The treatment of severely comminuted intra-articular fractures of the distal radius

Comminuted fractures of the distal end of the radius are caused by high-energy trauma and present as shear and impacted fractures of the articular surface of the distal radius with displacement of the fragments. The force of the impact and the position of the hand and carpal bone determine the pattern of articular fragmentation and their displacement and the amount and the extent of frequent concommitant ligament and carpal bone injury. The result of the osseous lesion in comminuted fractures was termed "pilon radiale", which emphasizes the amount of damage to the distal radius and the difficulties to be expected in restoring the articular congruity. Besides this the additional injury, either strain of disruption of the ligaments and the displacement of the carpus and/ or the triangular fibrocartilage complex will equally influence the functional outcome. This review will expand on the relevant anatomy, correct classification and diagnosis of the fracture, diagnostic tools and operative treatment options. Current treatment concepts are analysed with regard to actual literature using the tools of evidence based medicine criteria. A new classification of severely comminuted distal radius fractures is proposed using CT data of 250 complex intraarticular radius fractures. Finally a standardized treatment protocol using external fixation in combination with minimal invasive internal osteosynthesis is described

Computer-assisted pre-operative automatic segmentation and registration tool for malunited radius osteotomy: A proof-of-concept study

Corrective osteotomy is a standard treatment for distal radius fractures in malunited radius cases. In order to increase the efficiency of the osteotomy pre-operative plan, in this study, a proof-of-concept framework of automatic computer-assisted segmentation and registration tool was developed for the purpose of malunited radius osteotomy pre-operative planning. The program consisted of the functions of segmentation, virtual cutting, automatic alignment and registration. One computed tomography (CT) scanning dataset of a patient's bilateral forearm was employed as an illustration example in this study. Three templates of 3D models including the healthy radius, and the pre- and post-correction injured radius were output as STL geometries for pre-operative plan purposes

Translational Models for Advancement of Regenerative Medicine and Tissue Engineering

At the root of each regenerative medicine or tissue engineering breakthrough is a simple goal, to improve quality of healing, thus improving a patient’s quality of life. Each tissue presents its own complexities and limitations to healing, whether it is the scarring nature of tendon healing or the mechanical complexity driving bone regeneration. Preclinical, translational models aim to reflect these complexities and limitations, allowing for effective development and refinement of tissue engineered therapeutics for human use. The following body of work explores several of these translational models, both utilizing them for tissue regenerative therapy development and evaluating the benefits and complications incurred with each model. This work begins with a discussion of the complexity of bone healing and how dysfunction in the mechanical, surgical, and systemic fracture environment can lead to delayed healing and nonunion. A comprehensive review of the advances in preventative and corrective therapeutics for bone nonunion is included next, with specific focuses on mechanical and tissue-engineered technology. Then, this work presents a tissue-engineered application of mesenchymal stem cells in acute tendon injury, highlighting experimentation in cell fate direction in vitro and intralesional mesenchymal stem cell implantation in vivo. Next, this work presents a series of experiments that evaluated and refined a commonly utilized preclinical model of delayed bone healing, the caprine segmental tibial defect stabilized using single locking plate fixation. First, the biomechanical stability of the model was evaluated in vivo using plantar-pressure analysis of gait. Then, the surgical technique was refined through a retrospective analysis of the effects of plate length and position on fixation stability in vitro and in vivo. Finally, the comorbidities of this preclinical model were explored via an analysis of the effect of long-term tibial locking plate fixation on cortical dimensions and density

A new volar plate made of carbon-fiber-reinforced polyetheretherketon for distal radius fracture: analysis of 40 cases

BACKGROUND: Implants based on the polyetheretherketon (PEEK) polymer have been developed in the last decade as an alternative to conventional metallic devices. PEEK devices may provide several advantages over the use of conventional orthopedic materials, including the lack of metal allergies, radiolucency, low artifacts on magnetic resonance imaging scans and the possibility of tailoring mechanical properties. The purpose of this study was to evaluate the clinical results at 12-month follow-up using a new plate made of carbon-fiber-reinforced polyetheretherketon for the treatment of distal radius fractures. MATERIALS AND METHODS: We included 40 consecutive fractures of AO types B and C that remained displaced after an initial attempt at reduction. The fractures were classified according to the AO classification: 21 fractures were type C1, 9 were type C2, 2 were type C3, 2 were type B1 and 6 were type B2. RESULTS: At a 12-month follow-up no cases of hardware breakage or loss of the surgically achieved fracture reduction were documented. All fractures healed, and radiographic union was observed at an average of 6 weeks. The final Disabilities of Arm, Shoulder and Hand score was 6.0 points. The average grip strength, expressed as a percentage of the contralateral limb, was 92 %. Hardware removal was performed only in one case, for the occurrence of extensor tenosynovitis. CONCLUSION: At early follow-up this device showed good clinical results and allowed maintenance of reduction in complex, AO fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV

Are suprapectineal quadrilateral surface buttressing plates performances superior to traditional fixation? A finite element analysis

Acetabular fractures have a high impact on patient’s quality of life, and because acetabular fractures are high energy injuries, they often co-occur with other pathologies such as damage to cartilage that could increase related morbidity; thus, it appears of primary importance developing reliable treatments for this disease. This work aims at the evaluation of the biomechanical performances of non-conservative treatments of acetabular fractures through a finite element approach. Two pelvic plates models (the standard suprapectineal plate—SPP, and a suprapectineal quadrilateral surface buttressing plate—SQBP) were analyzed when implanted on transverse or T-shaped fractures. The plates geometries were adapted to the specific hemipelvis, mimicking the bending action that the surgeon performs on the plate intraoperatively. Implemented models were tested in a single leg stance condition. The obtained results show that using the SQBP plate in transverse and T-shaped acetabular fractures generates lower bone stress if compared to the SPP plate. Interfragmentary movement analysis shows that the SQBP plate guarantees greater stability in transverse fractures. In conclusion, the SQBP plate seems worthy of further clinical analysis, having resulted as a promising option in the treatment of transverse and T-shaped acetabular fractures, able to reduce bone stress values and to get performances comparable, and in some cases superior, to traditional fixation

Locking Compression Plating for Osteoporotic and Peri-Articular Fractures: A Short Term Outcome Analysis

INTRODUCTION: Peri-articular and osteoporotic fractures of long bones are becoming more common and are very challenging injuries to treat even for a veteran orthopaedician. Peri-articular fractures occur in two different age groups -due to different types of injuries. In young patients peri-articular fractures occur due to high velocity injury such as road traffic accidents, fire arm injuries and sport’s injuries while in elderly patients with osteoporosis it occurs usually due to low velocity injury like fall during walking. Also these conditions do result from fractures in the young treated by conservative methods and which in the long term end up in non-unions and further more these conditions are compounded by disuse osteoporosis. Because of the proximity of peri-articular fractures to the corresponding joints, regaining full motion and function may be difficult. Also achieving full union rates are increasingly difficult because of the lack of availability of good bone stock which is very common in periarticular fractures because of the cancellous nature of the metaphyseal fragment. The incidences of malunion, nonunion, and infection are relatively high in many reported series. In older patients, treatment may be complicated by coexisting osteoporosis. AIM: The aim of the study is to analyze the short term results in terms of union and functional outcome for osteoporotic and periarticular fractures treated with locking compression plating. MATERIALS AND METHODS: This is a study conducted in the Department of Orthopaedics, Madras Medical College, Government General Hospital, Chennai. This study is a prospective study Conducted in the Department of Orthopaedics from September 2007 to September 2009 with a sample size of 21 cases. Patients were randomly selected from among the admissions to the Orthopaedic ward in the Department of Orthopaedics, Government General Hospital, Chennai and recruited into the study prospectively based on the following criteria: Inclusion criteria - 1. Age more than 16 years. 2. Osteoporotic bones either disuse or pathological bones. 3. Fractures occurring at or near joints namely distal femur, proximal humerus, distal radius, distal tibia, proximal tibia. 4. Osteoporotic non-unions. 5. Patients who consents to be included in the study. Exclusion criteria - 1. Exclusion criteria were skeletal immaturity 2. Patients with tumourous conditions. 3. Severe articular comminution not possible to be reconstructed with internal fixation. 4. Undisplaced fracture patterns needing only conservative management. 5. Patients not willing for internal fixation. RESULTS: There were a total of 3 complications in two patients, two were infections( one case of superficial and one case of deep infection) the infection rate which was 0.01% and is similar to other reported series [11,14].They were treated with thorough wound debridement and i.v antibiotics for six weeks which soon resolved. There was one case of non-union which was due to the infection. Solid union was observed in 21 out of the 24 cases ( 88 %) which are similar to other studies[4,5,8,11,14]. The range of movements attained at an average follow-up of 15.5 months was 87 % of which 17 had excellent results, 4 had good outcome, 2 had fair outcome and 1 case had poor functional results according to the respective scoring systems like DASH, Harris hip score and HSS (Hospital Severity Score) knee score. CONCLUSION: This study highlights the role of locking compression plating in complex osteoporotic and peri-articular fractures in which conventional dynamic compression plates and reconstruction plates would fail prematurely. The correct application of locking compression plates requires a long learning curve and spurious use will negate the advantages of the locking plates. The results of our study have confirmed earlier reports that locking compression plates provide better fixation in osteoporotic fractures. The chances of implant failure are less as the screws are firmly position inside the bone. Also since these plates are limited contact plates there is less contact between plate and the bone and hence there is minimal disruption of sub-periosteal blood supply to the fracture ends and this aids in fracture union. The locked nuts prevent further tightening of the screws and hence reduction is maintained and secondary angular deformities are prevented

A closer look at fracture healing:fracture healing at the distal assessed using high-resolution peripheral quantitative computed tomography

Radial bone fractures in the wrist are one of the most common types of fractures. Post-menopausal women are particularly susceptible to these types of fractures. More research is needed to treat fractures like these. Standard X-rays do not provide a complete picture of the healing process. This dissertation is the first to demonstrate that changes in bone density, bone structure and bone strength during fracture healing can be carefully assessed using high-resolution quantitative CT scans. This is important for further research on improving treatment for wrist fractures; for example, research on the effects of anti-osteoporosis medication in the fracture healing process

ITAP: Clinical outcomes and implant design optimisation using numerical modelling

Redistribution of the flow of forces through the body, such as that after amputation and/or implantation of a skeletally anchored amputation prostheses, leads to bone remodelling. Periprosthetic bone resorption can destabilise skeletally anchored amputation prostheses. Therefore, implants that minimise bone resorption will achieve a more successful long term bone fixation. Bone remodelling outcome measures rely on implant design using mechanoregulatory bone remodelling theory. Mechanoregulation is implemented by functions that link a local mechanical stimulus to a local change in the structure or properties of bone material. This thesis uses the strain adaptive remodelling theory at the time of implantation with periprosthetic strain energy density as the outcome parameter. Clinical trial data was collected from a patient with a skeletally anchored amputation prostheses; The Intraosseous Transcutaneous Amputation Prosthesis (ITAP). The clinical trial ran from 2008 – 2019, the data was investigated for patterns between implant design and fixation success. This thesis reports trends in fixation success and bone change using a developed fixation success score. There was an ideal implant length to bone length ratio range and a straight, tapered stem with a flared bone collar growth shape were beneficial to fixation success. Conversely, one or more parameters associated with pressfit fixation were detrimental to fixation success. Results between the clinical and numerical data compared favourably; clinically, regions of periprosthetic bone growth were also observed by regions of high strain energy density in the finite element analysis and vice versa at the implant tip and osteotomy face. This thesis provides skeletally anchored amputation prostheses design guidelines that will minimise bone resorption when measured with strain energy density. Moreover, that future skeletally anchored amputation prostheses parameterised design can and should be used as a tool to assess bone fixation outcome in pre-clinical assessments