade were also significant risk factors in our cohort for failure of the osteosynthesis. Moreover, we introduced the nail-shaft axis a new potential risk factor and could show that a too medial or too lateral nail-shaft axis is also significantly associated with secondary varus displacement. CONCLUSION: When treating introchanteric fractures with PFNA reduction in neutral or even slight valgus, aiming for a TAD < 25 mm and a correct position of the blade within the femoral head reduced the risk for secondary varus displacement significantly. Furthermore, we suggest to aim for a central nail-shaft axis.

Polyester tape scapulopexy for chronic upper extremity brachial plexus injury.

PURPOSE: To report the results of scapular stabilization for winging in patients with chronic upper brachial plexus injury. METHODS: Eight patients, mean age 36 years, who had a winged scapula after successful restoration of major shoulder function by nerve transfer underwent scapular stabilization to the ribcage using polyester tape. The follow-up period ranged from 24 to 40 months (mean, 38 mo). Data collection included radiographic analysis, active range of motion measurement, University of California Los Angeles shoulder score, and visual analog scale pain score. RESULTS: All patients had clinical improvement with resolution of scapular winging. Five patients had no winging and 3 had mild winging after the surgery. Mean active forward flexion increased from 101° preoperatively to 127° postoperatively. Mean active shoulder abduction increased from 91° preoperatively to 121° postoperatively. Mean University of California Los Angeles shoulder score improved from 17 to 27 and mean visual analog scale pain score improved from 6.1 to 0.7. In addition, mean lateral deviated angle increased from 4° from neutral preoperatively to 9° at the last follow-up. All patients reported satisfaction with postoperative appearance. CONCLUSIONS: Outcomes of polyester tape scapulopexy in the short to intermediate term were favorable in terms of improved appearance, upper extremity function, and pain reduction in patients with winged scapula resulting from chronic upper brachial plexus injury, and with successful restoration of shoulder motion by previous nerve transfers. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.