Strategies in Trauma and Limb Reconstruction

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2017 | August | Volume 12 | Issue 2

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D. Verver, L. Timmermans, R. A. Klaassen, C. H. van der Vlies, D. I. Vos, N. W. L. Schep

Treatment of extra-articular proximal and middle phalangeal fractures of the hand: a systematic review

[Year:2017] [Month:August] [Volume:12] [Number:2] [Pages:14] [Pages No:63 - 76]

Keywords: Extra-articular phalangeal fractures, Fracture treatment, ORIF, Systematic review

   DOI: 10.1007/s11751-017-0279-5  |  Open Access |  How to cite  | 


The aim of the study was to systematically review the patient reported and functional outcomes of treatment for extra-articular proximal or middle phalangeal fractures of the hand in order to determine the best treatment options. The review methodology was registered with PROSPERO. A systematic literature search was conducted in electronic bibliographic databases. Two independent reviewers performed screening and data extraction. The evaluation of quality of the included studies was performed using the Structured Effectiveness Quality Evaluation scale. The initial search yielded 2354 studies. The full text manuscripts of 79 studies were evaluated of which 16 studies met the inclusion criteria. In total, 513 extra-articular proximal and middle phalangeal fractures of the hand were included of which 118 (23%) were treated non-operatively, 188 (37%) were treated by closed reduction internal fixation (CRIF) and 207 (40%) by open reduction internal fixation. It can be recommended that closed displaced extra-articular phalangeal fractures can be treated non-operatively, even fractures with an oblique or complex pattern, provided that closed reduction is possible and maintained. Conservative treatment is preferably performed with a cast/brace allowing free mobilization of the wrist. No definite conclusion could be drawn upon whether closed reduction with extra-articular K-wire pinning or transarticular pinning is superior; however, it might be suggested that extra-articular K-wire pinning is favoured. When open reduction is necessary for oblique or spiral extra-articular fractures, lag screw fixation is preferable to plate and screw fixation. But, similar recovery and functional results are achieved with transversally inserted K-wires compared to lag screw fixation. Type of study/level of evidence: therapeutic III.



R. J. O. de Muinck Keizer, K. M. Lechner, M. A. M. Mulders, N. W. L. Schep, D. Eygendaal, J. C. Goslings

Three-dimensional virtual planning of corrective osteotomies of distal radius malunions: a systematic review and meta-analysis

[Year:2017] [Month:August] [Volume:12] [Number:2] [Pages:13] [Pages No:77 - 89]

Keywords: 3-Dimensional, Corrective osteotomy, Distal radius, Malunion

   DOI: 10.1007/s11751-017-0284-8  |  Open Access |  How to cite  | 


The purpose of this study was to summarize and evaluate results of three-dimensional (3D-) planned corrective osteotomies of malunited distal radius fractures. 3D-planning techniques provide the possibility to address 3D-deformity that conventional planning methods might not address. We systematically searched PubMed, EMBASE and the Cochrane library for studies that performed a 3D-planned corrective osteotomy on patients with a malunited distal radius fracture. Fifteen studies with a total of 68 patients were included in the analysis. In 96% of cases, the preoperatively present palmar tilt, radial inclination and ulnar variance showed statistically significant improvement postoperatively with restoration to within 5° or 2 mm of their normal values. Mean flexion–extension, pro-supination and grip strength showed statistically significant improvement (p < 0.05). Complications were reported in 11 out of 68 patients (16%). With the current advances in 3D printing technology, 3D-planned corrective osteotomies seem a promising technique in the treatment of complex distal radius malunions. Level of evidence IV Systematic review of case series, Level IV.


Original Article

Y. V. Kleinlugtenbelt, K. Madden, S. R. Groen, S. J. Ham, Peter Kloen, R. Haverlag, M. P. Simons, Mohit Bhandari, J. C. Goslings, V. A. B. Scholtes, R. W. Poolman

Can experienced surgeons predict the additional value of a CT scan in patients with displaced intra-articular distal radius fractures?

[Year:2017] [Month:August] [Volume:12] [Number:2] [Pages:7] [Pages No:91 - 97]

Keywords: Distal radius fractures, CT scans, Clinical decision making

   DOI: 10.1007/s11751-017-0283-9  |  Open Access |  How to cite  | 


There are no clear guidelines when an additional CT scan should be obtained for the treatment of displaced intra-articular distal radius fractures (DRF). This study aimed to investigate whether surgeons can predict the usefulness of CT scans to facilitate choice of treatment plan and/or pre-operative planning for DRF. Four surgeons evaluated 51 patients with displaced DRF. The choice of treatment (operative or nonoperative) was based on conventional radiographs. Subsequently, the surgeons were asked whether they would have requested an additional CT scan to determine this treatment choice, and also whether they required a CT scan for pre-operative planning. After 4 weeks, the additional CT scan was provided and the cases were assessed again. Based on these data, we calculated the number needed to scan (NNS) and number needed to harm (NNH) for two decision models. Model 1: Only provide a CT scan if the surgeon requested one based on their judgment of the X-rays. Model 2: CT scans for all displaced intra-articular DRF. For choice of treatment, the NNS was lower for model 1 than for model 2 (2.6 vs. 4.3) and the NNH is higher for model 1 (3.1 vs. 1.3). For pre-operative planning, the NNS (1.3 vs. 1.4) and NNH (3.7 vs. 3.4) were comparable for both models. Surgeons are able to predict the usefulness of an additional CT scan for intra-articular displaced DRF for OR indication. However, for pre-operative planning the usefulness of a CT scan is much harder to predict.


Original Article

Søren Kold, Nikola Schuster, Peter H. Thaller

Lengthening of the humerus with intramedullary lengthening nails—preliminary report

[Year:2017] [Month:August] [Volume:12] [Number:2] [Pages:8] [Pages No:99 - 106]

Keywords: Humerus lengthening, Intramedullary lengthening, Distraction osteogenesis, Lengthening nail, FITBONE, PRECICE

   DOI: 10.1007/s11751-017-0286-6  |  Open Access |  How to cite  | 


Distraction osteogenesis of the humerus with fully implantable lengthening is now possible since the diameter of the available nails was reduced to 10 mm and below. We report on the first intramedullary lengthening cases of the humerus with two different lengthening devices (FITBONE and PRECICE). Two different approaches and implantation techniques were used. We retrospectively reviewed clinical and radiographic data and pointed out results, pitfalls and complications of the procedure. Four adult patients with relevant length discrepancy of the humerus were treated with fully implantable systems in two centers between 2012 and 2015. Three patients were treated with FITBONE by an antegrade approach; one patient had lengthening with a PRECICE and a retrograde approach. Average nail lengthening was 55 mm (40–65 mm), and the average duration of lengthening was 70 days (52–95 days). The average distraction index was 0.72 mm/day (range 0.4–1.0 mm/day) or 12.5 days/cm (range 8.0–16.2 days/cm). The average consolidation index was 33.6 days/cm (range 25–45 days/cm). There was an implant failure (arrest) with the PRECICE. After consolidation and exchange with a technically improved implant, the course of treatment was uneventful. In patients with antegrade lengthening shoulder abduction decreased, and in the patient with the retrograde approach it improved but elbow extension decreased marginally. Reduced motion of the adjacent joints can be a major problem in intramedullary lengthening of the humerus. This first case series in the field of a rare indication suggests that lengthening of the humerus by fully implantable lengthening nails might be a valuable alternative to lengthening with external fixation. Main advantage of the PRECICE technology is the possible shortening in-between of lengthening.


Original Article

Arnold V. Popkov, Elena N. Gorbach, Natalia A. Kononovich, Dmitry Popkov, Sergey I. Tverdokhlebov, Evgeniy V. Shesterikov

Bioactivity and osteointegration of hydroxyapatite-coated stainless steel and titanium wires used for intramedullary osteosynthesis

[Year:2017] [Month:August] [Volume:12] [Number:2] [Pages:7] [Pages No:107 - 113]

Keywords: Intramedullary osteosynthesis, Wire, Hydroxyapatite coating, Osteointegration, Bone formation, Osteosynthesis

   DOI: 10.1007/s11751-017-0282-x  |  Open Access |  How to cite  | 


A lot of research was conducted on the use of various biomaterials in orthopedic surgery. Our study investigated the effects of nanostructured calcium–phosphate coating on metallic implants introduced into the bone marrow canal. Stainless steel or titanium 2-mm wires (groups 1 and 2, respectively), and hydroxyapatite-coated stainless steel or titanium wires of the same diameter (groups 3 and 4, respectively) were introduced into the tibial bone marrow canal of 20 dogs (each group = 5 dogs). Hydroxyapatite coating was deposited on the wires with the method of microarc oxidation. Light microscopy to study histological diaphyseal transverse sections, scanning electron microscopy to study the bone marrow area around the implant and an X-ray electron probe analyzer to study the content of calcium and phosphorus were used to investigate bioactivity and osteointegration after a four weeks period. Osteointegration was also assessed by measuring wires' pull-off strength with a sensor dynamometer. Bone formation was observed round the wires in the bone marrow canal in all the groups. Its intensity depended upon the features of wire surfaces and implant materials. Maximum percentage volume of trabecular bone was present in the bone marrow canals of group 4 dogs that corresponded to a mean of 27.1 ± 0.14%, while it was only 6.7% in group 1. The coating in groups 3 and 4 provided better bioactivity and osteointegration. Hydroxyapatite-coated titanium wires showed the highest degree of bone formation around them and greater pull-off strength. Nanostructured hydroxyapatite coating of metallic wires induces an expressed bone formation and provides osteointegration. Hydroxyapatite-coated wires could be used along with external fixation for bone repair enhancement in diaphyseal fractures, management of osteogenesis imperfecta and correction of bone deformities in phosphate diabetes.



J. G. G. Dobbe, K. J. du Pré, L. Blankevoort, G. J. Streekstra, P. Kloen

Computer-assisted oblique single-cut rotation osteotomy to reduce a multidirectional tibia deformity: case report

[Year:2017] [Month:August] [Volume:12] [Number:2] [Pages:6] [Pages No:115 - 120]

Keywords: Additive manufacturing, Malunion, Corrective osteotomy, Computer-assisted surgery, Single-cut osteotomy

   DOI: 10.1007/s11751-017-0277-7  |  Open Access |  How to cite  | 


The correction of multiplanar deformity is challenging. We describe preoperative 3-D planning and treatment of a complex tibia malunion using an oblique single-cut rotation osteotomy to correct deformity parameters in the sagittal, coronal and transverse plane. At 5 years postoperatively, the patient ambulates without pain with a well-aligned leg.



Christos Koutserimpas, Georg Tsironis, Antonios Salasidis, Phillipp Swatoch, Konstantin Tsironis

Combined open bipolar Monteggia and Galeazzi fracture: a case report with a 1-year follow-up

[Year:2017] [Month:August] [Volume:12] [Number:2] [Pages:5] [Pages No:121 - 125]

Keywords: Combined Monteggia, Galeazzi, Forearm, Fracture

   DOI: 10.1007/s11751-017-0280-z  |  Open Access |  How to cite  | 


Monteggia and Galeazzi fractures account for 1–5% of total forearm fractures. A combined Monteggia and Galeazzi fracture is an extremely rare injury. We present a case of a Gustillo-Henderson type 2 open combined bipolar Monteggia and Galeazzi fracture, as well as fracture of the ulnar coronoid process in a 49-year old male. The patient was treated surgically, with open reduction and internal fixation. At 6 months postoperative, he was diagnosed with pseudarthrosis and underwent surgery with autologous bone grafting from the iliac crest. At the 1-year follow-up, the patient presented an extension deficit of 5° in elbow, a 15° deficit in pronation and 20° deficit in supination of the wrist. The patient continues to work as a painter without significant problems in his everyday routine and he is still regularly engaged in cycling. Additionally we provide a historical background of these injuries.



Shiraz A. Sabah, Shelain Patel, Gavin Spence

The silhouette technique: improving post-operative radiographs for planning of correction with a hexapod external fixator

[Year:2017] [Month:August] [Volume:12] [Number:2] [Pages:5] [Pages No:127 - 131]

Keywords: Radiograph, Deformity correction, Hexapod, Taylor spatial frame, Planning

   DOI: 10.1007/s11751-017-0287-5  |  Open Access |  How to cite  | 


Correction of deformity of a bone through use of a hexapod external fixator requires clear definition of the relationship between the bone and the frame. Achieving adequate orthogonal calibrated radiographs for this aim, with minimum X-ray exposure, can prove a challenge in the radiography suite. We describe a simple technique for obtaining adequate imaging, without the use of additional equipment. Introduction of the technique to our department has demonstrated an improvement in the adequacy of planning radiographs and a reduction in the requirement for repeat imaging.


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