Po-Cheng Lee

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.

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.