Search

Purpose: The aim of this study was to compare the functional outcome, quality of restoration, and complication rate after open reduction and internal fixation (ORIF) of displaced or unstable 2-, 3- and 4-part humeral fractures using two different locking plates., Methods: The data used in this analysis was prospectively collected in two large multicentre studies in 15 European Level 1 trauma centres. A total of 318 patients with proximal humeral fractures were treated with ORIF using either the locking proximal humerus plate (LPHP) or proximal humeral internal locking system (PHILOS). Outcome measurements included Constant and Neer scores, evaluation of local pain at the fracture site and complications, and radiographic assessment at one year., Results: At one year, the mean Constant scores (relative to the contralateral shoulder) improved significantly for both groups and were above 80% for 2-, 3-, and 4-part fractures. A significantly shorter surgical time, less pain at the fracture site, and better functional outcome was achieved by PHILOS-treated patients with 2-part fractures throughout the one-year follow-up month and with 3-part fractures at three months (p < 0.05). There was no difference between the treatment outcomes for 4-part fractures, and no difference in the complication rates (p > 0.05)., Conclusions: PHILOS and LPHP can be considered as useful implants for ORIF of displaced and unstable proximal humeral fractures. There was a slight advantage of the PHILOS system with regard to operative time and functional outcome, especially for the treatment of 2- and 3-part fractures.

Background: There is a lack of consensus regarding optimal surgical management of displaced and unstable three-part proximal humeral fractures., Questions/purposes: The objective of this prospective observational study was to compare the clinical and radiologic outcomes of plate versus nail fixation of three-part proximal humeral fractures., Patients and Methods: Two hundred eleven patients with unstable three-part proximal humeral fractures were treated with ORIF using plate (PHILOS [proximal humeral interlocking system]/LPHP [locking proximal humerus plate]) or nail (PHN [proximal humeral nail]) osteosynthesis. Outcome measurements included pain, Constant and Murley and Neer scores, and the occurrence of complications at 3, 6, and 12 months postsurgery. Regression analysis and the likelihood ratio test were used to evaluate differences between the cohorts., Results: Throughout the 1-year followup period the Constant and Murley scores improved significantly for both cohorts; there was no significant difference between the nail group compared with the plate group. Also, 1-year Neer scores were similar between the two cohorts. Patients in the PHN group perceived significantly less pain compared with patients in the plate fixation group at 3, 6 and 12 months after surgery. We observed 79 local complications in 60 patients with no significant risk difference between the treatment groups; 35 intraoperative complications were directly related to the initial surgical procedure., Conclusions: The similar 1-year outcomes for nail versus plate fixation of three-part proximal humeral fractures suggest that both techniques may be useful for internal fixation of these fractures. Many complications were related to incorrect surgical technique and therefore can be avoided. Advanced surgical skills and experience are considered to be more critical for successful operative treatment of three-part proximal humeral fractures than the selection of the implant., Level of Evidence: Level II, therapeutic study (prospective comparative study). See the Guidelines for Authors for a complete description of levels of evidence.

Background: Path analysis methods were used to test the prognostic value of 10 patient-related and treatment-related factors on the 1-year functional outcome of 463 proximal humeral fractures measured using the Constant score. Complex inter-relationships between these factors were also evaluated., Materials and Methods: Data were collected from a prospective cohort study that included 3 operative groups repaired using nail or plate fixation and 1 nonoperative group. From the available information, various factors potentially having a direct influence on the functional Constant score were identified. The process of creating a hypothetical causal path diagram was undertaken to order the factors in a sequence of associations or cause-and-effect relationships., Results: Our final multivariable regression model for the 1-year Constant score included the 6 factors of age, sex, treatment, occurrence of intraoperative and local post-treatment complications, and anatomic restoration. Being a woman aged older than 40 years, treated with a locking proximal humeral plate (LPHP), having experienced intraoperative and local post-treatment complications, and varus deformity of more than 30° were negative predictors of the Constant score (ie, poor shoulder function 1 year after treatment initiation). Three factors, the dominant side fractured and the Neer and AO fracture type, showed only significant association on intermediate factors. The presence of concomitant disease did not show any significant direct or indirect effect. A final pathway outlines these associations and inter-relationships., Conclusion: Prevention of local complications, in particular those leading to severe varus deviation, appears essential to improve shoulder function after a proximal humeral fracture., (Copyright © 2011 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Hypothesis: This study addresses the outcome after osteosynthesis or hemiarthroplasty, using a cohort of patients that was enrolled in a previous prospective study on humeral head perfusion and was consequently treated using a common conceptual approach., Materials and Methods: Between 1998 and 2001, 98 patients with 100 fractures of the proximal humerus were treated surgically by a single surgeon with open reduction and internal fixation (ORIF) (51/100, group A, median age 54 years; range, 21-88) or with hemiarthroplasty (49/100, group B, median age 66 years; range, 38-87). Seventy-six of 98 patients were available for re-evaluation at a mean follow-up of five years (3.3-7.3) using the Constant-Murley score (CMS), the Subjective Shoulder Value (SSV), and conventional radiographs., Results: The median total CMS was 77 (range, 37-98) for group A and 70 (range, 39-84) for group B. The median SSV was 92 (range, 40-100) for group A and 90 (range, 40-100) for group B. Avascular necrosis occured in 6/40 fractures treated with ORIF., Conclusion: Osteosynthesis and hemiarthroplasty yield similar functional results and comparable patient satisfaction following the applied decision making process in this selected patient cohort. Osteosynthesis with preservation of the humeral head is worth considering when adequate reduction and stable conditions for revascularization can be obtained. In patients with osteopenic bone and/or comminuted fractures, hemiarthroplasty is a viable alternative., Level of Evidence: Level 2; Prospective non-randomized comparison study.

The Point Contact-Fixator (PC-Fix) was designed as part of the developmental evolution of more biological devices for internal fixations. It is a device characterized by minimal contact to the underlying periosteum and bone, hereby minimizing potential damage to perfusion. A multicentre handling test was conducted in 1993 and 1994 in six hospitals to assess its performance. A total of 83 fractured forearm bones (34 radii and 49 ulnae) in 52 patients were stabilized with a PC-Fix. The mean age of the patients was 37 years. There were 24 AO type A, 24 type B and 5 type C fractures. Nine fractures were open. Mean follow-up was 15.6 months; follow-up was 100%. All 21 surgeons involved considered the use of the PC-Fix self-explanatory and relatively easy. Handling difficulties were mainly related to insertion of the monocortical screws. In particular, the precision required for insertion, the inability to incline the screw and the inability to pull the plate to the bone using the screw were considered hard to deal with. Stripping of the hexagonal slot was a problem at removal of the implant, possibly related to overtightening of the screws at insertion. In 76 of 83 bones (49 of 53 forearms), the fractures united without additional surgery. The healing pattern typically showed early callus formation bridging the fracture, followed by progressive mineralization of the central radiolucent line. Complications included one infection, one late displacement and four delayed unions, all requiring revision surgery. In 8 forearms, plate removal was performed after a mean of 10.3 months. Two refractures occurred after removal of the implant 6 and 7 months postoperatively. In conclusion, the practical handling of the new implant was straightforward and easily learnt. The treatment failures observed were related to technical and strategic errors. We consider that, when using devices with a locking compression principle, a minimum number of three screws should be placed on each side of the fracture, that interfragmentary compression of simple fractures is desirable in order to increase stability and that, contrary to in vivo animal studies, early plate removal is not indicated. The trend in fracture fixation is to improve the biomechanical and biological properties of operating technique and the devices used. The PC-Fix has proven a useful step in the right direction in this evolutionary process.

During the last decade, classic AO/ASIF techniques for internal fixation shifted from direct reduction and rigid fixation to biologic internal fixation using indirect reduction techniques. Biologic internal fixation is characterized by the preservation of bone and soft tissue vascularity and relative rather than absolute mechanical stability. Reduction is achieved by using soft tissue traction while obtaining axial and rotational alignment and the correct length. Stabilization is performed when possible by compression plating for load sharing or by bridge plating in comminuted fractures. Advancements of these techniques and the development of newer implants that minimize vascular damage have contributed to the development of biologic internal fixation. By using indirect reduction, by using longer plates to improve the mechanical leverage, and by applying fewer screws to avoid unnecessary damage to the bone, fracture union rates were high. There also was a decreased need for supplemental bone grafting. All of these factors provided stable fixation and allowed early motion.

Between 1968 and 1995, 37 patients with ununited fractures of the clavicle were treated by decortication and plate osteosynthesis. Thirty-two (86%) were failures of union of fractures of the middle third. Thirty-four (92%) patients had post-traumatic nonunion or delayed union. Sixteen (43%) patients had undergone primary operative treatment. Autogenous cancellous bone graft was used in 24 (65%) patients with atrophic nonunion. Nine tricortical, iliac crest, intercalary grafts were used for segmental bone loss equal to or greater than 15 mm. At the end of treatment, union had been achieved in 35 (95%) cases. At a mean follow-up of 8.6 years (range 13 months to 17 years), 32 (86%) patients had no symptoms and had a full range of motion of the shoulder. Decortication with plate osteosynthesis is a reliable, durable technique for the management of symptomatic, ununited fractures of the clavicle.

From 1986 to 1994 18 patients with 19 IIIB open tibial fractures were treated following similar therapeutic management. This included early and radical primary debridement, early and wherever possible immediate internal fixation of the bone and coverage with a local muscle flap (hemisoleus or gastrocnemius). At the time of follow-up all fractures had consolidated clinically as well as radiographically. The mean time to bony union was 7 months (3-20). Twelve patients did not have any severe pain and were able to walk for more than 4 km. The time to return to work averaged 8 months. In 2 cases a permanent disability of 50% was established. Fourteen of 18 patients were satisfied with the function of the leg. On the other hand, 9 didn't like the aesthetic appearance and were inhibited because of it. The following complications occurred within a period of 2 years: non-union (3), flap necrosis (2), osteomyelitis (2), delayed union (4). The mean number of reoperations was 3 (0-8). In no case did an amputation have to be performed.

Between January 1980 and December 1989, 133 consecutive patients were treated for a fracture of the shaft of one or both forearm bones (134 forearms in total). All fractures were stabilized with AO/ASIF 3.5 mm stainless-steel dynamic compression plates. The 1 year follow-up rate was 99 per cent; the long-term follow-up rate was 92 per cent (the mean long-term follow-up was 10.2 years (range, 2.7-15.2)) so there were 96 men and 35 women, with an average age of 37.5 years (range, 16-63). Twenty-two per cent of the forearms had open fractures, 26 per cent of patients had sustained multiple injuries and 19 per cent had a head injury. One hundred and twenty-seven of 132 forearms (96.2 per cent) underwent problem-free consolidation before 6 months. Two delayed unions and two non-unions required reoperation. There was one superficial infection in a patient with a closed fracture. Plates were removed from 70 patients (53 per cent) at a mean of 33.1 months (range, 8-122) after the first operation. In this group, there were three refractures (4.3 per cent) occurring at a mean of 8.7 months (range, 0-14) after plate removal. This study confirms the safety and efficacy of plate osteosynthesis in forearm shaft fractures: a high union rate and low complication rate can be anticipated. The data presented form the most reliable information on this subject currently available with the longest and highest rate of follow up of a sufficient number of patients using a single implant system in a single institution.

The purpose of this project was to verify the value of perfused periosteum as a possibly ideal bed for autogenous cancellous bone graft. The model consisted of a 7 cm defect in the sheep tibia, stabilized with a locked intramedullary nail. The defect was filled with conventional cortico-cancellous bone graft covered either with a muscle or a perfused osteoperiosteal flap. The incorporation of the graft was analysed by a series of radiological and mechanical examinations. The graft embedded in perfused osteo-periosteum was rapidly remodelled to a strong, circular bone. Mechanical testing revealed even better values than for normal bone. The graft embedded in muscle showed an important resorptive phase before scanty, incomplete, reconstitution of bone appeared. Mechanical properties were poor. The study supports the hypothesis that perfused osteo-periosteum is an ideal bed for cancellous bone graft and that perfused muscle is not the ideal environment for incorporation of the graft.

Vascularized fibular grafts have proven to have many advantages over nonvascularized transplants for treatment of large segmental bone defects in the extremities. Fibulas are typically impacted into the medullary canal and fixed with wires or screws. Consolidation has often been delayed and full weightbearing was only possible after graft hypertrophy, usually 12 to 18 months after reconstruction. In order to shorten the time of consolidation and to achieve early full weightbearing, the authors propose a sound biomechanical reconstructive concept: a) stable but not devascularizing osteosynthesis of the osteotomy to shorten the time of consolidation; b) a double-strut fibular graft that yields enough strength for early weightbearing, without the need for bone hypertrophy; and c) additional cancellous bone grafts, to enhance the long-term stability of the reconstruction. Seven patients with tibial defects ranging between 6 and 17.5 cm were treated according to this concept. In four cases, free vascularized fibula was transferred first. Six weeks later, a vascularized, ipsilateral fibula-pro-tibia procedure was done, and the space between the fibulas was filled with cancellous bone grafts. In three patients, a free, vascularized, double-barrel, fibula transfer was done, since the tibial defect was less than 10 cm. Cancellous bone grafts between the fibulas were added only 6 weeks later. In five cases, the free fibula transfer was combined with a latissimus dorsi myocutaneous flap. In six patients, healing was uneventful. In one patient, hypoperfusion of the lower extremity and the vascularized grafts eventually resulted in a below-knee amputation. In all six successful cases, union resulted within 3 months.(ABSTRACT TRUNCATED AT 250 WORDS)