Construct failure after open reduction and plate fixation of displaced midshaft clavicular fractures.

INTRODUCTION: Worldwide, implants mostly used for fixation of displaced midshaft clavicular fractures (DMCF) are the easily to bend reconstruction plate and the stiffer small fragment locking compression plate. Construct failure rates after plate fixation of DMCF are reported around 5 percent. Possible risk factors for construct failure are implant type and fracture type. However, little is known about the influence of fracture fixation method on construct failure. The aim of this study was to assess construct failure in plate fixation of DMCF and to identify possible risk factors. METHODS: All consecutive patients treated in a level 1 trauma centre with open reduction and fixation of DMCF using a 3.5-mm reconstruction plate or 3.5-mm small fragment locking compression plate between 2007 and 2015 were evaluated. Potential risk factors for construct failure were analysed using univariate analysis. RESULTS: Two hundred and fifty-nine patients were analysed. Fifty DMCF (19%) were fixated with a reconstruction plate and 209 (81%) with a small fragment locking compression plate. Construct failure was seen in 18 patients (6.9%), including 5 broken plates and 13 with screw loosening. Eight percent of all reconstruction plates broke in contrast to 0.5 percent of all small fragment locking compression plates (p=0.001). All broken implants were used as a bridging plate. Loosening of screws was seen in older patients and when the plate was fixated with less than three bicortical screws on one side of the fracture (p=0.002). CONCLUSIONS: Overall construct failure after open reduction and plate fixation of DMCF occurred in 6.9 percent. Risk factors for plate breakage were the use of a reconstruction plate and a bridging method for fracture fixation. Risk factors for screw loosening were an increasing patient age and plate fixation with less than three bicortical screws on one side of the fracture. RECOMMENDATIONS: Based on the results of this study our recommendation is to use a small fragment locking compression plate for open reduction and internal fixation of DMCF. The surgeon should always strive to fixate the plate on both sides of the fracture with at least three bicortical screws.

A systematic review on dynamic versus static distal tibiofibular fixation.

BLACKGROUND: In the last couple of years dynamic fixation for syndesmosis injuries, using a suture-button technique, raised more interest due to its advantages over the static fixation. In the current systematic review suture-button fixation is compared to the traditionally applied static fixation in unstable ankle fractures accompanied with distal tibiofibular syndesmosis injury, including the functional outcome, post-operative complications, reoperation rate, recurrent diastasis and financial aspects. METHODS: A computerized literature search using PubMed/MEDLINE and EMBASE was conducted in search of suitable articles between January 2006 and February 2016. A total of 4 suture-button studies, 5 suture-button vs. static fixation studies and 1 study discussing the financial aspects were identified. RESULTS: The AOFAS of 104 patients treated with the suture-button device was 91.08 points with an average study-follow up of 24.85 months. The AOFAS of 106 patients treated with a static fixation device was 87.95 with an average follow-up of 24.78 months. Removal of the suture-button device was reported in 10.5% of 229 patients and removal of the screws in 38.5%. CONCLUSIONS: Dynamic fixation demonstrated to be a viable alternative to the static fixation device, with lower reoperation rates and less complications. They can accurately stabilize the ruptured syndesmosis without device breakage or loss of reduction. LEVEL OF EVIDENCE: 1A economic/decision.

[A swelling at the mandibular angle during occlusion]. / Een zwelling ter plaatse van de angulus mandibulae bij occlusie.

An 18-year-old Dutch man presented himself at the emergency department of a hospital, with a spontaneously arisen unilateral swelling at the mandibular angle during occlusion. No additional complaints were present and the patient had no previous experience of such swelling. After an assessment of the patient's history and diagnostic procedures, the swelling was diagnosed as a partial rupture of the masseter muscle fascia. On the basis hereof a conservative approach was selected, and the swelling subsequently disappeared.

Spontaneous rupture of the oesophagus: Boerhaave's syndrome in 2008. Literature review and treatment algorithm.

OBJECTIVE: Boerhaave's syndrome is a spontaneous rupture of the oesophagus with a lack of diagnostic and treatment consistency in the literature. Therefore, we reviewed all published literature in order to design a treatment algorithm based on the literature. STUDY DESIGN: A systematic literature review written in the English language since 1975. RESULTS: We reviewed all known literature. Treatment of the Boerhaave syndrome was divided into three categories: conservative, endoscopic and surgical approach. The survival rate of all treatments was 75, 100 and 81%, respectively. CONCLUSION: Boerhaave's syndrome should be treated endoscopically when diagnosed within 48 h and when there are no signs of sepsis. However, when a patient is diagnosed within 48 h and has a septic profile, thoracotomy with hemifundoplication and pleural/mediastinal drainage should be performed; and in case of intra-abdominal leakage, a laparotomy for local repair should be performed. When a patient is diagnosed after 48 h, conservative treatment should be followed and only when a patient gets a septic profile is surgical treatment indicated.