Ivan Micic

Analysis of early failure of the locking compression plate in osteoporotic proximal humerus fractures

BackgroundAlthough there has been continuous evolution in the management of fracture fixation, treatment for osteoporotic proximal humerus fractures is still challenging to trauma surgeons. The purpose of this study was to report early failure of the locking compression plate (LCP) in the treatment of osteoporotic proximal humerus fracture and characterize the mode of failure.MethodsNine patients, older than 65 years, underwent internal fixation with the use of a locking compression plate and had early failure within 4 weeks postoperatively. According to Neer’s classification, five were included in a two-part surgical neck fracture, three in a three-part fracture, and one in a four-part fracture.ResultsAll failures occurred with back-out of the plate—screw construct, leading to varus displacement in eight patients and plate breakage in one. Revision surgery was performed in six patients using replating and tension band wiring with a bone graft, and three patients underwent hemiarthroplasty. The average UCLA score was 25 points for the hemiarthroplasty group and 30 points for the reconstruction group.ConclusionsEarly postoperative failure of the LCP developed within 4 weeks with a presentation of en bloc back-out of the plate-screw construct and plate breakage. Possible risk factors included malreduction, loss of medial support, and negligence of tension band sutures on the tuberosities.

Percutaneous Screw Fixation for Scaphoid Fracture: A Comparison Between the Dorsal and the Volar Approaches

PURPOSE To evaluate the position of the screws and find the difference of clinical and radiologic outcome between the volar approach and the dorsal approach groups in percutaneous screw fixation for acute scaphoid fractures. METHODS Forty-one consecutive patients with an acute scaphoid fracture, who had percutaneous fixation via either the volar approach or the dorsal approach, were evaluated at an average of 30 months after the surgery. The volar approach was used in 19 patients and the dorsal approach in 22 patients. By using a computerized digital image program, angles between the Herbert screw with respect to the long axis of the scaphoid and the fracture line were measured with plain radiographs in the posteroanterior, lateral, and the 45 degrees semipronated oblique views. RESULTS The screws showed no significant difference between the 2 groups in posteroanterior and lateral views; however, screws in the dorsal approach group were observed to be placed more parallel to the long axis of the scaphoid in the semipronated oblique view. The screws in the dorsal approach group were positioned more perpendicular to the fracture lines of the scaphoid compared with those of the volar approach group for all 3 different radiographic views. There was no statistically significant difference between the 2 treatment groups regarding fracture healing. According to the Mayo wrist score system, excellent results were recorded in 18 patients in the dorsal approach group and 15 patients in the volar approach group. CONCLUSIONS This study suggests that screws are placed more parallel to the long axis of the scaphoid and perpendicular to the fracture line via the dorsal approach; however, there was no significant difference with regard to functional outcome and bone union. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Treatment of Subtrochanteric Femoral Fractures Using Selfdynamisable Internal Fixator

Background Surgical treatment is the preferred method for treating subtrochanteric femoral fractures and the variety of extramedullary and intramedullary implants continues to evolve. The purpose of our study was to retrospectively evaluate the clinical and radiological results of subtrochanteric fractures that are treated with the Selfdynamisable internal fixator. Methods From January 2000 to January 2004, we treated 49 consecutive patients who had subtrochanteric fractures. According to the AO classification, 8 (16.3%) fractures were type 32-A, 16 (32.7%) were type 32-B and 25 (51%) fractures were type 32-C. The mean follow-up time was 22.3 months. Results The average operating time was 45 minutes (range, 32 to 90 minutes). The average blood loss was 250 mL (range, 125 to 350 mL). The average hospital stay was 10 days (range, 7 to 59 days). Implant failure was not observed and union was achieved in all the patients. Deep infection occurred in one (2%) patient in the early postoperative period. Fracture union was achieved at a mean of 14 weeks. Varus malalignment less then 10 degree was noted in three (6.1%) patients at the end of follow-up. Thirty-five patients were pain-free and 14 had mild pain. Conclusions The selfdynamisable internal fixator was successfully used for subtrochanteric fracture. It provides a short operative time, low blood loss, spontaneous biaxial dynamisation and healing in an optimal period of time without the need for secondary intervention.

CLINICAL RESULT OF OPERATIVE TREATMENT FOR SCAPHOID NON-UNION IN THE SKELETALLY IMMATURE: PERCUTANEOUS VERSUS OPEN PROCEDURE

This article is a retrospective study of 13 cases of scaphoid non-union in skeletally immature patients. For the fracture fixation, three cases of stable fibrous union with minimal sclerosis, without deformity or cystic changes were considered for the percutaneous Herbert screw fixation. Ten cases were managed with the open reduction and internal fixation with or without bone grafting. The average union time was 10.5 weeks post-operatively. The average union time was lesser in percutaneous Herbert screw fixation group (nine weeks) than open procedure group (11.5 weeks). All cases achieved union without any supplemental procedures. According to Cooneys clinical scoring, 12 cases were rated excellent result and one good result. The percutaneous Herbert screw fixation for scaphoid non-union in skeletally immature patients can be a good treatment option when it is fibrous union with no deformity.

Endoscopic carpal tunnel release using the modified Chow's extrabursal dual portal technique: Clinical results of 640 patients

During a 4-year period, a total of 784 wrists of 640 patients were treated using a modified Chows extrabursal dual portal endoscopic technique. All surgeries were performed under local anesthesia. A 1-cm incision was marked 1-2 cm proximal to the distal wrist crease, in the midline, ulnar to the palmaris longus. A distal portal was established along a line bisecting an angle created by the intersection of the ulnar border of the abducted thumb and the third web space. An obturator and cannula assembly were inserted under the portal, and three blades were used to cut under endoscopic vision. Subjective results showed that 706 hands (90%) had a reduction in the severity of pain after carpal tunnel release, 706 hands (90%) had a reduction in the severity of paresthesia and 729 hands (93%) had a reduction in the severity of numbness. Nocturnal pain and paresthesia were relieved in 745 cases (95%). Compared with the conventional open carpal tunnel release, less postoperative pain and faster recovery have been reported following endoscopic carpal tunnel release. This study suggests that extrabursal dual portal technique is a safe and reliable treatment option for carpal tunnel syndrome with a high success rate.

External fixator by Mitkovic in the treatment of comminuted intraarticular fractures of the distal radius

INTRODUCTION Comminuted intraarticular fractures of the distal radius metaphysis are a major challenge for orthopedic surgeons. The aim of this study was to present results of the survey on treatment of these fractures using an external fixator. MATERIAL AND METHODS 73 patients (30 females and 43 males) with closed comminuted intraarticular fractures of the distal radius, type C AO/ASIF (based on radiography at the moment of injury) were treated by a Mitkovic external fixator and followed-up for at least 2 years. An external fixator and Kirschner wires were used in 43 patients. An external fixator without Kirschner wires was used in 30 patients. RESULTS At the end of treatment, functional results and outcomes were excellent in 39 (53.4%), good in 19 (26%), fair in 10 (13.7%), and poor in 5 (6.8%) patients according to Jakim score. Lesser degree of limitation of the movement of the wrist joint was established in 19 patients (26%). Joint incongruity of the distal radius, 0-2 mm, was observed in 22 patients (30%) and over 2 mm in 3 patients. A minimal degree of posttraumatic osteoarthrosis was recorded in 21 patients (28.7%) and moderate ostheoarthrosis in 5 patients (6.8%). CONCLUSION The anatomic reduction of the articular surfaces and healing of the fracture in a proper functional position are prerequisites for adequate function of the wrist and hand. It appears that an external fixator, with or without Kirschner wires, can be a method of choice in treatment of these complex articular fractures.

Application of the New Self-dynamisable Internal Fixator in the Treatment of Femoral Shaft Fractures

Summary The aim of this study was to present the results of one original method application in internal fixation of long bones. The series of 27 patients with unilateral fractures of femoral shaft was analyzed. According to AO classification, 21 fractures were classified as 32A, five as 32B, and one as 32C type. Original diaphyseal self-dynamisable internal fixator (model 1) was used as a fixation implant, consisting of three components: specially designed extramedullary bar, clamps and screws. The main feature of this implant is a possibility to become dynamic in the axial direction spontaneously if there is no sufficient fracture healing. Because of that, this implant is known as an „intelligent implant“. Surgical method included a standard surgical approach and minimally invasive surgical approach. Minimally invasive technique of application required less blood transfusion and shorter surgery time when compared to the standard surgical approach. The duration of used intraoperative fluoroscopy control was 7(3-18) seconds. The average healing time was 4.3 (3.5-9.5) months. There were neither intra operative nor postoperative complications. In comparison to intramedullary nails, self-dynamisable internal fixator provides a similar treatment results, while in comparison to plates it provides fewer mechanical complications. Self-dynamisable internal fixator method preserves periosteal and intramedullary blood circulation, and it is the first fixation implant with a possibility of spontaneous axial dynamising activation when needed. This implant has been proven as suitable for routine use in the treatment of femoral shaft fractures.