Impact and torsional behavior of additive layer-manufactured biopolymer: An advancement for orthopedic applications.

Distal ulna locking bone plates (DLBPs) are commonly employed in the treatment of distal ulna fractures. However, commercially available metallic bone plates experience stress shielding and lack corrosion resistance. Poly lactic acid (PLA) is highly favored biopolymer due to its biocompatible and bioabsorbable nature with human tissues. The use of additive layer manufacturing (ALM) is gaining attention for creating customized implants with intricate structures tailored to patient autonomy. ALM-based PLA bone plates must provide high resistance against impact and torsional forces, necessitating the adjustment of printing process parameters. This study focuses on examining the influence of key printing parameters, on the impact strength and torque-withstanding capability of DLBPs. Experimental results, along with microscopic images, reveal that an increase in infill density (IF) and wall thickness imparts strong resistance to layers against crack propagation under impact and torsional loads. On the contrary, an increase in layer height and printing speed leads to delamination and early fracture of layers during impact and torsional testing. IF significantly contributes to improving the impact strength and torque-withstanding capability of DLBPs by 70.53% and 80.65%, respectively. The study highlights the potential of the ALM technique in developing DLBPs with sufficient mechanical strength for biomedical applications.

Benefits of Rib Fixation Utilizing Low-Cost Materials: A Randomized Pilot Trial.

INTRODUCTION: Surgical stabilization of rib fractures (SSRF) using standard rib plating systems has become a norm in developed countries. However, the procedure has not garnered much interest in low-middle-income countries, primarily because of the cost. METHODS: This was a single-center pilot randomized trial. Patients with severe rib fractures were randomized into two groups: SSRF and nonoperative management. SSRF arm patients underwent surgical fixation in addition to the tenets of nonoperative management. Low-cost materials like stainless steel wires and braided polyester sutures were used for fracture fixation. The primary outcome was to assess the duration of hospital stay. RESULTS: Twenty-two patients were randomized, 11 in each arm. Per-protocol analysis showed that the SSRF arm had significantly reduced duration of hospital stay (22.6 ± 19.1 d versus 7.9 ± 5.7 d, P value 0.031), serial pain scores at 48 h and 5 d (median score 5, IQR (3-6) versus median score 7, IQR (6.5-8), P value 0.004 at 48 h and median score 2 IQR (2-3) versus median score 7 IQR (4.5-7) P value 0.0005 at 5 d), significantly reduced need for injectable opioids (9.9 ± 3.8 mg versus 4.4 ± 3.4 mg, P value 0.003) and significantly more ventilator-free days (19.9 ± 8.7 d versus 26.4 ± 3.2 d, P value 0.04). There were no statistically significant differences in the total duration of ICU stay (median number of days 2, IQR 1-4.5 versus median number of days 7, IQR 1-14, P value 0.958), need for tracheostomy (36.4% versus 0%, P value 0.155), and pulmonary and pleural complications. CONCLUSIONS: SSRF with low-cost materials may provide benefits similar to standard rib plating systems and can be used safely in resource-poor settings.

Plate fixation of inferior ramus in pubis-ischium ramus improves mechanical stability in Tile B pelvic injures: a cadaveric biomechanical analysis and early clinical experience.

BACKGROUND: Management of inferior ramus of the pubis-ischium ramus remains controversial, and related research is sparse. The main intention of this study is to describe the biomechanical and clinical outcomes of pubis-ischium ramus fractures in Tile B pelvic injuries and to identify the feasibility and necessity of fixation of the inferior ramus of the pubis-ischium ramus. METHODS: This study comprised two parts: a biomechanical test and a retrospective clinical study. For the biomechanical tests, Tile B-type pelvic injuries were modeled in six cadaver specimens by performing pubis-ischium osteotomies and disruption of the anterior and interosseous sacroiliac ligaments. The superior and/or inferior rami of the pubis-ischium ramus were repaired with reconstruction plates and separated into three groups (A, B, and C). Specimens were placed in the standing position and were loaded axially with two-leg support for three cycles at 500 N. The displacements of sacroiliac joints at osteotomy were measured with Vernier calipers and compared using statistical software. To investigate the clinical outcomes of this technique, 26 patients were retrospectively analyzed and divided into a superior ramus fixation group (Group D) and a combined superior and inferior ramus of the pubis-ischium ramus fixation group (Group E). The main outcome measures were time of operation, blood loss, postoperative radiographic reduction grading, and functional outcomes. RESULTS: In the vertical loading test, Group E showed better pelvic ring stability than Group D (P < 0.05). However, the shift of the sacroiliac joints was almost identical among the three groups. In our clinical case series, all fractures in Group E achieved bony union. Group E demonstrated earlier weight-bearing functional exercise (2.54 ± 1.45 vs 4.77 ± 2.09; P = 0.004), earlier bony union (13.23 ± 2.89 vs 16.55 ± 3.11; P = 0.013), and better functional outcomes (89.77 ± 7.27 vs 82.38 ± 8.81; P = 0.028) than Group D. The incidence of sexual dysfunction was significantly lower in Group E than that in Group D (2/13 vs 7/13; P = 0.039). Bone nonunion occurred in two patients in Group D, and two patients in Group E had heterotopic ossification. None of the patients exhibited wound complications, infections, implant failures, or bone-implant interface failures. CONCLUSIONS: Fixation of the inferior ramus of a pubis-ischium ramus fracture based on conventional fixation of the anterior pelvic ring is mechanically superior in cadaveric Tile B pelvic injury and shows rapid recovery, good functional outcomes, and low incidence of complications.

Comparative Analysis of Intramedullary Nail versus Plate Fixation for Fibula Fracture in Supination External Rotation Type IV Ankle Injury.

BACKGROUND Lateral malleolus fractures, typically from trauma, sports, or accidents, are common, with supination external rotation (SER) injuries being most prevalent. SER injuries involve complex joint mechanics and often necessitate surgical intervention for instability. This study compares intramedullary nail and plate fixation for fibula fractures in SER type IV ankle injuries, considering their biomechanical properties and influence on fracture healing. MATERIAL AND METHODS A prospective, randomized study was conducted between January 2021 and December 2021. A total of 81 patients with SER injuries were included in the study. Surgical procedures were performed using either intramedullary nails or plates. The following parameters were recorded and analyzed: postoperative complications, operation times, bone healing times, American Orthopaedic Foot & Ankle Society (AOFAS) scores, visual analog scale (VAS) scores for pain, and ankle range of motion. RESULTS Out of the 81 cases, 42 were treated with intramedullary nails, while 39 received plate fixation. Statistical analysis revealed a significantly lower rate of postoperative complications in the intramedullary nail group than in the the plate fixation group (9.52% vs 30.77%, P<0.0164). However, there were no significant differences between the 2 groups in terms of operation time, bone healing time, AOFAS scores, VAS scores, and functional evaluations (P>0.05). CONCLUSIONS Plate fixation and intramedullary nail fixation are effective techniques for treating fibula fractures in SER type IV injuries. However, intramedullary nail fixation demonstrates a lower rate of complications. Therefore, intramedullary nails may be preferable to plate fixation for the management of fibula fractures in SER type IV ankle injuries.

Anterior Plate-Supported Cannulated Screw Surgery for Ankle Arthrodesis: Clinical and Radiologic Results in Patients with Trauma-Related End-Stage Ankle Osteoarthritis.

BACKGROUND This retrospective study included 31 patients from 2 centers in Türkiye with posttraumatic ankle osteoarthritis treated with anterior tibiotalar arthrodesis using an anterior plate and cannulated screw fixation, with 6 months of follow-up. MATERIAL AND METHODS In this bi-center study, conducted between January 2018 and July 2022, we retrospectively reviewed the digital records of 31 patients with end-stage posttraumatic ankle osteoarthritis who were treated with anterior tibiotalar arthrodesis surgery using 2 or 3 cannulated screws and the anterior plating technique. Data on age, gender, comorbidities, and smoking were recorded, as were operative technique and graft use. Union characteristics, complications, visual analog scale (VAS) results, and Maryland functional scoring were assessed preoperatively and at the 6-month follow-up visit. RESULTS The mean age of the 31 (n=13 male, n=18 female) patients was 55.5 (19-82) years. The union findings were good in 26 (83.9%) of the patients and late in 3 (9.7%) of them. Nonunion was seen in 2 (6.5%) patients. Complications were observed in 7 (22.6%) patients. Union formation was statistically significantly prolonged among the cases with complications (P=0.002). The smoking rate was significantly higher in patients encountering complications (P=0.001). Among cases with complications, the VAS and Maryland scores recorded in the postoperative sixth month were significantly higher (P=0.027, P=0.018, respectively). The mean union time was 13.5±6.5 weeks among all of the patients. CONCLUSIONS Our study showed that cannulated screw fixation, strengthened with the common and easy-to-supply anterior reconstruction plating technique, had high fixation power and good functional results in patients with end-stage posttraumatic ankle osteoarthritis.

Outcomes of Anterior Lateral Approach and Gerdy's Tubercle Osteotomy for Tibial Plateau Fractures Involving the Posterior Lateral Condyle: A Retrospective Study of 20 Patients.

BACKGROUND The objective of this investigation was to assess the effectiveness of using T-shaped steel plates through the anterior lateral approach and Gerdy's tubercle osteotomy for treating posterior lateral tibial plateau fractures. MATERIAL AND METHODS A retrospective analysis was conducted on clinical data from 20 patients, aged on average 53.9±10.36 years, who were admitted for tibial plateau fractures involving the posterior lateral condyle between January 2019 and October 2022. The fixation and reduction of the posterior lateral bone block were performed using the anterior lateral approach combined with Gerdy's tubercle osteotomy to address the posterior lateral tibial plateau fracture. Post-surgery assessment was conducted using the Hospital for Special Surgery (HSS) knee combined score. RESULTS During the 12-24 (14.2±1.7) month postoperative period, we conducted 20 surgeries. Within 9 to 12 weeks, fracture healing transpired without any complications such as incision infection, nerve injury, or fracture displacement being detected. Assessment of knee joint function at the final follow-up was conducted using the HSS knee combined score, with results indicating 16 cases rated as excellent, 3 cases as good, and 1 case as fair. CONCLUSIONS In tibial plateau fractures impacting the posterior lateral condyle, the anterior lateral approach, combined with Gerdy's tubercle osteotomy, allows for direct exposure and manipulation of the posterior lateral bone block fracture. Using a T-shaped support plate and a lateral locking plate provides a reliable method for fracture fixation, aiding in convenient surgical positioning and intraoperative fluoroscopy. The treatment approach effectively manages fractures located on the posterior lateral aspect of the tibial plateau.

Intraoperative radiographic analysis and adjustment of the optimal position of plate in high tibial osteotomy.

BACKGROUND: When high tibial osteotomy is performed for genu varus deformity, it is not easy to determine the accurate placement of the plate. PURPOSE: To determine a simple way to assess the position of the plate, to provide more effective mechanical support and to reduce the risk of implant rupture and vascular injury. MATERIAL AND METHODS: Two human anatomical marks, the patellar ligament and semimembranosus, were connected and divided into four parts to identify points Ⅰ, Ⅱ, and Ⅲ. These points determined the areas for Tomofix placement: anterior, anterolateral, and lateral. Simulated internal fixation placed hole B of Tomofix at points Ⅰ (anterior), Ⅱ (anterolateral), and Ⅲ (lateral). We analyzed the pointing direction of the locking screws in Tomofix holes on MRI to assess potential injury risk to the popliteal neurovascular bundle. RESULTS: In the X-ray: holes B and C appeared as the plate in the anterior, only hole C appeared as the plate in the anterolateral, and none of the holes appeared as the plate in the lateral. In the general view of the sawbones, the screw pointed towards the popliteal neurovascular bundle when the plate was in the anterior. CONCLUSION: If a small number of holes on the plate is visible under fluoroscopy, then several lateral positions of the plate can be obtained; the direction of the screw tunnel tends to deviate from the popliteal neurovascular bundle with the posterior position of the plate.

A finite element analysis of stress distribution with various directions of intermaxillary fixation using orthodontic mini-implants and elastics following mandibular advancement with a bilateral sagittal split ramus osteotomy.

OBJECTIVE: This finite element analysis (FEA) aimed to assess the stress distribution in the mandible and fixation system with various directions of the intermaxillary fixation (IMF) using mini-implants (MIs) and elastics following mandibular advancement with a bilateral sagittal split ramus osteotomy (BSSRO). MATERIALS AND METHODS: A total of nine mandibular advancement models were set according to the position of the MIs (1.6 mm in diameter, 8 mm in length) and direction of the IMF elastics (1/4 inch, 5 oz). Major and minor principal stresses in the cortical and cancellous bones, von Mises stresses in the fixation system (miniplate and monocortical screws), and bending angles of the miniplate were analysed. RESULTS: Compressive and tensile stress distributions in the mandible and von Mises stress distributions in the fixation system were greater in models with a Class III IMF elastic direction and a higher IMF elastic force than in models with a Class II IMF elastic direction and a lower IMF elastic force. The bending angle of the miniplate was negligible. CONCLUSIONS: Stress distributions in the bone and fixation system varied depending on the direction, amount of force, and position of IMF elastics and MIs. Conclusively, IMF elastics in the Class II direction with minimal load in the area close to the osteotomy site should be recommended.

The novel Kambin Torpedo full-endoscopic lumbar interbody fusion technique: a case series.

PURPOSE: Full-endoscopic lumbar interbody fusion (FELIF) is a new-generation treatment for spondylolisthesis. However, owing to their unique characteristics, the two main endoscopic fusion trajectories, the trans-Kambin and posterolateral approaches, have important limitations. Herein, we aimed to introduce a new technique called Kambin Torpedo FELIF (KT-FELIF). METHODS: The KT-FELIF technique is based on the trans-Kambin approach. It additionally completes ipsilateral total facetectomy and contralateral direct decompression. Thus, this novel technique combines the advantages of the trans-Kambin and posterolateral approaches. RESULTS: We reported on the indications and technical steps of KT-FELIF and provided intraoperative and animated videos to clarify the procedure. Short-term follow-up based on 3-month postoperative computed tomography and plain films images taken at least 3 months after surgery showed adequate bony decompression, a large bone graft contact area, and good intervertebral trabecular bone growth without radiolucent lines between the graft, cage, and end plate. The clinical results, such as ipsilateral and contralateral visual analog scale and Oswestry disability index values, gradually improved at 1 and 3 months postoperatively. No complications were observed. CONCLUSIONS: KT-FELIF is a promising FELIF technique for achieving bilateral direct decompression through a unilateral approach while accomplishing thorough discectomy and endplate preparation.

Myelopathy resulting from degenerative atlantoaxial subluxation.

PURPOSE: To present the clinical features and treatment strategy of degenerative atlantoaxial subluxation (DAAS). METHODS: Patients with DAAS treated in our institution from 2003 to 2020 were retrospectively reviewed. We utilized the Japanese Orthopedic Association (JOA) scale to evaluate the neurologic status and distance of Ranawat et al. (DOR) to measure vertical migration. RESULTS: We recruited 40 patients with > 2 years of follow-up and an average age of 62.3 ± 7.7 years. All the patients had myelopathy; only one patient had moderate trauma before exacerbation of symptoms, and the duration of symptoms was 34 ± 36 months. The most frequent radiological features were vertical migration of C1 (100%), sclerosis (100%), and narrowing of the atlantoaxial lateral mass articulations (100%). Two patients underwent transoral release combined with posterior reduction and fusion, and 38 patients underwent posterior reduction and fusion with C1 lateral mass screws-C2 pedicle screws and plate systems only. Forty cases (100%) achieved a solid atlantoaxial fusion, and 38 cases (95%) achieved anatomic atlantoaxial reduction. The JOA score increased from 9.3 ± 2.6 to 14.8 ± 2.1 (P < 0.01). DOR increased from 14.5 ± 2.5 to 17.8 ± 2.2 mm at the final follow-up (P < 0.01). Loosening of the locking caps was detected in one case, bony fusion was achieved, and harvest-site pain was reported in five patients. CONCLUSION: DAAS differs from other types of AAS and presents with anterior subluxation combined with vertical subluxation arising from degenerative changes in the atlantoaxial joints. We recommend anatomic reduction as an optimal strategy for DAAS.

Does a Point-of-Care 3-Dimensional Printer Result in a Decreased Length of Surgery for Orbital Fractures?

BACKGROUND: Utilization of point-of-care 3-dimensional printing (3DP) has decreased length of surgery in facial trauma. Little is known regarding 3DP's impact on length of surgery in orbital fracture. PURPOSE: The purpose of this study was to compare length of surgery between 3DP/preadapted (3DPPA) orbital plates and intraoperative adapted plates (IOAP) for orbital fracture reconstruction. STUDY DESIGN, SETTING, SAMPLE: This was a prospective, non-blinded, randomized clinical study of consecutive subjects with orbital fractures presented to Grady Memorial Hospital in Atlanta, Georgia, between January 2018 and June 2021. Subjects ≥ 18 years, unilateral fracture, no previous orbital surgery, and/or congenital craniofacial anomaly were included. We excluded subjects <18 years and bilateral fractures. PREDICTOR/EXPOSURE/INDEPENDENT VARIABLE: Primary predictor variable was the treatment approach. Randomization software was used, and subjects were randomized to 3DPPA or IOAP groups. MAIN OUTCOME VARIABLE(S): Primary outcome variable was length of surgery in minutes. Secondary outcomes were the time required for plate insertion and fixation in minutes, operating room (OR) charges, and orbital volume (OV) calculation. COVARIATES: Age, sex, race, etiology, laterality, location, dimension, indication for surgery, postoperative enophthalmos, and diplopia. ANALYSES: Univariate and bivariate analyses were calculated. Statistical significance was P < .05. RESULTS: Twenty-five subjects met the inclusion criteria. Mean ages in 3DPPA and conventional IOAP groups were 41.5 (±9) and 38.2 (±10, P = .31), respectively. The mean length of surgery was 32.6 (±13.7) in 3DPPA and 53.3 (±12.8, P < .001) in conventional IOAP. The mean time required for plate insertion and fixation was 15.8n (±14.4) in 3DPPA and 41.4 (±9.4, P < .001) in conventional IOAP. The mean OR charges were $1,072.5 (±524.6) in 3DPPA and $1,757.3 (±422.6, P ≤ 0.001) in conventional IOAP. The mean calculated OV of uninjured and reconstructed orbit for the 3DPPA was 23.5 (±3.2)cm3 and 23 (±3.5, P = .37)cm3, respectively. The mean calculated OV of uninjured and reconstructed orbit for conventional IOAP was 28.6 (±3.6)cm3 and 22.8 (±2.6, P < .001)cm3, respectively. CONCLUSION AND RELEVANCE: Using 3DP to produce a model that enables preoperative plate bending/adaptation reduces the length of surgery, decreases OR charges, and results in predictable OV.

Lower Insertional Torque of Fixation Screws for Mandibular Angle Fractures Is Associated With Complications.

BACKGROUND: Open reduction and internal fixation (ORIF) is a common treatment for mandibular angle fractures. It is unknown, however, whether the insertional torque of the fixation screws is a risk factor for postoperative complications. PURPOSE: The purpose of the study was to determine the association between fixation screw insertional torque and postoperative inflammatory complications (POICs). STUDY DESIGN, SETTING, SAMPLE: The authors conducted a prospective cohort study consisting of all adult patients treated with ORIF of mandibular angle fractures using a single six-hole lateral border plate secured with monocortical screws from January 1, 2020, to October 31, 2022, at a large, urban academic hospital. Patients with gunshot wounds, prolonged maxillomandibular fixation, and bilateral angle fractures were excluded. PREDICTOR VARIABLE: The predictor variables were the average and lowest insertional torque of the six screws placed for fixation during ORIF. MAIN OUTCOME VARIABLE: The outcome variable was the presence of POICs, defined as the occurrence of exposed or infected hardware, abscess formation, recurrent swelling/pain, nonunion, osteomyelitis, or fistula formation. COVARIATES: Demographics, medical history, mechanism, diagnosis, and treatment-related variables were also analyzed. ANALYSES: Descriptive and bivariate analyses were performed. A P value of ≤ .05 was considered significant. RESULTS: There were 51 patients included in the study, 37 (72.5%) men, with a mean age of 31.2 ± 10.1 years. POICs occurred in 15.7% of patients. The average insertional screw torque was 46.9 ± 7.8 Ncm, and the mean lowest insertional screw torque per plate was 34.3 ± 10.2 Ncm. The average torque values were not lower in patients who had POICs versus those who did not (45.0 ± 8.6 Ncm vs 48.4 ± 7.6 Ncm, respectively, P = .16). However, the lowest torque value was less in patients who had POICs compared to those who did not (27.5 ± 11.0 Ncm vs 35.6 ± 9.7 Ncm, respectively, P = .04). CONCLUSION AND RELEVANCE: Among patients with mandibular angle fractures treated with ORIF, decreased insertional torque for the lowest of the six screws placed for fixation was associated with complications. While previous studies have shown certain plating schemes have been associated with complications, the quality of fixation also plays a role.

Is a Novel Fluoroscopic Intraoperative Reference System Superior to Conventional Management for Distal Radius Fracture Reduction? A Propensity-matched Comparative Study.

BACKGROUND: Preoperative planning is generally performed to simulate the process of reduction as well as to determine the size and placement of implants in patients undergoing distal radius fracture surgery. We previously described a three-dimensional (3D) digital preoperative planning system for the osteosynthesis of distal radius fractures, and we have developed a novel intraoperative referencing system that superimposes preoperative planning (such as plate position and length) onto fluoroscopic images during surgery; however, its efficacy has not been evaluated compared with conventional planning and surgery. QUESTIONS/PURPOSES: Does use of a novel intraoperative referencing system result in (1) better Mayo wrist scores at 3 and 6 months after surgery and (2) less loss of reduction in terms of ulnar variance, palmar tilt, and radial inclination on plain radiographs taken 1 week, 3 months, and 6 months after surgery compared with conventional preoperative planning? METHODS: Between April 2014 and October 2021, we treated 294 patients with open reduction and volar plate fixation for distal radius fractures. Of 294 patients, 65% (191) underwent surgery using either conventional preoperative planning or a novel intraoperative referencing system. The remaining patients were excluded because they were younger than 18 years, they had some missing medical records related to the clinical outcomes, or they had a previous history of upper extremity injuries. During that time, we generally treated fractures with volar plates when there was: more than 2 mm of stepoff/gap in the articular surface, a dorsal tilt more than 15°, radial inclination less than 15°, or radial shortening more than 5 mm. Generally, we used a flexor carpi radialis approach. In some patients who had dorsal fragments, we added a dorsal approach. At that time, we were developing the new intraoperative referencing system, so it was not used consistently. To arrive at a fair assessment, we opted to perform propensity matching based on age, gender, and AO fracture type. During the period in question, 36% (69 of 191) of patients with distal radius fractures who received a volar plate were treated using our novel intraoperative referencing system, and 64% (122 of 191) had surgery using conventional preoperative planning (control group). Of those, 91% (63 of 69) of patients who were treated with the intraoperative referencing system and 89% (108 of 122) of those in the control group were available for follow-up with all imaging and Mayo wrist scores at least 6 months after surgery. After propensity matching, that left us with two groups of 39 patients, who were well matched in terms of age and fracture type; these were the study groups. We also tried to match them according to gender, but there were fewer patients in the intraoperative referencing group, and the percentage of women for each group differed: 70% (44 of 63) in the intraoperative referencing group and 76% (82 of 108) in the control group. Also, there were fewer men with C3 fractures in the control group. Therefore, 64% (25 of 39) of patients in the intraoperative referencing group were women and 77% (30 of 39) of patients in the control group were women. In the intraoperative referencing group, our novel intraoperative referencing system was used in combination with the 3D digital preoperative planning system for preoperative planning. In the control group, preoperative planning was performed manually in a conventional manner using tracing paper and implant templates or using a digital template. We compared the groups in terms of operative duration, the radiation dose used in surgery, and Mayo wrist scores at 3 and 6 months after surgery. We also compared the groups in terms of loss of reduction on ulnar variance, palmar tilt, and radial inclination on plain radiographs taken 3 months and 6 months after surgery. We considered the plain radiograph taken 1 week after surgery as a baseline. Each item was compared between the image fusion and control groups using a Welch t - test. RESULTS: Mayo wrist scores were no different between the intraoperative referencing system and the control group at 3 months (71 ± 7 versus 72 ± 11, mean difference 1 [95% CI -3.7 to 5.7]; p = 0.07) or at 6 months after surgery (76 ± 6 versus 79 ± 11, mean difference 3 [95% CI -3.5 to 7.9]; p = 0.12). There were no differences in surgical duration or radiation doses between the intraoperative referencing and control groups. We found only a small advantage in favor of the intraoperative referencing system in terms of loss of reduction on ulnar variance (3 months after surgery: 0.2 ± 0.4 mm versus 0.6 ± 0.7 mm, mean difference 0.4 mm [95% CI 0.15 to 0.69]; p = 0.003, 6 months after surgery: 0.4 ± 0.6 mm versus 0.8 ± 0.8 mm, mean difference 0.4 mm [95% CI 0.05 to 0.73]; p = 0.02 for the intraoperative referencing system and the control group, respectively). This difference in radial shortening was so small that it was not likely to have been clinically important. CONCLUSION: We found no clinically important advantages from the use of our novel intraoperative referencing system except a slight improvement in ulnar variance. Therefore, we recommend against its use in everyday practice at this time. However, future improvements may lead to better clinical outcomes, so we plan further investigations. LEVEL OF EVIDENCE: Level III, therapeutic study.

Patient-specific Implants Improve Volumetric Surgical Accuracy Compared to Stock Reconstruction Plates in Modern Paradigm Virtual Surgical Planning of Fibular Free Flaps for Head and Neck Reconstruction.

BACKGROUND: Virtual surgical planning (VSP) for composite microvascular free flaps has become standard of care for oncologic head and neck reconstruction. Controversy remains as to the use of three-dimensional (3D)-printed patient-specific titanium implants (PSIs) versus hand-bent stock reconstruction plates. Proponents of PSIs cite improved surgical accuracy, reduced operative times, and improved clinical outcomes. Detractors purport increased cost associated with PSIs and presumed equivalent accuracy with less expensive stock plates. PURPOSE: The study purpose was to measure and compare the 3D-volumetric accuracy of PSI versus stock reconstruction plates among subjects undergoing VSP-guided mandibular fibular free flap reconstruction. STUDY DESIGN, SETTING, SAMPLE: A retrospective cohort study of subjects undergoing VSP-guided fibular free flap reconstructions at Mayo Clinic between 2016 and 2023 was performed. Subjects were excluded for non-VSP guidance, midfacial reconstruction, nonfibular free flaps, and lack of requisite study variables. PREDICTOR VARIABLE: The primary predictor was the type of reconstruction plate utilized (PSI vs stock plate). MAIN OUTCOME VARIABLE: The main outcome was volumetric surgical accuracy of the final reconstruction compared to the preoperative surgical plan by root mean square error (RMSE) calculation. Lower RMSE values indicated a higher surgical accuracy. COVARIATES: Covariates included age, sex, race, smoking status, American Society of Anesthesiologists (ASA) Physical Status Classification System, Charlson Comorbidity Index, preoperative diagnosis, and number of fibular segments. ANALYSES: Differences in surgical accuracy were assessed between preoperative and postoperative segmented scans using volumetric overlays from which RMSE values were calculated. Univariate and multivariate modeling of plate type to RMSE calculation was performed. Statistical significance set to P < .05. RESULTS: Total of 130 subjects were identified, 105 PSI and 25 stock plates. Calculated mean RMSE in millimeters (mm) for stock plates was 1.46 (standard deviation: 0.33) and 1.15 (standard deviation: 0.36) for PSIs. Univariate modeling demonstrated a statistically significant difference in RMSE of 0.31 (95% confidence interval: 0.16-0.47) (P < .001) equating to a 21.2% (P < .001) improved volumetric surgical accuracy for PSIs. The association of improved volumetric accuracy with PSIs has been maintained in all multivariate models controlling for confounding. CONCLUSION AND RELEVANCE: In modern era VSP-guided head and neck fibular free flap reconstruction, patient-specific 3D-printed titanium implants confer a statistically significant improvement in volumetric surgical accuracy over stock reconstruction plates.

What Is the Likelihood of Union and Frequency of Complications After Parallel Plating and Supplemental Bone Grafting for Resistant Distal Femoral Nonunions?

BACKGROUND: Management of resistant distal femur nonunions is challenging because patients not only have disability from an unhealed fracture, but also often have a shortened femur, stiff knee, deformities, and bone defects to address during revision surgery. Dual plating of the distal femur in such a setting can maintain stability that allows the nonunion to heal while also addressing bone defects and correcting deformities simultaneously. Dual-plating techniques that have been described lack standardization with regard to the size and type of medial-side implants and configuration of the dual-plate construct. QUESTIONS/PURPOSES: (1) What proportion of patients achieve radiologic evidence of union after parallel plating of resistant distal femoral nonunions? (2) What improvements in function are achieved with this approach, as assessed by improvements in femoral length discrepancy, knee flexion, and patient-reported outcome scores? (3) What complications are associated with the technique? METHODS: Between 2017 and 2020, the senior author of this study treated 38 patients with resistant distal femoral nonunions, defined here as nonunions that persisted for more than 12 months since the injury despite a minimum of two previous internal fixation procedures. During the study period, our preferred technique for treating aseptic, resistant distal femoral nonunions was to use dual plates in a parallel configuration augmented with autografts. Of 38 patients, three patients with active signs of infection who underwent resection and reconstruction using bone transport techniques and two patients older than 65 years with deficient distal femur bone stock who underwent endoprosthetic reconstruction were excluded. Of the 33 included patients, 67% (22 of 33) were male. The median age was 40 years (range 20 to 67 years). Nonunion was articular and metaphyseal in 13 patients and metaphyseal only in 20 patients. Our surgical approach was to remove existing implants, perform intraoperative culturing to rule out infection, debride the nonunion, correct the deformity, perform intra-articular and extra-articular lysis of adhesions with quadriceps release, and apply fixation using medial and lateral fixed-angle anatomic locked implants positioned in a parallel configuration. Every attempt to improve length was undertaken, and the defects were filled with autografts. A total of 97% of patients were followed until union occurred (one of 33 was lost to follow-up before union was documented), and 79% (26 of 33) were assessed for functional outcomes at a minimum of 2 years (median 38 months [range 25 to 60 months]) after excluding patients lost to follow-up and those in whom union did not occur after parallel plating. Union was defined as evidence of central trabecular bridging on AP radiographs and posterior cortical bridging on lateral radiographs. These radiologic criteria were defined to overcome difficulties in assessing radiologic healing in patients with lateral and medial plates. With parallel plating, bridging trabecular bone along the posterior cortex on lateral radiographs and the central region on AP radiographs is visualized and can be appreciated and interpreted as evidence of healing in two orthogonal planes. Preoperative and follow-up clinical assessment of knee ROM, the extent of femoral length correction based on calibrated femoral radiographs before and after surgery, and the evaluation of improvement in lower limb function based on the preoperative and follow-up differences in responses to the lower extremity functional scale (LEFS) were studied (the LEFS is scored from 0 to 80, with higher scores representing better function). Complications and secondary surgical procedures to address them were abstracted from a longitudinally maintained trauma database. RESULTS: Sixty-seven percent (22 of 33) of nonunions showed radiologic healing by 24 weeks, and another 24% (eight of 33) healed by 36 weeks. Six percent (two of 33) did not unite, and one patient was lost to follow-up before union was documented. In the 79% (26 of 33) of patients available for final functional outcome assessment, the median femoral shortening had improved from 2.4 cm (range 0 to 4 cm) to 1.1 cm (range 0 to 2.3 cm; p < 0.001), and the median knee ROM had improved from 70° (range 20° to 110°) to 100° (range 50° to 130°; p = 0.002) after surgery. The median LEFS score improved to 63 (range 41 to 78) compared with 22 (range 15 to 33; p < 0.001) before surgery. Serious complications, including major thromboembolic events, iliac graft site infection, knee stiffness (flexion < 60°), and medial plate impingement necessitating removal, were seen in 30% (10 of 33) of patients. Secondary surgical interventions were performed in 24% (eight of 33) of patients to address procedure-related complications. CONCLUSION: Based on our findings, a high likelihood of union and improvements in knee and lower limb function can be expected with parallel plating of resistant distal femur nonunions using anatomic locked plates. However, the increased frequency of complications observed in our study suggests the need for improvements in dual-plating techniques and to explore possible alternative fixation methods through larger multicenter comparative studies. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Determination of the ideal plate for medial femoral condyle fracture fixation: an anatomical fit and biomechanical study.

BACKGROUND: The aim of this study is to determine the best plate to use as a substitute to fix a medial femoral condyle fracture. MATERIALS AND METHODS: The first part is to measure the best fit between several anatomical plates including the Proximal Tibia Anterolateral Plate (PT AL LCP), the Proximal Tibia Medial Plate (PT M LCP), the Distal Tibia Medial Locking Plate (DT M LCP) and the Proximal Humerus (PHILOS) plate against 28 freshly embalmed cadaveric distal femurs. Measurements such as plate offset and number of screws in the condyle and shaft shall be obtained. The subsequent part is to determine the compressive force at which the plate fails. After creating an iatrogenic medial condyle fracture, the cadavers will be fixed with the two plates with the best anatomical fit and subjected to a compression force using a hydraulic press. RESULTS: The PT AL LCP offered the best anatomical fit whereas the PHILOS plate offered the maximal number of screws inserted. The force required to create 2 mm of fracture displacement between the two is not statistically significant (LCP 889 N, PHILOS 947 N, p = 0.39). The PT AL LCP can withstand a larger fracture displacement than the PHILOS (LCP 24.4 mm, PHILOS 17.4 mm, p = 0.004). DISCUSSION AND CONCLUSION: Both the PT AL LCP and the PHILOS remain good options in fixing a medial femoral condyle fracture. Between the two, we would recommend the PT AL LCP as the slightly superior option.

3D printing assisted MIPO for treatment of complex middle-proximal humeral shaft fractures.

BACKGROUND: This study was designed to explore the clinical efficacy of 3-dimensional (3D) printing assisted minimally invasive percutaneous plate osteosynthesis (MIPO) technique by comparing the clinical outcomes with traditional open reduction and internal plating fixation (ORIF) for treating complex middle-proximal humerus fractures (AO 12C fracture type). MATERIALS AND METHODS: The data of 42 participants who received a complicated middle-proximal humerus fracture from the beginning of 2018 to the end of 2022 were retrospectively analyzed. All patients were assigned to two groups: MIPO with detailed preoperative planning assisted by 3D printing technique (MIPO group), and traditional ORIF (ORIF group). RESULTS: This study included 21 patients in the ORIF group and 21 patients in the MIPO group. All patients were followed-up for at least one year (mean: 16.12 ± 4.13 months), and no difference was observed in the range of shoulder joint motion (ROM), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) scores and Constant scores between the two groups. However, the occurrence of complications (surgical incision site infection, implant loosening, bone nonunion and radial nerve palsy) in ORIF group was remarkably higher compared to the MIPO group. All the cases achieved bone union within the MIPO group. Significant differences were found in surgical time, intraoperative blood loss and fracture healing time between the two groups. CONCLUSION: Preoperative 3D printing assisted MIPO technique exhibits obvious advantages in high operational efficiency and low occurrence of complications, which is worthy of clinical application for treating complex middle-proximal humeral shaft fractures.

Fixation of femoral neck fracture with femoral neck system: a retrospective cohort study of 43 patients.

BACKGROUNDS: This study aimed to analyze the clinical outcomes of femoral neck fractures (FNF) in patients treated with a femoral neck system (FNS, DePuy Synthes), which is a recently introduced device. METHODS: This retrospective cohort study of 43 patients who underwent osteosynthesis using FNS for FNF between July 2019 and June 2021 with a minimum follow-up of 6 months. The researchers examined the patients' demographic factors and radiologically evaluated the fracture type and fixation status, bone union, and postoperative complications. RESULTS: Of 43 patients, 25 were female, and the patients' mean age and body mass index were 62.1 years and 22.5 kg/m2, respectively. According to the Association of Osteosynthesis/Orthopaedic Trauma Association (AO/OTA) classification, the most common fracture types were 31B1.1 and B1.2 (13 cases each), followed by B2.3, B2.1, and B2.2 (seven, five, and four cases, respectively). Radiological bone union was confirmed in 39 patients (90.7%), and the mean time to union was 3.6 months. Two cases of nonunion, one case of lag screw cut-out, and one case of osteonecrosis were confirmed; all four cases later underwent arthroplasty. The mean time to reoperation was 4.5 months. Meanwhile, five patients underwent implant removal after the bone union, and distal locking screw stripping was noted in three patients. All three patients required metal plate cutting to remove the implants. CONCLUSIONS: Osteosynthesis of FNF using the newly introduced FNS showed favorable clinical outcomes and no specific hardware-related complications were reported during the follow-up. However, attention must be paid to the issue regarding distal locking screw failure during hardware removal.

Radiographic and clinical outcomes of muenster and sugar tong splints for distal radius fractures: a comparative study.

BACKGROUND: Non-operative management is typically indicated for extra-articular distal radius fractures. Conservative treatments such as Sugar tong splints (STs) and Muenster splints (MUs) are commonly used. However, there is limited research and outcome data comparing the two splint types. Therefore, this study aimed to investigate and compare the radiographic and clinical outcomes of treatment using STs and MUs. METHODS: In this retrospective comparative study, we aimed to evaluate and compare the radiographic and clinical outcomes of STs and MUs for the treatment of distal radius fractures. The study included 64 patients who underwent closed reduction (CR) in the emergency room and were treated with either STs or MUs splints (STs group: n = 38, MUs group: n = 26). Initial X-rays, post-CR X-rays, and last outpatient follow-up X-rays were evaluated. Radial height (RH), ulnar variance (UV), radial inclination (RI), and volar tilt (VT) were measured by a blinded investigator. The Quick DASH form was applied to measure patients' satisfaction after treatments. RESULTS: There were no significant differences in baseline characteristics, initial radiographic measurements, or radiographic measurements immediately after CR between the two groups. However, the overall radiological values deteriorated to some degree in both groups compared to the post-CR images. Furthermore, using a paired test, the STs group showed significant differences in RH and RI, and the MUs group showed significant differences in RH and UV between the last follow-up and post-CR images. CONCLUSIONS: The study concluded that there was no difference in clinical outcomes between the two splint types. However, both STs and MUs groups showed reduced radiographic parameters, and the MUs group showed a significant reduction of RH and UV in the treatment of distal radius fractures. LEVEL OF EVIDENCE: Level IV; Retrospective Comparison; Treatment Study.

Surgical treatment of acromioclavicular joint dislocation of Rockwood III/IV: a retrospective study on clavicular hook plate versus arthroscopic TightRope loop titanium button.

PURPOSE: To compare the clinical efficacy of arthroscopic TightRope loop titanium button and clavicular hook plate in the treatment of acromioclavicular joint (ACJ) dislocation of Rockwood III/IV. METHODS: A retrospective analysis of patients with ACJ dislocation in our hospital from January 2018 to December 2020 was conducted. The patients were assigned to be treated with arthroscopic TightRope loop titanium button (TR group) or clavicular hook plate (HP group). The preoperative, intraoperative and postoperative data and imaging findings of the two groups were compared. RESULTS: A total of 58 eligible patients were enrolled in this study. Compared with HP group, TR group had shorter incision length and less blood loss during operation. Postoperative follow-up ranged from 12 to 24 months (mean 15.4 months). At 6 months and 12months postoperatively, compared with HP group, TR group had lower VAS and higher CMS, and the difference was statistically significant. At 12 months postoperatively, compared with HP group, TR group had lower ACJ gap and coracoclavicular joint(CCJ) distance, and the difference was statistically significant.In HP group, there were 3 cases of subacromial impact, 1 case of redislocation, 2 cases of traumatic arthritis and 2 cases of wound infection. There was 1 case of redislocation in TR group. CONCLUSIONS: Compared with clavicular hook plate, arthroscopic TightRope loop titanium button is minimally invasive, safe and effective in the treatment of ACJ dislocation, and has a good trend in clinical application.