191 research outputs found
Unique stability of femoral neck fractures treated with the novel biplane double-supported screw fixation method: A biomechanical cadaver study
AbstractOsteosynthesis of femoral neck fractures is related to 20â46% complication rate. Filipov's novel method for biplane double-supported screw fixation (BDSF), using three cannulated screws, has demonstrated excellent clinical results since 2007. Its two calcar-buttressed screws are oriented in different coronal inclinations with steeper angles to the diaphyseal axis and intended to provide constant fixation strength under different loading situations.The aim of this study was to biomechanically evaluate BDSF fixation strength and compare it with the conventional fixation (CFIX) using three parallel cannulated screws.MethodsEight fresh-frozen and six embalmed human femoral pairs with simulated AO/OTA31âB2.2 fracture were fixed applying either CFIX or BDSF. Quasistatic tests were performed in anteroposterior (AP) bending, followed by axial quasistatic, cyclic and destructive quasistatic tests run in 10° flexion with 7° or 16° varus specimen inclination.ResultsInitial axial stiffness was significantly higher for BDSF in comparison with CFIX at 7° inclination (p=0.02) and not significantly different between BDSF and CFIX at 16° inclination. Compared with the intact state, it decreased significantly at 7° inclination only for CFIX (p=0.01), but not for BDSF. Interfragmentary displacement during cyclic testing was significantly smaller for BDSF than CFIX at 7° inclination (pâ€0.04) and not significantly different between BDSF and CFIX at 16° inclination. Failure load did not differ significantly between BDSF and CFIX at both inclinations.ConclusionsFemoral neck fracture stability can be substantially increased applying BDSF due to better cortical screw support and screw orientation. Having two calcar-buttressed screws oriented in different inclinations, BDSF can enhance constant stability during various patient activities. The more unstable the situation, the better BDSF stability is in comparison to CFIX
Plunging when drilling: Effect of using blunt drill bits
Objective: Plunging when drilling can be a detrimental factor in patient care. There is, although, a general lack of information regarding the surgeon's performance in this skill. The aim of this study was to determine the effect that using sharp or blunt instruments had on the drill bit's soft tissue penetration, using a simulator. Materials and Methods: Surgeons taking part in an International Trauma Course were invited to participate. Two groups were defined: experienced and inexperienced surgeons. Twelve holes were drilled in the following order: 3 holes with a sharp drill bit in normal bone (SNB), 3 holes with a sharp drill bit in osteoporotic bone (SOB), 3 holes with a blunt drill bit in normal bone, and 3 holes with a blunt drill bit in osteoporotic bone. Mean values and Student t tests were used for statistical analysis. Results: Thirty-seven surgeons participated, 20 experienced and 17 inexperienced surgeons. Mean plunging depths for SNB, SOB, blunt drill bit in normal bone, and blunt drill bit in osteoporotic bone were, respectively, 5.1, 5.4, 21.1, and 13.9 mm for experienced surgeons and 7.6, 7.7, 22, and 15.9 mm for inexperienced surgeons. Drilling with SNB and with SOB was statistically different, with inexperienced surgeons plunging 2.5 mm (P = 0.31) and 2.6 mm (P = 0.042) deeper, respectively. There was a difference (P less than 0.001) between sharp and blunt drill bits in all drilling conditions for both the groups. Conclusions: Our study showed a significant difference in plunging depth when sharp or bunt drill bit was being used. Surgeons, regardless of their experience level, penetrate over 20 mm in normal bone and over 10 mm in osteoporotic bone. Copyright © 2012 by Lippincott Williams and Wilkins
The role of big data management, data registries, and machine learning algorithms for optimizing safe definitive surgery in trauma: a review
Digital data processing has revolutionized medical documentation and enabled the aggregation of patient data across hospitals. Initiatives such as those from the AO Foundation about fracture treatment (AO Sammelstudie, 1986), the Major Trauma Outcome Study (MTOS) about survival, and the Trauma Audit and Research Network (TARN) pioneered multi-hospital data collection. Large trauma registries, like the German Trauma Registry (TR-DGU) helped improve evidence levels but were still constrained by predefined data sets and limited physiological parameters. The improvement in the understanding of pathophysiological reactions substantiated that decision making about fracture care led to development of patient's tailored dynamic approaches like the Safe Definitive Surgery algorithm. In the future, artificial intelligence (AI) may provide further steps by potentially transforming fracture recognition and/or outcome prediction. The evolution towards flexible decision making and AI-driven innovations may be of further help. The current manuscript summarizes the development of big data from local databases and subsequent trauma registries to AI-based algorithms, such as Parkland Trauma Mortality Index and the IBM Watson Pathway Explorer
Screw configuration in proximal humerus plating has a significant impact on fixation failure risk predicted by finite element models
Background: Proximal humeral fractures occur frequently, with fixed angle locking plates often being used for their treatment. No current quantitative evidence for the effect of different screw configurations exists, and the large number of variations makes biomechanical testing prohibitive. Therefore, we used an established and validated finite element osteosynthesis test kit to quantify the effect of variations in screw configuration on predicted failure risk of PHILOS plate fixation for unstable proximal humerus fractures. Methods: Twenty-six low-density humerus models were osteotomized to create malreduced unstable 3-part fractures that were virtually fixed with PHILOS plates. Twelve screw configurations were simulated: 6 using 2 screw rows, 4 using 3 rows, and 1 with either 8 or 9 screws. Three physiological loading cases were modeled and an established finite element analysis methodology was used. The average peri-screw bone strain, previously demonstrated to predict fatigue cutout failure, was used to compare the different configurations. Results: Significant differences in peri-screw strains, and thus predicted failure risk, were seen with different combinations. The 9-screw configuration demonstrated the lowest peri-screw strains. Fewer screw constructs showed lower strains when placed further apart. The calcar screws (row E) significantly (P < .001) reduced fixation failure risk. Conclusion: Screw configurations significantly impact predicted cutout failure risk for locking plate fixations of unstable proximal humerus fractures in low-density bone. Although requiring clinical corroboration, the result of this study suggests that additional screws reduce peri-screw strains, the distance between them should be maximized whenever possible and the calcar screws should be used.</p
Importance of locking plate positioning in proximal humeral fractures as predicted by computer simulations
Multifragmented proximal humeral fractures frequently require operative fixation. The locking plates commonly used are often placed relative to the greater tuberosity, however no quantitative data exists regarding the effect of positional changes. The aim of the study was to establish the effects from variations in proximalâdistal PHILOS humeral plate positioning on predicted fixation failure risk. Twentyâone leftâsided lowâdensity virtual humeri models were created with a simulation framework from CT data of elderly donors and osteotomized to mimic an unstable threeâpart malreduced AO/OTA 11âB3.2 fracture with medial comminution. A PHILOS plate with either four or six proximal screws was used for fixation. Both configurations were modelled with plate repositioning 2 and 4âmm distally and proximally to its baseline position. Applying a validated computational model, three physiological loading situations were simulated and fixation failure predicted using average strain around the proximal screws â an outcome established as a surrogate for cycles to failure. Varying the craniocaudal plate position affected the periâimplant strain for both four and sixâscrew configurations. Even though significant changes were seen only in the latter, all tests suggested that more proximal plate positioning results in decreased periâscrew strains whereas distalizing creates increases in strain. These results suggest that even a small distal PHILOS plate malpositioning may reduce fixation stability. Plate distalization increases the probability of being unable to insert all screws within the humeral head, which dramatically increases the forces acting on the remaining screws. Proximal plate shifting may be beneficial, especially for constructs employing calcar screws.This article is protected by copyright. All rights reserve
Importance of locking plate positioning in proximal humeral fractures as predicted by computer simulations
Multifragmented proximal humeral fractures frequently require operative fixation. The locking plates commonly used are often placed relative to the greater tuberosity, however no quantitative data exists regarding the effect of positional changes. The aim of the study was to establish the effects from variations in proximalâdistal PHILOS humeral plate positioning on predicted fixation failure risk. Twentyâone leftâsided lowâdensity virtual humeri models were created with a simulation framework from CT data of elderly donors and osteotomized to mimic an unstable threeâpart malreduced AO/OTA 11âB3.2 fracture with medial comminution. A PHILOS plate with either four or six proximal screws was used for fixation. Both configurations were modelled with plate repositioning 2 and 4âmm distally and proximally to its baseline position. Applying a validated computational model, three physiological loading situations were simulated and fixation failure predicted using average strain around the proximal screws â an outcome established as a surrogate for cycles to failure. Varying the craniocaudal plate position affected the periâimplant strain for both four and sixâscrew configurations. Even though significant changes were seen only in the latter, all tests suggested that more proximal plate positioning results in decreased periâscrew strains whereas distalizing creates increases in strain. These results suggest that even a small distal PHILOS plate malpositioning may reduce fixation stability. Plate distalization increases the probability of being unable to insert all screws within the humeral head, which dramatically increases the forces acting on the remaining screws. Proximal plate shifting may be beneficial, especially for constructs employing calcar screws.This article is protected by copyright. All rights reserve
Semi-occlusive dressing therapy versus surgical treatment in fingertip amputation injuries: a clinical study.
OBJECTIVES
Treatment of fingertip amputations is subject of controversial debates. Recently, semi-occlusive dressings have increased in popularity in these injuries.
AIMS
To compare clinical outcomes of conservative semi-occlusive dressing therapy versus surgical treatment of fingertip amputations.
METHODS
Eighty-four patients with fingertip amputations were re-examined clinically after a mean follow-up of 28.1Â months (range 9.6-46.2). Sixty-six patients (79%) were treated with semi-occlusive dressings (group 1) and 18 (21%) underwent surgery (group 2). Range of motion, grip strength, and two-point discrimination were measured at the final follow-up. Furthermore, VAS score, Quick-DASH score, subjective aesthetic outcome and loss of working days were obtained.
RESULTS
Group 1 demonstrated healing in all 66 patients (100%) while in Group 2 5 out of 18 patients (28%) failed to achieve healing after a mean of 17Â days (range 2-38) due to graft necrosis. Group 1 showed significantly lower VAS scores and significantly lower loss of two-point discrimination compared to Group 2. Work absence was significantly shorter in Group 1 versus Group 2. Trophic changes in finger (46%) and nail (30%) were significantly lower in Group 1 compared to Group 2 (44% and 70%, respectively). Disturbance during daily business activities (14%) and cold sensitivity (23%) were significantly lower in Group 1 compared to Group 2 (86% and 77%, respectively).
CONCLUSIONS
Semi-occlusive dressing therapy for fingertip amputations demonstrated excellent healing rates. Compared to surgical treatment, it resulted in significantly better clinical outcomes, lower complication rates and significantly higher reported satisfaction rates. Therefore, semi-occlusive dressing for fingertip injuries is a very successful procedure and shall be preferred over surgical treatment in most cases.
LEVEL OF EVIDENCE
III therapeutic
Intracapsular Femoral Neck FracturesâA Surgical Management Algorithm
Background and Objectives: Femoral neck fractures are common and constitute one of the largest healthcare burdens of the modern age. Fractures within the joint capsule (intracapsular) provide a specific surgical challenge due to the difficulty in predicting rates of bony union and whether the blood supply to the femoral head has been disrupted in a way that would lead to avascular necrosis. Most femoral neck fractures are treated surgically, aiming to maintain mobility, whilst reducing pain and complications associated with prolonged bedrest. Materials and Methods: We performed a narrative review of intracapsular hip fracture management, highlighting the latest advancements in fixation techniques, generating an evidence-based algorithm for their management. Results: Multiple different fracture configurations are encountered within the category of intracapsular hip fractures, with each pattern having different optimal surgical strategies. Additionally, these injuries typically occur in patients where further procedures due to operative complications are associated with a considerable increase in mortality, highlighting the need for choosing the correct index operation. Conclusions: Factors such as pathological causes for the fracture, pre-existing symptomatic osteoarthritis, patientâs physiological age and fracture displacement all need to be considered when choosing optimal management
Tips and tricks to avoid implant failure in proximal femur fractures treated with cephalomedullary nails: a review of the literature
Objective: To describe the surgical aspects potentially contributing to hardware failure of cephalomedullary nails.
Data Sources: A search of the Embase, PubMed (MEDLINE), Web of Science, and the Cochrane library for reports of hardware failures after intramedullary fixation of proximal femur fractures. Issues of cut out and cut through phenomena related to technique were excluded. Expert opinion of 3 surgeons, each trained on several fixation systems at Level | trauma centers is reported.
Data Extraction: Three authors extracted data using a predesigned form. Implant type, reported failure mechanism, and associated factors with implant failure were recorded as well as potential bias.
Results: Of 2182 search results screened, 64 articles were deemed relevant for our research question and were included. The authors identified factors associated with implant failure: preoperative patient and fracture characteristics, intraoperative reduction, implant handling, and postoperative nonunion. Issues were identified as independent modifiable intraoperative risk factors: inadequate fracture reduction, varus position of femoral neck, direct damage of the cephalomedullary nail aperture by eccentric drilling related to guide sleeve handling, and implant design mechanism failures.
Conclusions: Multiple factors associated with intraoperative handling can influence the healing of proximal femur fractures. Although many of these have been well described and are taught in fracture courses, surgeons should be aware of subtle intraoperative complications reported in the literature that can weaken implants and add to the likelihood of early failure
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