Gunasekaran Kumar

Case Report: A Technique to Remove a Jammed Locking Screw from a Locking Plate

BackgroundLocking titanium plates revolutionized the treatment of osteoporotic and metaphyseal fractures of long bones. However as with any innovation, with time new complications are identified. One of the problems with titanium locking plates is removal of screws, often attributable to cold welding of screw heads into the locking screw holes. Several techniques have been described to overcome this problem. We describe a new easy technique to remove a jammed locking screw in a locking plate that is easily reproducible and suggest an algorithm to determine the method to remove screws from locking plates.Case DescriptionA 57-year-old man underwent removal of a locking titanium plate from the distal femur. Because the screws could not be readily removed, we used a new technique to remove the jammed locking screws. A radial cut was made in the plate into the locking screw hole and wedged with an osteotome. This released the screw head from the locking screw hole. The screw holes were connected with radial cuts and jammed locking screws were removed in a similar fashion.Literature ReviewInstruments used for removal of locking screws, including conical extraction screws, hollow reamers, extraction bolts, modular devices, and carbide drill bits, have been described. However, these do not always work.Purposes and Clinical RelevanceRemoving screws from locking titanium plates can be difficult. There is no method of implant removal that can be universally applied. Therefore, this new technique and our algorithm may be used when removing screws from locking titanium plates.

Bicondylar tibial fractures: Internal or external fixation?

Bicondylar fractures of the tibia, representing the Schatzker V and VI fractures represent a challenging problem. Any treatment protocol should aim at restoring articular congruity and the metaphyseo-diaphsyeal dissociation (MDD)—both of these are equally important to long-term outcome. Both internal and external fixations have their proponents, and each method of treatment is associated with its unique features and complications. We review the initial and definitive management of these injuries, and the advantages and disadvantages of each method of definitive fixation. We suggest the use of a protocol for definitive management, using either internal or external fixation as deemed appropriate. This protocol is based on the fracture configuration, local soft tissue status and patient condition. In a nutshell, if the fracture pattern and soft tissue status are amenable plate fixation (single or double) is performed, otherwise limited open reduction and articular surface reconstruction with screws and circular frame is performed.

Regulation of Bone Formation by Applied Dynamic Loads

In vivo external loads were applied to a functionally isolated avian-bone preparation to evaluate the following data 1. Removal of load-bearing resulted in substantial endosteally bone remodelling, intracortically, and, to a lesser extent, periosteally. The balance of this remodelling was negative – bone mass declined. This suggests that functional load-bearing prevents a remodelling process that would lead to disuse osteoporosis. 2. Four consecutive cycles a day of an externally applied load that prevented physiological strain magnitudes but allowed an altered strain distribution prevented remodelling and was associated with no change in bone mass. A small exposure to, or the fi rst effect of, a suitable dynamic strain regimen appears to be suffi cient to prevent the negatively balanced remodelling that is responsible for disuse osteoporosis. 3. Thirty-six 0.5-Hz cycles per day of the same load routine also prevented intracortical resorption but was associated with substantial periosteal and endosteal new-bone formation. Over a 6 week period, bone mineral content increased to between 133 and 143 % of the original value. Physiological levels of strain applied with an abnormal strain distribution can produce an osteogenic stimulus that is able to increase bone mass. Neither the size nor the nature of the bone changes that were observed were affected by any additional increase in the number of load cycles from 36 to 1,800. The sensitivity of bone remodelling in this model to prevailing mechanical circumstances is apparent. Functional levels of bone mass in patients may only be maintained under the effects of continued load-bearing. The osteogenic effect of an unusual strain distribution suggests that a varied exercise program may provoke a greater hypertrophic response than an exercise program that is restricted. A substantial osteogenic response may be achieved after remarkably few cycles of loading.

Prevention of Infection in the Treatment of One Thousand and Twenty-Five Open Fractures of Long Bones. Retrospective and Prospective Analyses

In 673 open fractures of long bones (tibia and fibula, femur, radius and ulna, and humerus) treated from 1955 to 1968 at Hennepin County Medical Center, Minneapolis, Minnesota, and analyzed retrospectively, the infection rate was 12 per cent from 1955 to 1960 and 5 per cent from 1961 to 1968. In a prospective study from 1969to 1973,352 pa tients were managed as follows: débridementand copi ous irrigation, primary closure for Type I and II frac tures and secondary closure for Type III fractures, no primary internal fixation except in the presence of as sociated vascular injuries, cultures of all wounds, and oxacillm-ampicillin before surgery and for three days postoperatively. In 158 of the patients in the prospec tive study the initial wound cultures revealed bacterial growth in 70.3 per cent and the infection rate was 2.5 per cent. Sensitivity studies suggested that cephalospo rin is currently the prophylactic antibiotic of choice. For the Type III open fractures (severe soft-tissue in jury, segmental fracture, or traumatic amputation), the infection rates were 44 per cent in the retrospective study and 9 per cent in the prospective study. Prevention of wound sepsis remains the prime objec tive in the management of open fractures. The reported in fection rates in these fractures, which range from 3 to 25 per cent, are a challenge to every surgeon who treats them 6-8,lO.I4,15,2i,22.26 * Hennepin County Medical Ccnter. Fifth and Portland South. Minneapolis, Minnesota 55415. 1@Universityof Minnesota,Minneapolis. Minnesota. There is universal agreement that open fractures re quire emergency treatment, including adequate débridement and irrigation of the wound. Beyond these two basic tenets, opinions differ as to the following: I . Primary or secondary closure. If the wound is left open and secondary direct skin closure is not possible, when does one do skin-grafting, or create a cross-leg pedi cle flap or a rotational flap? 2. Use of primary internal fixation. What are the in dications for primary internal fixation and if internal fixation is delayed, when is the proper time for open reduc tion and internal fixation? 3. Use of antibiotics. Should they be used routinely? What antibiotics should be used and for how long? In an attempt to answer these questions we carried out retrospective and prospective analyses of a total of I ,025 open fractures of all the long bones treated at Hennepin County Medical Center, Minneapolis, Minnesota, from

A Randomized Controlled Trial Comparing Modular and Nonmodular Neck Versions of a Titanium Stem

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The Tension-Stress Effect on the Genesis and Growth of Tissues Part I. The Influence of Stability of Fixation and Soft-Tissue Preservation

To evaluate the optimum conditions for osteogenesis during limb lengthening and to study the changes in soft tissues undergoing elongation, a series of experiments were performed on the canine tibia. The experiments used the transfixionwire, Ilizarov circular external skeletal fixator in configurations of differing stability of fixation in combination with a second variable, i.e., preservation of the periosteum, bone marrow, and medullary blood supply. Both increased fixator stability, and maximum preservation of the periosseous and intraosseous soft tissues enhanced bone formation during limb lengthening. To assess the role that the direction of the elongation vector plays in osteogenesis, canine tibiae were widened rather than lengthened in a second series of experiments using an Ilizarov apparatus modified for lateral distraction. The new bone formed parallel to the tension vector even when perpendicular to the bones mechanical axis. As in longitudinal lengthening, damage to the bone marrow inhibits osteogenesis occurring by the influence of a lateral tension-stress vector. In a third series of experiments, halfand full-circumference cortical defects were created in canine tibiae to study the osteogenic potential of

Classic Papers in Trauma and Fracture Healing: Introduction

A ‘classic paper’ has no specific definition. The number of citations of a paper often reflects quality, but not always. At best therefore, the number of citations is a surrogate marker of how important a paper is and whether the paper is responsible for significant developments in orthopaedics.

The BMJ’s cover line on calcaneal fractures is misleading

The BMJ’s print cover of the issue of 2 August 2014 is misleading. It says boldly, “Calcaneal fractures: surgery provides no benefits.” Griffin and colleagues mentioned clearly the exceptions to their conclusion, which the front page does not convey. The authors excluded extra-articular fractures, open fractures, and “grossly displaced fractures,” the last two of which were presumably all treated surgically. Competing interests: None declared.