Peter A. Cole

Treatment of acute midshaft clavicle fractures Systematic review of 2144 fractures : On behalf of the evidence-based orthopaedic trauma working group

Background: Fractures of the clavicle were reported to represent 2.6% of all fractures1 with an overall incidence of 64 per 100,000 per year (1987, Malmö, Sweden).2 Midshaft fractures account for approximately 69% to 81% of all clavicle fractures.1-4 Treatment options for acute midshaft clavicle fractures include nonoperative treatment (mostly sling or figure-of-eight bandage), open reduction and internal fixation with plates, and closed or open reduction and internal fixation with intramedullary pins, wires, or a nail. Most surgeons prefer nonoperative treatment of nondisplaced midshaft clavicle fractures. However, the optimal treatment option for isolated acute displaced midshaft clavicle fractures remains controversial. Objectives: This study was designed to systematically summarize and compare results of different treatment options (nonoperative, operative extramedullary fixation, and operative intramedullary fixation) in the management of midshaft clavicle fractures, specifically for displaced fractures.

Treatment of distal femur fractures using the less invasive stabilization system: surgical experience and early clinical results in 103 fractures.

Objective: To summarize the complications and early clinical results of 123 distal femur fractures treated with the Less Invasive Stabilization System (LISS; Synthes, Paoli, PA). Design: Retrospective analysis of prospectively enrolled patients. Setting: Two academic level I trauma centers. Subjects and Participants: One hundred nineteen consecutive patients with 123 distal femur fractures (OTA type 33 and distal type 32 fractures) treated by 3 surgeons. One hundred three fractures (68 closed fractures and 35 open fractures) in 99 patients were followed up at least until union (mean follow-up = 14 months, range: 3–50 months). Intervention: Surgical reduction and fixation of distal femur fractures. Main Outcome Measurements: Perioperative complications, radiographic union, infection rate, loss of fixation, alignment, and range of motion. Results: Ninety-six (93%) of 103 fractures healed without bone grafting. All fractures eventually healed with secondary procedures, including bone grafting (1 of 68 closed fractures and 6 of 35 open fractures). There were 5 losses of proximal fixation, 2 nonunions, and 3 acute infections. No cases of varus collapse or screw loosening in the distal femoral fragment were observed. Malreductions of the femoral fracture were seen in 6 fractures (6%). The mean range of knee motion was 1° to 109°. Conclusions: Treatment of distal femur fractures with the LISS is associated with high union rates without autogenous bone grafting (93%), a low incidence of infection (3%), and maintenance of distal femoral fixation (100%). No loss of fixation in the distal femoral condyles was observed despite the treatment of 30 patients older than 65 years. The LISS is an acceptable surgical option for treatment of distal femoral fractures.

Biomechanical evaluation of the less invasive stabilization system, angled blade plate, and retrograde intramedullary nail for the internal fixation of distal femur fractures.

Objective: To evaluate the stability of the retrograde intramedullary nail (IMN), angled blade plate (ABP), and a locked internal fixator (Less Invasive Stabilization System [LISS], Synthes, Paoli, PA) for internal fixation of distal femur fractures. Design: Destructive biomechanical testing of matched pairs of fresh–frozen human cadaveric bone–implant constructs. Setting: Biomechanical laboratory. Methods: A fracture model was created to simulate an AO/OTA33-A3 fracture. Forty-eight matched pairs of specimens were used. Six groups of 8 pairs each were tested to failure: LISS versus ABP and LISS versus IMN (axial, torsional, and cyclical axial). Main Outcome Measurement: Load to failure, mode of failure, energy to failure, displacement at the load to failure, and stiffness. Results: Fixation strength (load/moment to failure) of the LISS constructs was 34% greater in axial loading (P = 0.01) and 32% less in torsional loading (P = 0.05) compared with ABP constructs and 13% greater in axial loading (P = 0.35) and 45% less in torsional loading (P < 0.01) compared with IMN constructs. Loss of distal fixation in axial loading occurred in 1 of 16 cases with the LISS, in 3 of 8 cases with the ABP, and in 8 of 8 cases with the IMN. Cyclical axial loading demonstrated significantly less plastic deformation for the LISS construct compared with ABP constructs (P < 0.01) and similar plastic deformation compared with IMN constructs (P = 0.98). Conclusions: All 3 fixation devices (LISS, ABP, and IMN) offer sufficient torsional stability and sufficient proximal fixation that withstands axial loading without failing. The LISS provides improved distal fixation, especially in osteoporotic bone, at the expense of more displacement at the fracture site.

Treatment of acute distal femur fractures above a total knee arthroplasty: Systematic review of 415 cases (1981–2006)

Background There is no consensus on the best treatment for periprosthetic supracondylar fracture. Material and methods We systematically summarized and compared results of different fixation techniques in the management of acute distal femur fractures above a total knee arthroplasty (TKA). Several databases were searched (Medline, Cochrane library, OTA and AAOS abstract databases) and baseline and outcome parameters were abstracted. Results We extracted data from 29 case series with a total of 415 fractures. The following outcomes were noted: a nonunion rate of 9%, a fixation failure rate of 4%, an infection rate of 3%, and a revision surgery rate of 13%. Retrograde nailing was associated with relative risk reduction (RRR) of 87% (p = 0.01) for developing a nonunion and 70% (p = 0.03) for requiring revision surgery compared to traditional (non-locking) plating methods. Point estimates also suggested risk reductions for locking plates, although these were not statistically significant (57% for nonunion, p = 0.2; 43% for revision surgery, p = 0.23) compared to traditional plating. RRRs for nonunion and revision surgery were also statistically significantly lower for retrograde nailing and locking plates compared to nonoperative treatment. Interpretation Modern-day treatment methods are superior to conventional treatment options in the management of distal femur fractures above TKAs. The results should be interpreted with caution, due to the lack of randomized controlled trials and the possible selection bias in case series.

Efficacy of a saccharin test for screening to detect abnormal mucociliary clearance

A simple, inexpensive and reproducible clinical test for determining abnormal mucociliary clearance is proposed which identifies those patients in whom in vitro study of ciliary motility and mucus properties should be carried out.

Less invasive stabilization system (LISS) for fractures of the proximal tibia: Indications, Surgical Technique and Preliminary Results of the UMC Clinical Trial

The surgical treatment of proximal tibia fractures, with or without intraarticular involvement, is associated with well-described patterns of failure and significant complication rates. Recent surgical advances allow for a minimally invasive approach to such injuries, which may improve healing times, increase union rates, and decrease complication rates. The Less Invasive Stabilization System (LISS) for proximal tibia fractures employs a laterally based fixed angled implant, allowing for the placement of locking screws proximal and distal to the fracture, which may be placed percutaneously. This manuscript presents the surgical technique and indications of the Tibia LISS. A preview of the early clinical results of the treatment of bicondylar tibial plateau fractures and proximal tibia diaphysis will also be presented.

Operative treatment of acute distal femur fractures: Systematic review of 2 comparative studies and 45 case series (1989 to 2005)

Background The incidence of distal femur fractures is approximately 37 per 100,000 person-years.1 Typically, distal femur fractures are caused by a high-energy injury mechanism in young men or a low-energy mechanism in elderly women.2 Managing these fractures can be a challenging task. Most surgeons agree that distal femur fractures need to be treated operatively to achieve optimal patient outcomes. The articular fracture component is usually treated with open reduction and internal lag screw fixation or external tension wire fixation (Illizarov). However, there is no consensus on the type of implant for the fixation of the metaphyseal–diaphyseal fracture component. Objective The aim of this study is to systematically summarize and compare the results of different fixation techniques (traditional compression plating, antegrade nailing, retrograde nailing, submuscular locked internal fixation, and external fixation) in the operative management of acute nonperiprosthetic distal femur fractures (AO/OTA type 33A and C) and the characteristics of the fractures for each treatment (articular/nonarticular and open/closed). Additionally an attempt was made to evaluate the impact of surgical experience on nonunion rate, fixation failure rate, deep infection rate, and secondary surgical procedure rate. In the context of this article compression plating relates to techniques/implants that require compression of the implant to the femoral shaft—it does not relate to interfragmentary compression.

Treatment of scapula fractures : Systematic review of 520 fractures in 22 case series

Background Fractures of the scapula account for 3% to 5% of all fractures of the shoulder girdle39–41 and make up less than 1% of all broken bones.42 Scapula fractures typically occur after high-energy trauma, and approximately 90% of the patients have associated injuries.39,43 Objective (1) To determine the incidences of nonoperative and operative treatment of different scapula fracture types, (2) to systematically stratify the reported results of nonoperatively and operatively treated scapula fractures on the basis of different fracture types and to summarize functional results, and (3) to quantify infection and secondary surgical procedure rates after operative treatment.

Operative Treatment of Chest Wall Injuries: Indications, Technique, and Outcomes

Most injuries to the chest wall with residual deformity do not result in long-term respiratory dysfunction unless they are associated with pulmonary contusion. Indications for operative fixation include flail chest, reduction of pain and disability, a chest wall deformity or defect, symptomatic nonunion, thoracotomy for other indications, and open fractures. Operative indications for chest wall injuries are rare.

What's New in Orthopaedic Trauma

The following update provides a summary of selected studies related to orthopaedic trauma that were published mainly in 2015. Methods (→), results (◊), and take-home points (₪) are presented in an abridged fashion. → In a retrospective, single-center study that included 235 consecutive patients over a 9-year period who were treated with primary plate fixation (superior placement only) for a substantially displaced midshaft clavicular fracture with shortening and/or deformity, the authors evaluated 20 potential risk factors for reoperation related to implant removal or nonunion, infection, or fixation failure1. ◊ Among the 65% of patients who had 2-year follow-up, 38% (58) underwent reoperation. ₪ Intraoperative plate contouring and a patient height of 55 years and alcohol use (>15 drinks per week); the presence of both factors led to a 78% reoperation risk. → In a prospective study, 76 consecutive Workers’ Compensation patients with displaced middle-third clavicular fractures were randomized to conservative treatment (n = 42) or surgical anatomic plate fixation (n = 34)2. ◊ Computed tomography (CT) scans at 6 and 12 weeks revealed advanced healing in the surgical treatment group: 24.1% at 6 weeks and 81% at 12 weeks versus 5.3% and 16.7%, respectively, in the conservative treatment group. The time from discharge to the return to full occupational duties was 3.7 ± 1.1 months in the conservative treatment group and 2.9 ± 0.8 months in the surgical treatment group. Four patients in the conservative treatment group experienced nonunion requiring surgery compared with no patient in the surgical treatment group. The reoperation rate …Whats new in orthopaedic trauma.