Strategies in Trauma and Limb Reconstruction

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2017 | November | Volume 12 | Issue 3

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Original Article

J. K. Wiggers, R. M. Snijders, J. G. G. Dobbe, G. J. Streekstra, D. den Hartog, N. W. L. Schep

Accuracy in identifying the elbow rotation axis on simulated fluoroscopic images using a new anatomical landmark

[Year:2017] [Month:November] [Volume:12] [Number:3] [Pages:7] [Pages No:133 - 139]

Keywords: Fluoroscopy, Elbow, Rotation axis, Landmark, Segmentation

   DOI: 10.1007/s11751-017-0289-3  |  Open Access |  How to cite  | 


External fixation of the elbow requires identification of the elbow rotation axis, but the accuracy of traditional landmarks (capitellum and trochlea) on fluoroscopy is limited. The relative distance (RD) of the humerus may be helpful as additional landmark. The first aim of this study was to determine the optimal RD that corresponds to an on-axis lateral image of the elbow. The second aim was to assess whether the use of the optimal RD improves the surgical accuracy to identify the elbow rotation axis on fluoroscopy. CT scans of elbows from five volunteers were used to simulate fluoroscopy; the actual rotation axis was calculated with CT-based flexion–extension analysis. First, three observers measured the optimal RD on simulated fluoroscopy. The RD is defined as the distance between the dorsal part of the humerus and the projection of the posteromedial cortex of the distal humerus, divided by the anteroposterior diameter of the humerus. Second, eight trauma surgeons assessed the elbow rotation axis on simulated fluoroscopy. In a preteaching session, surgeons used traditional landmarks. The surgeons were then instructed how to use the optimal RD as additional landmark in a postteaching session. The deviation from the actual rotation axis was expressed as rotational and translational error (±SD). Measurement of the RD was robust and easily reproducible; the optimal RD was 45%. The surgeons identified the elbow rotation axis with a mean rotational error decreasing from 7.6° ± 3.4° to 6.7° ± 3.3° after teaching how to use the RD. The mean translational error decreased from 4.2 ± 2.0 to 3.7 ± 2.0 mm after teaching. The humeral RD as additional landmark yielded small but relevant improvements. Although fluoroscopy-based external fixator alignment to the elbow remains prone to error, it is recommended to use the RD as additional landmark.


Original Article

Valentino Coppa, Luca Dei Giudici, Stefano Cecconi, Mario Marinelli, Antonio Gigante

Midshaft clavicle fractures treatment: threaded Kirschner wire versus conservative approach

[Year:2017] [Month:November] [Volume:12] [Number:3] [Pages:10] [Pages No:141 - 150]

Keywords: Clavicle fracture, Midshaft, Conservative treatment, Clavicle pinning, Mini invasive

   DOI: 10.1007/s11751-017-0293-7  |  Open Access |  How to cite  | 


Clavicle fractures are common, accounting for 2.6 to 10% of all fractures. Treatment of these fractures is usually non-surgical. Recent evidence, however, reveals that the final result of non-surgically midshaft clavicular fractures, particularly those with quite large displacements or shortening, is not like that which was previously thought. This study evaluated retrospectively all patients presented with a clavicle fracture at Emergency Department of our Institution, between January 2006 and December 2011. Fractures were classified according to Allman's radiographic classification system, modified by Nordqvist and Petersson. Patients were distinguished into two groups: one that underwent conservative treatment with a “figure-of-8” orthosis and one that underwent surgery with reduction in fracture and fixation with intramedullary threaded Kirschner wire. Pin removal was performed after 4 weeks of rest in Gilchrist bandage, after clinical and radiographic evaluation demonstrating the bone healing. The QuickDASH score and the Constant Murley Shoulder Score were used to evaluate the clinical outcomes. The radiographic outcome was evaluated at 1 and 6 months of follow-up. Database review provided a final cohort of 58 patients, with similar demographic features. There was no significant difference in qDASH and CS between the two groups. The results of qDASH and CS evaluated in function of the radiographic outcome show a statistically significant correlation between the worst qDASH and CS results and the grade of malunion in both groups. In particular, we have found unsatisfactory results when final shortening of the clavicle was 20 mm or more. On radiographic evaluation, surgical treatment demonstrated a greater efficacy in reducing initial shortening of the fractured bone; this is in opposition to conservative treatment that results very often in malunion, shortening, anatomic alterations and loss of functionality. The use of intramedullary threaded Kirschner wire for fixation of midshaft clavicle fractures is a safe procedure and is recommended in case of shortening greater than 2 cm in high-function-demand patients.


Original Article

Mohamed F. Mostafa, Yasser Y. Abed, Sallam I. Fawzy

Shaped graft for aneurysmal bone cyst of upper limb bones

[Year:2017] [Month:November] [Volume:12] [Number:3] [Pages:8] [Pages No:151 - 158]

Keywords: Aneurysmal, Bone cyst, Shaped graft

   DOI: 10.1007/s11751-017-0291-9  |  Open Access |  How to cite  | 


The optimal treatment of aneurysmal bone cyst remains challenging. The aim of this prospective study was to evaluate the results of using bone grafts shaped to the defects caused by aneurysmal bone cysts of upper limb bones. Fifteen patients (12 males and 3 females) with an average age of 12 years (range 6–16 years) were treated for aneurysmal bone cysts of upper limb bones by intralesional resection, argon beam coagulation and shaped bone graft. The grafts were harvested from 14 patients (11 fibulas and 3 iliac bones) and from the mother of one patient (proximal fibula). Osteosynthesis was required to stabilize the graft in four cases. The modified Enneking's scoring system was used for functional evaluation. One patient developed partial recurrence at 6 months and required reoperation. Superficial wound infection was encountered in one patient. Shortening of the humeral segment was seen in two patients (1 and 1.5 cm) but without angular deformity. After a mean follow-up of 45 months (range 24–68 months), the mean functional score was 97.3%. This technique proved to be reliable in obtaining a well reconstructed and growing bone with no or minimal deformity and good function.


Original Article

Austin T. Fragomen, Fiona R. Fragomen

Distal femoral flexion deformity from growth disturbance treated with a two-level osteotomy and internal lengthening nail

[Year:2017] [Month:November] [Volume:12] [Number:3] [Pages:9] [Pages No:159 - 167]

Keywords: Magnetic internal lengthening nail, Precice, TomoFix, Osteotomy, Deformity, Limb lengthening

   DOI: 10.1007/s11751-017-0298-2  |  Open Access |  How to cite  | 


Salter Harris fractures of the distal femur can lead to growth disturbance with resulting leg length inequality and knee deformity. We have looked at a case series (3) of patients who presented with a distal femur flexion malunion and shortening treated with a distal femoral osteotomy and plating and a proximal femoral osteotomy with a magnetic internal lengthening nail. Does a two-level osteotomy and internal fixation approach provide a reliable result both radiographically and functionally? The average knee extension loss was 12°, LLD 47 mm, PDFA 65°, MAD 2 mm. The patients were treated with an acute, posterior, opening wedge osteotomy of the distal femur stabilized with a lateral plate and screws and grafted with cancellous chips and putty. A second osteotomy was made proximally in the femur percutaneously, and the internal lengthening nail was inserted. Lengthening was done at approximately 1 mm/day. The average extension gain was 12°; amount of lengthening at the proximal site was 40 mm, LLD was 3 mm. The average PDFA was 81°, and MAD 3 mm. There were no complications. Functional results were excellent. Bone healing index was 24 days/cm. The average distance from the distal osteotomy to the joint line was 57 mm. The technique of two-level femur osteotomy stabilized with a plate and lengthening nail yielded excellent results with acceptable correction of deformity, full knee extension, and improved function. There were no complications including implant failure, infection, need for blood transfusion, knee stiffness, nonunion, compartment syndrome, or malunion.



John Dabis, Oliver Templeton-Ward, Alice E. Lacey, Badri Narayan, Alex Trompeter

The history, evolution and basic science of osteotomy techniques

[Year:2017] [Month:November] [Volume:12] [Number:3] [Pages:12] [Pages No:169 - 180]

Keywords: Osteotomy, Bone regenerate, Drill and osteotome, Gigli saw, Distraction osteogenesis, Ilizarov

   DOI: 10.1007/s11751-017-0296-4  |  Open Access |  How to cite  | 


Osteotomy techniques date back to Hippocrates circa 415 BC (Jones Hippocrates collected works I, Harvard University Press, Cambridge, 2006; Brorson in Clin Orthop Relat Res 467(7):1907–1914, 2009). There is debate about the best way to divide the bone surgically and which technique yields the best bone regenerate in lengthening; ensuring predictable new bone formation and healing of the osteotomy are the primary goals. We review the history and techniques of the osteotomy and consider the evidence for optimum bone formation. Methods discussed include variants of the ‘drill and osteotome’ technique, use of the Gigli saw and use of a power saw. Differences in bone formation through the different techniques are covered.



Marjolein A.M. Mulders, Monique M.J. Walenkamp, Fernande J.M.E. Bos, Niels W.L. Schep, J. Carel Goslings

Repair of the pronator quadratus after volar plate fixation in distal radius fractures: a systematic review

[Year:2017] [Month:November] [Volume:12] [Number:3] [Pages:8] [Pages No:181 - 188]

Keywords: Distal radius, Fracture, Volar plate fixation, Pronator quadratus, Repair

   DOI: 10.1007/s11751-017-0288-4  |  Open Access |  How to cite  | 


To position the volar plate on the distal radius fracture site, the pronator quadratus muscle needs to be detached from its distal and radial side and lifted for optimal exposure to the fracture site. Although the conventional approach involves repair of the pronator quadratus, controversy surrounds the merits of this repair. The purpose of this study was to compare the functional outcomes of patients with distal radius fractures treated with pronator quadratus repair after volar plate fixation versus no pronator quadratus repair. A systematic search was conducted in Medline, EMBASE and the Cochrane Central Register of Controlled Trials, on 23 July 2015. All studies comparing pronator quadratus repair with no pronator quadratus repair in adult patients undergoing volar plate fixation for distal radius fractures were included. The primary outcome was the Disability of the Arm, Shoulder and Hand (DASH) score at 12 months. Secondary outcomes included range of motion, grip strength, post-operative pain and complications. A total of 169 patients were included, of which 95 underwent pronator quadratus repair, while 74 patients underwent no pronator quadratus repair. At 12 months follow-up no statistically significant differences in DASH-scores and range of motion were observed between pronator quadratus repair and no repair. Moreover, post-operative pain and complication rates were similar between both groups. At 12 months of follow-up, we do not see any advantages of pronator quadratus repair after volar plate fixation in the distal radius. However, a definitive conclusion cannot be drawn from this systematic review due to a lack of available evidence.



Sandeep Kumar, Anshul Dahuja, M. S. Narula, Sangam Garg, Rashmeet Kaur

Neglected hip dislocation: an unusual presentation, its management and review of the literature

[Year:2017] [Month:November] [Volume:12] [Number:3] [Pages:4] [Pages No:189 - 192]

Keywords: Constrained, Dislocation, Total hip replacement

   DOI: 10.1007/s11751-017-0285-7  |  Open Access |  How to cite  | 


Neglected traumatic posterior hip dislocation is not an uncommon condition seen in developing countries. Its treatment is fraught with great difficulties and controversies. Here we present a 31-year-old female patient presented to our hospital 2 years after sustaining an accident. She had gone through multiple treatments for her dislocated hip without any success. After arrival to our hospital, patient managed by constrained total hip replacement (THR). Her Harris hip score improved from 48 (preoperative) to 81 (postoperative). On follow-up she had a good range of movement of the hip with no pain, deformity and limb length discrepancy. Constrained THR provides promising results in neglected hip dislocation.



Anshul Dahuja, Rashmeet Kaur, Shiraz Bhatty, Simmi Garg, Kapil Bansal, Mandeep Singh

Giant-cell tumour of proximal radius in a 50-year-old female with wrist drop: a rare case report

[Year:2017] [Month:November] [Volume:12] [Number:3] [Pages:4] [Pages No:193 - 196]

Keywords: Arthrodesis, Giant-cell tumour, Proximal radius, Sub-chondral bone, TENS (titanium elastic nail system)

   DOI: 10.1007/s11751-017-0281-y  |  Open Access |  How to cite  | 


Giant-cell tumour is a locally aggressive tumour of long bones of epiphyseal region commonly occurring in adults aged 20–40 years. Most common location is distal femur, proximal tibia, and distal radius. Different treatment options being used are curettage with bone graft or bone cement, resection with arthrodesis, reconstruction, radiation, and chemotherapy. We are reporting a case of giant-cell tumour of right proximal radius in a 50-year-old female with posterior interosseous nerve palsy. It is very rare, and only four cases have been reported in the literature. It was treated by wide margin resection with fibular grafting, titanium elastic nail system along with cancellous bone graft reconstruction.



Dmitry Popkov

Guided growth for valgus deformity correction of knees in a girl with osteopetrosis: a case report

[Year:2017] [Month:November] [Volume:12] [Number:3] [Pages:8] [Pages No:197 - 204]

Keywords: Osteopetrosis, Genu valgum, Tension band technique hemiepiphysiodesis, Guided growth

   DOI: 10.1007/s11751-017-0290-x  |  Open Access |  How to cite  | 


Autosomal dominant osteopetrosis (Albers-Schönberg disease) classically displays the radiographic signs of osteosclerosis. The main ADO complications involve the skeleton: low-impact bone fractures, scoliosis and hip osteoarthritis. Management of osteopetrosis-related orthopedic problems is a surgical challenge due to increased bone density. The healing process is very slow in these patients because of bone remodeling defects related to osteoblast function failure. In case of bone deformities, a realignment method should be appropriated to osteopetrosis conditions. This article presents a case report of operative treatment of an 11-year-old girl affected with ADO, who underwent a simultaneous valgus knee deformity correction of both limbs with medial eight-plate epiphysiodesis. Simultaneous correction of valgus deformity on both limbs using an extraperiosteal tension plate technique for medial tibial hemiepiphysiodesis was performed in a girl of 11.5 years old with autosomal dominant osteopetrosis. The treatment duration from surgery to complete deformity correction and removal of plates was 18 months. The final aMPTA was 86° on the right side and 85° on the left side. The correction rate was 0.61°/month (right tibia) and 0.67°/month (left tibia). The MAD correction rate was evaluated as 1.5 mm/month for the right limb and 1.6 mm/month for the left limb. At the moment of plate removal, one screw was broken because of tight fixation in osteopetrotic bone. But it did not compromise the final result. The latest follow-up visit at the age of 14 years 6 months revealed excellent realignment without any deformity relapse. There was no any functional impairment. We consider the guided growth by tension band technique as very interesting and promising solution for treatment of pediatric angular deformity in patients with OP. This method allows to avoid osteotomy and related important risk of delayed union or nonunion frequently observed in osteopetrosis. Level of evidence: Level IV.



Ayman Mohammad El Masry

Anterior hip dislocation with ipsilateral displaced fracture neck of femur treated by open reduction and internal fixation: case report and review of the literature

[Year:2017] [Month:November] [Volume:12] [Number:3] [Pages:6] [Pages No:205 - 210]

Keywords: Neck, Femur, Fracture, Hip, Dislocation

   DOI: 10.1007/s11751-017-0292-8  |  Open Access |  How to cite  | 


Combined fracture neck femur with anterior dislocation of the head of femur is a very rare injury with little resources available in the literature. This case report describes a case that was treated by open reduction and internal fixation with 2-year follow-up showing good radiological and functional outcome. Functional evaluation was done according to Merle d'Aubigné score modified by Matta JM, which takes into account the presence of pain, ability to walk and joint range of motion. The measured functional score was 15 points out of a maximum of 18, signifying a good postoperative result. Early intervention (within 6 h) achieving stable congruent reduction and rigid internal fixation provides the best chances for such patients.


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