Torstein Husby

Volar Locking Plates Versus External Fixation and Adjuvant Pin Fixation in Unstable Distal Radius Fractures: A Randomized, Controlled Study

PURPOSE To determine whether volar locking plates are superior to external fixation with adjuvant pins in the treatment of unstable distal radius fractures. METHODS A total of 111 unstable distal radius fractures were randomized to treatment with external fixation (EF) using adjuvant pins or with a volar locking plate (VLP). The mean age of the patients was 54 years (range, 20-84 y). Seven patients were lost to follow-up. At 1 year, 104 patients were assessed with a visual analog scale pain score, Mayo wrist score, Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH), range of motion, and radiological evaluation. The QuickDASH score at 52 weeks was the primary outcome measure. RESULTS The operative time in the EF group was 77 minutes, compared with 88 minutes in the VLP group. At 52 weeks, patients with VLPs had a higher Mayo wrist score (90 vs. 85), better supination (89° vs. 85°), and less radial shortening (+1.4 mm vs. +2.2 mm). There were more patients with pain over the ulnar styloid in the EF group (16 vs 6 patients). For AO type C2/C3, the patients with VLPs had better supination (90° vs. 76°) and less ulnar shortening (+1.1 mm vs. +2.8 mm). The complication rate was 30% in the EF group, compared with 29% in the VLP group. Eight (15%) plates were removed due to complications. The QuickDASH score was not significantly different between the groups. CONCLUSIONS Although we did not find a significant difference between the groups for the QuickDASH score, we believe that our results support the use of VLPs for the treatment of unstable distal radius fractures. A serious concern is that some patients will have to have their plates removed; therefore, improving the surgical technique is important. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.

LONG TERM RESULTS AFTER ARTHROSCOPIC RESECTION OF LESIONS OF THE TRIANGULAR FIBROCARTILAGE COMPLEX

Thirty-five patients with central and radial lesions of the triangular fibrocartilage complex (TFCC) were treated by arthroscopic resection and debridement. Their median age was 36 years (range 11-52), and preoperative duration of symptoms 18 months (range 4-132). Fall on a hyperextended wrist was the most common injury (n = 15), and nine patients had had a previous fracture of the radius. Eighteen patients had an additional arthroscopic debridement of coexisting chondral lesions. There were no complications. At a median follow up time of 39 months (range 18-58), grip strength was recorded as a median of 94% (range 4-164), flexion-extension sector as 94% (range 50-107), and pronation and supination sector as 100% (range 50-112) of the uninjured side. At follow up eight patients were free of pain, 14 much better, eight somewhat better, five unchanged, and no patient had got worse. The Mayo Modified Wrist Score assessed 13 patients as excellent, 14 good, four fair, and one poor. Thirty-one patients returned to full-time work, and four were unemployed (partly because of reasons not relevant to the operation). Thirty-three patients reported they would have had the same procedure if they had known the outcome of the surgery. We find arthroscopic debridement of central or radial lesions of the TFCC to be safe and reliable with good pain relief.

Open versus arthroscopic subacromial decompression: a prospective, randomized study of 34 patients followed for 8 years.

In a randomized prospective study, we selected 15 patients for arthroscopic subacromial decompression (ASD) and 19 patients for open subacromial decompression (OSD). All had impingement syndrome (Neer grade II), and had been unsuccessfully treated without surgery for more than 6 months. The UCLA Shoulder Rating Scale, Visual Analogue Scales for pain and satisfaction, isokinetic dynamometer recordings and physical testing were assessed preoperatively and at 1 (except isokinetic testing), 3, 6, and 12 months, and, finally, 8 years after surgery. We found essentially no differences in the clinical tests between the groups during this period. The use of ASD or OSD seems to be a matter of cosmesis and personal preference.

Early loss of fixation of femoral neck fractures Comparison of three devices in 244 cases

In successive series of displaced subcapital femoral neck fractures in the elderly, we operated on 75 cases with three Gouffon screws, 94 with three Mecron screws, and 75 with two von Bahr screws. Redisplacement within 3 months occurred in 20 Gouffon cases, 11 Mecron cases, and 12 von Bahr cases. Poor reduction contributed to the failures in all the groups. Although the reduction results in the three groups were similar, the Mecron group had better fixation and better social recovery than the Gouffon group. We concluded that, in addition to good reduction of the fracture, solid screws also contributed to the stability of the bone-implant construct.

Isolated, extra-articular neck and shaft fractures of the 4th and 5th metacarpals: a comparison of transverse and bouquet (intra-medullary) pinning in 67 patients

Although extra-articular metacarpal fractures are common, there is no consensus on the mode of treatment. We evaluated the outcome in 67 patients operated for isolated, extra-articular fractures in the neck or shaft of the ulnar two metacarpals 28 months post-operatively. There were 22 bouquet (intra-medullary) pinnings and 45 transverse pinnings; 11 were lost to follow-up. Overall, hand function was good, and no difference was detected between the two methods (QuickDASH, grip strength, range of motion, VAS pain and VAS satisfaction). Many patients suffered complications: 12% had a superficial infection (all treated with transverse pinning with wires left exposed); 39% had some impairment in skin sensation; 29% reported cold intolerance; and 10% had other complications. Due to the potential risk of a secondary fracture of the neighbouring metacarpal after transverse pinning, we recommend bouquet (intra-medullary) pinning. We also recommend burying wires beneath the skin surface to avoid infection.

Implant holding power of the femoral head. A cadaver study of fracture screws.

The holding power against axial pull-out forces of eight different screws implanted in the femoral heads of cadavers was tested. The Olmed screw had the greatest resistance to pull-out forces followed by the recently designed Ullevaal screw with long threads, and the von Bahr screw. There were substantial differences in the holding power in the four sectors of the femoral head. The holding power was strongly correlated with the logarithm of the moment of inertia of the screw threads, which is a function of the area and number of the threads (r = 0.94, P = 0.0002).

Bone-mass distribution in the femur A cadaver study on the relations of structure and strength

We measured the bone density and volume in the femoral head, cervicotrochanteric, midshaft, and condylar regions by quantitative computed tomography of the femora of 26 elderly cadavers. We also measured the shearing force at fracture of the femora in axial bending; 25 fractures occurred vertically in the neck and only one in the shaft. The bone mass-related measurements, calculated as the product of bone density times volume, increased steadily from the femoral neck down to the condyles. The bone densities of males and females did not differ, whereas the bone volumes were higher in males. Several correlations were found between the ultimate shearing force of the cervical trabecular/cortical bone and cortical and cancellous bone densities in different locations of the femur. The ultimate shearing force was correlated with the bone mass in all the locations.

Strength of femoral neck fracture fixation: Comparison of six techniques in cadavers

A neck osteotomy parallel to the femoral shaft was made on 36 cadaveric femora using the contralateral intact femur as a control. The osteotomies were fixed using a Thornton nail, two von Bahr screws, three Gouffon screws, three Knowles pins, a Haukebø compression screw, or an AO compression screw. The femora were then tested for bending strength using the load ratio test/control at 2- and 5-mm displacement as an expression of the relative strength of the osteosynthesis. There was no difference between the von Bahr, Haukebø, and the AO screws. These implants gave stronger fixation than the Thornton nail, Gouffon screws, and Knowles pins. The Thornton nail was stronger than three Gouffon screws or Knowles pins. The relatively stronger compression hip screws were thus not superior to two optimally placed 5-mm screws.

Stability of femoral neck osteosynthesis: Comparison of fixation methods in cadavers

Fixation of vertical femoral neck osteotomies in 50 cadavers was performed with either von Bahr screws or a sliding hip compression screw. One specimen from each pair of femora was used for the osteotomy, the other serving as an intact control. At 0.05 r of torsion the load-deformation test showed that three von Bahr screws provided the strongest fixation, and this was confirmed by the the ultimate torsional moment test. Regardless of positioning, even two von Bahr screws were stronger than the sliding compression screw with or without an additional lag screw. The results indicate that the best torsional stability in femoral neck fractures can be obtained with three 5.5-mm screws.

Rotational strength of the femoral neck: Computed tomography in cadavers

The mean bone density of the femur at different levels was determined by means of quantitative computed tomography (QCT) in 50 pairs of normal cadaveric femora and related to the rotational strength of the femoral neck. All the femora fractured vertically and spirally in the neck. The bone-mass-related measures at different levels were calculated from QCT densities and volumes. Cancellous bone was defined with threshold limits ranging from 50-500 Hounsfield units (HU), and attenuation values exceeding 500 HU were assessed as cortical bone. The recorded QCT mass-related measures of cortical and cancellous bone separately and as total bone masses gave significant right/left correlations. Correlations were found between the ultimate torsional strength of the femoral neck and QCT recordings of bone mass at all the femoral levels. The best correlations were demonstrated between the rotational strength of the femoral neck and the total bone-mass-related measures in the femoral shaft and condylar area. Bone mass of the femur measured by computed tomography may become useful as an index of the mechanical strength of the femoral neck.