Weak Points of Double-Plate Stabilization Used in the Treatment of Distal Humerus Fracture through Finite Element Analysis.

BACKGROUND: Multi-comminuted, intra-articular fractures of the distal humerus still pose a challenge to modern orthopedics due to unsatisfactory treatment results and a high percentage (over 50%) of postoperative complications. When surgical treatment is chosen, such fractures are fixed using two plates with locking screws, which can be used in three spatial configurations: either parallel or one of two perpendicular variants (posterolateral and posteromedial). The evaluation of the fracture healing conditions for these plate configurations is unambiguous. The contradictions between the conclusions of biomechanical studies and clinical observations were the motivation to undertake a more in-depth biomechanical analysis aiming to indicate the weak points of two-plate fracture stabilization. METHODS: Research was conducted using the finite element method based on an experimentally validated model. Three variants of distal humerus fracture (Y, λ, and H) were fixed using three different plate configurations (parallel, posterolateral, and posteromedial), and they were analyzed under six loading conditions, covering the whole range of flexion in the elbow joint (0-145°). A joint reaction force equal to 150 N was assumed, which corresponds with holding a weight of 1 kg in the hand. The biomechanical conditions of bone union were assessed based on the interfragmentary movement (IFM) and using criteria formulated by Steiner et al. Results: The IFMs were established for particular regions of all of the analyzed types of fracture, with distinction to the normal and tangential components. In general, the tangential component of IFM was greater than normal. A strong influence of the elbow joint's angular position on the IFM was observed, with excessive values occurring for flexion angles greater than 90°. In most cases, the smallest IFM values were obtained for the parallel plaiting, while the greatest values were obtained for the posteromedial plating. Based on IFM values, fracture healing conditions in particular cases (fracture type, plate configuration, loading condition, and fracture gap localization) were classified into one of four groups: optimal bone union (OPT), probable union (PU), probable non-union (PNU), and non-union (NU). CONCLUSIONS: No plating configuration is able to ensure distal humerus fracture union when the full elbow flexion is allowed while holding a weight of 1 kg in the hand. However, flexion in the range of 0-90° with such loadings is acceptable when using parallel plating, which is a positive finding in the context of the early rehabilitation process. In general, parallel plating ensures better conditions for fracture healing than perpendicular plate configurations, especially the posteromedial version.

Primary aldosteronism is highly prevalent in patients with hypertension and moderate to severe obstructive sleep apnea.

STUDY OBJECTIVES: It has been suggested that there might be a pathophysiological link and overlap between primary aldosteronism (PA) and obstructive sleep apnea (OSA). Therefore, in a prospective study, we evaluated the frequency of PA in hypertensive patients suspected of having OSA. METHODS: We included 207 consecutive hypertensive patients (mean age 53.2 ± 12.1 years, 133 M, 74 F) referred for polysomnography on the basis of one or more of the following clinical features: typical OSA symptoms, resistant or difficult-to-treat hypertension, diabetes, or cardiovascular disease. PA was diagnosed based on thew saline infusion test. RESULTS: Moderate-to-severe OSA was diagnosed in 94 patients (45.4% of the whole group). PA was diagnosed in 20 patients with OSA (21.3%) compared with 9 patients in the group without OSA (8.0%; P = .006). PA was also frequent in patients in whom symptoms of OSA were a sole indication for PA screening (15.4%) and in patients with and without resistant hypertension (24.5% and 17.8%, respectively). Most patients with PA and OSA were diagnosed with bilateral adrenal hyperplasia (18 patients, 90%). There were no major differences in clinical characteristics between patients with OSA with PA and those without PA. In multivariate models, moderate-to-severe OSA predicted the presence of PA (odds ratio 2.89, P = .018). CONCLUSIONS: Patients with clinically important moderate-to-severe OSA are characterized by a relatively high frequency of PA. Our results support the recommendations to screen patients with moderate-to-severe OSA for PA, regardless of the presence of other indications for PA screening.

Evaluation of stabilization of intra-articular fracture of distal humerus - finite element study.

PURPOSE: The treatment of comminuted fractures of distal humerus poses a challenge for orthopaedics. Previous studies assessing the global stiffness of the bone - stabilizer system - made it impossible to explicitly indicate an optimal configuration of the locking plates in the treatment of this kind of fractures. The aim of the present research was to comparatively analyze the stabilization conditions of intraarticular fractures of distal humerus with the use of various configurations of the stabilizer. METHODS: The research was based on the analysis of mutual displacements of bone fragments. Such evaluation was performed with the use of numerical simulation conducted with the use of the finite element method. A realistic model of humerus was based on the CT data. Three spatial configurations of the stabilizer (parallel, posteromedial and posterolateral) were considered. The mutual displacements of bone fragments as well as the deformity of the stabilizer under various loading conditions were analyzed. RESULTS: In most cases, the parallel setting of the plates ensures a better stabilization of the bone fragments than the perpendicular configuration. The most difficult conditions of stabilization were obtained for the lateral bone fragment. The value of the fragments' displacements significantly increases for loading directions occurring with ascending flexion angle of the joint. CONCLUSIONS: In most cases, the parallel setting of the plates ensures a better stabilization of the bone fragments than the perpendicular configuration.

Comparative Assessment of Outcomes of Surgical Treatment of Smith and Colles Distal Radius Fractures.

BACKGROUND: The aim of the present study was to assess the effectiveness of surgical treatment of distal radial fractures following open reduction and fixation with an angle-stable plate in relation to the type of injury (flexion vs. extension fracture). MATERIAL AND METHODS: A group of 25 patients with Colles fractures and 25 patients with Smith fractures treated surgically in the years 2012-2013 was analysed retrospectively. The results were evaluated using the quickDASH and Mayo Wrist Score. Radiographic follow-up assessments included radial inclination, radial height, volar tilt and articular step-off. RESULTS: The mean Mayo Wrist Score was 72.8 points for Colles fractures and 68.3 points for Smith fractures. The mean quickDASH score was 18.2 points for Colles fractures and 20.5 points for Smith fractures. However, these differences were not statistically significant. The only significant difference in the radiographic parameters investigated was in volar tilt, which was normal in the group of patients with Smith fractures (11°), whereas in the group with Colles fractures it was 5°. CONCLUSIONS: 1. In fractures of the distal radius, the type of displacement has no significant effect on the final outcome of surgical plate fixation. 2. In fractures with dorsal displacement of fragments, it is more difficult to restore volar tilt from a volar approach.

Comprehensive Treatment of the Multiply Injured Patient. A Case Study.

BACKGROUND: We describe the case of a 35-year-old man who suffered multiple organ injuries following a traffic accident. CASE REPORT: A total of 47 fractures were diagnosed in that patient. He was treated in stages according to the principles of Damage Control Orthopedics. He underwent 6 sessions of surgery with 23 surgical approaches. A follow-up examination at 12 months post injury found bone union of all fractures. The clinical and functional outcome of treatment was good as joint mobility was similar to the pre-accident status and the patient returned to work. CONCLUSIONS: In polytrauma patients, rapid and accurate diagnostic procedures combined with quick and accurate clinical decisions regarding treatment procedures have an impact on late outcomes. The order of stages of treatment should be determined by the general condition of the patient and type of injuries.

Surgical Treatment of Radial Head Fractures: Outcomes and Complications.

BACKGROUND: Appropriate treatment of radial head fractures remains an area of disputes and controversy. The present paper aims to assess the outcomes of surgical fixation of these injuries and identify the most common complications. MATERIAL AND METHODS: The medical records of 63 patients (25 women and 38 men) treated in 2011 -2014 were analysed retrospectively. The treatment outcomes were assessed according to the Broberg and Morrey rating system and the QuickDASH score. RESULTS: Of 21 patients with isolated fractures, all those with Type 2 fractures demonstrated excellent outcomes. In the group with Type 3 fractures, 11 patients showed satisfactory and 4 unsatisfactory outcomes. Of 19 patients with a fracture combined with elbow dislocation, all those with Type 2 fractures achieved excellent results while in the group with Type 3 fractures 8 patients had satisfactory and 4 had unsatisfactory outcomes. 23 patients were diagnosed with Hotchkiss' terrible triad; 7 of them had sustained Type 2 fractures and showed satisfactory outcomes while those with Type 3 fractures demonstrated 12 satisfactory and 4 unsatisfactory results. Complications included limited elbow mobility (59% of the patients), pain (52.9%), lower muscle strength (35.3%), posttraumatic arthrosis (29.4%), heterotopic ossification (11.8%) and nonunion (1.5%). Eleven patients required repeat surgery. CONCLUSIONS: 1. Today's materials used for the fixation of fracture fragments allow for a stable fixation of almost any fracture of the radial head. 2. As long as fixation of a given radial head fracture is technically possible, open reduction and internal fixation should be attempted. 3. If fixation is impossible, radial head replacement should be a method of choice.

Long-term Results of Operative Treatment of Calcaneal Fractures.

BACKGROUND: This paper presents the long-term results of surgical treatment of intra-articular calcaneal fractures, including subjective evaluation, orthopaedic examination and radiographic evaluation. MATERIAL AND METHODS: A total of 126 patients with 135 calcaneal fractures were treated surgically at the Department of Traumatology of the Military Medical Institute in Warsaw between 2008 and 2012. The analysis involves 73 patients (53 persons were lost to follow-up), including 45 men (61.6%). The mean age of the patients was 46.2 years (18-77 years). Based on imaging studies, patients required specific surgical techniques: the minimally invasive Westhues method involving fixation with a bundle of K-wires or open reduction and internal fixation with a plate and screws. The outcomes of the surgical treatment of calcaneal fractures were assessed on the basis of a subjective evaluation and orthopaedic and radiographic examinations. Statistical analysis was performed using Microsoft Excel. RESULTS: Based on the Creighton-Nebraska scores, in the group of patients treated with a bundle of K-wires (minimally invasive Westhues method), there were 12 excellent results (42.8%), 5 good (17.9%), 6 satisfactory (21.4%) and 5 poor (17.9%). In the group of patients treated with a plate and screws, excellent and good results (58.1%) prevailed in Sanders type II fractures. Most of the poor results were recorded in patients with type IV fractures. In general, radiographic results were better than functional and subjective evaluation. A statistically significant relationship between the subjective outcome of treatment and patient age was found (p <0.001). The least satisfying results were found for patients younger than 39 years of age. CONCLUSIONS: 1. The key to success in the surgical treatment of calcaneal fractures is appropriate restoration of Bôhler's angle 2. A good or excellent radiographic outcome did not always coincide with good functional results and good subjective evaluation 3. The poorer subjective scores in younger patients resulted from their inability to return to pre-injury activity levels.

Comparative Analysis of Clinical Outcomes of Tibial Plateau Fractures and Computed Tomography Examinations.

BACKGROUND: The aim of the study was to evaluate the outcomes of treatment of tibial plateau fractures. Based on CT examination, we set out to determine what factors were associated with a poor functional outcome. MATERIAL AND METHODS: The study involved 13 patients after surgery for tibial plateau fracture by locking plate osteosynthesis. CT studies using a MARS application were performed. The presence of subchondral defects was evaluated, including their area and depth. The reduction and widening of the tibial plateau were measured. The study data were correlated with the clinical outcome: pain according to a VAS scale, knee joint range of motion and the subjective IKDC score. RESULTS: Bone defects were observed in the majority of patients. On the basis of surface reconstruction, it was possible to accurately evaluate the articular step-off of the tibial plateau, which closely correlated with the range of motion and the subjective IKDC score (p <0.05). A correlation was also observed between widening of the lateral condyle and the IKDC score and pain level in the VAS scale (p<0.05). CONCLUSIONS: 1. Articular step-off and widening of the lateral condyle strongly correlates with the clinical outcome of tibial plateau fracture treatment. 2. The presence and extent of subchondral bone defects in the tibial plateau are related to knee pain in patients but have no effect on the range of motion and the IKDC score. 3. Bone graft remodeling cannot be fully assessed despite the use of MARS in CT imaging.

Comparison of different locking plate fixation methods in distal tibia fractures.

PURPOSE: The aim of our study was to assess the outcome of locking plate fixation of distal tibia fractures and evaluate which surgical approach and method of plate fixation is related to better functional result and lower complication rate. METHODS: A retrospective analysis of treatment of 45 patients was made. Patients were divided into two subgroups regarding surgical approach (medial vs anterior) and fixation method (bridge plating vs rigid fixation). Time from injury to full bone union was noted, and clinical outcome was assessed by AOFAS score. RESULTS: Nonunion was the most prevalent complication and was observed in 26.6 % of patients. Infection rate was 11.1 %. Higher rate of bone union complications was noted in the anterior approach group with anterolateral anatomical plate. Infection and re-operation rates were similar in all subgroups. There were no correlations between fracture extension, length of plate and screw placement with bone healing time and AOFAS score. CONCLUSIONS: Outcome of plate fixation of distal tibia fracture did not depend on the fixation method or surgical approach but, when possible, the medial plating via MIPO technique is a favourable method of treatment.

Outcomes after Open Reduction and Plate Fixation of Distal Humerus Fractures.

BACKGROUND: Distal humerus fractures (DHFs) have been a serious challenge since the beginning of surgery. The outcome of surgical treatment of a DHF should not only be assessed with clinical ratings. It is also important to take into account the patient's subjective evaluation of limb function. MATERIAL AND METHODS: The study involved 26 patients after surgical treatment of DHF. The Quick DASH (QDASH) scale was used to assess the subjective results of surgical treatment of DHF, and the objective Mayo Elbow Performance Score (MEPS) was used to assess the clinical outcome. Relationships between the subjective and objective scores were tested with Pearson's correlation coefficient. RESULTS: 85% of the patients had excellent or good QDASH scores, and 65% of patients had excellent or good MEPS scores. The Pearson correlation coefficient between the subjective and objective assessments was -0.91, indicating total dependence. CONCLUSIONS: Open reduction and internal fixation using two perpendicular plates allows for achieving good stability of fixation, early rehabilitation and quick return to the desired level of activity, which contributes to a high percentage of good objective and subjective results of treatment. Subjective assessment of upper limb function after DHF surgery fully correlates with objective assessment.

Results of the use of platelet rich plasma in the treatment of delayed union of long bones.

BACKGROUND: The aim of this study was to assess the efficacy of platelet rich plasma in the treatment of delayed union of long bones according to fracture location, the time between the fracture and PRP administration, and the type of surgical fixation. MATERIAL AND METHODS: A total of 1620 patients with long bone fractures were treated surgically at the Department of Traumatology of the Military Medical Institute in Warsaw between 2009 and 2012. Delayed union was diagnosed in 158 (9.75%) patients. Our analysis includes 132 patients (26 persons were lost to follow-up), with 53 women (40.15%) and 79 men (59.85%) aged 16 to 85 years (mean age 41). RESULTS: Bone union after PRP administration was found in 108 patients (81.8%) while the method proved ineffective in 24 patients (18.2%). It was most effective in patients with delayed union of the proximal tibia treated surgically by open reduction and plate fixation (100%), on average 3.5 months after PRP administration. The lowest efficacy was observed in patients with delayed union of the proximal humerus treated surgically by open reduction and plate fixation (63.64%), on average 3.2 months after PRP administration. CONCLUSIONS: 1. PRP is effective in the treatment of delayed union of long bones. 2. The highest incidence of delayed bone union was seen after the treatment of long bone fractures by open reduction and plate fixation whereas the lowest number of such cases was observed in patients treated by closed reduction with intramedullary nail fixation. 3. The mean time between surgical treatment and diagnosis of delayed bone union followed by PRP administration was 4.05 months.

Outcomes for high-energy distal femur articular fractures.

BACKGROUND: Distal femur fractures are relatively rare injuries that usually require surgical treatment. Angular-stable plates allowing for anatomical repositioning and stable fixation of splinters, particularly in articular fractures, are commonly used in such cases. The goal of the study was to analyze the outcomes of the surgical treatment of high-energy articular fractures of distal femur. MATERIAL AND METHODS: The study included 22 patients treated in years 2007-2013. The average follow-up period was 39.5 months. The range of knee motion was recorded during follow-up visits. Treatment outcomes are presented using the Prichett's criteria as well as using IKDC and KOOS scores. Bone union and lower limb axial deformity were assessed using X-ray images. RESULTS: The average range of motion was 0-99 degrees. According to Prichett's criteria, a total of 54% good and very good results as well as 36% of satisfactory results were recorded. The average IKDC score was 59.4 points while the average KOOS score was 54.7 points Bone union was achieved in 91.6% of fractures. Axial deformity was rare, and correlation between the valgus angle and the clinical and functional outcomes was observed. CONCLUSIONS: The applied methods for internal fixation afforded satisfactory treatment outcomes in most patients with high-energy distal femur fractures. No significant reduction in the mobility of the affected knee or axial deformation are observed after proper repositioning of distal femur fracture splinters using an angular-stable plate.

Complex dislocation of the second metacarpophalangeal joint. Case report.

Dislocation of the second metacarpophalangeal joint is a rare injury and despite trivial symptoms generally requires operative treatment. We present a case of complex dislocation treated operatively from a volar approach. This approach allows good visualization and repair of the volar plate. K-wire stabilization for 3 weeks was enough to avoid joint instability and did not limit the range of motion.

Results of two-stage operative treatment of anteromedial instability of the knee.

BACKGROUND: Proper treatment of massive knee injuries still constitutes a challenge for clinicians. Most often a torsion knee injury results in a rupture of the medial collateral ligament and anterior cruciate ligament. There is still no consensus on whether total rupture (Grade III) of the medial collateral ligament requires surgery, but it is well known that anterior cruciate ligament injury will require reconstructive surgery. MATERIAL AND METHODS: A total of 27 patients treated with two-staged surgery (primary MCL repair and delayed ACL reconstruction) were enrolled. Treatment outcomes were evaluated using the IKDC scale and Lysholm scale. The range of motion and knee stability was assessed during a clinical examination. Radiographs were used to evaluate the placement of suture anchors and development of osteoarthritic lesions. Static and dynamic ultrasound examinations were also performed to assess the post-operative morphology and performance of the medial collateral ligament. RESULTS: The patients who had undergone surgery for combined anteromedial instability of the knee, achieved good or very good clinical outcome according to the IKDC scale (63%, 17 of 27) and the Lysholm scale (74%, 20 of 27). Unsatisfactory functional outcomes were more often seen in older patients. Some patients developed complications, which significantly worsened the outcome. Those mainly included a limited range of movement, arthrofibrosis and Pellegrini-Stieda lesions. CONCLUSIONS: 1.Two-stage operative treatment produces good or very good results in most patients. Nevertheless, there is a risk of complications in some cases, mostly in patients aged 40 years. Accordingly, two-stage treatment is currently recommended in younger individuals. 2. A complete MCL tear at the distal attachment should be given particular attention. Although such injury is rare, due to the anatomical determinants and the risk of Stener-like lesions, i.e. unhealed ML, surgery is recommended. Surgery produces good clinical and functional results.

Outcome of comminuted proximal humerus fracture treatment with locking compression plate.

BACKGROUND: Therapeutic management of proximal humerus fractures is still controversial. There are several ways of proceeding in these cases, ranging from conservative treatment to shoulder joint arthroplasty. Open surgical reduction and stabilization with a locking compression plate is currently the most widely used method of treatment, especially in younger patients. The purpose of this study is to analyze the results of surgical treatment of fractures of the proximal humerus using locking compression plates. MATERIAL AND METHODS: The study included 69 patients, 57 of them reported for the follow-up (82.6% of respondents). Clinical and radiological evaluation was performed at 6 weeks and 6 months following the surgery. Functional outcome was assessed using the Constant score. We also evaluated shoulder flexion active range of motion. Bone union and common complications were evaluated on the basis of radiographs--humeral head necrosis and the evidence of loosening of the bone-binding material. RESULTS: The mean Constant score was 68.9 points and 75.94% relative to the opposite limb (relative mean score). No bone healing was observed in 7% (4 of 57) patients. There was a total of 21% (12 of 57) cases of humeral head necrosis. These changes varied in nature, location and severity. In 2 cases, reoperation was required due to loosening of the bone-binding material. Shoulder flexion active range of motion averaged 132 degrees and was lower in cases of 4-part fractures. CONCLUSIONS: Surgical treatment of stable 3-part fractures of the proximal humerus using locking compression plate should be the treatment of choice in younger patients. Given the poor results, the choice of treatment involving 4-part fractures should be individually tailored.

Evaluation of safety and efficacy of radiation-sterilized bone allografts in reconstructive oral surgery.

Bone grafting allows reconstruction of the atrophied or destroyed alveolar process. In orthopaedics and traumatology allogeneic grafting has been used to restore defects of osseous tissue for over 60 years. In order to improve safety of the graft recipient, sterilized allogeneic grafts have been use. The aim of the study was to assess the direct and long-term outcomes following augmentation of atrophied alveolar processes with the use of radiation-sterilized allogeneic bone grafts. Sixty-eight patients were surgically treated between 2004 and 2011: 29 underwent open sinus floor elevation, post-extraction alveoli augmentation was performed in 16 subjects and 23 underwent reconstruction of the atrophied alveolar process. Augmentation of bone defects used bone granulate in 63 patients and bone blocks stabilized with titanium screws in 5 patients. PRF membranes collected from the patient's blood were also used in all the procedures. In each of the cases optimal dimensions of the alveolar process were obtained allowing embedment of BIOMET 3I dental implant/-s. In all the patients the defects were successfully restored with implant-supported prostheses. Radiation-sterilized allogeneic bone grafts proved to be safe and effective for the patients and manageable for the surgeon constituting a good alternative to autogeneic material.

The oxidation status of ALDH3A1 in human saliva and its correlation with antioxidant capacity measured by ORAC method.

Oxidation status of the salivary aldehyde dehydrogenase (ALDH) was measured in healthy human population using two-assay fluorimetric method and compared with antioxidant capacity (ORAC) in non-smoking and heavy smokers group. Influence of high or low antioxidant diet was also examined. Except for the group of smokers, the salivary ALDH oxidation degree in human saliva was not correlated with antioxidant capacity. Simultaneously direct administration of the antioxidant-containing drug, Fluimucil, resulted in short-term, but statistically significant increase of the reduced (active) form of the enzyme, presumably due to a radical-scavenging activity of the drug.

Results of retrograde intramedullary nailing for distal femoral fractures--own experience.

BACKGROUND: Fractures of the distal femoral epiphysis and metaphysis are complex musculoskeletal injuries posing a significant clinical problem. The incidence of compound femoral fractures has been growing owing to the rapid development of the motor industry. The fractures are most commonly the result of high-energy traumas during road accidents or falls from a height. MATERIAL AND METHODS: A total of 74 patients with distal femoral fractures were treated at the Department of Traumatology and Orthopaedics of the Ministry of Defence's Military Institute of the Health Services, Central Clinical Hospital, in the years 2002-2006. Retrograde intramedullary femoral nailing was used in 39 patients (53%), including 17 (43%) women and 22 (57%) men. The primary objective of the surgical treatment was to restore the anatomy of the articular surface and the mechanical axis of the femur and convincing fracture fixation to enable early restoration of normal function in the knee joint. RESULTS: Bony union was obtained during 4 post-operative months in 36 (93%) of the patients. Gradual weight-bearing was allowed between 2 and 6 post-operative months. CONCLUSION: Retrograde intramedullary nailing of compound fractures of the femoral epiphysis and metaphysis affords the technical possibility of convincing fastening of bony fragments, while also allowing for early rehabilitation of the affected joint and helping to reduce primary deformities and secondary degenerative lesions for a good treatment outcome.