Clinical outcome of rim-plate-augmented separate vertical wiring with supplementary fixation for the treatment of patellar fracture associated comminuted inferior pole.

Despite the variety of treatment methods, comminuted inferior pole fractures of the patella remain difficult and technically demanding to achieve stable internal fixation. The purpose of this study is to evaluate the clinical outcomes of rim plate-augmented separate vertical wiring with supplementary fixation in the management of comminuted inferior pole fractures, AO/OTA 34-A1, C2, and C3, which has the secondary horizontal fracture line on lower articular boundary. From our study, bony union was achieved in all patients at an average of 3.1 ± 1.4 months after surgery. There was no patient with loss of reduction, fixation failure, or infection during follow-up. The average final range of motion was 131.6° ± 7.2°. Lysholm knee scores gradually increased over 3, 6, 9, and 12 months postoperatively by 58.7, 74.0, 82.9, and 89.4, respectively. Isokinetic peak torque deficit of the knee extensor muscles in 3, 6, 9, and 12 months postoperatively was 59.9%, 49.7%, 35.7%, and 28.1%, respectively. The rim plate-augmented separate vertical wiring with supplementary fixation for the treatment of patellar fracture associated comminuted inferior pole is effective and can be safely applied AO/OTA 34-C2 or C3 with favorable outcomes.

The Clinical Efficacy of Contouring Periarticular Plates on a 3D Printed Bone Model.

We report our experience of preoperative plate contouring for periarticular fractures using three-dimensional printing (3DP) technology and describe its benefits. We enrolled 34 patients, including 11 with humerus midshaft fractures, 12 with tibia plateau fractures, 2 with pilon fractures, and 9 with acetabulum fractures. The entire process of plate contouring over the 3DP model was videotaped and retrospectively analyzed. The total time and number of trials for the intraoperative positioning of precontoured plates and any further intraoperative contouring events were prospectively recorded. The mismatch between the planned and postoperative plate positions was evaluated. The average plate contouring time was 9.2 min for humerus shaft, 13.8 min for tibia plateau fractures, 8.8 min for pilon fractures, and 11.6 min for acetabular fractures. Most precontoured plates (88%, 30/34) could sit on the planned position without mismatch. In addition, only one patient with humerus shaft fracture required additional intraoperative contouring. Preoperative patient specific periarticular plate contouring using a 3DP model is a simple and efficient method that may alleviate the surgical challenges involved in plate contouring and positioning.

Radiographic rotational profiles of the proximal and distal humerus: analysis of 46 computed tomography scans with 3-dimensional simulation.

BACKGROUND: To date, no study has investigated the radiographic rotational profiles (RRPs) of the proximal and distal humerus. However, malrotation after minimally invasive surgery for humeral fracture has been an unsolved problem. Therefore, we aimed to investigate the RRPs of the proximal and distal humerus that linearly correlate with rotational status and show significant differences as the rotational status changes. METHODS: Forty-six computed tomography scans of the humerus were 3-dimensionally reconstructed, and 5 rotational statuses (20° and 10° of internal rotation; neutral; and 10° and 20° of external rotation) were simulated. Seven candidate RRPs of the proximal humerus and 4 candidates of the distal humerus were measured for each rotational status. The overall differences and trends in the RRPs as the rotational status changed were evaluated, and multiple comparisons were performed between the RRPs for each of the 5 rotational statuses. Moreover, the correlations between the RRPs and rotational status with adjustment of retroversion were analyzed. Finally, interobserver and intraobserver reliabilities were evaluated. RESULTS: The following proximal and distal RRPs were linearly correlated with rotational status, differed significantly between the rotational statuses, and showed a relatively low prediction error and excellent interobserver and intraobserver reliabilities: the distance from the tip of the lesser tuberosity to the lateral margin of the proximal humerus (PL1) and the medial margin of the head (PL2), as well as the PL1 to PL2 ratio (PRL), in the proximal humerus; and the distance from the medial margin of the olecranon process to the medial epicondyle (DOP), the widest width of the overlapped olecranon fossa (DOF), and the distance from the lateral margin of the capitellum to the lateral epicondyle (DC) in the distal humerus. CONCLUSION: Our findings suggest that PL1, PL2, and PRL in the proximal humerus and DOP, DOF, and DC in the distal humerus are potentially useful and reproducible RRPs for restoring the intrinsic rotational alignment in humeral fractures.

Outcome of multi-staged induced membrane technique based on post-debridement cultures for the management of critical-sized bone defect following fracture-related infection.

The authors' institution utilizes multi-staged induced membrane technique protocol based on post-debridement culture in treating patients with critical-sized bone defect in lower extremity due to infected nonunion or post-traumatic osteomyelitis. This study aimed to evaluate the success rate of this limb reconstruction method and which risk factors are associated with recurrence of infection. 140 patients were treated with multi-staged induced membrane technique from 2013 to 2018 and followed up more than 24 months after bone grafting. The primary success rate of limb reconstruction was 75% with a mean follow-up of 45.3 months. The mean Lower Extremity Functional Scale in success group improved from 12.1 ± 8.5 to 56.6 ± 9.9 after the treatment. There were 35 cases of recurrence of infection at a mean of 18.5 months after bone grafting. Independent risk factors for recurrence of infection were infected free flap, surprise positive culture, deviation from our surgical protocol, and elevated ESR before final bone graft procedure. In conclusion, this study showed that multi-staged induced membrane technique protocol based on post-debridement culture resulted in 75% success rate and revealed a number of risk factors for recurrence of infection.

The difference in the corridor of the antegrade posterior column screw according to the presence of pelvic dysmorphism.

INTRODUCTION: Antegrade posterior column screw (aPCS) fixation via the anterior approach has been widely used for separated the posterior columns in acetabular fracture treatment. Although the relationship between pelvic dysmorphism and sacroiliac screws has been widely studied, no studies have reported on the clinical impact of pelvic dysmorphism on acetabular fractures. This study aimed to reveal the difference in the insertion angle and entry point of aPCS between the dysmorphic and normal pelvises. METHODS: Patients diagnosed with unilateral acetabular fractures and who underwent pelvic computed tomography scans between 2013 and 2019 in two institutes were enrolled in this study. Patients were divided into the dysmorphic and control groups according to the sacral dysmorphic score, which predicts the presence of pelvic dysmorphism, and each group enrolled 130 patients. The semitransparent 3D hemipelvis model was reconstructed using a 3D reconstruction program. The sagittal and coronal angles of a virtual cylinder that fill the safe corridor of the column screw the most were measured. The surface area of the safe corridor and distance of the optimal entry point from the anterior border of the sacroiliac joint were analyzed. The measurements were compared between the dysmorphic and control groups. RESULTS: The average sacral dysmorphic score in the normal and dysmorphic pelvis groups was 56.1 and 81.0, respectively. There were no significant differences in demographic data, including age, sex, height, weight, and body mass index, between the dysmorphic and control groups. There was a significant difference in the average sagittal insertion angle of PCs, which was 38.3° in the control group and 27.2° in the dysmorphic group (P < 0.001). The coronal insertion angles were not significantly different. The dysmorphic group presented longer straight distances (25.9 vs 24.8 mm, P = 0.026) and had a smaller aPCS surface area (685 vs 757 mm2, P < 0.001) than the control group. CONCLUSION: The present study describes a difference in the corridor of aPCS between the dysmorphic and normal pelvis. Insertion of aPCS in the dysmorphic pelvis requires a more acute angular trajectory in the sagittal plane than that in the normal pelvis.

Stress fracture after implant removal from the tibia reconstructed by the induced membrane technique: A case report.

Background: The induced membrane technique promotes vascularization and corticalization of the grafted bone and has become one of the mainstays in treatment of segmental bone defects. However, there are clinical concerns regarding the quality of bony consolidation using the induced membrane technique including a thin cortex formation and cortical notching after consolidation. We present the case of a tibial stress fracture in the bone reconstructed by the induced membrane technique after implant removal. Case: A 49-year-old male presented post-traumatic osteomyelitis of the right tibia and was treated with staged segmental bone resection leading to an 11 cm defect which was reconstructed using the induced membrane technique. The patient requested implant removal at 33 months after bony consolidation. Four months after implant removal, he developed acute, atraumatic leg pain due to a tibial stress fracture caused by small notching in the reconstructed tibial segment. His stress fracture treated with intramedullary nailing and later healed uneventfully. Conclusion: Caution is warranted prior to implant removal from bone reconstructed by the induced membrane technique as cortical notching may result in stress fractures.

Effect of Recombinant Human Bone Morphogenetic Protein-2 (rhBMP-2) with Hydroxyapatite Carrier in Induced Membrane Technique: A Retrospective Propensity Score-Matched Study.

OBJECTIVES: To determine the effect of recombinant human bone morphogenetic protein-2 (rhBMP-2) with hydroxyapatite (HA) carrier augmentation in managing critical-sized bone defect (CSBD) with induced membrane technique (IMT). DESIGN: Retrospective comparative study. SETTING: Academic level I trauma center. PATIENTS/PARTICIPANTS: The study included 14 patients who underwent rhBMP-2 with HA carrier (rhBMP-2/HA) augmentation in IMT for managing CSBD (BMP group). Moreover, 14 patients who underwent IMT without rhBMP-2 augmentation were matched by propensity score analysis (non-BMP group). INTERVENTION: IMT with or without rhBMP-2/HA augmentation. MAIN OUTCOME MEASUREMENT: Changes in quality and quantity measurements of grafted bone to regenerated bone using serial computed tomography. RESULTS: In the BMP and non-BMP groups, the changes in densities from grafted bone to regenerated bone were +379.63 Hounsfield unit and +248.55 Hounsfield unit (P = 0.034), changes in dense bone percentage were +37.52% and +23.31% (P = 0.027), corticalization rates under the plate were 79.70% and 39.30% (P = 0.007), changes in volume were -20.77% and -23.35% (P = 0.812), union rates were 85.71% and 78.57% (P = 0.622), numbers of patients requiring additional procedures were 4 and 3 (P = 0.663), and time to union were 316.3 and 585.45 days (P = 0.040), respectively. CONCLUSIONS: RhBMP-2/HA augmentation increases the density of regenerated bone, enhances corticalization under the plate, and shortens the time to union while managing CSBD with IMT. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Multifragmentary patellar fracture has a distinct fracture pattern which makes coronal split, inferior pole, or satellite fragments.

The present study aimed to map the location and frequency of fracture lines on the coronal articular and sagittal planes in multifragmentary patellar fractures. 66 multifragmentary patellar fractures were digitally reconstructed using the 3D CT mapping technique. The coronal articular surface and midsagittal fracture maps were produced by superimposing each case over a single template. Each fracture line was classified based on the initial displacement and orientation. We evaluated the frequency and direction of the fracture line, coronal split fragment area, and satellite and inferior pole fragment presence. Coronal articular surface fracture mapping identified primary horizontal fracture lines between the middle and inferior one-third of the articular surface in 63 patients (95.4%). Secondary horizontal fracture lines running on the inferior border of the articular facet were confirmed (83.3%). Secondary vertical fracture lines creating satellite fragments were mostly located on the periphery of the bilateral facet. Midsagittal fracture mapping of primary and secondary horizontal fracture lines with the main coronal fracture line revealed a predominantly X-shaped fracture map. The consequent coronal split fragment and inferior pole fracture were combined in most cases. In conclusion, the multifragmentary patellar fracture has a distinct pattern which makes coronal split, inferior pole, or satellite fragments.

Proximal tibia with an inserted nail can be an available donor site for harvesting cancellous bone.

INTRODUCTION: A pre-existing implant at the harvesting site might dissuade the surgeon from considering the site as available for bone harvesting. This study aimed to investigate the quantity of cancellous bone graft that can be harvested from a proximal tibia with an inserted nail and to report the clinical outcomes of this bone graft harvesting technique. HYPOTHESIS: Our hypothesis was that a certain amount of cancellous bone graft could be harvested from a proximal tibia with an inserted nail without compromising the surrounding environment and outcome of nonunion treatment. MATERIAL AND METHODS: Bone grafting from an ipsilateral proximal tibia with an inserted nail was performed in 32 patients for treating defect nonunion. The amount of harvested bone was measured using three parameters (weight, height, and volume). The effects of the proximal locking screw position on the quantity and location of bone graft harvest were analyzed. Clinical outcomes were evaluated by assessing the radiologic healing of the bone graft site and by assessing the donor site complications. RESULTS: The mean bone defect volume in the nonunion site was 31.1±18.3 (range, 10.6-87.0) cm3. The mean quantity of harvested bone from proximal tibias with an inserted nail was 21.2g, height was 3.9cm, and volume was 26.3 cm3. A positive correlation was found between the quantity of harvested bone and the level of the lateral oblique interlocking screw hole in the tibial nail. All grafted bone successfully consolidated in all cases at an average of 5.8 months postoperatively. However, joint penetration during bone harvesting occurred in one case. DISCUSSION: The bony defect, which measured about 14.3 cm3 could be filled with cancellous bone from a PT with an existing IM nail, without additional bone graft requirements. Even if an intramedullary nail exists inside the proximal tibia, harvesting cancellous bone at this site can be a viable option without serious complications. LEVEL OF EVIDENCE: IV; Retrospective descriptive study.

Comparison of sliding distance of lag screw and nonunion rate according to anteromedial cortical support in intertrochanteric fracture fixation: A systematic review and meta-analysis.

INTRODUCTION: We compared the sliding distance of the lag screw, change in neck-shaft angle (NSA), and nonunion rates according to the anteromedial cortical support on anteroposterior (AP) and lateral view radiographs post intertrochanteric fracture reduction. MATERIAL AND METHODS: In this systematic review and meta-analysis, MEDLINE, Embase, and Cochrane Library databases were searched systematically for studies published before September 26, 2020. We performed synthetic analyses of the amount of lag screw sliding, change in NSA, and incidence of nonunion following reduction of intertrochanteric fractures by extramedullary reduction (EMR), neutral reduction (NR), and intramedullary reduction (IMR). The combined data of EMR and NR comprised the non-IMR group. RESULTS: Our study enrolled eight studies, representing 1,363 patients who underwent surgery for intertrochanteric fractures. A pooled analysis showed a larger sliding distance in the IMR group than in the non-IMR group (standard mean difference [SMD] = 1.47, 95% confidence interval [CI]: 0.73-2.20; P < 0.0001 and SMD = 1.27, 95% CI: 0.56-1.99; P = 0.0005, respectively) in both AP and lateral views. The pooled mean difference of change in NSA in the IMR group was -3.11° and differed significantly from that of the non-IMR group (95% CI: -4.07 to -2.16; P < 0.0001). In the lateral view, the nonunion rate was significantly higher in the IMR group than in the non-IMR group (odds ratio [OR] = 11.61; 95% CI, 3.32-40.62; P = 0.0001). In the subgroup analysis, the NR group showed a larger sliding distance than that of the EMR group in the AP view (SMD = 0.40, 95% CI: 0.04-0.76; P = 0.03); however, the reverse was true in the lateral view (SMD = 0.68, 95% CI: 0.38-0.97; P < 0.00001). CONCLUSION: In the current meta-analysis, larger sliding distances, more varus in NSA, and higher nonunion rates were observed in the IMR group than the non-IMR group, in both AP and lateral views. However, in the comparison between EMR and NR, it was difficult to conclude which of them was the ideal reduction method because of inconsistent results.

Which radiograph is most accurate for assessing hip joint penetration in infra-acetabular screw placement?

ABSTRACT: Although infra-acetabular screws have been used for anterior and posterior column transfixation, a screw penetrating the hip joint can result in harmful complications. However, the most accurate intraoperative radiologic imaging tool for identifying articular penetration has not been established. The purpose of the present study was, therefore, to evaluate the consistency with which standard pelvic radiographs compared with computed tomography (CT) can be used for demonstrating articular penetration.This retrospective review was performed between January 2015 and December 2020. We evaluated the records of patients with acetabular or pelvic fractures who underwent open reduction and internal fixation with infra-acetabular screw placement. We collected demographic data and described infra-acetabular screw placement as follows: ideal placement, articular penetration, and out of the bone. Articular penetration was assessed independently on each pelvic radiograph and compared statistically with the CT scans. Sensitivity, specificity, correct interpretation rate, and prevalence-adjusted bias-adjusted kappa (PABAK) were calculated for each radiograph.Thirty-nine patients underwent infra-acetabular screw placement. The mean age of patients was 55 years (range, 27-90 years); there were 29 men and 10 women. One patient underwent bilateral infra-acetabular screw placement; therefore, 40 infra-acetabular screws were included in total. Six (6/40, 15%) infra-acetabular screws showed articular penetration on CT and two (2/40, 5%) showed infra-acetabular screws extending out of the bone. Hip joint penetration was correctly identified at a rate of 92.5% (95% confidence interval [CI], 79.6-98.4%) on the outlet view and 87.5% (95% CI, 73.2-95.8%) on the anteroposterior (AP) view. The PABAK for the agreement between pelvic radiographs and CT scans was 0.85 in the outlet view and 0.75 in the AP view.The outlet view is an accurate method for detecting articular penetration of infra-acetabular screws. We recommend the insertion of an infra-acetabular screw under fluoroscopic outlet view to avoid articular penetration intraoperatively.

Mapping of acetabular posterior wall fractures using a three-dimensional virtual reconstruction software.

INTRODUCTION: The aim of this study was to analyze and describe the fracture patterns of the acetabular posterior wall based on quantitative measurements of the fracture characteristics. MATERIALS AND METHODS: Computed tomography images of 51 patients with acetabular posterior wall fractures from an initial cohort of 216 acetabular fractures were imported into a three-dimensional (3D) virtual software. The reconstructed 3D images were utilized to evaluate the following: (i) fracture line mapping on the inner articular and retro-acetabular surfaces, (ii) common zones of fracture and marginal impaction, and (iii) categorization by location and pattern of comminution. The clock-face position was applied for description: the midpoint of the transverse acetabular ligament served as the +180° reference point, and the 0° reference point was set perpendicular to the ligament. The fracture angle on the articular surface was defined as the intersection between the start and end points. The fracture span on the retro-acetabular surface was defined as the ratio of the perpendicular distance, which is between the fracture beak and acetabular rim, to the entire length, which is from the edge to the rim. Quantitative measurements were performed, and the fracture patterns were analyzed. A color scale bar was used to visualize the common and marginal impaction zones. RESULTS: The articular surface mapping of all the cases demonstrated that the average starting point of the fracture line was +6.2° (±12.8°) and the endpoint was 96.7° (±13.3°), and the average fracture angle was 119.6° (±7.6°) with 80.6% of the fragments having angles within 18.7-117°. The retro-acetabular surface mapping demonstrated that the average fracture span was 0.65 ±0.20, and 61.7 % of the fracture lines were located within 0.6 to 0.9. Marginal impaction was found in 21 cases (21/51, 41.2%; range: between +7° and +105°). CONCLUSION: The fracture maps showed fracture patterns and recurrent fracture zones on the articular and retro-acetabular surfaces. However, there was no remarkable pattern of marginal impaction. LEVEL OF EVIDENCE: Retrospective cohort study.

More weighted cancellous bone can be harvested from the proximal tibia with less donor site pain than anterior iliac crest corticocancellous bone harvesting: retrospective review.

BACKGROUND: Iliac crest is the most preferred autogenous bone graft harvesting donor site while it has sorts of complications like prolonged pain, hematoma, and fracture. Harvesting cancellous bone from proximal tibia is also increasingly being used because of lower complications and less donor site pain. However, there are lack of studies to compare these two donor sites in detail. Thus, we proposed to investigate the available amount of autogenous bone graft from the proximal tibia. METHODS: Fifty-one patients who underwent simultaneous bone graft harvest from the PT and the AIC to fill up the given critical sized bone defects were enrolled in this study. We prospectively collected data including the weight of the harvested bone, donor site pain using the visual analog scale (VAS) score, and complications between the two sites. RESULTS: The mean weight of cancellous bone harvested from the PT was greater than AIC (33.2g vs. 27.4g, p = 0.001). The mean VAS score was significantly lesser in the PT up to 60 days after harvesting (p < 0.001). There was persistent pain up to 90 days in four PT patients and in seven AIC patients. The major complication was reported only in AIC patients (11.8%). CONCLUSIONS: Harvesting cancellous bone from the PT is an acceptable alternative to the AIC for autogenous bone grafting owing to availability of more weighted graft bone and less donor site pain.

Usefulness of the obturator hook technique for guiding the initial trajectory control in infra-acetabular screw placement.

PURPOSE: Proper placement of infra-acetabular screws is technically demanding; there is a limited safe zone for screw fixation because of the complexity of the bone anatomy around the hip joint and the vulnerability of the major neurovascular bundles in the pelvic cavity. We aimed to present the obturator hook technique as a surgical technique for infra-acetabular screw placement in acetabular and pelvic fractures and report its radiological outcomes. METHODS: Patients treated with infra-acetabular screw placement using the obturator hook technique between January 2015 and August 2020 were enrolled in this study. We collected data on demographics, surgical approach, reduction status, complications, and outcomes. The radiological outcomes of infra-acetabular screw placement based on computed tomography findings were evaluated as follows: success, articular penetration, or out of the bone. RESULTS: Thirty-five patients underwent infra-acetabular screw placement (26 men, 9 women; mean age, 55 years; range, 27-90 years). One patient underwent bilateral infra-acetabular screw placement; therefore, 36 infra-acetabular screws were inserted in all patients. An ideal placement was achieved with 27 infra-acetabular screws (27/36, 75%). Seven infra-acetabular screws (7/36, 19%) showed articular penetration, and two infra-acetabular screws (2/36, 6%) were placed outside the bone. One patient with articular penetration and mechanical symptoms of the hip joint required screw replacement. No other complications, including obturator nerve and vascular injuries, were observed. CONCLUSION: The obturator hook technique could be a favorable and individualized method for infra-acetabular screw placement in patients with acetabular and pelvic fractures. LEVEL OF EVIDENCE: IV, retrospective descriptive study.

3D-printed, bioactive ceramic scaffold with rhBMP-2 in treating critical femoral bone defects in rabbits using the induced membrane technique.

Although autogenous bone grafts are an optimal filling material for the induced membrane technique, limited availability and complications at the harvest site have created a need for alternative graft materials. We aimed to investigate the effect of an rhBMP-2-coated, 3D-printed, macro/microporous CaO-SiO2 -P2 O5 -B2 O3 bioactive ceramic scaffold in the treatment of critical femoral bone defects in rabbits using the induced membrane technique. A 15-mm segmental bone defect was made in the metadiaphyseal area of the distal femur of 14 rabbits. The defect was filled with polymethylmethacrylate cement and stabilized with a 2.0 mm locking plate. After the membrane matured for 4 weeks, the scaffold was implanted in two randomized groups: Group A (3D-printed bioceramic scaffold) and Group B (3D-printed, bioceramic scaffold with rhBMP-2). Eight weeks after implantation, the radiographic assessment showed that the healing rate of the defect was significantly higher in Group B (7/7, 100%) than in Group A (2/7, 29%). The mean volume of new bone formation around and inside the scaffold doubled in Group B compared to that in Group A. The mean static and dynamic stiffness were significantly higher in Group B. Histological examination revealed newly formed bone in both groups. Extensive cortical bone formation along the scaffold was found in Group B. Successful bone reconstruction in critical-sized bone defects could be obtained using rhBMP-2-coated, 3D-printed, macro/microporous bioactive ceramic scaffolds. This grafting material demonstrated potential as an alternative graft material in the induced membrane technique for reconstructing critical-sized bone defects.

Clinical outcome of AO/OTA type C fracture of the distal humerus using the expanded paratricipital approach and cadaveric comparison of the exposure of the paratricipital and expanded paratricipital approaches to the distal humerus.

BACKGROUND: We investigated the overall clinical outcome of the expanded paratricipital approach in complex articular fractures of the distal humerus and the effect of lack of visualization in the surgical field. In addition, we performed a cadaveric study to investigate the expansion or limitation of articular access in the expanded paratricipital approach. METHODS: Forty-one AO/OTA type 13C fracture cases treated using the expanded paratricipital approach at a single trauma center from 2013 to 2017 were enrolled in this study. We evaluated the overall clinical outcome and analyzed the effect of lack of visualization in the surgical field with the expanded paratricipital approach by comparing outcomes between 2 groups classified by the location of the main articular fracture (group 1, limited visualization; group 2, without limited visualization). The length of inaccessible and accessible articular segments were analyzed using 40 matched-pair elbows. RESULTS: The average duration of follow-up was 15.1 months. All fractures (type C1 in 11 cases, type C2 in 21, and type C3 in 9) were radiologically healed at 3.2 months after surgery. No cases required additional surgery because of implant irritation. The average Mayo Elbow Performance Score was 90.5. The mean Disabilities of the Arm, Shoulder and Hand score was 18.5. Among the 41 cases, the limited visualization group (group 1, n = 21) had a longer surgical time and higher percentage of nonanatomic reduction than group 2. Although the expanded paratricipital approach allowed more articular exposure than the conventional approach, there was still a 20mm inaccessible articular segment (30% of transepicondylar width) in cadaveric dissection. CONCLUSIONS: The expanded paratricipital approach can be used in type C1, type C2, and selective type C3 articular fractures of the distal humerus with favorable results. Relative to surgical times and achieving anatomic reduction, it is more successful in a fracture with a main articular fragment and with good visualization.