Knee Arthrodesis Using Dual-Plate Construct is Following Failed Distal Femur Megaprosthesis-A Case Report.

Introduction: Knee arthrodesis following failed total knee arthroplasty is a viable limb salvage option, and this procedure is reserved for failed two-stage revision surgery in severe comorbid patients with irreparable extensor mechanism disruption, severe instability, and extensive soft tissue loss. Knee arthrodesis using a dual-plate construct has been scarcely reported. We report a case of knee arthrodesis using a dual-plate construct in a male in his 20s who presented to us with a broken distal femur megaprosthesis. Case Report: An anterior midline incision was given. The cement mantle and broken prosthetic components were removed. The bone surfaces were freshened up and fixed using two orthogonal locking plates. After 4 months, there was a solid fusion in the knee, and the patient started walking independently with a short limb gait. The patient was advised limb lengthening for a shortening of 3 cm, but he denied it and managed with a shoe raise. After 4 years, he was pain free, and radiographs revealed a solid knee fusion. The patient was fully satisfied with the procedure, and he resumed manual work. Conclusion: This case report revealed that knee arthrodesis using a dual-plate construct is an economically viable salvage option for failed distal femur megaprosthesis.

Risk of reverse golf club deformity with medial plating of distal femur fracture.

INTRODUCTION: This study described a deformity induced by medial plating of supracondylar distal femur fractures using plates that are precontoured for other anatomic locations. MATERIALS AND METHODS: OTA/AO 33A fractures were created in 12 sawbone femurs and fixed with either a proximal humerus locking plate (PH), an ipsilateral lateral tibial plateau plate (LTP), or an ipsilateral medial distal tibial plate (MDT). A motion capture system measured changes in length and rotation of the distal femur as the plate was applied. Each plate underwent four trials and the mean and standard deviation (SD) for each measurement was reported. An analysis of variance with post hoc Tukey test compared malreduction measures between plate types. RESULTS: All plates consistently created a varus deformity. There was lateral lengthening with a compensatory medial shortening and an increase in the lateral distal femoral angle. The distal fracture fragment was laterally translated, and internally rotated. The PH plate had significantly greater lateral length (27.39 mm SD 4.78, p = 0.007), shorter medial length (13.57 mm SD 4.99, p = 0.028), greater lateral translation (28.82 mm SD 5.70, p = 0.010) and greater widening of the lateral distal femoral angle (28.54° SD 4.98, p < 0.001) than the LTP and MDT plates. The MDT plate had significantly greater angulation anteriorly (8.40° SD 1.07, p < 0.001) and laterally (7.63° SD 3.10, p = 0.002) than the PH and LTP plates. There was no significant difference between plates in internal rotation (PH: 3.07° SD 2.79; LTP: 2.05° SD 1.05; MDT 3.81° SD 3.56; p = 0.659). CONCLUSION: When dual plating supracondylar distal femur fractures, poor plate positioning and a mismatch between plate contour and the slope of the medial distal femur can lead to varus angulation, internal rotation, and lateral translation or a "reverse golf club deformity". After comparing three types of precontoured plates, the authors recommend initial evaluation of the ipsilateral proximal tibial plate when placing a plate along the medial distal femur. LEVEL OF EVIDENCE: IV.

Does the type of medial plate fixation matter for supplemental fixation of distal femur fractures manage with a lateral pre-contoured locked plate? A Biomechanical study.

INTRODUCTION: Fixation of distal femur fractures with a lateral pre-contoured locking plate provides stable fixation and is the standard treatment in most cases, allowing early range of motion with a high rate of union. However, in situations, the stability achieved with the lateral plate alone may be insufficient, predisposing to fixation failure. The objective of the study was to compare, in synthetic bone models, the biomechanical behaviour of the fixation with a distal femur lateral pre-contoured locking plate solely and associated with a 3.5 mm proximal humeral locking plate applied upside down or a 4.5 mm helical locking compression plate on the medial side. MATERIAL AND METHODS: A total of 15 solid synthetic left femur samples were used. A metaphysical defect at the level of the medial cortex was simulated. The samples were randomly distributed into three groups equally. All groups received a 4.5/5.0 mm single lateral 9-hole distal femur lateral pre-contoured locking plate. Group 1 had no supplementary plate. Group 2 received a supplementary 6-hole 3.5 mm proximal humeral locking plate and Group 3 received a supplementary 4.5/5.0 mm helical 14-hole narrow locking compression plate. RESULTS: Both supplementary plate types used in groups 2 and 3 contributed to increase the apparent stiffness of the construct, but pairwise comparison showed statically significant difference only between group 1 and 3. No significant difference was observed between groups 2 and 3. CONCLUSION: Both supplementary plates might be considered for improving the fixation in distal femur fracture in selected cases.

New generation of superior single plating vs. low-profile dual minifragment plating in diaphyseal clavicle fractures: a biomechanical comparative study.

BACKGROUND: Recently, a new generation of superior clavicle plates was developed featuring the variable-angle locking technology for enhanced screw positioning and a less prominent and optimized plate-to-bone fit design. On the other hand, minifragment plates in dual plating mode have demonstrated promising clinical results. The aim of the current study was to compare the biomechanical competence of single superior plating using the new-generation plate vs. dual plating using low-profile minifragment plates. METHODS: Sixteen paired human cadaveric clavicles were pairwise assigned to 2 groups for instrumentation with either a superior 2.7-mm variable-angle locking compression plate (group 1), or with one 2.5-mm anterior combined with one 2.0-mm superior matrix mandible plate (group 2). An unstable clavicle shaft fracture (AO/OTA 15.2C) was simulated by means of a 5-mm osteotomy gap. Specimens were cyclically tested to failure under craniocaudal cantilever bending, superimposed with bidirectional torsion around the shaft axis, and monitored via motion tracking. RESULTS: Initial construct stiffness was significantly higher in group 2 (9.28 ± 4.40 N/mm) compared to group 1 (3.68 ± 1.08 N/mm), P = .003. The amplitudes of interfragmentary motions in terms of axial and shear displacement, fracture gap opening and torsion, over the course of 12,500 cycles were significantly higher in group 1 compared to group 2, P ≤ .038. Cycles to 2 mm shear displacement were significantly lower in group 1 (22,792 ± 4346) compared to group 2 (27,437 ± 1877), P = .047. CONCLUSION: From a biomechanical perspective, low-profile 2.5/2.0-mm dual plates could be considered as a useful alternative for diaphyseal clavicle fracture fixation, especially in less common unstable fracture configurations.

Supplementary medial plating in revision surgery for distal femoral fractures: A surgical technique with clinical outcomes.

INTRODUCTION: Distal femur fractures (DFF) are common, especially in the elderly and high energy trauma patients. Lateral locked osteosynthesis constructs have been widely used, however non-union and implant failures are not uncommon. Recent literature advocates for the liberal use of supplemental medial plating to augment lateral locked constructs. However, there is a lack of proprietary medial plate options, with some authors supporting the use of repurposing expensive anatomic pre-contoured plates. The aim of this study was to investigate the feasibility of an effective, readily available medial implant option. METHODS: A retrospective analysis from January 2014 to August 2023 was performed on DFF requiring revision open reduction internal fixation (rORIF) with supplemental medial plating with a Large Fragment Locking Compression Plate (LCP) T-Plate via a medial sub-vastus approach. The T-plate was contoured and placed superior to the medial condyle. A combination of 4.5 mm cortical, 5 mm locking and/or 6.5 mm cancellous screws were used, with oblique screw trajectories towards the distal lateral cortex of the lateral condyle. The primary outcome was union rate. RESULTS: This technique was utilised on fifteen patients. The mean age was 55±15 (range 23-81); 73 % of cases were male and the median follow-up was 61 weeks (IQR 49-87). The two most common fracture patterns were AO/OTA 33-C3 (n = 5) and 33-A3 (n = 4), and three patients had open fractures. The union rate was 93 % (14/15), with a median time to union of 29 weeks (IQR 18-49). There were two complications: a deep infection requiring two debridements and locally eluding antibiotic insertion, and a prominent screw requiring removal; both patients achieved union. The median range of motion was 0° (IQR 0-5) of extension and 100° (IQR 90-120) of flexion. CONCLUSION: Supplemental medial plating of DFF with a Large Fragment LCP T-Plate is a feasible, safe, and economical option for rORIF. Further validation on a larger scale is warranted, along with considerations to developing a specific implant in line with these principles.

Dual plate fixation of proximal humerus fractures: Retrospective review and surgical technique.

Introduction: Recent interest has been directed towards dual plate fixation for comminuted proximal humerus fractures, with an aim to improve construct stability and thus improve patient outcomes while decreasing the risk of fracture-associated complications. We present our experience with this technique in a case series of patients with proximal humerus fractures and describe our surgical technique. Methodology: This was a single-center retrospective case series of patients presenting with an acute (<6 weeks) proximal humerus fracture who underwent ORIF with dual plating fixation. Patient, fracture, and surgical data were collected. All patient outcomes were evaluated using Constant-Murley shoulder score and Single Assessment Numeric Evaluation. Results: Our series included nine patients with a mean age of 46.2 years (range: 27-70 years old). All fractures healed within 4 months and no complications were encountered. At 1 year follow-up, the mean SANE score was 69.4% and the mean Constant Murley shoulder score was 78.9 (range: 70-96). Conclusion: Our current series shows that applying the dual plating technique in severely comminuted proximal humerus fractures provides adequate fixation and thus good patient outcomes. Further research is required before this technique can be strongly recommended for management of these complex fractures. Level of Evidence: Level 5.

Dual Mini-Fragment Plate Fixation of Midshaft Clavicle Fractures Reduces Risk of Reoperation Compared With Single-Plate Fixation Techniques.

BACKGROUND: Recent studies have highlighted dual plating as a method of reducing high rates of postoperative complication after operative management of displaced midshaft clavicular fractures. However, few studies have reliably characterized reoperation rates and magnitude of risk reduction achieved when using dual versus anterior and superior single-plate techniques. HYPOTHESIS: There would be lower rates of reoperation among patients who underwent open reduction and internal fixation (ORIF) of displaced midshaft clavicular fractures via dual plating. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This was a retrospective analysis of patients who underwent ORIF for a displaced midshaft clavicular fracture between 2010 and 2021 at a level 1 trauma center with a minimum 12-month follow-up. Patients were separated into 3 cohorts based on fixation type: (1) orthogonal dual mini-fragment plate fixation, (2) superior plate fixation, and (3) anterior plate fixation. Data on patient characteristics, fracture pattern, and reoperations were documented. All-cause reoperation rates and hazard ratio (HR) estimates of dual, superior, and anterior plating were calculated using a multivariate multilevel mixed-effects parametric survival model. Significant confounders including high-risk fracture morphology and smoking status were controlled for in the final model. RESULTS: A final cohort of 256 patients was identified with mean follow-up of 4.9 ± 3.8 years. In total, 101 patients underwent superior plating, 92 underwent anterior plating, and 63 underwent dual plating. Overall, 31 reoperations took place (18 in superior, 12 in anterior, 1 in dual plating) among 22 patients. Major contributors to reoperation included symptomatic hardware (n = 11), nonunion (n = 8), deep infection (n = 7), and wound dehiscence (n = 2). Superior plating revealed the highest reoperation rate of 0.031 per person-years, followed by anterior plating with 0.026 per person-years and dual plating with 0.005 per person-years. Overall, single plating (either anterior or superior placement) had a nearly 8-fold greater risk of reoperation than dual plating (HR, 7.62; 95% CI, 1.02-56.82; P = .048). Further broken down by technique, superior plating had an 8-fold greater risk of reoperation than dual plating (HR, 8.36; 95% CI, 1.10-63.86; P = .041), but anterior plating did not demonstrate a statistically significant difference compared with dual plating (HR, 6.79; 95% CI, 0.87-52.90; P = .068). CONCLUSION: Dual-plate fixation represents an excellent treatment for displaced midshaft clavicular fractures, with low rates of nonunion and reoperation. When compared with single locked superior or anterior plate fixation, dual mini-fragment plate fixation has a nearly 8-fold lower risk of reoperation.

Our Experience with Posterior Approach for Posterior Tibial Plateau Fractures.

Introduction: Posterior tibial plateau fractures are a rare type of fractures. Most surgeons are accustomed to operate in the supine position, however, surgery in the posterior knee region and operating in prone position can be challenging because of the presence of neurovascular structures including the tibial nerve, popliteal artery and vein, common peroneal nerve and, also challenging to achieve effective reduction and fixation, thus, it is less commonly performed. Materials and methods: Between February and September 2022 four posterior tibial plateau fractures were diagnosed and operated in our clinic within a six months follow-up (2 female and 2 male with mean age of 48.5 years). All were diagnosed with X-rays and CT scans. All of the fractures were on the right leg. Posterior "S shape" approach in prone position was used to reduce the tibial condyle and fix it with a plate. In fracture patterns that include lateral plateau impressions, the posterior "S shape" approach may not be sufficient to perform open reduction and internal fixation of the lateral condyle, so an additional anterolateral approach was made and additional locking plate was placed. Radiographic evaluation included reduction quality and satisfactory alignment of the bone axis. Results: All fractures healed within 6 months, without secondary displacement. Throughout the follow-up period, there were no incidences of post-traumatic osteoarthritis of the knee. No patient complained of knee instability. Conclusion: The direct dorsal approach allowed for adequate open reduction and internal fixation, and early clinical results are promising. However, in fracture patterns that include lateral plateau impressions, the posterior "S shape" approach may not be sufficient to perform open reduction and internal fixation of the lateral condyle, so an additional anterolateral approach should be made and additional locking plate to be placed.

Clinical and Radiological Outcome of Dual Plating for Proximal Humerus Fractures.

Introduction Proximal humerus fractures account for approximately 4%-5% of all fractures. It accounts for approximately 45% of all humeral fractures. Proximal humerus fractures which are mostly stable or minimally displaced fractures are usually managed non-operatively with good outcomes. Displaced or unstable fractures may require reduction and stabilization. For proximal humerus fractures, conservative treatments often result in stiffness and malunion of the shoulder. In comminuted proximal humerus fractures the use of a proximal humeral internal locking system (PHILOS) only does not provide the required stable fixation which usually leads to complications such as varus collapse, malunion, anterior-posterior angulation, screw cutout, metal failure and nonunion and thus open reduction and internal fixation with dual plating are recommended for proximal humerus fractures. Material and methods The Institutional Ethics Committee of Dr. D. Y. Patil Vidyapeeth in Pune approved this prospective study. We included a sample size of 52 patients and conducted a study on these patients who were admitted under the Orthopedics department at Dr. D. Y. Patil Medical College and Hospital, Pune. Results In this study, 52 patients were treated with dual plating for proximal humerus fracture, an additional plate is used along with PHILOS. In our study, the majority of the study population belonged to > 50 years (34.6%), followed by 41-50 years (26.9%), 31-40 years (23.1%), and 21-30 years (15.4%). The mean age of the patient was 53.7 years including 33 male and 19 female patients. The majority of the patient in the study included was with RTA 40 patients and 12 patients with a history of falls from height. The fracture was classified using Neers classification, Neer type 2 fracture (23.1%), Neer type 3 fracture (46.2%), and Neer type 4 fracture (30.7%). In the current study, the mean DASH score at Baseline was 58.88±6.29, at three months was 36.23±5.05 and at six months was 31.85±4.16. The mean DASH score decreased significantly from baseline to three months to 6 months. As per the Paavolainen method, it was good among 40 (76.9%) and fair among 10 (19.2%), and poor among two (3.8%) cases. Out of 52 patients, we found varus collapse in immediate postop x-ray in two patient and screw protrusion in the glenohumeral joint in one patient. Conclusion Satisfactory clinical and radiological outcomes were noted. This dual mechanism prevents varus displacement of the proximal fragment, and as a result, it provides a good functional outcome with dual plates in proximal humerus fractures.

Medial and lateral dual plating of native distal femur fractures: a systematic literature review.

Introduction: Lateral locked plating (LLP) development has improved outcomes for distal femur fractures. However, there is still a modest rate of nonunion in fractures treated with LLP alone, with higher nonunion risk in high-energy fractures, intra-articular involvement, poor bone quality, severe comminution, or bone loss. Several recent studies have demonstrated both the safety and the biomechanical advantage of dual medial and lateral plating (DP). The purpose of this study was to evaluate the clinical outcomes of DP for native distal femoral fractures by performing a systematic review of the literature. Methods: Studies reporting clinical outcomes for DP of native distal femur fractures were identified and systematically reviewed. Publications without full-text manuscripts, those solely involving periprosthetic fractures, or fractures other than distal femur fractures were excluded. Fracture type, mean follow-up, open versus closed fracture, number of bone grafting procedures, nonunion, reoperation rates, and complication data were collected. Methodologic study quality was assessed using the Coleman methodology score. Results: The initial electronic review and reverse inclusion protocol identified 1484 publications. After removal of duplicates and abstract review to exclude studies that did not discuss clinical treatment of femur fractures with dual plating, 101 potential manuscripts were identified and manually reviewed. After final review, 12 studies were included in this study. There were 199 fractures with average follow-up time of 13.72 months. Unplanned reoperations and nonunion occurred in 19 (8.5%) and 9 (4.5%) cases, respectively. The most frequently reported complications were superficial infection (n = 6, 3%) and deep infection (n = 5, 2.5%) postoperatively. Other complications included delayed union (n = 6, 3%) not requiring additional surgical treatment and knee stiffness in four patients (2%) necessitating manipulation under anesthesia or lysis of adhesions. The average Coleman score was 50.5 (range 13.5-72), suggesting that included studies were of moderate-to-poor quality. Conclusions: Clinical research interest in DP of distal femoral fractures has markedly increased in the past few decades. The current data suggest that DP of native distal femoral fractures is associated with favorable nonunion and reoperation rates compared with previously published rates associated with LLP alone. In the current review, DP of distal femoral fractures was associated with acceptable rates of complications and generally good functional outcomes. More high-quality, directly comparable research is necessary to validate the conclusions of this review.

Intraoperative Periprosthetic Fractures during primary Total knee arthroplasty: Experience from an Asian high-volume arthroplasty centre.

BACKGROUND: Intraoperative periprosthetic fracture (IF) is an under-reported complication in primary total knee arthroplasty (TKA). This study aimed to audit the outcomes and complication rates in patients encountering IF during primary TKA and propose a new classification for its management. METHODS: A nested case-control study was performed at a tertiary referral hospital where 50 patients encountering IF during primary TKA operated by a single surgeon team between January 2016 to May 2021, were compared with 150 (3:1) age-, gender- and implant-matched patients not encountering IF. Demographic data, risk factors, outcomes and complications of both groups were compared at a minimum follow up of 1 year. RESULTS: The incidence of IF was 0.45%, with 44 fractures in the femur (88%), six (12%) in the tibia and none in the patella. Medial collateral ligament avulsion fracture (54.54%) in the femur and medial plateau fracture (66.66%) in the tibia were the most common fracture types. At final follow up, the fracture group had higher rates of 90-day re-admissions (8% vs. 2.66%, P = 0.095), deep infection (4% vs. 0.66%, P = 0.15) and revisions (6% vs. 1.33%, P = 0.06). The mean Knee Society Score was not significantly different between the two groups (152.22 ± 9.25 vs. 161.68 ± 11.22, P = 0.642) with union being achieved in all but one patient at a mean duration of 9.6 weeks. CONCLUSIONS: Patients with severe and fixed deformities have a higher risk for IF. The occurrence of fracture and the complexity of surgery equally contribute to the higher complication rates. Appropriately managed fractures have comparable functional outcomes.

Study of Clinical Results and Functional Outcome of Patients With Distal Femur Fracture Treated With Dual Plating.

Introduction Distal femur fracture has been routinely fixed with a single lateral locking plate. This method of fixation in intra-articular distal femur fractures has proved to give a higher outcome of varus collapse as well as higher rates of mal-union due to inadequate fixation of the medial aspect of the distal femur. To address this drawback of single lateral plating, the use of medial assisted plating (MAP) has been introduced recently, which was proposed to give better stability to the medial fragments. This Is a prospective case series of 50 patients with distal femur fractures treated with dual plating. Materials and methods Fifty cases of patients with distal femur fractures were treated with dual plating between August 2020 and September 2022. Patients were followed up postoperatively till the third month, when patients were assessed clinically and radiologically. Range of motion of the knee, postoperative fracture displacement, limb shortening, and signs of union and infection were checked. Neer's scoring and Kolmet's scoring were used to grade the outcome for the patients.  Results The mean age of the patients was 39. Only 12% of the cases were open fractures. Eighty-four percent of the cases did not have fixed flexion deformity (FFD) and only 4% had FFD of 15 degrees; 72% of the cases achieved flexion of the knee beyond 120 degrees. Eighty-four percent of patients had normal walking ability by the 12th week postoperatively; 16% of the cases had a postoperative displacement of more than 1.6 cm, with the maximum being 2.5 cm.  Conclusion From the study, we have concluded that outcomes were better for fractures of distal femur when treated with dual fixation, probably due to superior fixation and earlier postoperative mobilization.

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.

Double Plating for Complex Proximal Humeral Fractures: Clinical and Radiological Outcomes.

Double plating for proximal humeral fractures (PHF) is an option to increase the primary fixation stability. Clinical data is missing for assessment of clinical and radiological outcome, as well as complications. We retrospectively examined 35 patients with unilateral PHF, who were treated with double plating for PHF between 2013 and 2019. The mean age was 59.5 ± 12 years and the leading fracture type was a varus dislocation (Resch type IV in 55.3%). A head-split was present in 22.9% of the cases. The primary outcome measurement was the radiological neck shaft angle (NSA). The radiological follow-up was 21 ± 16.6 months and the NSA did not differ between the intraoperative and follow-up time point (131.5 ± 6.9° vs. 136.6 ± 13.7°; p = 0.267). The clinical follow-up was 29.5 ± 15.3 months. The Constant-score was 78.5 ± 17 points, the simple-shoulder-test (SST) was 9.3 ± 3.2 points and the subjective shoulder value (SSV) was 78.8 ± 19.5%. The over-all complication rate was 31.4%, and without stiffness 14.3%. An avascular necrosis occurred in two patients (5.7%). In conclusion, this study shows good radiological and functional outcomes after double plating of highly complex proximal humeral fractures, while the complication rate is comparable to the literature. Double plating is a viable option especially for younger patients with complex fractures as a potential alternative to fracture arthroplasty.

Minimally invasive dual plating of a complex femoral fracture; a case report.

Complex femur fractures are defined as combined fractures of shaft and proximal or the distal femur. It usually occurs in young adults due to high energy trauma. Treatment of this type of fracture is challenging. Herein, we present the management of multi-level complex femoral fracture in 38 years old using minimally invasive overlapping dual plating with bridge proximal femoral locking plate from above and distal femoral locking plate from below. Favourable clinical and radiologic outcomes were observed. The result demonstrates dual plating of complex femoral fracture using MIPO could be considered as a suitable treatment option for complex femoral fracture.

Preventing varus collapse in proximal humerus fracture fixation: 90-90 dual plating versus endosteal fibular allograft strut.

INTRODUCTION: Screw cut out and varus collapse are the most common complication of locked plate fixation of proximal humerus fractures. The purpose of this study was to compare dual plating and endosteal fibular allograft struts as augmentation strategies to prevent varus collapse. MATERIALS AND METHODS: A trapezoidal osteotomy was created at the metaphysis to create a 2-part proximal humerus model in 18 paired shoulder specimens. Each specimen was assigned to group A, B, or C and was fixed with either a lateral locking plate, a lateral locking plate and anterior one-third tubular plate in an orthogonal 90/90 configuration, or a lateral locking plate with intramedullary fibular strut, respectively. The specimens were stressed in axial compression to failure. Displacement, elastic limit, ultimate load, and stiffness were recorded and calculated. RESULTS: There was no difference in mean cyclic displacement between the three groups (0.71 mm vs 0.89 mm vs 0.61 mm for Group A, B, C, respectively). Lateral plating demonstrated the greatest absolute and relative displacement at the elastic limit (5.3 mm ± 1.5 and 4.4 mm ± 1.3) without significance. The elastic limit or yield point was greatest for fibular allograft, Group C (1223 N ± 501 vs 1048 N ± 367 for Group B and 951 N ± 249 for Group A) without significance. CONCLUSIONS: Dual plating of proximal humerus fractures in a 90-90 configuration demonstrates similar biomechanical properties as endosteal fibular strut allograft. Both strategies demonstrate superior stiffness to isolated lateral locked plating.

Novel classification system for periprosthetic distal femoral fractures: a consideration for comminution.

PURPOSE: Comminution is an aspect of periprosthetic distal femoral fractures (PDFFs) that can influence postoperative outcomes and treatment selection, but is not included in current classification systems. We propose a new classification system for PDFFs based on comminution and cortical reads. This study aims to prove its reliability and efficacy to predict fracture severity and guide treatment. METHODS: A retrospective chart review of patients treated with single or dual locking plates for PDFFs was performed. Two fellowship-trained orthopedic joint reconstruction specialists used available imaging to classify each PDFF as either type 1 (minimal or no comminution allowing for reconstruction of medial and lateral cortices), type 2 (comminution reasonably allowing for reconstruction of either medial or lateral cortex), and type 3 (extensive comminution not allowing reasonable reconstruction of medial or lateral cortex). Each PDFF was then analyzed for radiographic outcomes including lateral distal femoral angle (LDFA) and the posterior distal femoral angle (PDFA). RESULTS: Interobserver reliability assessed by Cohen's Kappa statistic was 0.707, and average intraobserver reliability was 0.843, showing substantial reliability. Type 3 PDFFs had greater varus deformity than type 1 (p = 0.0457) or 2 (0.0198). CONCLUSION: The proposed classification system accounts for comminution, demonstrates strong interobserver and intraobserver reliability, and can be used to guide treatment in regard to single versus dual plating. LEVEL OF EVIDENCE: Retrospective comparative study, Level IV.

Supplementary Posteromedial Plating for the Fixation of Complex Tibial Plateau Fractures: A Prospective Study.

Introduction The management of complex tibial plateau fractures (CTPF) involving the posterior tibial plateau remains challenging and achieving maintenance of an axially stable construct with a single lateral locked plate is uncertain. Dual plating for such fractures via separate incisions can provide better fixation with superior clinical and radiological outcomes. This prospective study aimed to evaluate the results of the management of Schatzker type V and VI complex tibial plateau fractures using a conventional anterolateral plate along with a posteromedial buttress plate via two separate approaches and the potential complications associated with it. Methods Fifty-six patients presenting with tibial plateau fractures to the Department of Orthopaedics at a tertiary care center in the northern part of the state of Uttar Pradesh, India, between January 2018 and July 2022 were screened. Subsequently, 28 patients with CTPFs (AO/OTA types 41C1, 41C2, AND 41C3) were included in the study, managed with dual plating, and followed up for a duration of 12 months. The clinico-radiological outcome was assessed using Rasmussen's Functional Grading System (RFS), Oxford Knee Score (OKS), knee range of motion achieved, and Rasmussen's Radiological Scoring System (RRS), and statistical analysis of the data was performed. Results A total of 24 (85.71%) patients had excellent OKS and good to excellent RFS at the final follow-up. The average knee range of motion was 3.21° to 122°, with only two patients reporting an extensor lag of more than 10°. The final follow-up radiographs showed a mean medial proximal tibial angle (MPTA) of 83.98° ± 6.89 (75.44-89.21) and a mean posterior tibial plateau angle (PTPA) of 12.31 ± 4.69 (5.12 to 16.49) with the RRS showing excellent or good radiographic results with a mean score of 14.1 ± 1.7 (range 8-16). None of the patients showed signs of deep infection, whereas superficial infection was reported in two patients. A single case of secondary loss of particular reduction was seen. Conclusion Supplementary posterior buttress plating, along with the conventional anterolateral plate for the management of CTPF, achieves rigid fixation with superior articular reduction, a high knee score, a good range of motion, lower complication rates, and limited deformities with a good radiological outcome, with a few demerits of prolonged operative time, technically demanding procedure, increased blood loss, and a protracted hospital stay which can be minimized in most instances using minimally open reduction techniques and careful soft-tissue handling.

Modified use of the proximal humeral internal locking system (PHILOS) plate for distal femoral nonunions.

PURPOSE: Nonunion is a common complication after a distal femoral fracture (DFF). Standard treatment consists of revision plating and/or bone grafting. Single lateral plating for a distal femoral nonunion can be insufficient in case of a persistent medial gap and compromised bone stock. Alternatively, dual plating can be used to treat a distal femoral nonunion, but to date there is no Gold standard. The aim of our study was to report our results after use of a minimally invasively placed proximal humeral internal locking system (Philos) plate as a medial buttress in the treatment of a distal femoral nonunion. METHODS: Fifteen adult patients with a distal femoral nonunion were prospectively entered in a trauma database and retrospectively assessed. All patients underwent a similar operation, which included removal of failed hardware, nonunion debridement, fixation with a lateral plate, and a medial Philos plate combined with bone grafting. Data collected included union rate, time to union, complications and functional outcome. RESULTS: In twelve out of fifteen patients (80%), the fracture united after our index operation. Median time to union was 4.8 months (range 1.6-15). Three patients (20%) needed additional bone grafting surgery. One patient underwent a Judet quadricepsplasty. CONCLUSION: This study suggests that the Philos plate is a safe and effective adjunct as a medial buttress plate for distal femoral nonunions.