Cheng-Yo Yen

Locked plating for proximal humeral fractures: differences between the deltopectoral and deltoid-splitting approaches.

BACKGROUND Locking proximal humerus plate (LPHP) fixation has recently become available for the treatment of proximal humeral fractures. However, the preliminary results were contradictory. The technical requirements for success when using LPHP remain to be defined. Maybe the approach to the proximal humerus plays an important role, not the implants. We analyzed two surgical approaches to proximal humeral fractures. METHODS Between April 2004 and October 2007, 63 consecutive patients with displaced proximal humeral fractures who underwent LPHP osteosynthesis in our institute were classified to two treatment groups retrospectively: the deltopectoral incision and the deltoid-splitting incision according to surgeons preference. The Constant and Disabilities of the Arm, Shoulder and Hand scores were recorded for clinical assessment. Quality of reduction, fracture union, and radiographic complications were recorded for radiographic assessment. Electrophysiological abnormalities were also assessed. RESULTS There were no significant differences between the groups with regard to demographic data, preoperative radiographic findings, and duration of follow-up. There were also no significant differences between the groups with regard to operative time (p = 0.918), blood loss (p = 0.407), hospital stay (p = 0.431), postoperative head-shaft angle (p = 0.769), union time (p = 0.246), final head-shaft angle (p = 0.533), Constant score (p = 0.677), Disabilities of the Arm, Shoulder and Hand score (p = 0.833), radiographic complications (p = 1.000), and presence of electrophysiological abnormalities (p = 0.296). Avascular necrosis of the humeral head was found in three patients, all of whom in the deltopectoral approach group. CONCLUSION We found no statistically significant difference in clinical, radiographic, and electrophysiological outcomes between the deltopectoral approach and deltoid-splitting approach while surgical treatment of proximal humeral fractures.

Soft-tissue injury management and flap reconstruction for mangled lower extremities

SUMMARY The treatment for mangled lower extremities poses a clinical challenge for orthopaedic surgeons. The complexities of soft-tissue injury combined with open fractures and osteomyelitis have frequently resulted in amputation of the lower extremity. The current advances in soft-tissue flap reconstruction techniques have significantly improved the results of limb-salvage attempts. Understanding the reconstructive ladders around the zone of injury, debridement, timing and nuances of techniques regarding skin graft, local and distant flaps and microsurgical reconstruction is necessary to complete limb salvage in a timely and appropriate fashion. Various soft-tissue flap applications have been described, including emergent flow-through flap, acute soft-tissue flap, acute combined soft-tissue and bone flap, pedicle gastrocnemius/soleus flap, pedicle sural artery flap, soft-tissue flap for chronic osteomyelitis, composite osseous-myocutaneous flap for chronic osteomyelitis and free functioning muscle flap for functional reconstruction of mangled lower limbs. Clinical experience of 850 flaps reconstructions for mangled lower limbs in both acute and chronic stages has revealed that adequate application of flap technique was able to achieve quite acceptable results. This article provides a comprehensive review of the soft-tissue injury management and flap reconstruction for mangled lower limbs.

Staged external and internal locked plating for open distal tibial fractures A retrospective study of 16 patients

Background and purpose Based on reported success with staged treatment of distal tibial fractures, we designed a 2-stage protocol including external/internal locked plating. We retrospectively assessed the outcome of open distal tibial fractures treated according to this protocol. Patients and methods From March 2006 through July 2008, 16 patients who sustained open distal tibial fractures were treated by a two-stage protocol. The first stage consisted of low-profile, locked plates for temporary external fixation after debridement and anatomic reduction, followed by soft tissue reconstruction. The second stage consisted of locked plates for definitive internal fixation, using minimally invasive percutaneous osteosynthesis. All fractures were followed for median 2 (1–3) years. Results The reduction was classified as being good in 15 patients and fair in 1 patient. All fractures united at a median of 6 (6–12) months. At the latest follow-up, 7 patients had excellent and 9 had good Iowa ankle scores; ankle motion ranged from a median of 10 (5–20) degrees of dorsiflexion to 40 (20–60) degrees of plantar flexion. Interpretation We believe that the 2-stage external/internal locked plating technique is an effective procedure for treatment of open distal tibial fractures in patients who need a long period of external fixation. We achieved good reduction with immediate ankle-sparing stable fixation. Soft tissue reconstruction and subsequent definitive fixation led to union of all fractures with good function.

Treatment for scaphoid fracture and nonunion—the application of 3.0 mm cannulated screws and pedicle vascularised bone grafts

SUMMARY BACKGROUND Scaphoid fractures are very common in wrist trauma, and scaphoid nonunions with avascular necrosis are frequent complications of a fractured scaphoid. The purpose of these two retrospective studies was to examine the clinical and x-ray results of treatments for acute scaphoid fracture and scaphoid nonunion. The surgical techniques of cannulated screw fixation and pedicled vascularised bone graft are described. METHODS From 2001-2004, 80 patients with scaphoid fractures were treated with 3.0 mm cannulated screws and 5.5 mm threaded washers in our hospitals. The average age was 35 years, and the average time from injury to surgery was 16.5 hours. Outcomes were assessed by x-ray and the modified Mayo wrist score system. During the 6-year period of 1998-2004, 72 patients with scaphoid nonunions were treated using pedicled vascularised bone graft (VBG)in our hospitals. The average age was 38.5 years, and the average time from injury to surgery was 9.5 months. RESULTS The union rate was 96.25% and satisfactory function rate was 93.75% in acute scaphoid fractures with an average follow-up of 3.5 years. The union rate (90.28%) and satisfactory function rate (81.94%) achieved in scaphoid nonunions were acceptable, with an average follow-up of 5 years. CONCLUSIONS Our studies suggested that appropriate application of a cannulated screw and threaded washer was able to produce satisfactory results in scaphoid fracture, and that pedicled vascularised bone graft was effective for treating scaphoid nonunion.

Inferior vena Cava Syndrome Following Percutaneous Vertebroplasty With Polymethylmethacrylate

Study Design. A case of inferior vena cava syndrome following percutaneous vertebroplasty is described herein. Objective. To alert clinicians to the potential occurrence of inferior vena cava syndrome following percutaneous vertebroplasty. Summary of Background Data. Vertebroplasty is a less invasive treatment solution for the osteoporotic compression fracture. There complications of the cement leakage would appear to have been rather infrequent. We report a case of inferior vena cava syndrome related to the cement leakage. Methods. A 59-year-old woman underwent percutaneous vertebroplasty for painful T11, L1, L2, and L3 compression fractures, under general anesthesia at a community hospital. A contralateral transpedicular approach was made in order to inject polymethylmethacrylate resin into the fractured vertebra. Results. Just subsequent to surgery, this patient developed dyspnea, arthralgia, myalgia, and progressive right lower-limb pain, redness, and swelling., conservative treatment being then undertaken, albeit in vain. One week after the attempted remediation of this patient’s condition, she was transferred to our hospital for further management. After admission, radiography of the patient’s lumbar spine (lateral view) revealed multiple cement leakage in the area of the posterior longitudinal ligament and also in the anterior paravertebral area. The abdominal and pelvic CT scan and venography revealed vertebroplasty cement leakage into the lumbar vein, the left renal vein, and the inferior vena cava. Thrombosis at the left common iliac vein and left femoral vein were noted with extension into the inferior part of the inferior vena cava. Intravenous heparin was then administered to our patient for the ensuing 20 days, at which time heparin was replaced by warfarin, in order to attempt to prevent progressive venous thrombosis. The patient’s leg edema appeared to improve 10 weeks subsequent to her surgery, she then being able to perambulate using a rigid walker. Conclusion. This case illustrates the need for clinicians to be critically aware of the potential occurrence of inferior vena cava syndrome among patients who have undergone percutaneous vertebroplasty, especially when multiple levels of vertebra are injected as part of the vertebroplasty procedure.

Staged external and internal less-invasive stabilisation system plating for open proximal tibial fractures

High-energy proximal tibial fractures are complex injuries that may lead to significant complications. Staged treatment of these injuries using a spanning external fixator across the knee joint in the acute setting decreases the incidence of complications. This article is a prospective evaluation of outcomes using a two-stage procedure for treatment of 15 patients who sustained open proximal tibial fractures between April 2006 and January 2008. In the first stage, we used low profile, less-invasive stabilisation system (LISS) plates for temporary external fixation to immobilise the fractures after anatomic reduction, followed by soft-tissue reconstruction. In the second stage, we applied LISS plates for definitive internal fixation, using minimally invasive percutaneous osteosynthesis. All fractures were monitored for a mean of 20.4 months (range, 12-32 months). All fractures united at a mean of 38.6 weeks (range, 18-66 weeks). Knee motion ranged from a mean of 1 degrees (range, 0 degrees to 5 degrees ) to 125 degrees of flexion (range, 100 degrees to 145 degrees ). The reduction was scored as good in 13 patients and fair in two patients. At follow-up, 10 patients had excellent, and five had good knee scores. The complications included minor screw-track infections in three patients. In conclusion, the two-stage technique was well suited for treating these difficult injuries, and for patients who needed longer periods of external fixation. Surgeons were able to achieve gross anatomy restoration, soft-tissue reconstruction, stable fixation and high union rates. Patients obtained good-to-excellent motion, function and comfort after treatment.

Masquelet technique with external locking plate for recalcitrant distal tibial nonunion

OBJECTIVE In the present retrospective study, we aimed to analyze the results of treatment for recalcitrant distal tibial nonunion using Masquelet technique with locking plate as a definitive external fixator. MATERIALS We included 15 consecutive cases of distal tibial nonunion treated at our hospital between January 2012 and December 2015. The reconstructive procedure comprised debridement of the nonunion site, deformity correction, stabilization with an external locked plate, defect filling with cement spacer for inducing membrane formation, and bone reconstruction using a cancellous bone autograft (Masquelet technique). All patients were followed-up for at least one year. RESULTS Fracture union occurred in all cases after a median of 6.5 months (range, 5-12 months). Mean ankle motion ranged from 12.3 (range, 5-20) degrees of dorsiflexion to 35 (range, 5-55) degrees of plantar flexion. At the final follow-up, the median Iowa ankle score was 83 (range, 68-91). Eight patients had excellent scores, six had good scores, and one had fail score. CONCLUSION Although the current study involved only a small number of patients and the intervention comprised two stages, we consider that the used protocol is a simple and valuable alternative for the treatment of recalcitrant distal tibial nonunion.

Total elbow arthroplasty failure due to a broken snap pin: A case report

Posttraumatic arthritis and rheumatoid arthritis are the 2 leading indications for total elbow replacement. Numerous designs have been used for total elbow arthroplasty (TEA), including linked and unlinked designs. Compared with unlinked designs, linked semiconstrained devices have intrinsic stability and do not carry the potential complication of instability. These implants can be used in the presence of significant bone or ligamentous deficiencies. Of 36 elbows treated with a Coonrad-Morrey total elbow replacement prosthesis for distal humeral nonunion, Morrey and Adams reported 2 cases of bushing wear and 1 case of synovitis at a mean follow-up period of 50 months. They attributed the worn bushings to heavy users. Wright and Hastings reported 10 patients who had a previous CoonradMorrey TEA and presented with C-ring and bushing wear. The C-ring is the previous version of linked apparatus in a Coonrad-Morrey prosthesis. With the advent of the new snap pin fixation, which is a much stronger coupling device, a displaced C-ring will no longer be seen; however, the underlying process is unchanged. In high-demand patients with a Coonrad-Morrey TEA, there is significant edge loading of the polyethylene as the elbow is moved from the varus to the valgus position. No studies have reported the breakage of a new snap pin fixation apparatus. We report the case of a patient who received Coonrad-Morrey TEA, and the snap pin of the prosthesis broke 8 years later. From July 2005 until August

Middle term result of two-stage total knee arthroplasty for prosthetic knee joint infection

Introduction: The treatment of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA) is a challengeable task. Two-stage exchange arthroplasty is a commonly used treatment for chronic PJI. Purpose: The aim of this study was to investigate the successful rate and possible failure risk factors in patients undergoing a planned two-stage exchange arthroplasty for treatment of knee PJI. Methods: From March 2004 to February 2015, we retrospectively reviewed 35 patients have more than 36 months clinical follow-up with periprosthetic knee joint infections. The clinical outcomes were recorded to define the successful or fail treatment for the periprosthetic knee joint infections. Multiple factors such as obesity, comorbidities, diabetes, were recorded and analyzed to evaluate the risk factors of poor outcome. Results: Five patients were unable to receive second stage surgery with cement spacer retained due to variable reasons. Three patients ended with amputation due to uncontrolled infectious process. Overall 27 patients received two-stage exchange arthroplasty to treat knee PJI were analyzed in this study. However, two patients were loss follow-up during the period between 1st and 2nd time surgery. Two patients were treated with static cement spacer due to poor soft tissue condition. These 4 patients were excluded and overall 23 patients were included and analyzed. Overall success rate is 78.26%. 4 patients with recurrent infection were treated with additional surgical debridement. One patient with recurrent infection was treated with the second time two-stage arthroplasty. All of these patients were successful treated without further recurrent infection. Conclusion: We found that failure rate is increasing when considerate the failure between first stage and second stage surgery. In addition, patients without more than 36 months follow-up may have infection free due to honeymoon period but still in risk of reinfection.

External locked plating as the definitive treatment for open proximal tibial fractures-A biomechanical feasibility study

Background: Open proximal tibial fractures are associated with significant morbidity due to increased risks of infection, nonunion, malunion, knee stiffness, and possible amputation. Several authors demonstrated the benefits of bridging external fixation followed by definitive internal fixation once the soft-tissue envelope had sufficiently healed. We recently demonstrated the benefits of external locked plating followed by definitive internal fixation. Purpose: The purpose of this study was to evaluate the biomechanical feasibility of definitive external locked plating for open proximal tibial fractures. Methods: Two types of constructs were tested: (1) internal locked plate fixation (ILPF) and (2) external locked plate fixation (ELPF). Specimens were evaluated under static or dynamic axial loading to assess construct stiffness, strength, durability and failure mode. Results: The mean of construct strength of the ILPF and ELPF groups was 2147.4 ± 460.56 N and 793.2 ± 96.78 N, respectively. The mean of construct stiffness of the ILPF and ELPF groups was 384.01 ± 40.37 N/mm and 87.35 ± 7.40 N/mm, respectively. Conclusion: In this study, external locked plating showed biomechanical flexibility and could reduce construct stiffness to promote fracture healing by callus formation. However, ELPF constructs were not as strong as standard locked plating constructs. If we want to use ELPF constructs as definitive treatment, further biomechanical study to improve construct strength is warranted.