Indirect Coronal Reduction Technique Using a Volar Locking Plate in Distal Radius Fractures: A Case Series.

This is a retrospective case series of patients with distal radius fractures treated with an indirect coronal reduction technique previously described by the senior author using volar locking plates. Seventeen distal radius fractures underwent treatment at a Level I Trauma Center and were retrospectively reviewed for anatomic alignment, surgical complications, and wrist range of motion in the global period. Near-anatomic restoration was achieved with the average radial inclination, radial height, and volar tilt measured as 23.2 ± 3.9 degrees, 11.8 ± 2.1 degrees, and 8.5 ± 5.4 degrees, respectively. Average coronal translation was 2.8 ± 2.7 mm. Postoperative wrist motion on average was within the normal ranges for pronation, supination, wrist flexion, and wrist extension at an average of 36 weeks follow-up. There were no complications related to surgical technique or implant. This case series demonstrates the reliability for coronal reduction with a volar locking plate technique without complications. (Journal of Surgical Orthopaedic Advances 33(1):037-040, 2024).

Skin Antisepsis before Surgical Fixation of Extremity Fractures.

BACKGROUND: Studies evaluating surgical-site infection have had conflicting results with respect to the use of alcohol solutions containing iodine povacrylex or chlorhexidine gluconate as skin antisepsis before surgery to repair a fractured limb (i.e., an extremity fracture). METHODS: In a cluster-randomized, crossover trial at 25 hospitals in the United States and Canada, we randomly assigned hospitals to use a solution of 0.7% iodine povacrylex in 74% isopropyl alcohol (iodine group) or 2% chlorhexidine gluconate in 70% isopropyl alcohol (chlorhexidine group) as preoperative antisepsis for surgical procedures to repair extremity fractures. Every 2 months, the hospitals alternated interventions. Separate populations of patients with either open or closed fractures were enrolled and included in the analysis. The primary outcome was surgical-site infection, which included superficial incisional infection within 30 days or deep incisional or organ-space infection within 90 days. The secondary outcome was unplanned reoperation for fracture-healing complications. RESULTS: A total of 6785 patients with a closed fracture and 1700 patients with an open fracture were included in the trial. In the closed-fracture population, surgical-site infection occurred in 77 patients (2.4%) in the iodine group and in 108 patients (3.3%) in the chlorhexidine group (odds ratio, 0.74; 95% confidence interval [CI], 0.55 to 1.00; P = 0.049). In the open-fracture population, surgical-site infection occurred in 54 patients (6.5%) in the iodine group and in 60 patients (7.3%) in the chlorhexidine group (odd ratio, 0.86; 95% CI, 0.58 to 1.27; P = 0.45). The frequencies of unplanned reoperation, 1-year outcomes, and serious adverse events were similar in the two groups. CONCLUSIONS: Among patients with closed extremity fractures, skin antisepsis with iodine povacrylex in alcohol resulted in fewer surgical-site infections than antisepsis with chlorhexidine gluconate in alcohol. In patients with open fractures, the results were similar in the two groups. (Funded by the Patient-Centered Outcomes Research Institute and the Canadian Institutes of Health Research; PREPARE ClinicalTrials.gov number, NCT03523962.).

Retrograde intramedullary nailing of the femur: identifying the true anatomic axis for the ideal start point.

PURPOSE: Retrograde femoral intramedullary nailing (IMN) is commonly used to treat distal femur fractures. There is variability in the literature regarding the ideal starting point for retrograde femoral IMN in the coronal plane. The objective of this study was to identify the ideal starting point, based on radiographs, relative to the intercondylar notch in the placement of a retrograde femoral IMN. METHODS: A consecutive series of 48 patients with anteroposterior long-leg radiographs prior to elective knee arthroplasty from 2017 to 2021 were used to determine the femoral anatomic axis. The anatomic center of the isthmus was identified and marked. Another point 3 cm distal from the isthmus was marked in the center of the femoral canal. A line was drawn connecting the points and extended longitudinally through the distal femur. The distance from the center of the intercondylar notch to the point where the anatomic axis of the femur intersected the distal femur was measured. RESULTS: On radiographic review, the distance from the intercondylar notch to where the femoral anatomic axis intersects the distal femur was normally distributed with an average distance of 4.1 mm (SD, 1.7 mm) medial to the intercondylar notch. CONCLUSION: The ideal start point, based on radiographs, for retrograde femoral intramedullary nailing is approximately 4.1 mm medial to the intercondylar notch. Medialization of the starting point for retrograde intramedullary nailing in the coronal plane aligns with the anatomic axis. These results support the integration of templating into preoperative planning prior to retrograde IMN of the femur, with the knowledge that, on average, the ideal start point will be slightly medial. Further investigation via anatomic studies is required to determine whether a medial start point is safe and efficacious in patients with distal femur fractures treated with retrograde IMNs.

Dual Plate Fixation of Periprosthetic Distal Femur Fractures.

OBJECTIVES: Dual implants for distal femur periprosthetic fractures is a growing area of interest for these challenging fractures with dual plating (DP) emerging as a viable construct for these injuries. In the current study, an experience with DP constructs is described. DESIGN: Retrospective case series with comparison group. SETTING: Level 1 academic trauma center. PATIENT SELECTION CRITERIA: Adults >50 years old sustaining comminuted OTA/AO 33-A2 or 33-A3 DFPF treated with either DP or a single distal femur locking plating (DFLP). Patients with simple 33-A1 fractures were excluded. Prior to 2018, patients underwent DFLP after which the treatment of choice became DP. OUTCOME MEASURES AND COMPARISONS: Reoperation rate, alignment, and complications. RESULTS: 34 patients treated with DFLP and 38 with DP met inclusion and follow up criteria. Average follow up was 18.2 ± 13.8 months in the DFLP group and 19.8 ± 16.1 months in the DP group ( P = 0.339). The average patient age in the DFLP group was 74.8 ± 7.3 years compared to 75.9 ± 11.3 years in the DP group. There were no statistical differences in demographics, fracture morphology, loss of reduction, or reoperation for any cause ( P >.05). DP patients were more likely to be weight bearing in the twelve-week postoperative period ( P <0.001) and return to their baseline ambulatory status ( P = 0.004) compared to DFLP patients. CONCLUSIONS: Dual plating of distal femoral periprosthetic fractures maintained coronal alignment with a low reoperation rate even with immediate weight bearing and these patients regained baseline level of ambulation more reliably as compared to patients treated with a single distal femoral locking plate. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Comparison of Lateral versus Medial Entry Femoral Traction Pin Complication Rates.

Distal femoral skeletal traction is a common procedure for the stabilization of fractures of the pelvis, acetabulum, and femur following trauma. Femoral traction pins are traditionally inserted via medial-to-lateral (MTL) entry to accurately direct the pin away from the medial neurovascular bundle. Alternatively, cadaveric studies have demonstrated low risk to the neurovascular bundle using a lateral-to-medial (LTM) approach. The purpose of this study was to compare the incidence of complications of LTM and MTL femoral traction pin placement at a single institution. This was a retrospective review of patients from the orthopaedic consult registry at a academic Level I Trauma Center. We identified 233 LTM femoral traction pin procedures in 231 patients and 29 MTL pin procedures in 29 patients. The two pin placement techniques were compared with respect to complications, specifically the incidence of neurovascular injury, cellulitis, septic arthritis, osteomyelitis, and heterotopic ossification after femoral traction pin placement. Two complications were reported. One patient developed heterotopic ossification along the pin tract after LTM traction pin placement. Another patient developed septic arthritis after LTM pin placement, likely attributable to retrograde intramedullary nailing of his open femur fracture rather than his traction pin. There were no reports of neurovascular injury, cellulitis, or osteomyelitis associated with pin placement. The complication rate was 0.9% for LTM group and 0.0% for MTL group (p = 0.616). LTM femoral traction pin placement is a safe procedure with a similarly low complication rate compared with traditional MTL placement when the limb is positioned in neutral alignment. (Journal of Surgical Orthopaedic Advances 32(4):259-262, 2023).

Nonsurgical Management of Distal Radius Fractures in the Elderly: Approaches, Risks and Limitations.

The elderly have conventionally been defined as individuals over the age of 65 and are projected to represent about 21% of the United States (US) population by the year 2030. Distal radius fractures (DRF) in particular are one of the most common fractures among elderly patients and their incidence continues to rise in part due to increased activity levels among the elderly, increased life expectancy, rising rates of obesity, changes to dietary habits, and the prevalence of osteoporosis. Although various treatment options exist for these injuries, nonsurgical treatment of distal radius fractures remains a mainstay among elderly patients with mounting evidence of its non-inferiority to surgical fixation in the literature. Here, we summarize the overall approach to nonsurgical treatment of distal radius fractures in the elderly population while examining its supporting data and highlighting potential risks and limitations to it.

Rethinking the Coronal Anatomic Axis of the Distal Tibia for Intramedullary Nail Placement: A Cadaveric Study.

Background: Recent studies have reported that targeting a center-center position at the distal tibia during intramedullary nailing (IMN) may result in malalignment. Although not fully understood, this observation suggests that the coronal anatomic center of the tibia may not correspond to the center of the distal tibia articular surface. Questions/Purposes: To identify the coronal anatomic axis of the distal tibia that corresponds to an ideal start site for IMN placement utilizing intact cadaveric tibiae. Methods: IMN placement was performed in 9 fresh frozen cadaveric tibiae. A guidewire was used to identify the ideal start site in the proximal tibia and an opening reamer allowed access to the canal. Each nail was then advanced without the use of a reaming rod until exiting the distal tibia plafond. Cadaveric and radiographic measurements were performed to determine the center of the nail exit site in the coronal plane. Results: Cadaveric and radiographic measurements identified the IMN exit site to correspond with the lateral 59.5% and 60.4% of the plafond, respectively. Conclusions: Tibial nails inserted using an ideal start site have an endpoint that corresponds roughly to the junction of the lateral and middle third of the plafond. Further studies are warranted to better understand the impact of IMN endpoint placement on the functional and radiographic outcomes of tibia shaft fractures.

No false elevation in ankle brachial index in patients with tibial plateau fractures and vascular risk factors.

Objectives: The ankle brachial index (ABI) is a useful tool in detection of lower extremity vascular injury. However, diabetes mellitus (DM), chronic kidney disease (CKD), and peripheral vascular disease (PVD) may affect extremity perfusion leading to possible false elevation of the ABI value. If true in trauma patients, this can affect initial evaluation, diagnostics, and management. We therefore explored mean ABI values in tibial plateau fractures of patients with vascular risk factors to help determine whether there is a difference. Design: This is a retrospective chart review of patients sustaining tibial plateau fractures with a specific ABI value recorded in the medical record. Patients were identified as either having vascular risk factors or not and data analysis performed to determine if their ABI differed and whether they were more likely to have a vascular injury. Results: 282 acute tibial plateau injuries with specific ABI values were identified, 46 of which carried the risk factors in question. The average risk factor group ABI was 0.95 ±â€¯0.15 versus those without risk factors 1.0 ±â€¯0.15 (p = 0.057). No patient with risk factors required a vascular intervention or four-compartment fasciotomy. Conclusions: This study shows no statistical significance between the presenting ABI of patients with risk factors such as DM, CKD, or PVD and those without those risk factors who sustained acute tibial plateau fractures. Therefore, in general the ABI still holds as a useful screening tool for evaluation of vascular insult in the setting of acute lower extremity trauma.

Contributions of Pubic Rami Fracture Morphology and Fixation to Pelvic Ring Stability in Type 1 Lateral Compression Injuries: A Biomechanical Cadaveric Study.

BACKGROUND: Treatment of lateral compression type 1 (LC-1) injuries has historically been nonoperative with immediate weight-bearing. However, management of these injuries remains controversial, with reports of displacement at follow-up for nonoperatively managed LC-1 fractures. The goal of our study was to determine the effect of superior pubic ramus fracture morphology and fixation construct on pelvic stability. METHODS: Ten fresh-frozen cadaveric were transected into hemi-pelvises. Incomplete Denis type 1 sacral fractures were made. Hemi-pelvises were randomized to receive a transverse-type or oblique-type superior pubic ramus fracture with the contralateral hemi-pelvis receiving the opposing morphology. A lateral load to 135N was applied with an Instron materials testing machine and lateral displacement of the hemi-pelvis was recorded. Deflection and stiffness were calculated. Statistical analysis was conducted using a t test assuming unequal variances with an alpha = 0.05. RESULTS: Oblique-type superior pubic ramus fractures allowed more deflection compared with transverse-type fractures in the absence of fixation (P = 0.018). The posterior-only and combined anterior and posterior fixation configurations on average reduced deflection more than no fixation or anterior fixation only. In all fixation configuration cases, the average deflection for transverse-type fractures was less than that of the oblique-type fractures. CONCLUSIONS: Our findings suggest that displacement of LC-1 pelvic injuries may be related to pubic rami fracture morphology. When looking at initial injury imaging, oblique-type pubic rami fractures may suggest an increased potential for displacement over time. In such cases, we recommend an examination under anesthesia to evaluate for underlying instability and consideration for fixation. LEVEL OF EVIDENCE: Therapeutic Level V.

Defining Incidence of Acute Compartment Syndrome in the Research Setting: A Proposed Method From the PACS Study.

OBJECTIVE: To compare the retrospective decision of an expert panel who assessed likelihood of acute compartment syndrome (ACS) in a patient with a high-risk tibia fracture with decision to perform fasciotomy. DESIGN: Prospective observational study. SETTING: Seven Level 1 trauma centers. PATIENTS/PARTICIPANTS: One hundred eighty-two adults with severe tibia fractures. MAIN OUTCOME MEASUREMENTS: Diagnostic performance (sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver-operator curve) of an expert panel's assessment of likelihood ACS compared with fasciotomy as the reference diagnostic standard. SECONDARY OUTCOMES: The interrater reliability of the expert panel as measured by the Krippendorff alpha. Expert panel consensus was determined using the percent of panelists in the majority group of low (expert panel likelihood of ≤0.3), uncertain (0.3-0.7), or high (>0.7) likelihood of ACS. RESULTS: Comparing fasciotomy (the diagnostic standard) and the expert panel's assessment as the diagnostic classification (test), the expert panel's determination of uncertain or high likelihood of ACS (threshold >0.3) had a sensitivity of 0.90 (0.70, 0.99), specificity of 0.95 (0.90, 0.98), PPV of 0.70 (0.50, 0.86), and NPV of 0.99 (0.95, 1.00). When a threshold of >0.7 was set as a positive diagnosis, the expert panel assessment had a sensitivity of 0.67 (0.43, 0.85), specificity of 0.98 (0.95, 1.00), PPV of 0.82 (0.57, 0.96), and NPV of 0.96 (0.91, 0.98). CONCLUSION: In our study, the retrospective assessment of an expert panel of the likelihood of ACS has good specificity and excellent NPV for fasciotomy, but only low-to-moderate sensitivity and PPV. The discordance between the expert panel-assessed likelihood of ACS and the decision to perform fasciotomy suggests that concern regarding potential diagnostic bias in studies of ACS is warranted. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions for Authors for a complete description of levels of evidence.

Thermal Output of Oscillation Versus Forward Drilling of Bone.

This study's objective was to identify a difference in maximum temperature change during forward versus oscillating drilling of cadaveric bone. Paired femurs were dissected from the soft tissue of five cadavers. Each cadaver had one femur assigned to forward and the other to oscillation. The first drill hole was 2.5 cm distal to the lesser trochanter and the remaining 10 holes were evenly spaced 2 cm apart. A System 7 drill and 3.5 mm drill bit were attached to an Instron 5500R to provide a progressive force of 50 Newtons per minute for each drill hole. A thermal camera recorded each drilling. A new drill bit was used for each femur. Fifty bicortical drillings were analyzed in each group. The average time to complete forward drilling (45.0 seconds) was shorter compared to oscillation (55.5 s, p < 0.001). The average force required for forward drilling (27.7 N) was lower than for oscillation (44.3N, p < 0.001). The maximum change in temperature during the drilling process was similar (oscillating 100.2° F vs. forward 100.7° F, p = 0.871). The maximum change in temperature at the near cortex was lower for oscillation (78.1°F) compared to forward drilling (89.1°F, p = 0.011), while the maximum change at the far cortex was lower for forward drilling (89.3°F) compared to oscillation (95.8°F, p = 0.115) but not significantly. Overall, there is no difference in the thermal output between techniques. Oscillation may be beneficial in proximity to vital structures or to navigate narrow bony corridors, but it requires additional time and force. (Journal of Surgical Orthopaedic Advances 31(4):233-236, 2022).

Distal Radius Fractures: Setting Yourself Up for Success in the Active Geriatric Patient.

SUMMARY: Distal radius fractures are common in the geriatric population; however, treatment of these fractures remains controversial. Patients undergoing operative fixation may experience a quicker recovery with increased grip strength, which is beneficial in the active geriatric patient. Treatment options include fragment-specific fixation, volar locked plating, and dorsal bridge plating. External fixation alone leads to poor outcomes and is indicated in patients with soft tissue compromise or as a supplemental aid. Implant selection should be tailored to fracture parameters. With a thoughtful surgical algorithm and rehabilitation protocol, good outcomes can be achieved with a high rate of patient satisfaction.

Maintaining the Neutral Axis in the Treatment of Distal Femur Fractures Via Dual Plate or Nail Plate Combination Technique: When and How?

SUMMARY: Distal femur fractures in the elderly have been historically treated with locked plating or retrograde intramedullary nailing with good, reliable results. However, in certain more complex fracture patterns (native or periprosthetic), increased density of fixation via dual-plate or nail plate combination can help achieve immediate weight-bearing. It can also potentially increase rates of union by shifting and maintaining the neutral axis, distributing forces more evenly across the fracture site. Here, we discuss the indications, pros and cons of both dual-plate and nail plate combination techniques in a concise case-based format.

Operative vs. Nonoperative Treatment of Isolated Humeral Shaft Fractures: A Prospective Cohort Study.

The purpose was to compare plate and screw fixation (open reduction internal fixation [ORIF]) and functional bracing (FB) of isolated humeral shaft fractures with treatment and patient-based outcomes. We performed a prospective trial of ORIF v. FB at 12 centers. Surgeons counseled patients on treatment options and a patient centered decision was made. We enrolled 179 patients, of which 6-month data was analyzed for 102 (39 female; 63 male). Forty-five were treated with ORIF and 57 with FB. We found no difference in the disability of the arm, shoulder and hand (DASH) score, visual analogue score (VAS) or elbow range of motion (ROM) at 6 months. However, 11% of the FB group developed nonunion. Complications in the ORIF group included a 2% infection and nonunion rate and 13% iatrogenic radial nerve dysfunction (RND). ORIF can be expected to result in higher union rates with the inherent risks of infection and RND. Finally, at 6 months, both groups demonstrated higher DASH scores than population norms, indicating a lack of full recovery. (Journal of Surgical Orthopaedic Advances 30(2):067-072, 2021).

Is There a Critical Radiographic Angle That Portends Poor Functional Outcome Scores in Nonoperative Treatment of Isolated Humeral Shaft Fractures?

Our purpose was to evaluate radiographic alignment of nonoperatively treated humerus fractures and determine if there is a critical angle associated with worse outcomes. All patients with humeral shaft fractures that were prospectively followed as part of a larger multicenter trial were reviewed. These patients were selected for nonoperative management based on shared decision making. There were 80 patients that healed with adequate data. The receiver operating characteristic (ROC) had best fit with a sagittal radiographic angle of 10° (AUC: 0.731) and coronal angle of 15° (AUC: 0.580) at 1-year follow-up. We found increased or worse disabilities of the arm, shoulder and hand (DASH) scores with > 10° sagittal alignment or > 15° of coronal alignment. Poor DASH scores were observed at angles lower than previously accepted for nonoperative treatment. These findings are useful in decision making and patient guidance. (Journal of Surgical Orthopaedic Advances 30(2):073-077, 2021).

Early to midterm radiographic loosening of the press fit radial head prosthesis.

BACKGROUND: Radiographic loosening is frequently seen around the radial head (RH) implant. The hypothesis of this study was that radiographic loosening will be more frequent in patients in which the RH prosthesis was implanted due to elbow trauma leading to instability that required lateral collateral ligament repair (LCL). MATERIALS AND METHODS: A retrospective review of the patients who had RH implantation between 2012 and 2019 was performed. Evaluation included evidence of radiographic loosening, stress shielding, formation of heterotopic ossification, and rate of removal of the implant. Range of motion of the elbow at the latest follow up was also recorded. RESULTS: At a mean follow up of 18 months (range 1.4 - 80) eight out of 25 patients had radiographic loosening around the implant. The radial head implant was removed in 8 patients (in 3 due to painful radiographic loosening, in 4 due pain without radiographic loosening and in 1 due to infection). Radiographic loosening around the RH implant had no association with LCL repair (p=0.18) or future removal of implant (p=0.18) or the diagnosis of Monteggia lesion (p=0.68). In addition, removal of the RH implant had no association with prior LCL repair (p=0.60) or the diagnosis of Monteggia lesion (p=0.15). Stress shielding was seen in 5 patients and was of no clinical significance. Heterotopic ossification was seen in 12 patients and was classified as Class I in 3, IIA in 3, IIC in 6, according to the Hastings Classification. The average flexion-extension arc was 23° to 130°, and average pronation-supination was 76° to 69°. CONCLUSION: One third of the patients had radiographic loosening around the RH implant at a mean follow up of 18 months. Pain with or without radiographic loosening were the main reasons for removal of the implant. No associations were found between the development of radiographic loosening and LCL repair at the time of RH replacement. Limitations of this study are: (a) the retrospective design (b). the small sample size and the possibility of a type II statistical error.

Economic impact of orthopaedic care for non-fatal gunshot wounds: analysis of a public health crisis.

BACKGROUND: The purpose of this study was to perform an epidemiological evaluation and an economic analysis of 90-day costs associated with non-fatal gunshot wounds (GSWs) to the extremities, spine and pelvis requiring orthopaedic care in the United States. METHODS: A retrospective epidemiological review of the Medicare national patient record database was conducted from 2005 to 2014. Incidence, fracture location and costs associated where evaluated. Those patients identified through International Classification of Disease (ICD)-9 revision codes and Current Procedural Terminology (CPT) Codes who sustained a fracture secondary to a GSW. Any type of surgical intervention including incision and drainage, open reduction with internal fixation, closed reduction and percutaneous fixation, etc. were identified to analyze, and evaluate costs of care as seen by charges and reimbursements to the payer. The 90-day period after initial fracture care was queried. RESULTS: A total of 9,765 patients required surgical orthopaedic care for GSWs. There was a total of 2,183 fractures due to GSW treated operatively in 2,201 patients. Of these, 22% were femur fractures, 18.3% were hand/wrist fractures and 16.7% were ankle/foot fractures. A majority of patients were male (83.3%) and under 65 years of age (56.3%). Total charges for GSW requiring orthopedic care were $513,334,743 during the 10-year study period. Total reimbursement for these patients were $124,723,068. Average charges per patient were highest for fracture management of the spine $431,021.33, followed by the pelvis $392,658.45 and later by tibia/fibula fractures $342,316.92. CONCLUSIONS: The 90-day direct charges and reimbursements of orthopedic care for non-fatal GSWs are of significant amounts per patient. While the number of fatal GSWs has received much attention, non-fatal GSWs have a large economic and societal impact that warrants further research and consideration by the public and policy makers.

Technical Trick: Dual Plate Fixation of Periprosthetic Distal Femur Fractures.

SUMMARY: Treatment of periprosthetic distal femur fractures remains challenging due to assuring adequate distal fixation. Traditional treatment options include lateral locked plating and retrograde nailing, although recently dual implant constructs have been explored with promising results. Allowing immediate weight-bearing in this patient population has benefits with regards to rehabilitation and outcome. Recent literature has focused on nail-plate constructs, however plate-plate constructs are preferred at our institution as they do not require arthroplasty component compatibility, facilitate the coronal plane reduction, and allow for immediate weight-bearing.

Newer generation of proximal tibia locking plates demonstrate large variability in their ability to capture the posteromedial fragment in bicondylar tibial plateau fractures.

INTRODUCTION: The early generations of proximal tibial locking plates demonstrated inferior results when compared to dual plating in bicondylar tibial plateau fractures with posteromedial fragments (PMF). Modern plates have multiple rows of locking screws and variable angle technology -which tote the ability to capture the PMF. The purpose of this study was to determine if the modern plates could capture the PMF in a large series of bicondylar tibial plateau fractures. MATERIALS & METHODS: Axial computer topography (CT) scans of 114 bicondylar tibial plateau fractures with PMF were analyzed. Five proximal tibia locking plates-in seven total configurations-were applied to radiopaque tibiae models. All possible screws were placed. Templates of screw trajectories were created based on the model CT scans. These were superimposed onto patient CT scan images to assess for screw penetration into the PMF. Number of screws fully within the PMF were recorded. Capture of the PMF was defined as having at least two screws within the fragment. RESULTS: On average, all plates were able to capture 81.6% of PMF with an average of 3.77 [95% Confidence Interval (CI): 3.47-4.07] screws. However, their ability to capture all fragments varied greatly, from 55.7%-95.2% in fixed angle constructs. Overall, variable angle constructs had a significantly higher capture rate (98.5% vs. 74.9%; p<0.0001) and more screws in the PMF (5.88 [95% CI: 5.58-6.17] vs 2.93 [95% CI: 2.62-3.24]; p<0.0001) when compared to fixed angle constructs. CONCLUSION: Newer generation locking plates vary greatly in their ability to capture the PMF. Variable angle technology dramatically increases the ability to capture the majority of PMFs. Prior biomechanical and clinical studies may yield substantially different results if repeated with these newer implants. Use of newer generation locked plates should not replace thorough preoperative planning.

Reconstruction of Distal Humerus Fractures with Severe Bone Loss: A Case Series and Review of the Literature.

The objective of this study was to describe examples and review the literature of distal humerus fracture reconstruction in the setting of severe bone loss. Four individuals (ages 19-59 years) were treated with either fibular strut allograft or fresh frozen osteochondral allograft in the setting of unreconstructable periarticular bone loss. The radiographs were evaluated for evidence of union. Pain and degrees of range of motion were reported when available. The follow-up period ranged from 3 to 42 months. While additional surgery was often needed, union was ultimately obtained in each case. Normal range of motion was not obtained, but two of the four patients were near normal upon union. Two of the four patients were pain free, and the other two had mild pain. All were limited in their activities, even after union. This case series describes satisfactory results with the use of allograft in this difficult clinical problem. (Journal of Surgical Orthopaedic Advances 29(2):65-72, 2020).