Mini Fragment Locking Compression Plate Fixation of a Rare Case of Displaced Medial End Clavicle Fracture.

Clavicle fractures at the medial end are very rare. Even in cases where there is severe displacement, such fractures have usually been managed nonoperatively. Yet, there are many patients who remain symptomatic over a year following injury, and the non-union rate is also high. Operative intervention for displaced clavicle fractures of the medial end has been more common in the past decade. The possibility of iatrogenic injury due to the near proximity of critical vascular structures continues to be a concern. This case report describes the management of a rare displaced medial end clavicle fracture in a young male. The patient is a 28-year-old male who came with a week-old displaced medial end left clavicle fracture. On examination, tenting of skin was seen over the medial end clavicle region. CT angiography of the left upper limb was performed to check the vascular structures in relation to the fracture, as there remain concerns about the close proximity of underlying vascular structures and the potential for iatrogenic damage. A vascular surgeon was kept on standby during the surgery. The patient was taken up for surgery after a pre-anesthetic checkup and open reduction and internal fixation was done with a 2.4-mm system mini fragment locking compression plate over the anterior surface of the clavicle. The surgery was uneventful, and the patient had a good clinical and radiological outcome postoperatively.

Vertical Fracture of the Medial Malleolus With Concurrent Ipsilateral Achilles Tendon Rupture in a Patient With Progressive Collapsing Foot Deformity: A Rehabilitation Dilemma.

A male in his 40s presented with a vertical shear type medial malleolar fracture with an ipsilateral Achilles tendon rupture with a pes planovalgus deformity. Both injuries were diagnosed concurrently on presentation. This is a rare injury pattern with no consensus on optimum management. This is the first case report where pes planus is also described alongside the injuries. The medial malleolar fracture was successfully treated surgically with an open reduction and internal fixation (ORIF) with antiglide plating. Following ORIF, the patient underwent functional rehabilitation for the Achilles tendon rupture. The purpose of this case report is to highlight this infrequent injury pattern, which poses a great therapeutic dilemma. The therapeutic considerations regarding surgical and non-surgical approaches to management are thoroughly presented and discussed.

Locking Attachment Plate for the Surgical Treatment of Periprosthetic and Periimplant Fractures: Long-Term Follow-Up.

Objectives: The surgical management of periprosthetic fractures (PPF) and periimplant fractures (PIF) can be challenging. The locking attachment plate (LAP) was proposed in recent years for the osteosynthesis of such fractures. The aim of this study was to assess the experience of a third-level hospital with LAP for the treatment of PPF and PIF, and analyse the clinical outcomes. Methods: Data were prospectively collected and analysed from all patients whose PPF/PIF was treated surgically with LAP in a third-level hospital from June 2018 to June 2022. All fractures were postoperative low-energy femur fractures. The minimum follow-up period was six months. Results: Thirty-eight patients (31 women) met the eligibility criteria. The mean age was 86.3 years. The median time until surgery was 4 days. A mean of 3.61 screws were used for each LAP. The mean femur plate length was 14 holes, and the mean working length 7.1 holes. The median hospital stay was nine days. The mean follow-up was 19.56 months. At one month, 12 patients tolerated partial weight-bearing. Five patients walked independently indoors. One patient had died and seven patients were readmitted. At six months, six more patients had died. Fifteen patients tolerated full weight-bearing (FWB). Nine patients walked independently indoors, six outdoors. Twenty-five patients reached fracture consolidation without malalignment. Nine patients were readmitted. At 12 months, another patient had died. Seventeen patients tolerated FWB. Eleven patients walked independently indoors, six outdoors. Twenty-five patients achieved fracture consolidation without malalignment. Five patients were readmitted. Fourteen patients crossed the two-year postoperative threshold. All achieved fracture consolidation. Two patients passed the 4-year postoperative milestone. Conclusion: The clinical results of patients whose PPF or PIF was treated with the LAP are promising. This fixation method is a viable option to be considered when planning surgery for such fractures.

Subchondral rafting wires reduce tibial plateau fracture subsidence.

PURPOSE: To determine if subchondral rafting wires retained as adjunctive tibial plateau fracture fixation affect postoperative articular subsidence. METHODS: A retrospective cohort study was conducted at one Level 1 trauma center and one academic university hospital. Consecutive adults with closed, displaced OTA/AO 41B/C tibial plateau fractures treated between 2018 and 2023 with open reduction internal fixation were included. Patients who were not ambulatory, with contralateral injuries limiting weight bearing, and without follow-up radiographs of the injured extremity were excluded. The intervention was retention of subchondral rafting wires as definitive fixation. The primary outcome was linear articular surface subsidence between postoperative and follow-up AP knee radiographs. Linear subsidence was compared between groups using Welch's two sample t test. Associations of linear subsidence with patient, injury, and treatment characteristics were assessed by multivariable linear regression. RESULTS: We identified 179 patients of a mean age of 44 ± 14 years, of whom 15 (8.4%) received subchondral rafting wires. Median follow-up was 121 days. No patients who received rafting wires as definitive implants experienced linear subsidence ≥ 2 mm, while 22 patients (13.4%) who did not receive rafting wires experienced linear subsidence ≥ 2 mm (p = 0.130). Subchondral rafting wires were associated with less linear subsidence (0.3 mm [95% confidence interval - 0.3-0.9 mm] vsersus 1.0 mm [- 0.9-2.9 mm], p < 0.001). The depth of linear subsidence was significantly associated on multivariable regression with male sex, depressed plateau area, active smoking, and retained rafting wires. CONCLUSION: Subchondral rafting wires were associated with a small reduction in articular subsidence after internal fixation of tibial plateau fractures. Routine rafting wires may be useful for patients and fractures at high risk of articular subsidence.

The effect of different hybrid rigid internal fixation techniques on the postoperative stability following a mandibular advancement using a bilateral sagittal split ramus osteotomy: A retrospective three-dimensional comparative study.

OBJECTIVE: To three-dimensionally evaluate post-operative mandibular stability following bilateral sagittal split ramus osteotomies between hybrid and non-hybrid rigid internal fixation techniques. MATERIALS AND METHOD: Seventy adults with skeletal class II deformity who underwent bilateral split sagittal osteotomy with mandibular advancement were included. Patients were divided into four groups based on their fixation techniques: hybrid technique (HT) groups I, II, and IV received a 4-hole 2 mm miniplate with either a bicortical screw (BS), additional 2 mm 4-hole miniplate, or two-hole miniplate, while non-HT group III received a 4-hole 2 mm miniplate with four mini-screws (MS). Measurements were taken pre-operatively (T0), immediately postoperatively (T1), and ≥1 year after surgery (T2) using 3D Slicer software. RESULTS: Age, sex, and follow-up period did not correlate significantly with postoperative relapse or stability. Significant differences were observed in the advancement on the right side between groups II, III, and IV and on the left side between groups I, III, and IV. However, the type of surgical intervention showed no significant effect on postoperative relapse and stability. All groups of fixations showed satisfactory stability with irrelevant relapse (< 2 mm or 2°). CONCLUSION: The study demonstrated satisfactory and comparable stability among different fixation groups on patients undergoing mandibular advancement following bilateral split sagittal osteotomy. The results highlighted the importance of considering the degree of advancement when planning orthognathic surgery and managing postoperative outcomes.

Treatment of Complex Central Talar Fractures with Lateral Plate Combination with Medial Screw Fixation.

OBJECTIVE: The treatment of talar neck and/or body fractures is known to be difficult and challenging, with significant impact on the long-term functional outcome for the patient. The optimal management, including the choice of surgical approaches and implants, are still under constant discussion. The purpose of the study was to investigate the clinical effects of lateral mini-plate combined with medial lag screws for the treatment of complicated central talar fractures. METHODS: The data of eight patients with complex central talus fractures treated between June 2019 and January 2021 were retrospectively analyzed. There were six males and two females, ranging in age from 15 to 66 years, with an average age of 37.4 years. There were three cases on the left and five cases on the right. All fractures were comminuted, including talar neck with talar body fracture in seven cases and talar body comminuted with subluxation of subtalar joint in one case. All patients were treated with the anteromedial combined anterolateral approach, lateral talar mini-plate fixation and medial lag screw fixation. Fracture reduction quality, union time, and complications were recorded, and functional outcomes were evaluated using the American Orthopedic Foot & Ankle Society (AOFAS) scoring system. RESULTS: The time from injury to surgery was 1-6 days, with an average of 3.38 days. The follow-up period was 34-53 months (mean 44.88 months). All fractures healed with a mean healing time of 16.75 weeks (13-23 weeks). Anatomical reduction was observed in six cases and near in two cases. After operation, there was no loosening or breakage of implant, loss of fracture reduction, and irritation of skin and soft tissue by internal fixation. The average AOFAS score was 87.38 (48-100), with excellent five cases, good two cases and poor one case, and the excellent and good rate was 87.5%. Superficial skin necrosis in one surgical incision healed after dressing exchange. No deep infection occurred. One case (1/8, 12.5%) developed avascular necrosis of the talus without collapse. Posttraumatic arthritis was found in four cases (4/8, 50%). CONCLUSION: The utilization of lateral mini-plates in combination with medial screws for treating complex central talar fractures results in satisfactory reduction and stable fixation, mitigating complications associated with poor reduction. However, due to the absence of an anatomical mini-plate, pre-contouring is necessary when applying the lateral plate. This demands a surgeon's thorough familiarity with the anatomical morphology of the talus and proficiency in surgical techniques. Posttraumatic arthritis is the most common complication of complex central talar fractures.

Treating pathological metastatic fractures of the humerus by compound osteosynthesis: a retrospective cohort study.

Background: The number of malignant tumors is increasing as are bone metastases, such as those in the humerus. Arm function is important for an independent everyday life. In this study, compound osteosynthesis of metastatic fractures of the humerus is examined for its suitability in light of the competing risk of death. Methods: This retrospective monocentric study includes a cohort of tumor patients who underwent primary compound osteosynthesis for pathological humeral fractures. The main endpoint was the continued existence of compound osteosynthesis using competing risk analysis to contrast failure and death. Failure was defined as mechanical failure of the osteosynthesis construct like refracture or plate-and-screw dislocation or loosening, which provides an indication for reintervention. Other complications are also described. Results: We included 36 consecutive patients (64% male, mean age: 71.6 yr) from September 2007 to October 2020. In 58% of the cases, the left humerus was fractured. Lung carcinoma was the most common cause of bone metastases (27.8%). Compound osteosynthesis was performed with a median delay of 5 days after diagnosis of the pathologic fracture. Postoperative complications occurred in 7 of the 36 patients (19.4%): radial nerve palsy (n = 3), postoperative hematoma (n = 2), refracture (n = 2), and screw loosening (n = 1). Few mechanical failures (8.3%) occurred within the first year; only 1 patient needed revision of the osteosynthesis (2.8%). Median patient survival after compound osteosynthesis was 26.6 weeks. Competing risk analysis showed that for up to 2 years, the risk of death is clearly dominant over the risk of osteosynthesis failure from surgery. Conclusion: Our study shows that compound osteosynthesis of the humerus is a suitable option for patients with pathologic humerus fractures. Compound osteosynthesis of the humerus usually survives the duration of malignant tumor disease.

Compositional and surface changes of retrieved stainless-steel hardware and its effects on surrounding soft tissues: A prospective study.

Purpose: To evaluate the surface, compositional, and histological changes in the overlying soft tissues of retrieved stainless-steel mini-plates and screws used for rigid internal fixation in the maxillofacial skeleton. Materials and Method: A prospective study was conducted comprising 60 patients who sustained maxillofacial trauma and underwent ORIF in our unit previously and who required hardware retrieval in the post-operative phase. The retrieved hardware was evaluated for surface and compositional changes with the help of a scanning electron microscope for surface roughness and corrosion changes. Energy-dispersive X-ray study was done to know the composition and metal release from the hardware. The data obtained from these results were compared with a control unused and a sterile stainless-steel mini-plate and screw. The effects of the corrosion changes of this hardware on the adjacent soft tissues were evaluated histologically to assess the cellular changes of the soft tissue cover overlying the stainless-steel mini-plates and screws. Results: A total of 96 stainless-steel mini-plates and 380 stainless-steel screws were retrieved from 60 patients. The control plate was smooth without any surface and corrosion defects, while the retrieved mini-plates irrespective of the reason for removal have shown surface roughness. Fe and Ni ions were found to be significantly reduced in the retrieved mini-plates. The presence of CrC in the retrieved plates indicates corrosion, which was seen only in hardware retrieved from symptomatic patients. The histological study revealed chronic inflammatory cell infiltrate with hyalinized connective tissue in all the samples irrespective of the reason for the removal of the plate. Conclusion: Stainless-steel mini-plates and screws act as a potent foreign body material and initiate a localized inflammatory reaction due to its corrosive products with longer duration of stay. Hence, the authors advocate the overall shift in the use of stainless-steel hardware to titanium hardware for ORIF.

A Systemic Review of Adolescent Supracondylar Fractures: What Is the Surgical Treatment, Open Reduction With Internal Fixation (ORIF) or Closed Reduction With Percutaneous Pinning (CRPP)?

Supracondylar humerus (SCH) fractures represent the most frequent elbow injury in young children. These fractures can be treated through either closed reduction with percutaneous pinning (CRPP) or open reduction with internal fixation (ORIF). Yet, the optimal treatment option for adolescents remains unclear. This research contrasts the results of CRPP and ORIF treatments for distal humerus fractures in adolescents. In June 2023, we conducted a comprehensive search of PUBMED, OVID MEDLINE, Web of Science, Cochrane Central Register of Controlled Trials, and various trial registries without any time restrictions. We evaluated the quality of qualifying studies using the Methodological Index for Non-randomized Studies (MINORS) and Cochrane risk measures for bias. We extracted data particularly related to patient demographics, fracture details, medical procedures followed, complications encountered, and the resulting outcomes. Out of the 488 studies identified, only four satisfied the inclusion criteria. Both methods illustrated comparable outcomes in terms of range of motion, averaging approximately 118 degrees in the ORIF group versus a span of 114 to 128 degrees in the CRPP group. The immobilization period varied, spanning 10 to 13 days for ORIF versus 24 to 29 days for CRPP. Despite this, CRPP displayed a decreased necessity for additional surgery. Notably, one study indicated a higher frequency of heterotopic ossification within the ORIF group. This review indicates that both CRPP and ORIF are effective for treating supracondylar fractures in adolescents, yielding similar results. However, CRPP has a lower need for follow-up surgery. Future studies with larger sample sizes are needed to solidify these findings, providing stronger guidance for treatment.

Anterior internal versus external fixation of unstable pelvis fractures was not associated with discharge destination, critical care, length of stay, or hospital charges.

PURPOSE: Determine if anterior internal versus supra-acetabular external fixation of unstable pelvic fractures is associated with care needs or discharge. METHODS: A retrospective cohort study was performed at two tertiary trauma referral centers. Adults with unstable pelvis fractures (AO/OTA 61B/61C) who received operative fixation of the anterior and posterior pelvic ring by two orthopedic trauma surgeons from October 2020 to November 2022 were included. The primary outcome was discharge destination. Secondary outcomes included intensive care unit (ICU) or ventilator days, length of stay, and hospital charges. RESULTS: Eighty-three eligible patients were 38.6% female, with a mean age of 47.2 ± 20.3 years and BMI 28.1 ± 6.4 kg/m2. Fifty-nine patients (71.1%) received anterior pelvis internal fixation and 24 (28.9%) received external fixation. External fixation was associated with weight-bearing restrictions (91.7% versus 49.2%, p = 0.01). No differences in demographic, functional status, insurance type, fracture classification, or injury severity measures were observed by treatment. Internal versus external anterior pelvic fixation was not associated with discharge to home (49.2% versus 29.2%, p = 0.10), median ICU days (3.0 [interquartile range (IQR) 7.8 versus 5.5 [IQR 4.3], p = 0.14, ventilator days (0 [IQR 6.0] versus 0 [IQR 2.8], p = 0.51), length of stay (13.0 [IQR 13.0] versus 17.5 (IQR 20.5), p = 0.38), or total hospital charges (US dollars 180,311 [IQR 219,061.75] versus 243,622 [IQR 187,111], p = 0.14). CONCLUSIONS: Anterior internal versus supra-acetabular external fixation of unstable pelvis fractures was not significantly associated with discharge destination, critical care, hospital length of stay, or hospital charges. This sample may be underpowered to detect differences between groups. LEVEL OF EVIDENCE: Therapeutic Level IV.

Malunion of distal humeral fractures: current concepts.

The incidence of complex articular fractures of the distal humeral in adults has increased and will be growing in the future due to the greater incidence of high energy trauma and to the higher percentage of elderly population. Successful treatment is challenging for the needed balance between a stability of often comminuted fracture and early motion. Malunion is a common complication after distal humerus fractures, which is influenced by a variety of factors such as biology, particularly the blood supply of the metaphysis, the non-anatomical reduction of the fracture, the methods of fixation and mechanical failure. These can involve the intra-articular or extra-articular areas. Clinical presentation may be mainly with pain and instability as for cubitus varus or with disfunction and stiffness as for an intra-articular malunion. However, the symptoms will depend on the degree of articular surfaces damage and the degree of deformities in specific planes. The surgical treatment can be challenging varying from supracondylar osteotomies and re-contouring arthroplasty for extra-articular deformities to interposition arthroplasty and elbow replacement for intra-articular deformities.

Surgical treatment outcomes of acetabular posterior wall and posterior column fractures using 3D printing technology and individualized custom-made metal plates: a retrospective study.

BACKGROUND: Fractures involving the posterior acetabulum with its rich vascular and neural supply present challenges in trauma orthopedics. This study evaluates the effectiveness of 3D printing technology with the use of custom-made metal plates in the treatment of posterior wall and column acetabular fractures. METHODS: A retrospective analysis included 31 patients undergoing surgical fixation for posterior wall and column fractures of the acetabulum (16 in the 3D printing group, utilizing 3D printing for a 1:1 pelvic model and custom-made plates based on preoperative simulation; 15 in the traditional group, using conventional methods). Surgical and instrument operation times, intraoperative fluoroscopy frequency, intraoperative blood loss, fracture reduction quality, fracture healing time, preoperative and 12-month postoperative pain scores (Numeric Rating Scale, NRS), hip joint function at 6 and 12 months (Harris scores), and complications were compared. RESULTS: The surgical and instrument operation times were significantly shorter in the 3D printing group (p < 0.001). The 3D printing group exhibited significantly lower intraoperative fluoroscopy frequency and blood loss (p = 0.001 and p < 0.001, respectively). No significant differences were observed between the two groups in terms of fracture reduction quality, fracture healing time, preoperative pain scores (NRS scores), and 6-month hip joint function (Harris scores) (p > 0.05). However, at 12 months, hip joint function and pain scores were significantly better in the 3D printing group (p < 0.05). Although the incidence of complications was lower in the 3D printing group (18.8% vs. 33.3%), the difference did not reach statistical significance (p = 0.433). CONCLUSION: Combining 3D printing with individualized custom-made metal plates for acetabular posterior wall and column fractures reduces surgery and instrument time, minimizes intraoperative procedures and blood loss, enhancing long-term hip joint function recovery. CLINICAL TRIAL REGISTRATION: 12/04/2023;Trial Registration No. ChiCTR2300070438; http://www.chictr.org.cn .

Acetabular fractures in geriatric patients: epidemiology, pathomechanism, classification and treatment options.

The incidence of geriatric acetabular fractures has shown a sharp increase in the last decades. The majority of patients are male, which is different to other osteoporotic fractures. The typical pathomechanism generally differs from acetabular fractures in young patients regarding both the direction and the amount of force transmission to the acetabulum via the femoral head. Geriatric fractures very frequently involve anterior structures of the acetabulum, while the posterior wall is less frequently involved. The anterior column and posterior hemitransverse (ACPHT) fracture is the most common fracture type. Superomedial dome impactions (gull sign) are a frequent feature in geriatric acetabular fractures as well. Treatment options include nonoperative treatment, internal fixation and arthoplasty. Nonoperative treatment includes rapid mobilisation and full weighbearing under analgesia and is advisable in non- or minimally displaced fractures without subluxation of the hip joint and without positive gull sign. Open reduction and internal fixation of geriatric acetabular fractures leads to good or excellent results, if anatomic reduction is achieved intraoperatively and loss of reduction does not occur postoperatively. Primary arthroplasty of geriatric acetabular fractures is a treatment option, which does not require anatomic reduction, allows for immediate postoperative full weightbearing and obviates several complications, which are associated with internal fixation. The major issue is the fixation of the acetabular cup in the fractured bone. Primary cups, reinforcement rings or a combination of arthroplasty and internal fixation may be applied depending on the acetabular fracture type.

Which radial head fractures are best treated surgically?

Despite the common occurrence of radial head fractures, there is still a lack of consensus on which radial head fractures should be treated surgically. The radial head is an important secondary stabilizer in almost all directions. An insufficient radial head can lead to increased instability in varus-valgus and posterolateral rotatory directions, especially in a ligament-deficient elbow. The decision to perform surgery is often not dictated by the fracture pattern alone but also by the presence of associated injury. Comminution of the radial head and complete loss of cortical contact of at least one fracture fragment are associated with a high occurrence of associated injuries. Nondisplaced and minimally displaced radial head fractures can be treated non-operatively with early mobilization. Displacement (>2 mm) of fragments in radial head fractures without a mechanical block to pronation/supination is not a clear indication for surgery. Mechanical block to pronation/supination and comminution of the fracture are indications for surgery. The following paper reviews the current literature and provides state-of-the-art guidance on which radial head fractures should be treated surgically.

[Treatment of cervical ossification of posterior longitudinal ligament with titanium alloy trabecular bone three-dimensional printed artificial vertebral body].

Objective: To evaluate the effectiveness of using titanium alloy trabecular bone three-dimensional (3D) printed artificial vertebral body in treating cervical ossification of the posterior longitudinal ligament (OPLL). Methods: A retrospective analysis was conducted on clinical data from 45 patients with cervical OPLL admitted between September 2019 and August 2021 and meeting the selection criteria. All patients underwent anterior cervical corpectomy and decompression, interbody bone graft fusion, and titanium plate internal fixation. During operation, 21 patients in the study group received titanium alloy trabecular bone 3D printed artificial vertebral bodies, while 24 patients in the control group received titanium cages. There was no significant difference in baseline data such as gender, age, disease duration, affected segments, or preoperative pain visual analogue scale (VAS) score, Japanese Orthopaedic Association (JOA) score, Neck Disability Index (NDI), vertebral height, and C 2-7Cobb angle ( P>0.05). Operation time, intraoperative blood loss, and occurrence of complications were recorded for both groups. Preoperatively and at 3 and 12 months postoperatively, the functionality and symptom relief were assessed using JOA scores, VAS scores, and NDI evaluations. The vertebral height and C 2-7 Cobb angle were detected by imaging examinations and the implant subsidence and intervertebral fusion were observed. Results: The operation time and incidence of complications were significantly lower in the study group than in the control group ( P<0.05), while the difference in intraoperative blood loss between the two groups was not significant ( P>0.05). All patients were followed up 12-18 months, with the follow-up time of (14.28±4.34) months in the study group and (15.23±3.54) months in the control group, showing no significant difference ( t=0.809, P=0.423). The JOA score, VAS score, and NDI of the two groups improved after operation, and further improved at 12 months compared to 3 months, with significant differences ( P<0.05). At each time point, the study group exhibited significantly higher JOA scores and improvement rate compared to the control group ( P<0.05); but there was no significantly difference in VAS score and NDI between the two groups ( P>0.05). Imaging re-examination showed that the vertebral height and C 2-7Cobb angle of the two groups significantly increased at 3 and 12 months after operation ( P<0.05), and there was no significant difference between 3 and 12 months after operation ( P>0.05). At each time point, the vertebral height and C 2-7Cobb angle of the study group were significantly higher than those of the control group ( P<0.05), and the implant subsidence rate was significantly lower than that of the control group ( P<0.05). However, there was no significant difference in intervertebral fusion rate between the two groups ( P>0.05). Conclusion: Compared to traditional titanium cages, the use of titanium alloy trabecular bone 3D-printed artificial vertebral bodies for treating cervical OPLL results in shorter operative time, fewer postoperative complications, and lower implant subsidence rates, making it superior in vertebral reconstruction.

[Effectiveness of Kirschner wire fixation for proximal phalangeal bone avulsion fracture caused by A2 circular trochlea injury of flexor digitorum tendon].

Objective: To explore the mechanism, surgical method, and effectiveness of proximal phalangeal bone avulsion fracture caused by A2 circular trochlea injury of the flexor digitorum tendon. Methods: A retrospective analysis was conducted on the clinical data of 4 patients with proximal phalangeal bone avulsion fracture caused by A2 circular trochlea injury of flexor digitorum tendon admitted between May 2018 and September 2022. The patients were all male, the age ranged from 26 to 52 years, with an average of 33 years. The injured fingers included 1 case of middle finger and 3 cases of ring finger. The causes of injury were rock climbing of 2 cases and carrying heavy objects of 2 cases. Preoperative anteroposterior and lateral X-ray films and CT examination of the fingers showed a lateral avulsion fracture of the proximal phalanx, with a fracture block length of 15-22 mm and a width of 3-5 mm. The total active range of motion (TAM) of the injured finger before operation was (148.75±10.11)°. The grip strength of the middle and ring fingers was (15.50±2.88) kg, which was significantly lower than that of the healthy side (50.50±7.93) kg ( t=-8.280, P<0.001). The time from injury to operation was 2-7 days, with an average of 3.5 days. One Kirschner wire with a diameter of 1.0 mm was used for direct fixation through the fracture block, while two Kirschner wires with a diameter of 1.0 mm were used for compression fixation against the fracture block. The fracture healing was observed, and the TAM of the injured finger and the grip strength of the middle and ring fingers were measured. The finger function was evaluated according to the upper limb functional assessment trial standards of the Chinese Medical Association Hand Surgery Society. Results: The incisions all healed by first intention after operation. All patients were followed up 6-28 months, with an average of 19 months. X-ray films showed that all avulsion fractures of proximal phalanx reached bony union, and the healing time ranged from 4 to 8 weeks, with an average of 4.6 weeks. At last follow-up, the grip strength of the middle and ring fingers was (50.50±7.76) kg, which significantly improved when compared with preoperative one ( t=-8.440, P<0.001). The TAM of the injured finger reached (265.50±2.08)°, and there was a significant difference when compared with preoperative one ( t=-21.235, P<0.001). According to the upper limb functional assessment trial standards of the Chinese Medical Association Hand Surgery Society, the finger function was all evaluated as excellent in 4 cases. Conclusion: Using Kirschner wire fixation through bone blocks and external compression fixation of bone blocks for treating proximal phalangeal bone avulsion fracture caused by A2 circular trochlear injury of the flexor digitorum tendon can achieve good effectiveness.

Do postoperative outcomes vary between midshaft clavicle fractures of 2, 3, or more than 3 fragments?

OBJECTIVE: This study aims to assess differences in clinical and surgical outcomes associated with the surgical treatment of midshaft clavicle fractures of different complexities based on fragment number. Additionally, the investigation seeks to present the outcomes of a series of patients who underwent surgery at our institution. MATERIALS AND METHODS: A retrospective analysis was conducted on the medical records of patients aged over 18 who underwent midshaft clavicle fracture surgery at our center from November 2009 to May 2021. Patients were categorized based on the number of fracture fragments into groups of two, three, or more than three fragments. Consolidation, implant removal, complications, surgical duration, and functional outcomes (assessed through VAS, ASES, and Constant-Murley scale) were evaluated for each specific group and for the overall cohort. RESULTS: In total, 260 patients were analyzed. There were no significant differences in any of the parameters between the three groups except for surgical time, which was shorter in simple fractures than in those with more than three fragments (68.2 min vs. 75.3 min; p = 0.01). Pseudoarthrosis rate was 2.69%, implant removal rate was 9.61%, and 4.23% of patients presented with complications other than the previous ones. Functional results were excellent, with averages of 97.3 (72.7-100) for the ASES score, 97.5 (75-100) for the Constant score, and 0.6 (0-8) on the VAS. CONCLUSION: According to our results, there were no differences in postoperative results between simple and multifragmentary midshaft clavicle fractures. Patients across all groups reported satisfactory results.

Finite Element Analysis of Six Internal Fixations in the Treatment of Pauwels Type III Femoral Neck Fracture.

OBJECTIVE: The current investigation sought to utilize finite element analysis to replicate the biomechanical effects of different fixation methods, with the objective of establishing a theoretical framework for the optimal choice of modalities in managing Pauwels type III femoral neck fractures. METHODS: The Pauwels type III fracture configuration, characterized by angles of 70°, was simulated in conjunction with six distinct internal fixation methods, including cannulated compression screw (CCS), dynamic hip screw (DHS), DHS with de-rotational screw (DS), CCS with medial buttress plate (MBP), proximal femoral nail anti-rotation (PFNA), and femoral neck system (FNS). These models were developed and refined using Geomagic and SolidWorks software. Subsequently, finite element analysis was conducted utilizing Ansys software, incorporating axial loading, torsional loading, yield loading and cyclic loading. RESULTS: Under axial loading conditions, the peak stress values for internal fixation and the femur were found to be highest for CCS (454.4; 215.4 MPa) and CCS + MBP (797.2; 284.2 MPa), respectively. The corresponding maximum and minimum displacements for internal fixation were recorded as 6.65 mm for CCS and 6.44 mm for CCS + MBP. When subjected to torsional loading, the peak stress values for internal fixation were highest for CCS + MBP (153.6 MPa) and DHS + DS (72.8 MPa), while for the femur, the maximum and minimum peak stress values were observed for CCS + MBP (119.3 MPa) and FNS (17.6 MPa), respectively. Furthermore, the maximum and minimum displacements for internal fixation were measured as 0.249 mm for CCS + MBP and 0.205 mm for PFNA. Additionally, all six internal fixation models showed excellent performance in terms of yield load and fatigue life. CONCLUSION: CCS + MBP had the best initial mechanical stability in treatment for Pauwels type III fracture. However, the MBP was found to be more susceptible to shear stress, potentially increasing the risk of plate breakage. Furthermore, the DHS + DS exhibited superior biomechanical stability compared to CCS, DHS, and PFNA, thereby offering a more conducive environment for fracture healing. Additionally, it appeared that FNS represented a promising treatment strategy, warranting further validation in future studies.

Stable Clinical and Radiological Outcomes at Medium and over 5 Year follow up of Calcaneus Fracture Open Reduction Internal Fixation using a Sinus Tarsi Approach.

The Sinus Tarsi Approach is increasingly growing in popularity for open reduction internal fixation of calcaneus fractures. Multiple studies have demonstrated favorable short-term results compared to the traditional extensile L incision, however long-term data over 5 years is currently limited to a single retrospective case series. Following local ethical approval, all patients who had completed a minimum 5 years from time of operation were contacted with a standardised telephone questionnaire completed. This followed a previous retrospective chart review, with follow up telephone or clinic consultation performed by Davey et al of this cohort at mean 35 months. Thirty-four fractures (31 patients) completed minimum 5 year follow up from the eligible group of 54 fractures (49 patients). Regarding functional outcomes, a significant improvement in mean Maryland Foot Score was observed between short- (mean 35.8 months) and medium-term (mean 81.9 months) of 77.6 (SD 15.0) to 86 (SD 7.9). (p=0.0082.) There was no significant difference in postoperative and long term radiographic Bohler's angle. (p=0.9683.) Eleven feet (32%) proceeded to require reoperation, with removal of metal performed in 10 (29%), fusion in 2 (6%) and skin grafting following wound breakdown for 1 (3%). Four feet (12.9%) experienced post operative wound complications, including 3 (9.68%) cases of infection and 2 (6.45%) of delayed wound healing. This study demonstrated stable clinical and radiographic outcomes over 5 years following Calcaneus Fracture Open Reduction Internal Fixation using a Sinus Tarsi Approach, supporting its continued usage when treating intraarticular calcaneus fractures for which operative intervention is indicated.