Mini-Invasive Intramedullary Fixation of Displaced Midshaft Clavicle Fractures with an Elastic Titanium Nail.

BACKGROUND: The treatment of completely displaced midshaft clavicle fractures is still controversial, but surgical treatment provides a shorter recovery period and higher union rates than nonoperative treatment with a sling1-5. Even though the literature does not clearly support surgery for these fractures, surgery is becoming more frequent6. Elastic stable intramedullary nailing (ESIN) with a titanium nail is a well-documented mini-invasive procedure with functional outcomes comparable with those of plate fixation after 1 year but a high rate of implant removal of up to 80%6-8. The ideal injury for ESIN is a fracture without comminution that is available for surgery within a couple of days. ESIN is also a good option for fractures with comminution, but a somewhat slower functional recovery during the first 6 months should be expected. DESCRIPTION: The patient is placed in beach-chair position with the fluoroscope placed on the injured side or cranially in relation to the fracture. The surgeon pushes the skin gently with his/her index finger at the jugular fossa before incising it. This places the skin incision inferior to the implant. A 1 to 2-cm incision down to the bone is then placed about 1 to 2 cm lateral to the sternoclavicular joint. A unicortical entry hole is made at the medial end with a 2.5-mm drill bit and then widened and directed laterally with an awl. Two reduction forceps are placed percutaneously and used by the assistant to align the main fragments. The nail is passed with oscillating movements until it is secured into the lateral fragment. If it is not possible to obtain a closed reduction, an open reduction is performed. The nail is cut short down to the bone, and the myocutaneous layer and skin are closed with sutures. Five to 10 mL of bupivacaine is injected into the fracture area for postoperative pain management. The arm is placed in a simple sling for comfort. A non-weight-bearing active range of motion of <90° is encouraged. ALTERNATIVES: Closed completely displaced midshaft clavicle fractures can be treated operatively or nonoperatively with a sling. Superior plate fixation is well documented, but use of anterior or several mini-fragment plates is also an option. There are several intramedullary implant techniques, but most require an open reduction. RATIONALE: Most intramedullary implant methods are open procedures, whereas closed reduction and internal fixation is possible with ESIN. This ensures preservation of the fracture hematoma and no periosteal stripping, in contrast with the open intramedullary techniques. The nail enters the fracture medially, which decreases the chance of perioperative pulmonary or neurovascular injury. The procedure is less time-consuming than plate fixation, the result is cosmetically superior, and the functional outcomes after 1 year are equal. When ESIN is used for fractures without intermediary fragments, the functional recovery time is equal to that after plate fixation, although it is longer when used for fractures with intermediary fragments8.

Calcar screws and adequate reduction reduced the risk of fixation failure in proximal humeral fractures treated with a locking plate: 190 patients followed for a mean of 3 years.

BACKGROUND: Fixation of proximal humeral fractures (PHF) with locking plates has gained popularity over conservative treatment, but surgery may be complicated with infection, non-union, avascular necrosis (AVN) of the humeral head and fixation failure. Failure to achieve structural support of the medial column has been suggested to be an important risk factor for fixation failure. The aims of this study were to examine the effect of calcar screws and fracture reduction on the risk of fixation failure and to assess long-term shoulder pain and function. METHODS: This was a single-centre retrospective study of 190 adult PHF patients treated with a locking plate between 2011 and 2014. Reoperations due to fixation failure were the primary outcome. Risk factors for fixation failure were assessed using the Cox regression analysis. Postoperative shoulder pain and function were assessed by the Oxford Shoulder Score (OSS). RESULTS: Thirty-one of 190 (16%) patients underwent a reoperation: 14 (7%) due to fixation failure, 10 (5%) due to deep infection and 2 (1%) due to AVN. The absence of calcar screws and fixation with residual varus malalignment (head-shaft angle < 120°) both increased the risk of fixation failure with an adjusted hazard ratio (95% CI) of 8.6 (1.9-39.3; p = 0.005) and 4.9 (1.3-17.9; p = 0.02), respectively. The median (interquartile range) OSS was 40 (27-46). CONCLUSION: The use of calcar screws, as well as the absence of postoperative varus malalignment, significantly reduced the risk of fixation failure. We, therefore, recommend the use of calcar screws and to avoid residual varus malalignment to improve the medial support of proximal humeral fractures treated with a locking plate.

Long-Term Survival of the Native Hip After a Minimally Displaced, Nonoperatively Treated Acetabular Fracture.

BACKGROUND: Few studies have evaluated the long-term results for nonoperatively treated acetabular fractures. The purpose of this study was to describe the long-term survival of the native acetabulum as well as the clinical and radiographic outcome for patients with nonoperatively treated acetabular fractures. METHODS: All patients with acetabular fractures are prospectively registered in our acetabular fracture database and followed up at regular intervals for up to 20 years. We identified 236 patients (237 fractures) who had been treated nonoperatively between 1994 and 2004; 51 patients with incomplete data were excluded. For the survival analysis, 186 fractures with an average follow-up of 9 years (range, 1 to 20 years) were included. For the long-term clinical outcome, 104 patients with an average follow-up of 12.1 years (range, 9 to 20 years) were included. RESULTS: The 10-year survival of the native hips was 94% (111 hips were at risk). Eighty-nine percent of the patients had a good or excellent Harris hip score, and 88% had a good or excellent Merle d'Aubigné and Postel score. The most important negative predictor for clinical outcome and survival of the hip was a fracture step-off of ≥2 mm measured in the obturator oblique radiograph. CONCLUSIONS: Nonoperative treatment of minimally displaced acetabular fractures yields good to excellent long-term results. For patients with a questionable indication for fracture surgery, oblique radiographs (Judet views) are a helpful tool in the decision-making process, as a fracture step-off of ≥2 mm is a strong predictor for a poor clinical and radiographic result at 10 years. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The natural history of bone bruise and bone remodelling in the traumatised hip: A prospective 2-year follow-up study of bone bruise changes and DEXA measurements in 13 patients with conservatively treated traumatic hip dislocations and/or fractures.

INTRODUCTION: The purpose of this study was to assess the natural history of bone bruise and bone mineral density (BMD) after traumatic hip dislocations and conservatively treated acetabular fractures. Our hypothesis was that poor bone quality can influence degree of bone bruise and, in time, cause degenerative changes. MATERIALS AND METHODS: Eight consecutive patients with traumatic hip dislocations and five patients with conservatively treated fractures in the femoral head and/or acetabulum were included. Magnetic resonance imaging (MRI) was obtained after 1, 17, 42, 82 and 97 weeks. Dual-emission X-ray absorptiometry (DXA) measurements were made after 10 days and 2 years. Sizes of bone bruise lesions were measured and classified. At the 2-year follow-up, Harris hip score (HHS) was calculated and signs of radiological osteoarthritis (OA) registered. RESULTS: The bone bruise changes were small and all changes resolved within 42 weeks in all, except for three patients; one with a small Pipkin fracture had segmental avascular necrosis (AVN) of the femoral head, one had persisting1-3mm small spots of bone bruises in the femoral head and the third had <1cm lesions in both the femoral head and the acetabulum. The lesions were bigger in the femoral head in the hip dislocations and more pronounced in the acetabulum in the fractured acetabuli. We found no significant changes in BMD in four regions of interest (ROIs) after 2 years. No patients developed OA, and all had excellent HHS except for the one patient with AVN. CONCLUSION: The post-traumatic bone bruise changes in the dislocated hips and the fractured acetabuli were small and transient compared to findings of other authors examining traumatised knees. The patients had excellent function and no OA after 2 years if they did not develop AVN. In our small sample of relatively young patients with normal age-adjusted BMD, no post-traumatic osteopenia was observed. This might differ in the elderly with poorer bone quality; further studies are needed to assess that.

No difference in functional and radiographic results 8.4 years after quadricortical compared with tricortical syndesmosis fixation in ankle fractures.

OBJECTIVE: To assess long-term functional and radiologic results after two types of syndesmosis fixation, comparing one quadricortical syndesmotic screw fixation with two tricortical screw fixation in ankle fractures. DESIGN: Follow up of a previously conducted prospective, randomized clinical study. SETTING: University clinic, Level I trauma center. PATIENTS: Forty-eight patients with closed ankle fractures and concomitant syndesmotic rupture were operated on with quadricortical (n = 23) or tricortical (n = 25) syndesmotic fixation. RESULTS: Follow-up time was 8.4 years (range, 7.7-8.9 years). There were no statistical differences in the two groups regarding Olerud-Molander Ankle score, Orthopaedic Trauma Association score, or degree of osteoarthritis. Patients with a difference in the syndesmotic width between the operated and the nonoperated ankle of 1.5 mm or more showed a tendency toward poorer functional results (P = 0.056). Twenty-one patients showed synostosis on plain radiographs. Of these, only seven patients had synostosis verified on computed tomography, all of whom had significantly worse function. Patients with a posterior fracture fragment at time of operation had poorer Olerud-Molander Ankle score (73.1 versus 85, P = 0.05) and all had osteoarthritis as compared with 55% of those without a posterior fragment. Obese patients (body mass index greater than 30 kg/m2) also had poorer Orthopaedic Trauma Association score, but neither obesity nor being overweight predicted late arthritis. CONCLUSIONS: Follow up 8.4 years after surgery of ankle fractures with syndesmotic injury showed satisfactory functional results with only minor differences between the two groups of syndesmotic fixation. Obese patients had significantly poorer functional results. The presence of a posterior fracture fragment was an important negative prognostic factor regarding functional results. Plain radiographs overestimated tibiofibular synostosis. Synostosis on computed tomography, however, predicted impaired ankle function. A difference in syndesmotic width 1.5 mm or greater between the two ankles seemed to be associated with an inferior clinical result.