Ching-Hou Ma

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.

Using external and internal locking plates in a two-stage protocol for treatment of segmental tibial fractures.

BACKGROUND The tibial segmental fractures usually follow high-energy trauma and are often associated with many complications. We designed a two-stage protocol for these complex injuries. The aim of this study was to assess the outcome of tibial segmental fractures treated according to this protocol. METHODS A prospective series of 25 consecutive segmental tibial fractures were treated using a two-stage procedure. In the first stage, a low-profile locking plate was applied as an external fixator to temporarily immobilize the fractures after anatomic reduction had been achieved followed by soft-tissue reconstruction. The second stage involved definitive internal fixation with a locking plate using a minimally invasive percutaneous plate osteosynthesis technique. The median follow-up was 32 months (range, 20-44 months). RESULTS All fractures achieved union. The median time for the proximal fracture union was 23 weeks (range, 12-30 weeks) and that for distal fracture union was 27 weeks (range, 12-46 weeks; p = 0.08). Functional results were excellent in 21 patients and good in 4 patients. There were three cases of delayed union of distal fracture. Valgus malunion >5 degrees occurred in two patients, and length discrepancy >1 cm was observed in two patients. Pin tract infection occurred in three patients. CONCLUSIONS Use of the two-stage procedure for treatment of segmental tibial fractures is recommended. Surgeons can achieve good reduction with stable temporary fixation, soft-tissue reconstruction, ease of subsequent definitive fixation, and high union rates. Our patients obtained excellent knee and ankle joint motion, good functional outcomes, and a comfortable clinical course.

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.

Metaphyseal locking plate as a definitive external fixator for treating open tibial fractures—Clinical outcome and a finite element study

We evaluated both the outcome of using a locking plate as a definitive external fixator for treating open tibial fractures and, using finite element analysis, the biomechanical performance of external and internal metaphyseal locked plates in treating proximal tibial fractures. Eight open tibial patients were treated using a metaphyseal locked plate as a low-profile definitive external fixator. Then, finite element models of internal (IPF) as well as two different external plate fixations (EPFs) for proximal tibial fractures were reconstructed. The offset distances from the bone surface to the EPFs were 6 cm and 10 cm. Both axial stiffness and angular stiffness were calculated to evaluate the biomechanical performance of these three models. The mean follow-up period was 31 months (range, 18-43 months). All the fractures united and the mean bone healing time was 37.5 weeks (range, 20-52 weeks). All patients had excellent or good functional results and were walking freely at the final follow-up. The finite element finding revealed that axial stiffness and angular stiffness decreased as the offset distance from the bone surface increased. Compared to the IPF models, in the two EPF models, axial stiffness decreased by 84-94%, whereas the angular stiffness decreased by 12-21%. The locking plate used as a definitive external fixator provided a high rate of union. While the locking plate is not totally rigid, it is clinically stable and may be advisable for stiffness reduction of plating constructs, thus promoting fracture healing by callus formation. Our patients experienced a comfortable clinical course, excellent knee and ankle joint motion, satisfactory functional results and an acceptable complication rate.

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.

Metaphyseal locking plate as an external fixator for open tibial fracture: Clinical outcomes and biomechanical assessment

OBJECTIVE This study aimed to evaluate the outcome of using a metaphyseal locking plate as a definitive external fixator for treating open tibial fractures based on biomechanical experiments and analysis of clinical results. METHODS A metaphyseal locking plate was used as an external fixator in 54 open tibial fractures in 52 patients. The mean follow-up was 38 months (range, 20-52 months). Moreover, static axial compression and torsional tests were performed to evaluate the strength of the fixation techniques. RESULTS The average fracture healing time was 34.5 weeks (range, 12-78 weeks). At 4 weeks postoperatively and at the final follow-up, the average Hospital for Special Surgery knee score was 85 (range, 81-100) and 94 (range, 88-100), respectively, and the American Orthopaedic Foot and Ankle Society score was 88 (range, 80-100) and 96 (range, 90-100), respectively. Based on the static test result, the axial stiffness was significantly different among groups (p=0.002), whereas the torsional stiffness showed no significant difference (p=0.068). CONCLUSIONS Clinical outcomes show that the use of locking plate as a definitive external fixator is an alternative choice for tibial fractures after obtaining appropriate fracture reduction. However, external locked plating constructs were not as strong as standard locked plating constructs. Therefore, the use of external locked plating constructs as a definitive treatment warrants further biomechanical study for construct strength improvement.

Homocysteine causes dysfunction of chondrocytes and oxidative stress through repression of SIRT1/AMPK pathway: A possible link between hyperhomocysteinemia and osteoarthritis

Emerging evidence has indicated that the perturbed expression of homocysteine (Hcy) may induce mitochondrial dysfunction and disturb bone metabolism. Sirtuin 1 (SIRT1) and AMP-activated protein kinase (AMPK) are two critical sensors that regulate mitochondrial biogenesis and have been recognized as therapeutic targets in osteoarthritis (OA). This study was designed to test whether Hcy caused pro-osteoarthritic changes through modulation of SIRT1 and AMPK. Our results showed that administration of Hcy reduced the SIRT1/AMPK/PGC-1α signaling in chondrocytes, leading to mitochondrial dysfunction as a result of increased oxidative stress and apoptosis. Moreover, we demonstrated that the expression of NF-κB, COX-2, IL-8, and MMP-13 were elevated subsequent to inhibition of SIRT1/AMPK/PGC-1α/PPAR-γ pathway by homocysteine, thereby causing detrimental effects on chondrocytes. In the animal model of diet-induced hyperhomocysteinemia (HHcy), we observed the similar findings that SIRT1/PGC-1α/PPAR-γ cascades were downregulated with elevated MMP-13 and COX-2. Taken together, data from the current study revealed that the reduced SIRT1 by Hcy may contribute to degradative cartilage process, which provided insight into the etiology of OA.

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.

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.