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The Bone & Joint Journal May 2019The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades.... (Review)
Review
The medial malleolus, once believed to be the primary stabilizer of the ankle, has been the topic of conflicting clinical and biomechanical data for many decades. Despite the relevant surgical anatomy being understood for almost 40 years, the optimal treatment of medial malleolar fractures remains unclear, whether the injury occurs in isolation or as part of an unstable bi- or trimalleolar fracture configuration. Traditional teaching recommends open reduction and fixation of medial malleolar fractures that are part of an unstable injury. However, there is recent evidence to suggest that nonoperative management of well-reduced fractures may result in equivalent outcomes, but without the morbidity associated with surgery. This review gives an update on the relevant anatomy and classification systems for medial malleolar fractures and an overview of the current literature regarding their management, including surgical approaches and the choice of implants. Cite this article: 2019;101-B:512-521.
Topics: Ankle Fractures; Ankle Joint; Fracture Fixation; Humans; Orthopedic Fixation Devices; Postoperative Complications
PubMed: 31038989
DOI: 10.1302/0301-620x.101B5.BJJ-2019-0070 -
Deutsches Arzteblatt International May 2014Ankle fractures are common, with an incidence of up to 174 cases per 100 000 adults per year. Their correct classification and treatment are of decisive importance for... (Review)
Review
BACKGROUND
Ankle fractures are common, with an incidence of up to 174 cases per 100 000 adults per year. Their correct classification and treatment are of decisive importance for clinical outcome.
METHOD
Selective review of the literature.
RESULTS
Ankle fractures are initially evaluated by physical examination and then by x-ray. They can be classified according to either the AO Foundation (Association for the Study of Internal Fixation) or the Weber classification. Dislocated fractures need emergency treatment with immediate reduction; this is crucial for the prevention of hypoperfusion and nerve damage. Weber A fractures can usually be treated conservatively, while Weber B and C fractures are usually treated with surgery. An evaluation of the stability of the syndesmosis is important for anatomical reconstruction of the joint. Wound hematoma and wound-edge necrosis are the most common complications, and the postoperative infection rate is 2%. Up to 10% of patients develop ankle arthrosis over the intermediate or long term.
CONCLUSION
With properly chosen treatment, a good clinical outcome can be achieved. The long-term objective is to prevent post-traumatic ankle arthrosis. The evidence level for optimal treatment strategies is low.
Topics: Ankle Fractures; Combined Modality Therapy; Diagnostic Imaging; Foot Orthoses; Fracture Fixation; Humans; Physical Examination; Physical Therapy Modalities; Severity of Illness Index
PubMed: 24939377
DOI: 10.3238/arztebl.2014.0377 -
Current Osteoporosis Reports Aug 2021Fracture fixation aims to provide stability and promote healing, but remains challenging in unstable and osteoporotic fractures with increased risk of construct failure... (Review)
Review
PURPOSE OF REVIEW
Fracture fixation aims to provide stability and promote healing, but remains challenging in unstable and osteoporotic fractures with increased risk of construct failure and nonunion. The first part of this article reviews the clinical motivation behind finite element analysis of fracture fixation, its strengths and weaknesses, how models are developed and validated, and how outputs are typically interpreted. The second part reviews recent modeling studies of the femur and proximal humerus, areas with particular relevance to fragility fractures.
RECENT FINDINGS
There is some consensus in the literature around how certain modeling aspects are pragmatically formulated, including bone and implant geometries, meshing, material properties, interactions, and loads and boundary conditions. Studies most often focus on predicted implant stress, bone strain surrounding screws, or interfragmentary displacements. However, most models are not rigorously validated. With refined modeling methods, improved validation efforts, and large-scale systematic analyses, finite element analysis is poised to advance the understanding of fracture fixation failure, enable optimization of implant designs, and improve surgical guidance.
Topics: Female; Femoral Fractures; Finite Element Analysis; Fracture Fixation; Humans; Humeral Fractures; Osteoporotic Fractures
PubMed: 34185266
DOI: 10.1007/s11914-021-00690-y -
BMJ (Clinical Research Ed.) Jul 2014To investigate whether surgery by open reduction and internal fixation provides benefit compared with non-operative treatment for displaced, intra-articular calcaneal... (Comparative Study)
Comparative Study Randomized Controlled Trial
OBJECTIVE
To investigate whether surgery by open reduction and internal fixation provides benefit compared with non-operative treatment for displaced, intra-articular calcaneal fractures.
DESIGN
Pragmatic, multicentre, two arm, parallel group, assessor blinded randomised controlled trial (UK Heel Fracture Trial).
SETTING
22 tertiary referral hospitals, United Kingdom.
PARTICIPANTS
151 patients with acute displaced intra-articular calcaneal fractures randomly allocated to operative (n=73) or non-operative (n=78) treatment.
MAIN OUTCOME MEASURES
The primary outcome measure was patient reported Kerr-Atkins score for pain and function (scale 0-100, 100 being the best possible score) at two years after injury. Secondary outcomes were complications; hindfoot pain and function (American Orthopaedic Foot and Ankle Society score); general health (SF-36); quality of life (EQ-5D); clinical examination; walking speed; and gait symmetry. Analysis was by intention to treat.
RESULTS
95% follow-up was achieved for the primary outcome (69 in operative group and 74 in non-operative group), and a complete set of secondary outcomes were available for 75% of participants. There was no significant difference in the primary outcome (mean Kerr-Atkins score 69.8 in operative group v 65.7 in non-operative group; adjusted 95% confidence interval of difference -7.1 to 7.0) or in any of the secondary outcomes between treatment groups. Complications and reoperations were more common in those who received operative care (estimated odds ratio 7.5, 95% confidence interval 2.0 to 41.8).
CONCLUSIONS
Operative treatment compared with non-operative care showed no symptomatic or functional advantage after two years in patients with typical displaced intra-articular fractures of the calcaneus, and the risk of complications was higher after surgery. Based on these findings, operative treatment by open reduction and internal fixation is not recommended for these fractures.Trial registration Current Controlled Trials ISRCTN37188541.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Calcaneus; Female; Fracture Fixation; Fracture Fixation, Internal; Fractures, Bone; Fractures, Closed; Humans; Intra-Articular Fractures; Male; Middle Aged; Pain, Postoperative; Patient Compliance; Physical Therapy Modalities; Pilot Projects; Range of Motion, Articular; Recovery of Function; Reoperation; Treatment Outcome; Young Adult
PubMed: 25059747
DOI: 10.1136/bmj.g4483 -
JAMA May 2020Humeral shaft fractures traditionally have been treated nonsurgically, but there has been a steady increase in the rate of surgery over the past 2 decades without... (Comparative Study)
Comparative Study Randomized Controlled Trial
IMPORTANCE
Humeral shaft fractures traditionally have been treated nonsurgically, but there has been a steady increase in the rate of surgery over the past 2 decades without high-quality evidence to justify the trend.
OBJECTIVE
To compare the effectiveness of surgical treatment with open reduction and internal plate fixation to nonsurgical treatment with functional bracing in the treatment of closed humeral shaft fractures.
DESIGN, SETTING, AND PARTICIPANTS
Randomized clinical trial conducted at 2 university hospital trauma centers in Finland, enrollment between November 2012 and January 2018 with a final follow-up of January 2019. A total of 82 adult patients with closed, unilateral, displaced humeral shaft fracture met criteria for inclusion. Patients were excluded if they had cognitive disabilities preventing them from following the protocol or had multimorbidity or multiple trauma.
INTERVENTIONS
Patients were randomly assigned to surgical treatment with open reduction and internal plate fixation (n = 38) or to nonsurgical treatment with functional bracing (n = 44).
MAIN OUTCOME AND MEASURE
The primary outcome was Disabilities of Arm, Shoulder and Hand (DASH) score at 12 months (range, 0 to 100 points, 0 denotes no disability and 100 extreme disability; minimal clinically important difference, 10 points).
RESULTS
Among 82 patients who were randomized (mean age, 48.9 years; 38 women [46%]; 44 men [54%]), 78 (95%) completed the trial. Thirteen (30%) of the patients assigned to functional bracing underwent surgery during the 12-month follow-up period to promote healing of the fracture. At 12 months, the mean DASH score was 8.9 (95% CI, 4.2 to 13.6) in the surgery group and 12.0 (95% CI, 7.7 to 16.4) in the bracing group (between-group difference, -3.1 points; 95% CI, -9.6 to 3.3; P = .34). Eleven patients (25%) allocated to functional bracing developed fracture nonunion. Three patients (8%) allocated to surgery developed a temporary radial nerve palsy.
CONCLUSIONS AND RELEVANCE
Among patients with closed humeral shaft fracture, internal fixation surgery, compared with nonoperative functional bracing, did not significantly improve functional outcomes at 12 months. However, the substantial amount of treatment crossover from nonoperative to surgical treatment should be considered when interpreting the trial results.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT01719887.
Topics: Adult; Aged; Aged, 80 and over; Bone Plates; Braces; Closed Fracture Reduction; Disability Evaluation; Female; Fracture Fixation, Internal; Fractures, Ununited; Humans; Humeral Fractures; Male; Middle Aged; Open Fracture Reduction; Recovery of Function
PubMed: 32396179
DOI: 10.1001/jama.2020.3182 -
Turkish Journal of Medical Sciences Nov 2020The success of treatment of bone fracture and defects are based on a proper contact and compression between the bone fracture fragments. Intraoperative manipulations... (Review)
Review
BACKGROUND/AIM
The success of treatment of bone fracture and defects are based on a proper contact and compression between the bone fracture fragments. Intraoperative manipulations such as bone compression or distractions are generally done in order to achieve this. However, none of the bone plates currently in routine use allow these manipulations after fixation to the bone, requiring refixation and repeated drilling, and screwing operations. Based on this shortcoming, we designed a novel adjustable bone plate (ABP) system which allows bone shortening and lengthening even after fixation to the bone surface. The aim of the paper is to clarify the unique properties of the novel bone plate.
MATERIALS AND METHODS
In this paper, the new generation adjustable bone plate applicability, design, indication, and new characteristics in addition to conventional bone plates with review of the literature were discussed and surgical technique was demonstrated in a saw bone model.
RESULTS
This novel design allows for compression and distraction at the fracture ends post fixation as well as bone segment transfers.
CONCLUSIONS
The potential of the new generation ABP plate for use in bone compression, distraction, and the segmental bone transfer is a promising invention for clinical applications in the future.
Topics: Bone Plates; Fracture Fixation, Internal; Fractures, Bone; Humans
PubMed: 32222126
DOI: 10.3906/sag-2002-69 -
PLoS Medicine Jul 2019Although increasingly used, the benefit of surgical treatment of displaced 2-part proximal humerus fractures has not been proven. This trial evaluates the clinical... (Comparative Study)
Comparative Study
BACKGROUND
Although increasingly used, the benefit of surgical treatment of displaced 2-part proximal humerus fractures has not been proven. This trial evaluates the clinical effectiveness of surgery with locking plate compared with non-operative treatment for these fractures.
METHODS AND FINDINGS
The NITEP group conducted a superiority, assessor-blinded, multicenter randomized trial in 6 hospitals in Finland, Estonia, Sweden, and Denmark. Eighty-eight patients aged 60 years or older with displaced (more than 1 cm or 45 degrees) 2-part surgical or anatomical neck proximal humerus fracture were randomly assigned in a 1:1 ratio to undergo either operative treatment with a locking plate or non-operative treatment. The mean age of patients was 72 years in the non-operative group and 73 years in the operative group, with a female sex distribution of 95% and 87%, respectively. Patients were recruited between February 2011 and April 2016. The primary outcome measure was Disabilities of Arm, Shoulder, and Hand (DASH) score at 2-year follow-up. Secondary outcomes included Constant-Murley score, the visual analogue scale for pain, the quality of life questionnaire 15D, EuroQol Group's 5-dimension self-reported questionnaire EQ-5D, the Oxford Shoulder Score, and complications. The mean DASH score (0 best, 100 worst) at 2 years was 18.5 points for the operative treatment group and 17.4 points for the non-operative group (mean difference 1.1 [95% CI -7.8 to 9.4], p = 0.81). At 2 years, there were no statistically or clinically significant between-group differences in any of the outcome measures. All 3 complications resulting in secondary surgery occurred in the operative group. The lack of blinding in patient-reported outcome assessment is a limitation of the study. Our assessor physiotherapists were, however, blinded.
CONCLUSIONS
This trial found no significant difference in clinical outcomes at 2 years between surgery and non-operative treatment in patients 60 years of age or older with displaced 2-part fractures of the proximal humerus. These results suggest that the current practice of performing surgery on the majority of displaced proximal 2-part fractures of the humerus in older adults may not be beneficial.
TRIAL REGISTRATION
ClinicalTrials.gov NCT01246167.
Topics: Aged; Aged, 80 and over; Bone Plates; Europe; Female; Fracture Fixation; Fracture Fixation, Internal; Fracture Healing; Humans; Male; Middle Aged; Orthotic Devices; Pain, Postoperative; Physical Therapy Modalities; Quality of Life; Recovery of Function; Shoulder Fractures; Time Factors; Treatment Outcome
PubMed: 31318863
DOI: 10.1371/journal.pmed.1002855 -
Proceedings of the Institution of... Sep 2022Metal and its alloys have been predominantly used in fracture fixation for centuries, but new materials such as composites and polymers have begun to see clinical use... (Review)
Review
Metal and its alloys have been predominantly used in fracture fixation for centuries, but new materials such as composites and polymers have begun to see clinical use for fracture fixation during the past couple of decades. Along with the emerging of new materials, tribological issues, especially debris, have become a growing concern for fracture fixation plates. This article for the first time systematically reviews the most recent biomechanical research, with a focus on experimental testing, of those plates within ScienceDirect and PubMed databases. Based on the search criteria, a total of 5449 papers were retrieved, which were then further filtered to exclude nonrelevant, duplicate or non-accessible full article papers. In the end, a total of 83 papers were reviewed. In experimental testing plates, screws and simulated bones or cadaver bones are employed to build a fixation construct in order to test the strength and stability of different plate and screw configurations. The test set-up conditions and conclusions are well documented and summarised here, including fracture gap size, types of bones deployed, as well as the applied load, test speed and test ending criteria. However, research on long term plate usage was very limited. It is also discovered that there is very limited experimental research around the tribological behaviour particularly on the debris' generation, collection and characterisation. In addition, there is no identified standard studying debris of fracture fixation plate. Therefore, the authors suggested the generation of a suite of tribological testing standards on fracture fixation plate and screws in the aim to answer key questions around the debris from fracture fixation plate of new materials or new design and ultimately to provide an insight on how to reduce the risks of debris-related osteolysis, inflammation and aseptic loosening.
Topics: Biomechanical Phenomena; Bone Plates; Bone Screws; Cadaver; Fracture Fixation; Fracture Fixation, Internal; Humans; Materials Testing
PubMed: 35920401
DOI: 10.1177/09544119221108540 -
European Journal of Trauma and... Feb 2017
Topics: Aged; Fracture Fixation; Frail Elderly; Humans; Osteoporotic Fractures; Spinal Fractures
PubMed: 28078372
DOI: 10.1007/s00068-016-0752-8 -
Journal of Orthopaedic Trauma Feb 2011The development of far cortical locking (FCL) was motivated by a conundrum: locked plating constructs provide inherently rigid stabilization, yet they should facilitate... (Review)
Review
The development of far cortical locking (FCL) was motivated by a conundrum: locked plating constructs provide inherently rigid stabilization, yet they should facilitate biologic fixation and secondary bone healing that relies on flexible fixation to stimulate callus formation. Recent studies have confirmed that the high stiffness of standard locked plating constructs can suppress interfragmentary motion to a level that is insufficient to reliably promote secondary fracture healing by callus formation. Furthermore, rigid locking screws cause an uneven stress distribution that may lead to stress fracture at the end screw and stress shielding under the plate. This review summarizes four key features of FCL constructs that have been shown to enhance fixation and healing of fractures: flexible fixation, load distribution, progressive stiffening, and parallel interfragmentary motion. Specifically, flexible fixation provided by FCL reduces the stiffness of a locked plating construct by 80% to 88% to actively promote callus proliferation similar to an external fixator. Load is evenly distributed between FCL screws to mitigate stress risers at the end screw. Progressive stiffening occurs by near cortex support of FCL screws and provides additional support under elevated loading. Finally, parallel interfragmentary motion by the S-shaped flexion of FCL screws promotes symmetric callus formation. In combination, these features of FCL constructs have been shown to induce more callus and to yield significantly stronger and more consistent healing compared with standard locked plating constructs. As such, FCL constructs function as true internal fixators by replicating the biomechanical behavior and biologic healing response of external fixators.
Topics: Biomechanical Phenomena; Bone Plates; Bone Screws; Equipment Design; Fracture Fixation, Internal; Humans
PubMed: 21248556
DOI: 10.1097/BOT.0b013e318207885b