Reconstruction of malunited diaphyseal fractures of the forearm

The forearm is a complex anatomical and functional unit with unique osseous, soft tissue and articular relationships. Disruption of these important relations can have a significant impact, leading to pain, instability of the radio-ulnar articulation and reduced range of motion. The gold standard for treating forearm fractures in adults remains anatomic reduction, stable plate fixation and preservation of the surrounding blood supply. Failure to achieve these goals may lead to malunion, requiring reconstructive surgery, which can be technically challenging. In this review, we discuss the essential aspects of anatomy and pathomechanics, clinical and radiological assessment and the state of the art in pre-operative planning and deformity correction surgery

The management of elbow trauma from a historical perspective

The origins of contemporary orthopedics can be traced all the way back to antiquity. Despite the absence of modern imaging techniques, a few bright minds were able to lay the groundwork for understanding these fractures. This historical review will cover the process behind the various treatments for elbow fractures, such as splinting and casting, mobilization, amputation, fracture fixation, arthroplasty, and arthroscopy.</p

Incidence and Functional Outcomes of Scapholunate Diastases Associated Distal Radius Fractures: A 2-year Follow-Up Scapholunate Dissociation

Background: The Scapholunate Interosseous Ligament (SLIL) is the first intrinsic carpal ligament to be injured in wrist trauma, present in up to 64% of the distal radius fractures. However, it remains unclear what patients develop symptoms, making primary treatment of these injuries accompanying distal radius fractures remains questionable. Objective: The aim of this study was to evaluate the functional outcomes of patients with scapholunate diastasis associated with distal radius fractures. Methods: We evaluated 391 patients with a distal radius fracture. Using Computer Tomography (CT) scans the scapholunate interval was measured. We identified 14 patients with an SLD (>3mm) of the injured wrist, which underwent a CT-scan of the contralateral wrist. To evaluate the functional outcomes at a mean follow up of 136±90 weeks, we used the Quick Disabilities of the Arm, Shoulder and Hand (qDASH) Score. Results: There were 8 patients with bilateral SLD and 6 patients with unilateral SLD. Five patients had a qDASH score of 0 and one patient showed a qDASH score of 18.2. The patient with a poor score had bilateral preexisting osteoarthritis of the wrist. No patient had additional surgery of the SLIL. Conclusion: In patients with distal radius fractures, more than half of the 14 patients with an SL gap on CT had widening on the contralateral side. It is therefore worthwhile to image the contralateral wrist before diagnosing a SLD. The patients with unilateral SLD should not be surgically treated at initial presentation because they may have good functional outcomes after a follow up of 2 years

Computer-assisted versus non-computer-assisted preoperative planning of corrective osteotomy for extra-articular distal radius malunions: a randomized controlled trial

<p>Abstract</p> <p>Background</p> <p>Malunion is the most common complication of distal radius fracture. It has previously been demonstrated that there is a correlation between the quality of anatomical correction and overall wrist function. However, surgical correction can be difficult because of the often complex anatomy associated with this condition. Computer assisted surgical planning, combined with patient-specific surgical guides, has the potential to improve pre-operative understanding of patient anatomy as well as intra-operative accuracy. For patients with malunion of the distal radius fracture, this technology could significantly improve clinical outcomes that largely depend on the quality of restoration of normal anatomy. Therefore, the objective of this study is to compare patient outcomes after corrective osteotomy for distal radius malunion with and without preoperative computer-assisted planning and peri-operative patient-specific surgical guides.</p> <p>Methods/Design</p> <p>This study is a multi-center randomized controlled trial of conventional planning versus computer-assisted planning for surgical correction of distal radius malunion. Adult patients with extra-articular malunion of the distal radius will be invited to enroll in our study. After providing informed consent, subjects will be randomized to two groups: one group will receive corrective surgery with conventional preoperative planning, while the other will receive corrective surgery with computer-assisted pre-operative planning and peri-operative patient specific surgical guides. In the computer-assisted planning group, a CT scan of the affected forearm as well as the normal, contralateral forearm will be obtained. The images will be used to construct a 3D anatomical model of the defect and patient-specific surgical guides will be manufactured. Outcome will be measured by DASH and PRWE scores, grip strength, radiographic measurements, and patient satisfaction at 3, 6, and 12 months postoperatively.</p> <p>Discussion</p> <p>Computer-assisted surgical planning, combined with patient-specific surgical guides, is a powerful new technology that has the potential to improve the accuracy and consistency of orthopaedic surgery. To date, the role of this technology in upper extremity surgery has not been adequately investigated, and it is unclear whether its use provides any significant clinical benefit over traditional preoperative imaging protocols. Our study will represent the first randomized controlled trial investigating the use of computer assisted surgery in corrective osteotomy for distal radius malunions.</p> <p>Trial registration</p> <p>NCT01193010</p

Challenges and barriers to improving care of the musculoskeletal patient of the future - a debate article and global perspective

<p>Abstract</p> <p>Background</p> <p>With greater technological developments in the care of musculoskeletal patients, we are entering an era of rapid change in our understanding of the pathophysiology of traumatic injury; assessment and treatment of polytrauma and related disorders; and treatment outcomes. In developed countries, it is very likely that we will have algorithms for the approach to many musculoskeletal disorders as we strive for the best approach with which to evaluate treatment success. This debate article is founded on predictions of future health care needs that are solely based on the subjective inputs and opinions of the world's leading orthopedic surgeons.</p> <p>Hence, it functions more as a forum-based rather than a scientific-based presentation. This exposé was designed to stimulate debate about the emerging patients' needs in the future predicted by leading orthopedic surgeons that provide some hint as to the right direction for orthopedic care and outlines the important topics in this area.</p> <p>Discussion</p> <p>The authors aim to provide a general overview of orthopedic care in a typical developed country setting. However, the regional diversity of the United States and every other industrialized nation should be considered as a cofactor that may vary to some extent from our vision of improved orthopedic and trauma care of the musculoskeletal patient on an interregional level.</p> <p>In this forum, we will define the current and future barriers in developed countries related to musculoskeletal trauma, total joint arthroplasty, patient safety and injuries related to military conflicts, all problems that will only increase as populations age, become more mobile, and deal with political crisis.</p> <p>Summary</p> <p>It is very likely that the future will bring a more biological approach to fracture care with less invasive surgical procedures, flexible implants, and more rapid rehabilitation methods. This international consortium challenges the trauma and implants community to develop outcome registries that are managed through health care offices and to prepare effectively for the many future challenges that lie in store for those who treat musculoskeletal conditions.</p

Operative management of distal radial fractures with 2.4-millimeter locking plates: a multicenter prospective case series

Background: In the past decade, there has been a trend toward open reduction and internal fixation of unstable distal radial fractures. There are now more than thirty different implant designs specific for the fixation of distal radial fractures. A multicenter prospective study of a case series was conducted to determine the efficacy of the operative management of distal radial fractures stabilized with 2.4-mm locking plates.\ud \ud Methods: One hundred and fifty patients were entered into the study over a two-year period. The mean age of these patients was fifty-one years, and the cohort included eighty-eight women and sixty-two men. Eighty-six patients sustained a low-energy injury. Seventy-one percent of the fractures in the series were intra-articular and were Type C according to the Müller-AO Comprehensive Classification. The follow-up evaluations, which were conducted at six weeks, six months, one year, and two years, included assessments of pain, motion, grip strength, and standard radiographs. Gartland and Werley scores were recorded at six months and one and two years, and Disabilities of the Arm, Shoulder and Hand (DASH) scores were recorded at one and two years.\ud \ud Results: One hundred and twenty-five patients (83%) had a complete follow-up at six months; 121 (81%), at one year; and 117 (78%), at two years. Significant improvements in motion, grip strength, and patient satisfaction were observed between six months and one year, but further improvements were not seen at the two-year follow-up examination. The mean DASH score changed from a preinjury baseline of 2 points to 8 points at one year and 7 points at two years (p < 0.0001). The mean Gartland and Werley score improved significantly from 4 points at six months to 2 points at two years. Of the 102 intra-articular fractures examined in the immediate postoperative period, twenty had a step-off of =2 mm and seven had a step-off of >2 mm. Of the seventy-one intra-articular fractures seen at two years, sixty-one had no step-off, five had a step-off of =2 mm, and five had a step-off of >2 mm. Twenty-seven percent of the patients showed an increase of at least one grade in radiographic signs of arthritis at two years. There were twenty-eight complications, twenty of which were considered minor. Tendon inflammation occurred in nine patients. There were two tendon ruptures, one of which was due to a prominent dorsal screw tip placed through a volar plate and one of which was due to a prominent volar plate. Loss of reduction occurred in two patients, and screw loosening occurred in two patients.\ud \ud Conclusion: Internal fixation of displaced distal radial fractures with implants featuring locking screw fixation can result in good-to-excellent outcomes with a limited number of complications