A Prospective study on Functional Outcome of Comminuted Fracture Shaft of Humerus Operated by Minimally Invasive Anterior Plate Osteosynthesis

BACKGROUND: ORIF with plate osteosynthesis has been accepted as the standard technique for fixation of humeral shaft fractures. Certain disadvantages with conventional humeral plating are extensive incision, increased risk of infection, disruption of periosteal blood supply & violation of the fracture site hematoma thereby leading to nonunion. Similarly, Intramedullary nailing has limited use because of post operative shoulder dysfunction due to rotator cuff injury and impingement caused by prominent nail end. MIPO violates these risks. AIM OF THE STUDY: To assess the functional outcome of comminuted fracture shaft of humerus operated by minimally invasive anterior plate osteosynthesis. MATERIALS & METHODS: 15 Patients with comminuted shaft of humerus fracture attending Department of Orthopaedics in Government Rajaji Hospital and Madurai Medical College from Nov 2016 to Oct 2018. RESULTS: 15 patients with mean age of 42.7 years diagnosed to have comminuted diaphyseal humerus fracture were included in this study. Out of 15, 3 cases had reported varus angulation >10 degree, but without functional impairment. 1 case reported posterior angulation. The average union time is 11.9 weeks, ranging from 8-20 weeks. The average CONSTANT MURLEY SCORE for shoulder & MEPS score for elbow was 87 & 97.3. 2 cases of radial nerve palsy were reported. No incidence of infection & non union. CONCLUSION: MIPO offers excellent functional outcome for comminuted shaft of humerus with better union rate compared to ORIF. There is decreased postoperative morbidity and infection rate with early return to function. The operating time and blood loss are less compared to ORIF

Prospective study on the closed interlocking humerus nailing in comminuted and segmental humerus fractures

INTRODUCTION: Fracture shaft of humerus constitutes 3 % of all bony injuries. The uniqueness in the anatomy, the fracture configuration and the functional significance of the region influences the treatment options. The humerus is covered by sleeve of muscles and has rich vascularity which helps in fracture healing. The mobility of the shoulder and the elbow joint accommodates for a minimal degree of angulation and shortening. Moreover the limb does not take part in weight bearing or ambulation; hence some amount of shortening is functionally acceptable. But rotational deformity is not tolerated well. Open reduction and internal fixation with plate osteosynthesis has been gold standard for treatment of fractures of the humeral diaphysis. Intramedullary fixation devices have been used very effectively in the treatment of lower limb fractures. Interlocking nailing done with closed reduction has definite advantages over plate osteosynthesis in indicated cases. AIM: To analyse the outcome of closed interlocking Humerus nailing in comminuted and segmental Humerus fractures. MATERIALS AND METHODS: Our study was conducted in the Institute of Orthopaedics and Traumatology, Madras Medical College from August 2007 to September 2009. It is a case series of 23 diaphyseal fractures in 22 patients. One patient died in the postoperative period and two patient was lost in the follow up so were excluded from the study. Selection Criteria - 1. Comminuted fractures, 2. Segmental fractures, 3. Polytrauma, 4. Age more than 17 years when the physis is fused, 5. The fracture line is 3 cms beyond the surgical neck and 4 cms from the olecranon fossa, 6. compound fractures. Exclusion Criteria - 1. Presence of open physis, 2. Grossly contaminated compound fractures, 3. Fractures involving the proximal 3 cms and the distal 4 cms of the diaphysis. RESULTS: The results of the use of intramedullary interlocking nailing for the diaphyseal fractures of the humerus has been mixed, with some studies showing good outcome and some showing not so good outcome. In most studies a significant percentage of patients do not return for follow up once the limb is functional and painless40. Non union and functional disability of the shoulder are the most common complaints in most patients postoperatively in many series. Post operative mobilization of the shoulder and elbow was very critical in attaining the amount of movements of the shoulder. Patients who adhered to the mobilization programme had a better functional result compared to others. CONCLUSION: Locked intramedullary nailing is a novel treatment option for diaphyseal fractures of the humerus. It is ideal in treating diaphyseal fractures of the humerus in patients with osteoporosis and polytrauma where reduction in operating time and early rehabilitation are primary objective. It also useful in comminuted and segmental humeral fractures wherein done by closed method, the periosteum is not stripped and the fracture haematoma not violated leading to better and faster fracture healing. The concept of biological fixation in terms of unreamed nailing, closed reduction, static locking and fracture site compression promotes early and adequate fracture union. Locked intramedullary nailing is an alternative in treating patients with pathological fractures of humerus. Locked humeral intramedullary nailing is an effective and safe alternative for the treatment of diaphyseal humeral fractures. It is suitable for treatment in patients with comminuted, segmental, polytrauma, osteoporosis and pathological fractures. It provides early rehabilitation and lessens morbidity

Nonunion of the clavicle: novel use of clinical recovery and ultrasound to improve our ability to predict fracture healing

The aim of this thesis was to progress our understanding of clavicle nonunion and the ability to accurately predict fracture healing in order to improve the current management of these injuries. Although only one in seven fractures go onto nonunion, these are challenging to predict. It is unclear if the recent widespread increase in the use of acute plate fixation for displaced fractures is justified on current evidence. It is unknown whether the early accurate prediction of fractures at high risk of nonunion is advantageous. Currently the perceived risk of nonunion is largely based on factors available at time of injury alone. The evaluation of clinical recovery following non-operative management and the novel use of ultrasound may advance our ability to accurately predict fracture healing for these injuries. The cost-effectiveness of acute clavicle plate fixation versus non-operative treatment was estimated from randomized controlled trial data that had been previously published. This was completed prior to the start of this thesis and the author was not involved in the original trial. A large retrospective review of clavicle fracture fixations was undertaken to determine whether delayed clavicle fixation has an increased risk of complications compared to acute operative management. A prospective study of displaced midshaft fractures was carried out over a two-year period to determine the influence of functional recovery on the ability to predict fracture healing. The influence of clavicle fracture management on the early functional recovery was evaluated with data from a randomized controlled trial and second prospective cohort. Finally, the novel use of ultrasound to detect early callus formation and determine whether this allows accurate prediction of fracture healing was evaluated for a cohort of clavicle and tibia fractures. The estimated cost per quality-of-life adjusted year of acute plate fixation over non-operative treatment is £480,309.41/QALY. For a threshold of £20,000/QALY the benefit of acute fixation would need to be present for 24 years to be cost-effective over conservative treatment. Linear regression analysis identified nonunion as the only factor to negatively influence the SF-6D at 12-months (p<0.001). A ten-year cohort of 259 clavicle plate fixations found failed primary surgery requiring revision fixation occurred in 7.7% of all patients. Smoking (p<0.001), presence of a post-operative infection (<0.001), increasing age (p=0.018), and greater time delay from injury to surgery (p=0.015) was identified as significant independent predictors on regression analysis. Receiver operating curve analysis (ROC) revealed that surgery beyond 96 days from injury has an increased rate of major complications and revision surgery. Using a matched case cohort of cases before (n=67) and after the ‘safe window’ (n=77), the risk of post-operative infection increased (Odds ratio (OR) 7.7, p=0.028), fixation failure (OR 3.8, p=0.017) and revision surgery (OR 4.8 p=0.004). A delay to operative fixation beyond 3 months following injury would appear to be associated with an increased risk of major operative complications and revision surgery. A large prospective cohort of 200 patients managed non-operatively with a displaced midshaft clavicle fracture were recruited. Regression modelling found a QuickDASH ≥40 (p=0.001), no callus on radiograph (p=0.004) and fracture movement on examination (p=0.001) were significant predictors of nonunion. If none were present the predicted nonunion risk was 3%, found in 40% of the cohort. Conversely if two or more of the predictors were present, found in 23.5% of the cohort, the predicted nonunion risk was 60%. The delayed assessment nonunion model appeared to have superior accuracy when compared to the estimation of nonunion at time of injury alone healing on ROC curve analysis (Area Under Curve analysis; 87.3% vs 64.8% respectively). Data from a randomized controlled trial was used to compare 86 patients who underwent operative fixation against 76 patients that united with non-operative treatment. The recovery of normal shoulder function, as defined by a DASH score within the predicted 95% confidence interval for each respective patient was similar between each group at six-weeks (operative 26.7% vs non-operative 25.0%, p=0.80), three-months (52.3% vs 44.2%, p=0.77) and six-months post-injury (86.0% vs 90.8%, p=0.35). The mean DASH score and return to work was also comparable at each time point. Regression analysis found no specific patient, injury or fracture predictor was associated with an early return of function following non-operative management at six or twelve weeks. From a pilot study of twenty clavicle fractures, six-week sonographic bridging callus appeared to be the most accurate, and repeatable, predictor of fracture healing with a strong agreement on intra class correlation (ICC) between four reviewers (ICC 0.82, 95% confidence interval 0.68-0.91). In a large prospective study of 112 patients, sonographic bridging callus was detected in 62.5% (n=70/112) of the cohort at six weeks post-injury. If present, union occurred in 98.6% of the fractures (n=69/70). If absent, nonunion developed in 40.5% of cases (n=17/42). The sensitivity to predict union with sonographic bridging callus at six weeks was 73.4% and the specificity was 94.4%. Three-dimensional fracture reconstruction can be created using multiple ultrasound images in order to evaluate the presence of bridging callus. This imaging modality has the potential to enhance the usability and accuracy of identification of fracture healing at an early stage following injury. Nonunion following a displaced midshaft clavicle fractures accounts for the majority of poor functional recovery and impaired quality of life over the first-year post-injury. Prediction of clavicle fracture healing at six weeks following injury maybe a safe and effective strategy to identify patients at greatest risk of nonunion. The use of functional recovery enables a more accurate estimation of nonunion risk compared to conventional prediction at time of injury alone. The use of ultrasound may further refine our ability to predict fracture healing

Clavicle Injuries : Treatment of midshaft clavicle fractures and acromioclavicular joint dislocations in adults

Traditionally, clavicle fractures and acromioclavicular (AC) joint dislocations have been treated nonoperatively. However, recent studies have shown that surgical treatment may diminish nonunion and sequels. Although articles discussing clavicle fractures and AC joint dislocations are abundant, the quality of evidence is still poor. To assess the various treatment modalities for clavicle fractures we performed an electronic database search of the literature from 1966 until the end of March 2011. The aim was to find potential high-quality comparative studies discussing acute clavicle fractures in adults. We conducted a randomized controlled trial comparing sling to plate fixation for completely displaced midshaft clavicle fractures to assess functional and radiological results after 1-year follow-up. Long-term results of surgery for acute and chronic AC joint dislocation were surveyed retrospectively. From electronic databases came 1072 abstracts discussing clavicle fractures. After exclusion, 230 reports remained, from which we assessed 13 for review. Midshaft fractures were discussed in 12 studies, lateral fractures in 1 study, but none concerned medial fractures. Evidence was mainly low or very low. Due to the lack of high-quality evidence, no conclusions can be drawn as to the best treatment for medial or lateral third fractures. Regarding midshaft fractures, it appears that after short-term follow-up, surgery leads to better function and less disability than does nonoperative treatment; benefits of surgery are small after 6 months; union is better secured with surgery; and nonoperative treatment usually leads to adequate function, pain relief, and union rates. Of the 60 randomized patients in our study, 28 came to an operative group, and 32 to a nonoperative group. At 1-year follow-up, we found no difference between these groups in function, in disability, or in pain. All fractures in the operative group healed. Nonoperative treatment was related to high nonunion rate (24%). Fracture displacement was associated with nonunion. After a mean 18-year follow-up, we found no difference in function or disability between the injured and uninjured shoulders in patients who had surgery for acute AC joint dislocation. Lateral clavicle osteolysis seemed to be related to constant AC joint dislocation. After a mean 4-year follow-up, patients who had undergone surgery for chronic AC joint dislocation with tendon grafts had moderately functional results. In almost half the patients, the AC joint remained unstable. Lateral clavicle osteolysis (56%) and tunnel widening (80%) were common. Thus, in chronic AC-joint dislocation, surgery may not necessarily restore shoulder function.Solisluun murtumia ja olkalisäke-solisluu nivelen (AC-nivel) vammoja on perinteisesti hoidettu konservatiivisesti eli ilman leikkausta. Viime vuosina julkaistut tutkimukset ovat osoittaneet, että leikkaushoito näyttäisi vähentävän luutumattomuuden ja jäännösoireiden ilmaantuvuutta. Vaikka solisluun vammoja käsitteleviä artikkeleja on julkaistu runsaasti, on aiheeseen liittyvä tutkimusnäyttö kuitenkin vielä laadultaan heikkoa. Tässä tutkimuksessa selvitettiin järjestelmällisen kirjallisuuskatsauksen avulla äkillisen solisluumurtuman konservatiivisen hoidon ja leikkaushoidon tuloksia, selvitettiin satunnaistetun vertailevan tutkimuksen avulla äkillisen solisluun keskiosan murtuman konservatiivisen ja leikkaushoidon tuloksia, arvioitiin äkillisen AC-nivelen sijoiltaanmenon leikkaushoidon pitkäaikaistuloksia ja arvioitiin pitkäaikaisen, jännesiirteellä korjatun AC-nivelen sijoiltaanmenon leikkaushoidon tuloksia. Aikavälillä 1.1.1966 31.3.2011 lääketieteellisistä tietokannoista löytyi 1072 tiivistelmää koskien solisluun murtumia. Aineiston käsittelyn jälkeen lopulliseen tutkimukseen sisältyi 6 satunnaistettua vertailevaa tutkimusta ja 7 ei-satunnaistettua vertailevaa tutkimusta. Näistä 12 käsitteli solisluun keskiosan ja 1 ulko-osan murtumia. Kirjallisuuden perusteella vaikuttaa siltä, että solisluun keskiosan murtumassa olkanivelen toiminta palautuu nopeammin leikkaushoidolla kuin konservatiivisella hoidolla ja että murtuman luutuminen on selkeästi parempi leikkaushoidolla. Toisaalta, myös konservatiivisella hoidolla näyttäisi olevan saavutettavissa riittävä olkanivelen toimintakyky ja kivunlievitys. Solisluun sisä- ja ulko-osan murtumien parhaasta hoitomenettelystä ei voi näytön puuttuessa tehdä johtopäätöksiä. Vertailevaan tutkimukseen satunnaistettiin 60 solisluun keskiosan murtumapotilasta, joista 28 hoidettiin leikkauksella ja 32 konservatiivisesti. Vuoden seuranta-aikana ei havaittu eroa ryhmien välillä olkanivelen ja yläraajan toiminnassa tai suorituskyvyssä eikä kivun määrässä. Kaikki leikkauksella hoidetut murtumat luutuivat. Konservatiivisen hoidon ryhmässä murtuma jäi luutumatta 24 % potilaista. Murtuman siirtymän määrä vaikutti olevan yhteydessä luutumattomuuden riskiin. Tuoreen AC-nivelen sijoiltaanmenon leikkaushoidon pitkäaikaistulokset ovat erinomaisia 18 vuoden seuranta-aikana. Olkanivelen toimintakyvyssä ei ollut havaittavissa eroa terveeseen puoleen verrattuna. Pitkäaikaisen, viiveellä leikatun AC-nivelen sijoiltaanmenon leikkaustulokset ovat sen sijaan keskinkertaisia. Leikkauksesta huolimatta melkein puolella potilasta AC-nivel jäi epävakaaksi. Olkanivelen toimintakyky näytti jäävän heikommaksi terveeseen puoleen verrattuna 4 vuoden seuranta-aikana. Pitkäaikaisen AC-nivelen sijoiltaanmenon korjausleikkaus on vaativa ja siihen liittyi melko paljon komplikaatiota, joista yleisimpiä olivat solisluun ulko-osan luun liukeneminen (56 %) ja solisluussa olevien porakanavien laajentuminen (80 %)

Neurovascular structures at risk from proximal locking of retrograde femoral nails

The Richards retrograde femoral nail (Smith and Nephew 1997) is inserted into the medullary canal of the femur via an entry point in the intercondylar fossa, just anterior the anterior cruciate ligament. This particular implant requires insertion of both proximal and distal interlocking screws for maximal axial and rotational stability. The distal screws are inserted lateral to medial in a relatively safe area of the lower thigh using an external guide. The proximal locking screws by contrast are inserted 'freehand' at the level of the lesser trochanter in an anteroposterior direction using X-Ray control. The proximal thigh contains many vital neurovascular structures and it is the proximity of the femoral nerves and vessels which is of significant concern due to the relative inaccuracy of the freehand technique (Riina et al 1998). Hypothesis This led me to my first null hypothesis that 'proximal anteroposterior locking screws of retrograde femoral nails can be inserted in the proximal end of the femur through the proximal thigh without damage to the nerves and vessels'. To test this hypothesis we proposed to: 1). Dissect the main nerves and vessels of the thigh and describe their position and relation to the lesser trochanter. 2). Place investigative drill holes in a modified anatomical procedure to imitate insertion of the proximal anteroposterior locking screws. 3). Dissect the proximal thigh to determine whether important anatomical structures are at risk of being damaged by the proximal anteroposterior locking screws. The preliminary results of this first investigation lead to a second null hypothesis:- That the nerves and vessels of the upper thigh are at risk from proximal locking screws inserted in a lateral to medial direction in the upper thigh. To test this hypothesis we propose to; 4). Plan dissections to compare lateral to medial locking with anteroposterior locking, for use with a redesigned nail. 5). Finally we proposed a modified clinical trial of the redesigned nail. This would involve attaching the redesigned nail to the side of a volunteer's thigh and taking X-Rays in theatre to determine whether the redesigned nail could be adequately screened to allow its use in practice

Biomechanical analysis of femoral fracture fixation using the expert adolescent lateral femoral nail system

Femoral fracture in adolescents is a severe injury. Recent studies of intramedullary nail fixation with rigid titanium alloy helical nail viz. Expert adolescent lateral femoral nail (ALFN) have reported good results. However, there is no in vitro biomechanical data available on this nail in the literature. Experimental testing and finite element analysis (FEA) were used to establish the stiffness parameters of small composite femurs with simulated fractures stabilised using ALFN. In comparison to intact femur, construct stiffness ranged from maximum (114%) to minimum (20%) for healed fracture and segmental fracture, respectively. Simulation testing in SolidWorksTM was performed with validated FEA model to evaluate the effect of clinical and implant factors. Maximum predicted stress in the distal interlocking screw remained in an acceptable range (160.25 - 188.51 MPa) irrespective of the level of femoral shaft fracture with a relative decrease in stress values as the fracture callus healed over a 16 week period. The relative angle between the ALFN and proximal interlocking screw and implant material were two significant factors influencing stress at the interlocking screw and nail interface. In conclusion, a rigid helical titanium alloy femoral intramedullary nail can perform satisfactorily under physiological loading conditions experienced in the perioperative period

3D Innovations in Personalized Surgery

Current practice involves the use of 3D surgical planning and patient-specific solutions in multiple surgical areas of expertise. Patient-specific solutions have been endorsed for several years in numerous publications due to their associated benefits around accuracy, safety, and predictability of surgical outcome. The basis of 3D surgical planning is the use of high-quality medical images (e.g., CT, MRI, or PET-scans). The translation from 3D digital planning toward surgical applications was developed hand in hand with a rise in 3D printing applications of multiple biocompatible materials. These technical aspects of medical care require engineers’ or technical physicians’ expertise for optimal safe and effective implementation in daily clinical routines.The aim and scope of this Special Issue is high-tech solutions in personalized surgery, based on 3D technology and, more specifically, bone-related surgery. Full-papers or highly innovative technical notes or (systematic) reviews that relate to innovative personalized surgery are invited. This can include optimization of imaging for 3D VSP, optimization of 3D VSP workflow and its translation toward the surgical procedure, or optimization of personalized implants or devices in relation to bone surgery

Pain Management

Pain Management - Current Issues and Opinions is written by international experts who cover a number of topics about current pain management problems, and gives the reader a glimpse into the future of pain treatment. Several chapters report original research, while others summarize clinical information with specific treatment options. The international mix of authors reflects the "casting of a broad net" to recruit authors on the cutting edge of their area of interest. Pain Management - Current Issues and Opinions is a must read for the up-to-date pain clinician