Metaphyseal tibial level (MTL) screws: a modified percutaneous technique for lateral plateau depression fractures

Introduction: Lateral tibial plateau fractures are more frequent than medial fractures, and those with articular depression are particularly challenging because of high displacement risk. To prevent secondary subsidence, the gold standard is raft screws with a periarticular or anti-glide plate. Graft is used to fill the metaphyseal defect created by reduction in the depressed fragment. We present a case of Schatzker II fracture managed in a complete percutaneous fashion, with a new combined technique of raft screws and interference screw used as a support. Case report: A 51-year-old female sustained a Schatzker II tibial plateau fracture. Based on pre-operative CT, direction of reduction force to apply was drawn on coronal and sagittal cuts. Operative technique: Under fluoroscopic control, the split component of the fracture was reduced. The cortical window was then drilled in the lateral cortex, and a K wire advanced under the depressed fragment under fluoroscopic guidance. After fragment reduction with a bone impacter, internal fixation was completed by percutaneous introduction of two subchondral cortical screws. A bioabsorbable interference screw was then introduced in the impacter tunnel to support impacted bone under the reduced articular surface. Finally, a cortical screw was introduced, from anterior to posterior to prevent screw cut-out. Conclusion: The combination of subchondral screws in a jail technique with a bioabsorbable interference screw that we named metaphyseal tibia level (MTL) screw technique is, to our knowledge, not described. The MTL screw promises to be a true percutaneous reduction and fixation technique for Schatzker II and III fractures in patients with reasonable bone quality

Are clinical outcomes affected by type of plate used for management of mid-shaft clavicle fractures?

Abstract Background Open reduction and internal fixation (ORIF) using plate osteosynthesis for midshaft clavicle fractures is often complicated by the prominence of the implant due to the subcutaneous position of the clavicle. Reoperation rates for symptomatic clavicle plate removal have been reported to be as high as 53%. We sought to determine to which degree do clinical outcomes (all cause reoperation rate and rate of fracture union) differ between types of clavicle plates. Materials and methods A retrospective chart review was performed using our hospital database for patients treated with ORIF for mid-shaft clavicle fractures (OTA/AO type 15-B). Implants included in this review were 2.7 mm reconstruction plates, 3.5 mm reconstruction plates, 3.5 mm precontoured clavicle plates and 3.5 mm locking compression plates. The primary outcome measure was the all cause reoperation rate. Secondary outcomes compared the rate fracture union, documented infection, hardware failures and clinical symptoms at the surgical site among the various plate types. Data was collected and descriptive statistics were analyzed. p values < 0.05 were considered statistically significant. Results A total of 102 midshaft clavicle fractures treated with ORIF were included in this study. The majority of patients were ≤ 50 years old (83.3%) and male (72.5%). The overall union rate for all plating constructs was 97.1%. We found that age, sex and smoking were not associated with the rate of re-operation. In addition, the fracture classification, type of implant used and number of screws used didn’t increase the risk of revision surgery. In addition, more than 50% of patients complaining of pain at 6 weeks post-operatively required a second surgery for removal of hardware. Moreover, there was no association between age, sex, smoking, fracture classification or plate type and the rate of union. Interestingly, clavicle fractures fixed with 3.5 mm reconstruction plates were more likely to have hardware failure due to plastic deformation, whereas 2.7 mm plates were more likely to fail by plate breakage. Conclusion Although different types of implants have different biomechanical properties, no difference in reoperation, union and plate removal rates were found between the various plate types. Future studies with a larger sample size are required to further examine these outcomes. Level of evidence Level III

Harvesting local cylinder autograft from adjacent vertebral body for anterior lumbar interbody fusion: surgical technique, operative feasibility and preliminary clinical results

Autogenous iliac crest has long served as the gold standard for anterior lumbar arthrodesis although added morbidity results from the bone graft harvest. Therefore, femoral ring allograft, or cages, have been used to decrease the morbidity of iliac crest bone harvesting. More recently, an experimental study in the animal showed that harvesting local bone from the anterior vertebral body and replacing the void by a radio-opaque β-tricalcium phosphate plug was a valid concept. However, such a concept precludes theoretically the use of posterior pedicle screw fixation. At one institution a consecutive series of 21 patients underwent single- or multiple-level circumferential lumbar fusion with anterior cages and posterior pedicle screws. All cages were filled with cancellous bone harvested from the adjacent vertebral body, and the vertebral body defect was filled with a β-tricalcium phosphate plug. The indications for surgery were failed conservative treatment of a lumbar degenerative disc disease or spondylolisthesis. The purpose of this study, therefore, was to report on the surgical technique, operative feasibility, safety, benefits, and drawbacks of this technique with our primary clinical experience. An independent researcher reviewed all data that had been collected prospectively from the onset of the study. The average age of the patients was 39.9 (26–57) years. Bone grafts were successfully harvested from 28 vertebral bodies in all but one patient whose anterior procedure was aborted due to difficulty in freeing the left common iliac vein. This case was converted to a transforaminal interbody fusion (TLIF). There was no major vascular injury. Blood loss of the anterior procedure averaged 250 ml (50–350 ml). One tricalcium phosphate bone plug was broken during its insertion, and one endplate was broken because of wrong surgical technique, which did not affect the final outcome. One patient had a right lumbar plexopathy that was not related to this special technique. There was no retrograde ejaculation, infection or pseudoarthrosis. One patient experienced a deep venous thrombosis. At the last follow up (mean 28 months) all patients had a solid lumbar spine fusion. At the 6-month follow up, the pain as assessed on the visual analog scale (VAS) decreased from 6.9 to 4.5 (33% decrease), and the Oswestry disability index (ODI) reduced from 48.0 to 31.7 with a 34% reduction. However, at 2 years follow up there was a trend for increase in the ODI (35) and VAS (5). The data in this study suggest that harvesting a cylinder of autograft from the adjacent vertebral body is safe and efficient. Filling of the void defect with a β-tricalcium phosphate plug does not preclude the use of posterior pedicle screw stabilization