Chi-Chuan Wu

Tension band wiring for olecranon fractures: relative stability of Kirschner wires in various configurations.

BACKGROUND To assess clinical and functional outcomes as well as the relative stability of various configurations of tension band wiring approaches for treating olecranon fractures, a retrospective cohort study was conducted. METHODS Seventy-seven consecutive adult patients with 78 olecranon fractures were treated using tension band wiring techniques in three different configurations. The configurations differed in the location of the ends of Kirschner wires with the following locations being used: in the proximal ulnar canal, through the anterior ulnar cortex, and in the distal ulnar canal. RESULTS Based on average follow-up of 2.76 years (range, 1.1-5.5 years), all three techniques achieved high union rates and low complication rates. However, the Kirschner wires in the first technique allowed proximal pin migration with elbow irritation as compared with the second and the third techniques (p = 0.001, 0.03, respectively). CONCLUSIONS Placement of the ends of Kirschner wires in the proximal ulnar canal should be avoided whenever possible. Because placement of the ends of Kirschner wires through the anterior ulnar cortex may produce serious complications as reported in medical literature, placement of the ends of Kirschner wires in the distal ulnar canal may be the most effective approach.

Dynamic hip screws for unstable intertrochanteric fractures in elderly patients--encouraging results with a cement augmentation technique.

BACKGROUND Despite the good and reliable results of the dynamic hip screw (DHS) for stable fracture patterns, complications of excessive sliding of the lag screw and inadequate bone anchorage occur frequently in elderly patients with unstable intertrochanteric fractures. Although polymethylmethacrylate (PMMA) bone cement has been widely used as a secondary fixation to facilitate fixation stability, there has been no prospective study on the clinical significance of PMMA cement to prevent these two complications in unstable fracture patterns. METHODS A prospective study was conducted. The DHS was applied either with or without PMMA cement augmentation in 108 elderly patients. The Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association fracture classification was 31-A2 in 91 patients and 31-A3 in 17 patients. The average age of the patients was 81.9 years (range, 75-96 years). The average follow-up period was 13.9 months (range, 12-30 months). PMMA cement was injected precisely into the proximal fragment with an average amount of 13.7 mL (range, 10-19 mL) in 55 patients. RESULTS All but six patients (5.6%) had eventual bone union, and the average time to union was 18.1 week (range, 12-36 weeks). Screw sliding, femoral shortening, and varus collapse of the proximal fragment were all significantly reduced in the cemented group at the 1-year follow-up (p < 0.001, p < 0.001, p < 0.001, respectively). The mean hip pain score was 1.9 (range, 1-4) in all 102 patients and was significantly lower in the cemented group (p = 0.008). One patient with a deep infection in the cemented group and five patients with lag screw penetration in the noncemented group received a total hip replacement. All 18 patients with malunion were in the noncemented group. Of these 18 patients, 14 patients (77.8%) had excessive sliding of the lag screw. The overall complication rate was significantly higher in the noncemented group (p < 0.001). CONCLUSIONS With the meticulous augmentation technique demonstrated in this study, the PMMA cemented DHS proved to have better outcome than a conventional DHS for unstable intertrochanteric fractures in elderly patients. Typical complications related to a conventional DHS device for the treatment of such fractures were successfully prevented.

Medial gastrocnemius muscle flap for treating wound complications after double-plate fixation via two-incision approach for complex tibial plateau fractures.

BACKGROUND In medical literature, few articles have reported the treatment of wound complications occurring after double-plate fixation via a two-incision approach for complex tibial plateau fractures. A retrospective study was conducted to evaluate the efficacy of a medial gastrocnemius muscle flap transfer in treating this complicated disability. METHODS We treated 16 consecutive adult patients, including 6 cases of wound complications without previous deep infection and 10 cases of wound complications with deep wound infection. A one-stage medial gastrocnemius muscle flap transfer was performed after excision of gangrened eschar in cases with wound complication after fracture fixation without infection. A staged flap transfer was performed after debridement and antibiotic administration in cases with wound complication after fracture fixation and wound infection. Bone grafting supplementation was performed in cases where a sequestrectomy had been performed. RESULTS All 16 patients were followed up for an average of 31 months (range, 13-50 months). The wound complications were successfully treated in 93.8% (15/16) of patients by medial gastrocnemius flap transfer. The fracture healed in 93.8% (15/16) of patients within an average period of 17.2 weeks (range, 10-51 weeks). One patient had gastrocnemius muscle necrosis with fracture nonunion and was treated with free vascularized muscle and osseous flap transfers. Knee function was satisfactory in 62.5% (10/16) of patients. CONCLUSION Medial gastrocnemius muscle flap transfer is a reliable technique for treating wound complications that occur after double-plate fixation via a two-incision approach in the treatment of complex tibial plateau fractures. A high success rate of wound healing with bone union can normally be achieved. We, therefore, recommend its widespread use in candidate patients.

Factors affect stability of intertrochanteric fractures when elderly patients fall.

Background Factors affecting the stability of intertrochanteric fractures when elderly patients fall are few to be reported. In this retrospective study, possible factors were investigated. Methods Two hundred and twenty-three consecutive elderly patients (≥65 years) with intertrochanteric fractures due to low energy injuries were studied. Patient age, gender, body mass index (BMI), body weight and height were compared between fractures with stable (AO/OTA type A1, intact lesser trochanter, 80 patients) and unstable (AO/OTA types A2, A3, displaced lesser trochanter or reverse obliquity fractures, 143 patients) types. Statistical approaches with univariate and multivariate analyses were performed. Results There was no statistical difference in patient gender, age, body weight or height between patients with stable and unstable fractures in both univariate and multivariate analysis. However, BMI was statistically higher in patients with unstable fractures (22.7 vs 21.4, p = 0.01) in univariate analysis, but without a difference in multivariate analysis (p = 0.07). Conclusions Stability of intertrochanteric fractures may be not associated with gender, age, body weight and height or BMI when elderly patients fall. Bone mineral density or impact direction may be other possible contributing factors but requires further proofs.

Comments on Hsu et al.: Surgical treatment of syndesmotic diastasis: emphasis on effect of syndesmotic screw on ankle function

Dear Editor, With great interest we read the article of Hsu et al. entitled “Surgical treatment of syndesmotic diastasis: emphasis on effect of syndesmotic screw on ankle function” [1]. The authors report on screw fixation in patients with syndesmotic diastasis. They describe a syndesmotic diastasis recurrence in six of 52 patients (11.5%) with an average increase in widening of 3.8 mm (range 3–7 mm) diagnosed on anteroposterior radiographs. At 19 months (range 12–36) follow-up they observed no difference in ankle function, as defined by Bray’s scoring system, between patients with and without recurrence of syndesmotic diastasis. We were surprised by their conclusion and would like to make some remarks that we feel should be discussed. Distal tibiofibular syndesmotic injuries occur in over 10% of ankle fractures [2]. Syndesmotic instability is most commonly associated with pronation external rotation, pronation abduction or less frequently with supination external rotation trauma mechanisms. Syndesmotic instability leads to mortise widening and this should be treated with syndesmotic stabilisation to prevent long-term complications. Widening of the ankle mortise leads to increased stress on the articular cartilage. This statement is based on the studies of Ramsey and Hamilton, and later of Lloyd et al. When the talus moves 1 mm laterally, the contact area in the tibiotalar articulation is decreased by 42%. This results in an increase in the stress per unit area on the articular cartilage [3, 4]. Leeds and Ehrlich found a negative correlation between syndesmosis instability and subjective outcome, objective outcome and degenerative changes in the ankle joint at four years follow-up [5]. Pettrone et al. concluded that if the syndesmosis is not adequately reduced the function scores were significantly lower after one to five years follow-up [6]. We think that there are some potential reasons why the authors came to their conclusions.

Treatment of Floating Elbow Injury

Background: A floating elbow injury (FEI, concomitant ipsilateral fractures of the humerus, ulna, and radius shafts) is rare and difficult to treat. The optimal methods for treating this complex injury have not been well defined. Materials and methods: Twenty-six adult patients with a FEI were treated between 2004 and 2010. Twenty patients were followed for at least one year and were included in this study. Each forearm fracture was treated with open reduction and plate fixation. Humeral fractures were treated with internal fixation using a plate or intramedullary nail. 6 patients received one stage operation and 14 patients were staged operation. The Mayo Elbow Performance Score was used to evaluate elbow function. Prognostic factors were studied according to injury severity and treatment methods. Results: Twenty patients (77%, 20/26) were followed for at least one year (average, 25.8 ± 10.2 month) and were included in this study. The rate of open forearm fractures (45%, 9/20) was higher than that of humeral fractures (30%, 6/20); moreover, 66.7% (10/15) of these open fractures were Gustilo type III open fractures. The union rates of the humerus, radius, and ulna were 95%, 90% and 85%, respectively. The average union times of the humerus, radius, and ulna were 17.7 ± 8.6, 25.9 ± 10, and 25.1 ± 10.8 weeks, respectively. The union time of the humerus was significantly shorter than that of the radius (p=0.008) and ulna (p=0.01). Satisfactory elbow function was observed in 13 patients (65%, 13/20). Eleven patients (55%, 11/20) had isolated or multiple nerve injuries. Radial nerve injury was most common (40%, 8/20). Recovery may be spontaneous in 62.5% of all radial nerve injury cases and 100% in patient with isolated radial nerve injury. In univariate analysis (Mann-Whitney U test), open fractures, vascular injury, nonunion, and deep infection were found to significantly associated with unsatisfactory elbow functions. Based on a Kruskal Wallis test, BPI or multiple nerve injuries was associated with significantly poorer surgical outcomes than no nerve injury and transient nerve palsy (p=0.01). Conclusions: A FEI is difficult to treat and only 65% of patients may achieve satisfactory elbow function. An unsatisfactory prognosis may be related to open fractures, BPI or multiple nerve injuries, vascular injury, nonunion, and deep infection. Radial nerve injury was most common (40%, 8/20). Recovery may be spontaneous in 62.5% of all radial nerve injury cases and 100% in patient with isolated radial nerve injury. Humeral fractures may heal faster than radial or ulnar fractures.