Management of geriatric acetabular fractures:Contemporary treatment strategies

Acetabular fractures in the geriatric population are typically low-energy fractures resulting from a fall from standing height.Compromised bone quality in the elderly,as well as this population’s concomitant medical comorbidities,render the management of such fractures challenging and controversial.Non-operative management remains the mainstay of treatment,although such a choice is associated with numerous and serious complications related to both the hip joint as well as the general condition of the patient.On the other hand,operatively treating acetabular fractures(e.g.,with osteosynthesis or total hip arthroplasty)is gaining popularity.Osteosynthesis can be performed with open reduction and internal fixation or with minimally invasive techniques.Total hip arthroplasty could be performed either in the acute phase combined with osteosynthesis or as a delayed procedure after a period of non-operative management or after failed osteosynthesis of the acetabulum.Regardless of the implemented treatment,orthogeriatric co-management is considered extremely crucial,and it is currently one of the pillars of a successful outcome after an acetabular fracture.

Clinical outcomes of triceps reflecting anconeus pedicle and olecranon osteotomy approach for distal humerus intercondylar fractures

BACKGROUND The preferred treatment for distal humeral intercondylar fractures is open reduction and internal fixation.While there is consensus about the posterior approach,several posterior approaches have been developed.It is debatable as to which approach is best.AIM To compare triceps reflecting anconeus pedicle(TRAP)and olecranon osteotomy approaches for internal fixation of distal humeral intercondylar fracture.METHODS In total,40 cases of Arbeitsgemeinschaft für Osteosynthesefragen/Association of the Study of Internal Fixation type C,closed,and Gustilo type I intercondylar humeral fractures were included.Patients ranged in age from 18 years to 70 years.The patients were randomized into two groups:TRAP group and olecranon osteotomy group,with 20 cases in each.All were followed up at 6 wk,3 months,6 months,and 12 months.Functional outcomes were measured in terms of flexion-extension arc,Disabilities of Arm,Shoulder and Hand score,and Mayo Elbow Performance Score.RESULTS The mean age was 43.2 years in the TRAP group and 37.5 years in the olecranon osteotomy group.The mean operative time and mean duration of hospital stay in the TRAP group were significantly higher than in the olecranon osteotomy group(119.5 vs 111.5 min and 9.85 vs 5.45 d,respectively).The mean arc of flexion-extension,Disabilities of Arm,Shoulder and Hand score,and Mayo Elbow Performance Score were comparable without any significant difference in the groups at the 12-month follow-up(107.0 vs 106.2,18.3 vs 15.7,and 84.2 vs 86.2,respectively).Ulnar paresthesia and superficial infections were comparable in both groups(2 cases vs 3 cases and 3 cases vs 2 cases,respectively).Hardware prominence was significantly higher in the olecranon osteotomy group,mostly due to tension band wiring.CONCLUSION Both approaches were equivalent,but there is a need for further study including higher numbers of subjects and longer study duration to prove the benefits of one approach over the other.

Selection of internal fixation method for femoral intertrochanteric fractures using a finite element method

BACKGROUND Failure to fix unstable intertrochanteric fractures impairs return to daily activities.AIM To simulate five different internal fixation methods for unstable proximal femoral fractures.METHODS A three-dimensional model of the femur was established from sectional computed tomography images,and an internal fixation model was established.Finite element analysis of the femur model was established,and three intertrochanteric fracture models,medial defect,lateral defect,and medial-lateral defects,were simulated.Displacement and stress distribution after fixation with a proximal femoral anti-rotation intramedullary nail(PFNA),integrated dual-screw fixation(ITN),PFNA+wire,PFNA+plate,and PFNA+wire+plate were compared during daily activities.RESULTS The maximum displacement and stress of PFNA and ITN were 3.51 mm/473 MPa and 2.80 mm/588 MPa for medial defects;2.55 mm/288 MPa and 2.10 mm/307 MPa for lateral defects;and 3.84 mm/653 MPa and 3.44 mm/641 MPa for mediallateral defects,respectively.For medial-lateral defects,reconstructing the medial side alone changed the maximum displacement and stress to 2.79 mm/515 MPa;reconstructing the lateral side changed them to 3.72 mm/608 MPa,when both sides were reconstructed,they changed to 2.42 mm/309 MPa.CONCLUSION For medial defects,intramedullary fixation would allow early low-intensity rehabilitation exercise,and ITN rather than PFNA reduces the risk of varus and cut-out;for lateral wall defects or weakness,intram-edullary fixation allows higher-intensity rehabilitation exercise,and ITN reduces the risk of varus.For both medial and lateral defects,intramedullary fixation alone will not allow early functional exercise,but locating lateral or medial reconstruction will.For defects in both the inner and outer sides,if reconstruction cannot be completed,ITN is more stable.

Open reduction and Herbert screw fixation of Pipkin type IV femoral head fracture in an adolescent:A case report

BACKGROUND Femoral head fracture is extremely rare in children.This may be the youngest patient with femoral head fracture ever reported in the literature.There are few pediatric studies that focus on cases treated with open reduction via the modified Hardinge approach.CASE SUMMARY A 14-year-old female adolescent suffered a serious traffic accident when she was sitting on the back seat of a motorcycle.A pelvic radiograph and computed tomography revealed a proximal femoral fracture and slight acetabular rim fracture.This was diagnosed as a Pipkin type IV femoral head fracture.An open reduction and Herbert screw fixation was performed via a modified Hardinge approach.After 1-year follow-up,the patient could walk without aid and participate in physical activities.The X-ray results showed that the fractures healed well with no evidence of complications.CONCLUSION Open reduction and Herbert screw fixation is an available therapy to treat Pipkin type IV femoral head fractures in children.

Using shape-memory alloy staples to treat comminuted manubrium sterni fractures: A case report

BACKGROUND Comminuted manubrium sterni fractures are rare,and internal fixation methods are limited.This report explored a practical and feasible method of internal fixation for comminuted manubrium sterni fractures.CASE SUMMARY A 17-year-old female was injured in a car accident for which she underwent debridement and suturing of her head and anterior chest wounds in another hospital.Eight days later,the patient was transferred to our hospital for surgical treatment.The manubrium sterni was found intraoperatively to be split into three irregular fragments with obvious overlap and separation displacement.Meanwhile,a manubriosternal joint dislocation and left first rib cartilage fracture were observed.The retraction force of the shape-memory alloy staples was used to pull the fracture fragments together.Two more titanium locking plates were then used to fix the manubrium sterni and corpus sterni longitudinally,and the left first rib cartilage fracture was repositioned and fixed with a titanium locking plate.A postoperative computed tomography scan showed reduced and rigid fixation of the comminuted manubrium sterni fractures.The patient recovered well with no significant complaints of discomfort.The patient was discharged 10 days postoperatively after the stitches had been removed.CONCLUSION Shape-memory alloy staples had the advantage of being safe and effective during the repositioning and internal fixation of comminuted manubrium sterni fractures.Therefore,they provided a new surgical option for comminuted manubrium sterni fractures.

External fixation is more suitable for intra-articular fractures of the distal radius in elderly patients

The purpose of this study was to compare the functional outcomes, psychological impact, and complication rates associated with external fixation and volar or dorsal plating in relation to the functional parameters following treatment of intra-articular fractures of the distal radius （IFDR） in patients older than 65 years. We hypothesized that using volar or dorsal plating would improve functional outcomes, but that it would be associated with more complications and equivalent functional outcomes when compared with the external fixation group. A total of 123 consecutive patients suffering from IFDR were recruited into the study. The patients were measured for clinical, radiological, and psychosocial functioning outcomes and were followed up after I week and 3, 6 and 12 months. After 3 months, the plating group had better pronation （P = 0.001）, supination, （P = 0.047） and extension （P = 0.043） scores. These differences were somewhat attenuated by 6 months and disappeared at I year. The plating group had a greater occurrence of wound infection （P = 0.043）, tendonitis, （P = 0.024） and additional surgery compared with the external fixation group. The only TNO-AZL Adult Quality of Life scores in the plating group that were lower than those in the external fixation group were in the ＂gross motor＂ category （walking upstairs, bending over, walking 500 yards; P = 0.023）. Internal fixation was more advantageous than external fixation in the early rehabilitation period; after I year the outcomes were similar. The plating group showed significantly higher levels of wound infection and tendonitis and had a greater need for additional surgeries.

Stability of unicortical locked fixation versus bicortical non-locked fixation for forearm fractures

Locking plate fixation is being widely applied for fixation of forearm fractures and has many potential advantages, such as fixed angle fixation and improved construct stability, especially in osteoporotic bone. Biomechanical data comparing locking devices to commonly used Low Contact Dynamic Compression （LCDCP） plates for the fixation of forearm fractures has been lacking. The purpose of this study was to compare the fixation stability of a 3.5-mm unicortical locked plate with bicortical non-locked LCDCP plates. Six matched pairs of fresh frozen cadaveric forearms were randomly assigned to unicortical locked and bicortical unlocked groups. Non-destructive four-point bending and torsional test was performed on the ulna and radius separately, using a servohydraulic testing system to obtain construct stiffness of the intact specimens and specimens after osteotomy and plating. The specimens were then loaded to failure to test the fixation strength. The locked unicortical fixation showed significantly higher bending stiffness than the unlocked bicortical fixation, but with significantly lower stiffness and strength in torsion. Fixation strength was comparable between the two groups under bending, but significantly greater in the bicortical non-locked group under torsion. Findings from this study suggest that postoperative rehabilitation protocols may need modification to limit torsional loading in the early stage when using locked unicortical fixation. The study also points out the potential advantage of a hybrid fixation that combines locked unicortical and unlocked bicortical screws.

A comparison of three fixations for intertrochanteric femoral fractures in the elderly

Objective To compare the efficacy of 3 internal fixations,locking proximal femoral plate (LPFP),ASI-AN IMHS and InterTAN,for intertrochanteric femoral fractures in elderly patients.Methods A retrospective study was done to analyse

MIPPO technique and LCP internal fixation for open tibial shaft fractures

Objective To explore the efficacy of minimally invasive percutaneous plate osteosynthesis (MIPPO) technique and locking compression plate (LCP) for open tibial shaft fractures.Methods From March 2005 to May 2009,16 cases with open tibial

Free-hand cervical pedicle screw fixation for upper cervical fracture and instability

Objective To evaluate the clinical effect of the free-hand cervical pedicle screw fixation in treatment of the upper cervical fracture and instability. Methods A retrospective review was performed on 15 patients

Atlantoaxial pedicle screw fixation for old odontoid fracture combined with atlantoaxial instability

Objective To explore the clinical effect of the trans-atlantoaxial pedicle screw-rod internal fixation and fusion in treatment of old odontoid fracture combined with atlantoaxial instability. Methods The study involved 48 patients with

Navigation-guided posterior fixation plus transpedicular vertebroplasty for thoracolumbar fractures

Objective To assess the outcomes of navigationguided posterior fixation plus transpedicular vertebroplasty for thoracolumbar fractures.Methods From June,2005 through March,2009,30 patients with thoracolumbar fracture

Value of helical CT volume rendering technique in post-operative evaluation of screw in screw fixation of axis fractures

To explore the value of helical CT volume rendering technique (VRT) in post-operative evaluation of screw fixation of axis fractures.Methods There were 21 cases of screw fixation of axis fractures between February 2002 and May 2004 in the study including six cases with fractures on axis body,five on odontoid process and 10 on axis body and odontoid process.All cases received X-ray plain film,helical CT scanning,multi-planar reformatting(MPR) and VRT.Results Screw fixation through axis body and massa lateralis atlantis was performed in 10 cases and that through axis body and odontoid process in 11.VRT could clearly display full aperture of screw orbit,location of screw and angle of fixation and hence was superior to X-ray plain film and MPR.Multi-angle VRT displayed asymmetrical space of odontoid process and massa lateralis atlantis in four cases and medial deviation of 2～5 mm of half screw in screw fixation through axis body and massa lateralis atlantis in six.Conclusion VRT can eliminate false shadow of fixation screw,clearly display full aperture of screw orbit and hence supply improtant imaging evidence for post-operative evaluation of screw fixation of axis fractures.7 refs,1 fig,1 tab.

Clinical study of polydloxanone suture tension band fixation for treatment of patellar fractures

To explore biomechanic characteristics and clinical outcome of absorbable polydloxanone (PDS) treating patellar fractures.Methods The tensile strength test of PDS 0-0 or PDS 1-0 sutures were made in WDW305 electro-universal tester.A total of 60 cases were classified randomly and equally into two groups:treatment group (treated with the absorbable PDS tension hand) and Kirschner wire metals tension band control group (control group).Anatomy reduction was performed with towel clip fixation during operation.Treatment group was managed with diameter 1.5 mm Kirschner wires drilling two pores on the near or distal segment of patellar fracture end are penetrating through two strands of absorbable PDS 0-0 or PDS 1-0 sutures for a satisfactory fracture fixation.Control group was treated with Kirschner wires (2.0 mm in diameter) and steel wire (1.0 mm in diameter) of type “8” tension band fixation.Results Tensile strength testing showed that the biggest tensile of a strand PDS 0-0 sutures was 71.50 N and that of PDS 1-0 97.48 N,when the length was three times more than the initial.Two groups were followed up and the mean fracture healing time was two months,without broken wire or dislocation.Treatment group showed excellent clinical results in 21 cases,good in six and fair in three;while control group showed excellent clinical results in 19 cases,good in seven and fair in four,with no statistical difference compared with treatment group (χ2=0.32,P>0.05).Conclusion Absorbable PDS tension band has better characteristics of mechanics and creepage in treating patellar fractures.It can avoid defects of secondary operation and complications like needle-tail pain and sharped skin resulted from metal tension band fixation.Meanwhile,it is economic and worthy of further clinical application.16 refs,4 figs.

Clinical significance of Baumann's angle in the percutaneous pinning fixation for supracondylar fractures of the humerus in children

To evaluate the clinical significance of Baumann’s angle in the closed reduction and percutaneous pinning fixation for supracondylar fractures of the humerus in children.Methods There were 97 children (male 59,female 38,mean age of 6.8 years) with displaced supracondylar fracrtures of the humerus were treated in this hospital.Under fluoroscopy guidance,three-dimensional displacement of fractures was corrected by closed reduction.The percutaneous Kirschner wire pinning was applied only if the radiographs demonstrated that Baumann’s angle was less than 4 degree compared to that on the normal side.All of them were followed up for 34.5 months (range,12 to 48 months).Results There was one case with ulnar nerve palsy associated with the pinning.There were no Volkmann’s contracture in this group.X-ray examinations revealed an average 73.7 degrees of Baumann angle on the injured and 72.8 on uninjured side.An average 7.6 degrees of the carrying angle on the injured and 9.7 on uninjured side were also demonstrated by radiography.Five patients developed slight cubitus varus deformity.The result according to Flynn criteria were excellent in 85 patients (87.6%),good in 12 patients (12.4%).Conclusion The satisfactory results can be gained in children with displaced supracondylar fractures of the humerus by restoration of the normal Baumann angle and percutaneous pinning fixation.18 refs,2 figs.

Association between anterior internal fixation systems and post-operative lateral angulation in thoracolumbar fractures

Objective To explore the effects of the anterior internal fixation systems on the post-operative lateral angulation in treatment of thoracolumbar fractures.Methods A retrospective study was done to analyze the 172 patients who had

Three-dimensional finite element analysis with different internal fixation methods through the anterior approach

BACKGROUND With the modernization of society and transportation in the last decades in China,the incidence of high-energy trauma increased sharply in China,including that of acetabular fractures.AIM To establish different finite element models for acetabular posterior column fractures involving the quadrilateral area of the acetabulum.METHODS The three-dimensional models of the normal and fractured pelvis and the five internal fixations were established using the computed tomography data of the pelvis of a living volunteer.After the vertebral body model was inserted in the way of origin matching and all cancellous bones were copied using the duplicated cancellous bone model as the subtractive entity,the Boolean operation was performed on the pelvis model to obtain the model of the complete pelvis cortical and cancellous bones.RESULTS In the standing position,the maximum stress was 46.21 MPa.In the sitting position,the sacrum bore the simulated gravity load at the upper end.When comparing the five fixations,there were no significant differences in the stress mean values among groups(sitting:P=0.9794;standing:P=0.9741).In terms of displacement,the average displacement of the internal iliac plate group was smaller than that of the spring plate group(P=0.002),and no differences were observed between the other pairs of groups(all P>0.05).In the standing position,there were no significant differences in the mean value of displacement among the groups(P=0.2985).It can be seen from the stress nephogram of the internal fixations in different positions that the stress of the internal fixation was mainly concentrated in the fracture segment.CONCLUSION There were no significant differences among the fixations for acetabular posterior column fractures involving the quadrilateral area of the acetabulum.

Diagnosis,treatment and complications of radial head and neck fractures in the pediatric patient

Radial head and neck fractures represent up to 14%of all pediatric elbow fractures and can be a difficult challenge in the pediatric patient.In up to 39%of proximal radius fractures,there is a concomitant fracture,which can easily be overlooked on the initial standard radiographs.The treatment options for proximal radius fractures in children range from non-surgical treatment,such as immobilization alone and closed reduction followed by immobilization,to more invasive options,including closed reduction with percutaneous pinning and open reduction with internal fixation.The choice of treatment depends on the degree of angulation and displacement of the fracture and the age of the patient;an angulation of less than 30 degrees and translation of less than 50%is generally accepted,whereas a higher degree of displacement is considered an indication for surgical intervention.Fractures with limited displacement and non-surgical treatment generally result in superior outcomes in terms of patient-reported outcome measures,range of motion and complications compared to severely displaced fractures requiring surgical intervention.With proper management,good to excellent results are achieved in most cases,and long-term sequelae are rare.However,severe complications do occur,including radio-ulnar synostosis,osteonecrosis,rotational impairment,and premature physeal closure with a malformation of the radial head as a result,especially after more invasive procedures.Adequate follow-up is therefore warranted.

Intramedullary bone pedestal formation contributing to femoral shaft fracture nonunion:A case report and review of the literature

BACKGROUND Femoral shaft fracture is a commonly encountered orthopedic injury that can be treated operatively with a low overall delayed/nonunion rate.In the case of delayed union after antegrade or retrograde intramedullary nail fixation,fracture dynamization is often attempted first.Nonunion after dynamization has been shown to occur due to infection and other aseptic etiologies.We present a unique case of diaphyseal femoral shaft fracture nonunion after dynamization due to intramedullary cortical bone pedestal formation at the distal tip of the nail.CASE SUMMARY A 37-year-old male experienced a high-energy trauma to his left thigh after coming down hard during a motocross jump.Evaluation was consistent with an isolated,closed,left mid-shaft femur fracture.He was initially managed with reamed antegrade intramedullary nail fixation but had continued thigh pain.Radiographs at four months demonstrated no evidence of fracture union and failure of the distal locking screw,and dynamization by distal locking screw removal was performed.The patient continued to have pain eight months after the initial procedure and 4 mo after dynamization with serial radiographs continuing to demonstrate no evidence of fracture healing.The decision was made to proceed with exchange nailing for aseptic fracture nonunion.During the exchange procedure,an obstruction was encountered at the distal tip of the failed nail and was confirmed on magnified fluoroscopy to be a pedestal of cortical bone in the canal.The obstruction required further distal reaming.A longer and larger diameter exchange nail was placed without difficulty and without a distal locking screw to allow for dynamization at the fracture site.Post-operative radiographs showed proper fracture and hardware alignment.There was subsequently radiographic evidence of callus formation at one year with subsequent fracture consolidation and resolution of thigh pain at eighteen months.CONCLUSION The risk of fracture nonunion caused by intramedullary bone pedestal formation can be mitigated with the use of maximum length and diameter nails and close follow up.