Top PDF A comparative analysis between methods of open reduction and closed reduction in internal fixation of proximal tibia fractures

This is to certify that this dissertation titled “A COMPARATIVE ANALYSIS BETWEEN METHODS OF OPEN REDUCTION AND CLOSED REDUCTION IN INTERNAL FIXATION OF PROXIMAL TIBIA FRACTURES” is a bonafide record of work done by DR. VINOTH.S , during the period of his Post graduate study from May 2013 to April 2016 under guidance and supervision in the INSTITUTE OF ORTHOPAEDICS AND TRAUMATOLOGY, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai-600003, in partial fulfillment of the requirement for M.S.ORTHOPAEDIC SURGERY degree Examination of The Tamilnadu Dr. M.G.R. Medical University to be held in April 2016.

Abstract: Objective: To compare the efficacy of open reduction and internal fixation versus closed reduction and external fixation in treating distal radius fracture. Methods: A total of 77 patients with distal radius fracture were ret- rospectively analyzed. There were 40 patients in the open reduction and internal fixation group (observation group) and 37 patients in the closed reduction and external fixation group (control group). The fracture symptoms, healing time of fracture, postoperative evaluation of wrist function, disabilities of the arm, shoulder and hand (DASH) score and life quality for 3 months after operation were compared. Results: In terms of fracture symptoms, the patients in the observation group had better improvements in pain, swelling and ecchymosis over the patients in the control group. The differences were statistically significant (P<0.05). Healing time of the patients’ fracture in the observa- tion group was less than that of the patients in the control group (P<0.05). As for the recovery of wrist function, the observation group showed better recovery of the palmar tilt angle, ulnar deviation angle and radius height than the control group (P<0.05). What’s more, the excellent and good scores of DASH scale was higher in the observation group than in the control group (P<0.05). Lastly, with regard to postoperative life quality, physical function, physical role functioning, social functioning, emotional role functioning and bodily pain of the patients in the observation group were all significantly better than those of the patients in the control group (P<0.05). Conclusion: Open reduc- tion and internal fixation is better than closed reduction and external fixation in treating distal radius fracture. When treated by open reduction and internal fixation, patients with distal radius fracture have shorter healing time and good postoperative life quality. Therefore, it is worthwhile to popularize and apply open reduction and internal fixa- tion in clinical practice.

Emergency internal fixation is one of the main options for the treatment of displaced femoral neck fractures [5]. It contains open reduction internal fixation (ORIF) and closed reduction internal fixation (CRIF). Both of the two methods have their advantages and disadvantages [6]. Although ORIF has advantages of direct look and restoration of normal function, its application still lim- ited by the potential negative effects of nerve damage, swelling, incomplete healing of the bone, increased pres- sure and blood clot [7]. CRIF has advantages of avoiding injury to the medial circumflex femoral artery [8]. How- ever, intracapsular pressure formed by CRIF compro- mised femoral head circulation, and prolonged extension and internal rotation position on the fracture table re- duced the blood supply to the femoral head, what’s more, the repeated forceful manipulation increased the risk of AVN [6]. Thus, the optimal treatment of femoral

Abstract: Objective: We aimed to compare both functional and radiological outcomes of AO classification type C1 distal radial fractures managed using volar locking plates and percutaneous K-wire fixation. Materials and methods: In total, 15 patients were included in group 1, in which open reduction and internal fixation using volar locking plates were performed, whereas 15 patients were included in group 2, in which closed reduction and percutaneous K-wire fixation were utilized. In both groups, the functional outcomes were evaluated according to the Gartland-Werley scoring system. The Knirk and Jupiter scoring system was used to classify arthritic changes. Stewart’s radiological assessment criteria were used in angular assessments. Grip strength measurement was performed. Results: At the end of the follow-up, a significant difference was detected between the groups in volar tilt value (P<0.05) but not in radial inclination and radial length (P>0.05). Significant differences were detected in the Gartland-Werley score and the mean Knirk and Jupiter score between the two groups (P<0.05). No significant difference was found in the mean Stewart score between the groups (P>0.05). Conclusion: It was concluded that K-wire fixation seems insufficient in distal radius fractures of the complex intra-articular type.

The goals of the treatment should be anatomic reconstruction of articular surface and early mobilisation. This goal can be achieved only when acetabulum is adequately exposed and rigid internal fixation is done. Displaced fractures of the pelvis that involve the acetabulum are difficult to treat. With closed methods, it is difficult, if not impossible, to restore the art icular surfaces completely and obtain sufficient stability for early motion of the hip.

Background: The use of minimally invasive plate osteosynthesis (MIPO) via anterolateral deltoid splitting has good outcomes in the management of proximal humerus fractures. While using this approach has several advantages, including minimal soft tissue disruption, preservation of natural biology and minimal blood loss, there is an increased risk for axillary nerve damage. This study compared the advantages and clinical and radiological outcomes of MIPO or open reduction and internal fixation (ORIF) in patients with proximal humerus fractures. Methods: A matched-pair analysis was performed, and patient groups were matched according to age (±3 years), sex and fracture type. Forty-three pairs of patients (average age: MIPO, 63 and ORIF, 61) with a minimum follow-up of 12 months were enrolled in the study group. The patients were investigated radiographically and clinically using the Constant score.

This study is strengthened by its prospective design. The study had clearly defined eligibility criteria prior to study initiation to ensure that all included participants were an appropriate representation of the target popula- tion. Additional strength was gained through the large sample size and use of multi-centre recruitment. The study also was able to capture details regarding current clinical practices in India, as standardized treatment methods and antibiotic regimens were not provided for the study. Attending surgeons treated patients as they would in typical clinical practice, and eligibility criteria did not remove patients based on clinical factors such as prolonged delay between injury and treatment. This was important to ensure that results were an honest depic- tion of tibial fracture patients seen in India. The study is limited by the low number of events seen within the co- hort, as only 23 infections were seen across all partici- pants. This may be a result of the large proportion of closed fractures within the study, as they are generally at low risk of infection. The low number of infections decreases the power of our statistical analysis, as the

The articular cartilage of the lateral tibial plateau is thicker than the medial plateau. The lateral plateau is higher than the medial plateau. The medial plateau rests deeper in the proximal tibia than the lateral plateau. The different levels of the plateau are of significance for arthroscopic portals and K-wire placement. Screw inserted from lateral to medial in the subchondral bone if placed perpendicular to the tibial shaft, will penetrate the articular surface of the medial plateau 12 . Intermeniscal ligament connects the anterior horn of two menisci, while the coronary ligaments attach periphery of the menisci to the peripheral rim of their respective tibial plateau 13 .

dimensional anatomy of calcaneus and various classification schemes were propounded. Bohler and Essex-Lopresti were instrumental in explaining the anatomical and surgical prospects in the calcaneum fractures. With the fascinating advances in diagnostics like computer tomography, these fractures can now be analyzed and classified in a much better way. A computer tomography-based classification propounded by Sanders is commonly used nowadays. Due to refining of the meticulous surgical techniques, the surgical methods are now being routinely adopted for the management of these fractures. However, it is well accepted that there is a long learning curve. 4 Currently, open reduction and internal

Objectives: To evaluate the benefits of Cell Salvage (CS) therapy in patients with traumatic pelvis and/or acetabulum fractures. Design: Retrospective cohort study. Data collected from medical records and radiographs. Setting: Level-1 trauma center. Patients/Participants: 157 patients with traumatic pelvis and/or acetabulum fractures treated operatively under the care of one surgeon between 2008 and 2012 were included. Exclusion criteria included nonsurgical patients and those treated with percutaneous fixation. Intervention: All patients underwent open reduction internal fixation of their pelvis and/or acetabulum fractures. The use of cell salvage therapy was randomly selected for trauma patients based on the availability of the system. Main Outcome Measurements: Volume of allogeneic blood transfused (ABT), estimated blood loss (EBL), hemoglobin (Hb) levels preoperatively and postoperatively, and blood-related costs to the patient. Results: CS was used in 89 cases (56.7%) with an average volume of 86 mL. There was a significantly higher ABT in the CS group than the no CS group (625 vs. 376 mL, p < 0.05) however this difference disappeared when controlling for blood loss with the ABT/EBL ratio (1.08 vs. 0.74, p = 0.10). Cell saver showed some benefit in patients with high blood loss (> 500 mL) in which case there was a significantly higher volume of salvaged blood than patients with low blood loss (162 vs. 27 mL, p < 0.05), and in patients with > 7 days to surgery (135 vs. 64 mL, p < 0.05). The cost difference of $1,375 was seen between the two groups, favoring the No CS group. Conclusions: Our results suggest limited overall benefit to the use of CS in patients treated with ORIF for traumatic pelvis and acetabulum fractures. Journal of Nature and Science, 1(5):e99, 2015

Besides internal fixation, primary arthroplasty has been advocated for displaced FNFs by many studies. Swart et al. found that primary total hip arthroplasty (THA) can be a cost-effective treatment for displaced FNFs among 45–65-year-old patients [27]. Rogmark et al. found that patient treated with arthroplasty have superior outcomes compared with those treated by internal fixation if there is no major complication [28]. Similarly, a national sur- vey published in 2013 reported that patients treated with THA have less pain and better satisfaction compared with those treated with hemiarthroplasty or internal fix- ation [29]. However, the clinical judgement between in- ternal fixation and arthroplasty is limited in countries with strict national health insurance programs. For ex- ample, Taiwanese patients are not covered for arthro- plasty until the age of 60 years. Therefore, some middle-aged patients with high failure rate, such as Pau- wels’ III fracture with excessive alcohol consumption, have no alternative but to receive a primary internal fix- ation and an unavoidable revision surgery.

One of the reasons for the poor result of previous studies has postulated to a residual displacement of 10mm and more was critical for a significant increase of residual pain [16]. Semba et al also reported a correlation of primary anterior and posterior displace- ment exceeding 10mm being correlated with a markedly higher incidence of severe low back pain [13]. Holdsworth in 1948 reported that 50% of the patients they studied re- turned to their original job [1]. Our study showed that 7 patients returned to their original jobs. In the largest series of patients treated with open reduction and internal fixation of unstable posterior pelvic injuries, 67% returned to their former jobs without restrictions [18]. In other study where all fractures were reduced operatively to less than 10mm of residual displacement; 35% of patients had neurologic injuries, and another 23% had associated injuries inhibiting nor- mal gait. Females with pelvic fractures tended to have increased urinary complaints and dyspareunia, which were shown to cor- relate with residual displacement of >5mm [19].Our study has shown that anatomical restoration of the pelvic ring correlated with higher probability of a good functional and clinical outcomes.

used for classifying intra articular fractures.12 intra articular fractures(50%) which included Sanders type-I, poor local condition, medically unfit patients, peripheral vascular isease and patients who are unwilling for surgery have been treated conservatively with limb elevation and immobilization in plaster for 8 weeks. 12 intra articular fractures(50%) were fixed internally under fluoroscopic guidance on an average in 10 days of injury once wrinkle sign is positive. The aim of treatment was to achieve articular surface reconstruction, to restore height, width of axis of heel by performing primary osteosynthesis

Surgical approach: The patients with trans- verse facture and complicated acetabular frac- tures involving with two columns underwent ORIF via anterior and posterior combined approach. Those presenting with single column or/and anterior wall, anterior column, posterior wall or/and posterior column injuries were sub- jected to ORIF via single surgical approach. Intraoperatively, the fracture ends of the bone were fully isolated and exposed. ORIF was first delivered to treat the single fracture. Then, the reduction and fixation of the acetabular frac- tures at the linear extension location were per- formed (from linear extension of the fracture to abarticular iliac bone, ischial bone, pubis and sacroiliac joint). The anatomic relationship of dislocated or disordered femoral head mortar was restored, bone fracture plate was recon- structed and fixed with proper tensile force simultaneously. Patients with posterior wall fracture defects received bone repairing and maintenance by using autologous iliac bone. Bone implantation was performed at the poste- rior wall to elevate the height of posterior wall. The posterior wall soft tissues repair was con- ducted to replace the function of joint capsule, aiming to prevent the posterior dislocation of hip joint and enhance the structural stability. The surgery was performed under general anesthesia. The patients were kept in semi- prone position on the healthy side when single posterior approach was selected, in a lying pos- ture when the anterior approach was adopted and in a “drifting” posture when combined approach was chosen. The operating table should be fully penetrable by the χ-ray. All patients were subjected to re-infusion of autol- ogous blood during the surgery. Thus, the intra- Figure 3. The patient restored normal hip joint func-

Major pelvic injuries are predominantly occurred following road traffic collision [1]. Pelvic fractures represent 3% to 6% of all fractures in adults and occur in up to 20% of all polytrauma cases [2] [3] [4] [5]. About 75% of all pelvic injuries occur in men [6] [7] [8] [9] [10]. The incidence of pelvic fracture resulting from blunt trauma increases with obese patients [11]. A study shows most of the patients with acetabulum fracture were male, in an economically active age group, and were victims of traffic accidents. Edge and/or posterior column fractures were the most frequent types. Associated injuries were common and most of the fractures operated in our service came [12]. These frac- tures are often associated with other life-threatening injuries [13]. Peltier reported an incidence of 24% acetabular fractures in his series of adult pelvic fractures. [14] Com- plex acetabular fracture is not clearly defined in the literature [15]. Some authors re- stricted its use the term for any fracture that involves both columns of the acetabulum [16]-[24]. However surgical approach is not fixed, the reduction is more difficult and the overall clinical results are known to be worse than simpler fracture patterns [25] [26] [27]. Displacement of the fragmented bones leads to articular incongruity of hip joint, distribution on the articular surface which leads to arthritis of joint [28]. The main goal of treatment of acetabulum fracture is to return the patient to normal func- tional level and to daily activities. Numerous factors, including fracture type and/or dislocation, femoral-head status, intra-articular osteochondral fragments, injury dura- tion, reduction quality, local complications, associated injuries and surgical approach influence on results [29] [30]. Osteoarthritis of the hip joint, avascular necrosis of the femoral head and heterotopic ossification lead to poor functional outcome despite good fracture reduction and internal fixation [31] [32]. The present study reports results at 10 years follow-up, with an analysis of ORIF management in patients with complex acetabular fractures and determine factors that may contribute adversely to satisfactory functional outcome.

The present study was undertaken in the Department of Oral and Maxillofacial Surgery, Kannur Dental College, Anjarakkandy, Kannur district, Kerala, India. The criteria for selection of cases were patients below 14 years of age with mandibular fractures, gross displacement of the fracture segments, and without any medical problems. The study, conducted between 2011 and 2013, included 10 patients (7 boys and 3 girls) reported, the youngest patient being 6 and the oldest 12 years. The causes included road traffic accident (RTA), fall from cycle, and sports injuries. All 10 patients were the subjects of this follow-up study with informed consent. Each patient was given the following evaluation: Extraoral and intraoral clinical examination, periapical radiographs of the affected site, lateral oblique view where required, preoperative and postoperative orthopantomograph (OPG), routine blood investigation, chest X-ray, ECG. All the diagnostic procedures were performed without medication or sedation. All 10 patients were advised treatment by ORIF. Average time for surgery was 45 to 70 minutes. All the patients selected for ORIF were operated under general anesthesia (GA) with nasotracheal intubation. An intraoral approach was used in all the patients treated. In this approach, a vestibular incision was placed to expose the fracture site. Care was taken to make the exposure and stripping of periosteum to the minimum, since it reportedly can interfere with future growth of mandible. Reduction was achieved by gentle manipulation and held in occlusion with temporary intermaxillary fixation (IMF) using minimal eyelets and tie wires.

Methods: From July 2010 to July 2014, 20 consecutive patients who underwent open reduction and internal fixation for a closed Mason type II radial head fracture were retrospectively reviewed. Patients with Mason type I, III, simple type II, and comminuted type II fractures treated without bone grafting were excluded. A clinical examination and radiographic evaluation were performed. The overall functional result was evaluated using the Mayo Elbow Performance Score (MEPS). The Broberg and Morrey classification was used to evaluate traumatic arthritis. Results: The average follow-up duration was 31 months (range, 24 – 50 months). Bone union of the radial head fracture was achieved in all patients at an average of 13.5 weeks (range, 12 – 17 weeks). Postoperative radiographs showed no cases of postsurgical ligamentous instability, necrosis of the radial head, or internal fixation failure. The mean range of motion of the affected elbow was 128° ± 8.4° in flexion, 14.5° ± 11.1° in extension, 68.7° ± 14.1° in pronation, and 65.2° ± 18.2° in supination. The mean MEPS was 92 ± 7.9 points (range, 80 – 100); the outcome was excellent (90 – 100 points) in 13 patients and good (75 – 89 points) in 7 patients. The MEPS tended to be higher in patients with an isolated fracture ( p = 0.016). Based on the Broberg and Morrey classification for radiographic assessment of post-traumatic arthritis, 15 elbows had no evidence of degenerative changes (grade 0), and 5 elbows had grade 1 changes.

An above-the-knee plaster cast was applied to the op- erated extremity for one week after surgery. Active range of motion exercises were encouraged at the end of first postoperative week. The patients were allowed full weight- bearing after radiologically confirmed bone union. Frac- ture union was assessed radiologically with respect to the appearance of bony bridging between fracture fragments in both anteroposterior and lateral views (Figure 1).

The FCE rate for internal fixation of leg fractures varies from 0.34 per 10,000 residents in Doncaster to 1.11 in Nottingham. The Trent average is 0.7 FCEs per 10,000 residents. For a typical district of 500,000 adult residents, this equates to an average of 35 internal fixations of the lower leg per annum, ranging from 17 to 56. In terms of lower leg fracture workload for this group of patients, the proportion of workload classified to internal fixation ranges from 13.8% in Doncaster to 27.4% in Nottingham. Performing a chi-square independence test to test the null hypothesis that the rate of internal fixations performed does not vary across Trent districts, leads to a rejection of the Null Hypothesis at the 1% level. In other words, there is strong statistical evidence that the rate of internal fixations for lower leg fractures varies across the Region. Whilst casemix could be an issue, there is no reason to believe that the casemix of fractures should vary greatly between Districts other than for age and occupational factors.

with the patients placed supine and their feet in a standard position to minimize the effect of rotation of the hip joint. To evaluate the restoration of the HJC following ORIF, we measured the vertical and horizontal shifts of the postop- erative center of femoral head from the estimated center of femoral head referring to the contralateral intact hip joint (Figure 1). In brief, the vertical axis of the pelvis (VA line) was defined by connecting the middle of the inter-sacroiliac line and the middle of the pubic symphysis in digitized postoperative AP view radiographs. With built-in tools, the distance (D1) between the postoperative femoral head center and the VA line was measured using Digimizer® image analysis software (MedCalc Software Ltd, Mariakerke, Belgium), the same as the distance (D2) between the contralateral intact femoral head center and the VA line. The horizontal shift (X) of the postoperative HJC was then calculated as the absolute value of the dif- ference between D1 and D2 (X = |D1 – D2|). The vertical shift (Y) was measured as the distance between the paral- leled D1 line and D2 line (Figure 1). The direction of the horizontal and vertical shift was also recorded. All the measurements were calibrated with the diameters of the 3.5 mm cortical screws measured in digitized radiographs as reference. Two senior orthopaedic surgeons (JFW and WJW) performed the measurements independently, with the interobserver quantitative data averaged for statistical analysis. The interobserver reliability was examined via in- terclass correlation coefficient (ICC).