Strategies in Trauma and Limb Reconstruction

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2012 | November | Volume 7 | Issue 3

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S. Jain, P. Harwood

Does the use of an intramedullary nail alter the duration of external fixation and rate of consolidation in tibial lengthening procedures? A systematic review

[Year:2012] [Month:November] [Volume:7] [Number:3] [Pages:9] [Pages No:113 - 121]

Keywords: Ilizarov, Tibia, Lengthening, Nail, Intramedullary

   DOI: 10.1007/s11751-012-0144-5  |  Open Access |  How to cite  | 


We performed this systematic review to evaluate tibial lengthening procedures with the use of an intramedullary nail. We investigated the hypothesis that lengthening over a nail can reduce the time spent in an external fixator and increase the rate of consolidation thereby reducing the risk of complications and improving patient satisfaction. We conducted a comprehensive literature search using the MEDLINE, EMBASE and PubMed databases using the key words ‘tibia’ or ‘tibial lengthening’ and ‘nail’. This search was performed in December 2011 and repeated by both authors. Specific outcome measures were the duration of external fixation, rate of consolidation and complication rates. A total of 6 comparative studies published between 2005 and 2011 consisting of 494 procedures met our inclusion and exclusion criteria and were eligible for critical appraisal. The methodological quality of the studies was variable, and they were not homogenous enough for meta-analysis. Patients who have tibial lengthening over an intramedullary nail spend significantly less time in an external fixator. However, there is no reliable evidence to suggest that the rates of consolidation or complication are any different to those lengthened without an intramedullary nail.



Annick den Daas, Wouter J. van Zuuren, Stéphane Pelet, Arthur van Noort, Michel P. J. van den Bekerom

Flexible stabilization of the distal tibiofibular syndesmosis: clinical and biomechanical considerations: a review of the literature

[Year:2012] [Month:November] [Volume:7] [Number:3] [Pages:7] [Pages No:123 - 129]

Keywords: Syndesmosis, Screw, Ankle fracture, Flexible implant, Instability, Biomechanical

   DOI: 10.1007/s11751-012-0147-2  |  Open Access |  How to cite  | 


Syndesmotic rupture is present in 10 % of ankle fractures and must be recognized and treated to prevent late complications. The method of fixation is classically rigid fixation with one or two screws. Knowledge of the biomechanics of the syndesmosis has led to the development of new dynamic implants to restore physiologic motion during walking. One of these implants is the suture-button system. The purpose of this paper is to review the orthopaedic trauma literature, both biomechanical and clinical, to present the current state of knowledge on the suture-button fixation and to put emphasis on the advantages and disadvantages of this technique. Two investigators searched the databases of Pubmed/Medline, Cochrane Clinical Trial Register and Embase independently. The search interval was from January 1980 to March 2011. The search keys comprised terms to identify articles on biomechanical and clinical issues of flexible fixation of syndesmotic ruptures. Ninety-nine publications met the search criteria. After filtering using the exclusion criteria, 11 articles (five biomechanical and six clinical) were available for review. The biomechanical studies involved 90 cadaveric ankles. The suture-button demonstrated good resistance to axial and rotational loads (equivalent to screws) and resistance to failure. Physiologic motion of the syndesmosis was restored in all directions. The clinical studies (149 ankles) demonstrated good functional results using the AOFAS score, indicating faster rehabilitation with flexible fixation than with screws. There were few complications. Preliminary results from the current literature support the use of suture-button fixation for syndesmotic ruptures. This method seems secure and safe. As there is no strong evidence for its use, prospective randomized controlled trials to compare the suture-button to the screw fixation for ankle syndesmotic ruptures are required.



K. Wegmann, J. Dargel, K. J. Burkhart, G. P. Brüggemann, L. P. Müller

The Essex-Lopresti lesion

[Year:2012] [Month:November] [Volume:7] [Number:3] [Pages:9] [Pages No:131 - 139]

Keywords: Essex-Lopresti lesion, Longitudinal forearm instability, Radial head fracture, Distal radio-ulnar joint, Interosseous membrane, Radial head prosthesis

   DOI: 10.1007/s11751-012-0149-0  |  Open Access |  How to cite  | 


The Essex-Lopresti lesion represents a severe injury of the forearm unit. In the 1940s, it's pathology and consequences have already been mentioned by several authors. Over the course of time, the pathophysiology of the lesion was displayed in more detail. Therefore, an intensive analysis of the involved anatomic structures was done. The interosseous membrane was shown to play a major role in stabilising the forearm unit, in the situation of a fractured radial head, which is the primary stabiliser of the longitudinal forearm stability. Moreover, biomechanical analyses showed a relevant attribution of the distal radio-ulnar joint to the forearm stability. If, in the case of a full-blown Essex-Lopresti lesion, the radial head, the interosseous membrane and the distal radio-ulnar joint are injured, proximalisation of the radius will take place and will come along with secondary symptoms at the elbow joint and the wrist. According to actual studies, the lesion seems to occur more often than realised up to now. Thus, to avoid missing the complex injury, subtle clinical diagnosis combined with adequate imaging has to be undertaken. If the lesion is confirmed, several operative treatment options are available, yet not proofed to be sufficient.


Original Article

Ismael Auñón-Martín, Pedro Caba Doussoux, Jose Luís León Baltasar, Elena Polentinos-Castro, Juan Pretell Mazzini, Carlos Resines Erasun

Correlation between pattern and mechanism of injury of free fall

[Year:2012] [Month:November] [Volume:7] [Number:3] [Pages:5] [Pages No:141 - 145]

Keywords: Free fall, Polytrauma, ISS, NISS, Mortality rate

   DOI: 10.1007/s11751-012-0142-7  |  Open Access |  How to cite  | 


To define the pattern of injury and aetiology of death of patients who have sustained major trauma due to high fall and its relationship with the mechanism of free fall. A total of 188 consecutive patients who sustained a high fall were included after the TRAUMASUR database was retrospectively reviewed. Demographic characteristics, severity scores, injury type, aetiology of high fall, mortality rate and aetiology of death were analysed. The mean age was 39.7 years (SD 15.5). The main aetiologies were work related (40.4 %) and suicide attempt (22.3 %). The mean injury severity score (ISS) and New Injury Severity Score (NISS) were 27.3 and 34.1, respectively. The most common cause of mortality within the intentional group was exsanguination (66 %), and the most frequent aetiology of death within the non-intentional group was endocranial hypertension (69 %). Differences were found with regard to the pattern of injuries and the aetiology of death according to the mechanism of free fall.


Original Article

S. D. Kaufman, J. A. Fagg, S. Jones, M. J. Bell, M. Saleh, J. A. Fernandes

Limb lengthening in congenital posteromedial bow of the tibia

[Year:2012] [Month:November] [Volume:7] [Number:3] [Pages:7] [Pages No:147 - 153]

Keywords: Limb lengthening, Posteromedial bow, Deformity correction

   DOI: 10.1007/s11751-012-0145-4  |  Open Access |  How to cite  | 


Congenital posteromedial bowing of the tibia (PMBT) is a rare condition affecting one lower limb. The bowing of the tibia usually resolves; however, there is associated limb length discrepancy (LLD), which often persists and can cause functional deficits. Advances in limb lengthening techniques allow this issue to be addressed, often with concomitant angular deformity correction. This study examined eleven patients who have had limb lengthening procedures with mean pre-operative LLD of 3.7 cm (range 1.5–5 cm), mean increase in length was 3.9 cm (range 1.5–5.8 cm), and mean LLD at last follow-up was less than 0.6 cm (range 0–2.0 cm). The main complications were minor or moderate grades, such as pin site infection. Greater LLD was found than previously reported, and we believe that the tertiary referrals were those of a severe form of PMBT. The authors conclude that in view of deformity with discrepancy, in select cases, correction and lengthening would be an option rather than only contralateral epiphysiodesis.


Original Article

G. Kouvidis, V. I. Sakellariou, A. F. Mavrogenis, J. Stavrakakis, D. Kampas, J. Galanakis, P. J. Papagelopoulos, P. Katonis

Dual lag screw cephalomedullary nail versus the classic sliding hip screw for the stabilization of intertrochanteric fractures. A prospective randomized study

[Year:2012] [Month:November] [Volume:7] [Number:3] [Pages:8] [Pages No:155 - 162]

Keywords: Dual lag screw intramedullary nail, Sliding hip screw, Intertrochanteric fractures

   DOI: 10.1007/s11751-012-0146-3  |  Open Access |  How to cite  | 


This study is a randomized prospective study comparing two fracture fixation implants, the extramedullary sliding hip screw (SHS) and the dual lag screw cephalomedullary nail, in the treatment of intertrochanteric femoral fractures in the elderly. One hundred and sixty-five patients with low-energy intertrochanteric fractures, classified as AO/OTA 31A, were prospectively included during a 2-year period (2005–2006). Patients were randomized into two groups: group A included 79 hip fractures managed with sliding hip screws and group B included 86 fractures treated with cephalomedullary nails. Delay to surgery, duration of surgery, time of fluoroscopy, total hospital stay, implant-related complications, transfusion requirements, re-operation details, functional recovery, and mortality were recorded. The mean follow-up was 36 months (24–56 months). The mean surgical time was statistically significantly shorter and fluoroscopy time longer for the group B. No intraoperative femoral shaft fractures occurred. There was no statistically significant difference in the functional recovery score, reoperation, and mortality rates between the 2 groups. A new type of complication, the so-called Z-effect phenomenon, was noticed in the cephalomedullary nail group. There are no statistically significant differences between the two techniques in terms of type and rate of complications, functional outcome, reoperation and mortality rates when comparing the SHS and the cephalomedullary nail for low-energy AO/OTA 31A intertrochanteric fractures. Our data do not support recommendations for the use of one implant over the other.


Original Article

C. Dall Oca, T. Maluta, F. Lavini, M. Bondi, G. M. Micheloni, P. Bartolozzi

Tibial plateau fractures: compared outcomes between ARIF and ORIF

[Year:2012] [Month:November] [Volume:7] [Number:3] [Pages:13] [Pages No:163 - 175]

Keywords: Tibial plateau fractures, ARIF, Arthroscopically assisted reduction, Post-traumatic arthrosis, External fixation

   DOI: 10.1007/s11751-012-0148-1  |  Open Access |  How to cite  | 


The purpose of this study is to compare arthroscopic assisted reduction internal fixation (ARIF) treatment with open reduction internal fixation (ORIF) treatment in patients with tibial plateau fractures. We studied 100 patients with tibial plateau fractures (54 men and 46 women) examined by X-rays and CT scans, divided into 2 groups. Group A with associated meniscus tear was treated by ARIF technique, while in group B ORIF technique was used. The follow-up period ranged from 12 to 116 months. The patients were evaluated both clinically and radiologically according to the Rasmussen and HSS (The Hospital for Special Surgery knee-rating) scores. In group A, the average Rasmussen clinical score is 27.62 ± 2.60 (range, 19–30), while in group B is 26.81 ± 2.65 (range, 21–30). HSS score in group A was 76.36 ± 14.19 (range, 38–91) as the average clinical result, while in group B was 73.12 ± 14.55 (range, 45–91). According to Rasmussen radiological results, the average score for group A was 16.56 ± 2.66 (range, 8–18), while in group B was 15.88 ± 2.71 (range, 10–18). Sixty-nine of 100 patients in our study had associated intra-articular lesions. We had 5 early complications and 36 late complications. The study suggests that there are no differences between ARIF and ORIF treatment in Schatzker type I fractures. ARIF technique may increase the clinical outcome in Schatzker type II–III–IV fractures. In Schatzker type V and VI fractures, ARIF and ORIF techniques have both poor medium- and long-term results but ARIF treatment, when indicated, is the best choice for the lower rate of infections.



Jane Halliday, Tim Hems, Hamish Simpson

Beware the painful nerve palsy; neurostenalgia, a diagnosis not to be missed

[Year:2012] [Month:November] [Volume:7] [Number:3] [Pages:3] [Pages No:177 - 179]

Keywords: Neurostenalgia, Limb lengthening, Decompression, Radial nerve

   DOI: 10.1007/s11751-012-0143-6  |  Open Access |  How to cite  | 


We present a case of painful radial nerve palsy following application of a humeral lengthening frame. At re-operation, the radial nerve was found to be compressed against a distal pin. This was re-sited providing immediate pain relief and a gradual resolution of the radial nerve palsy. Pain in association with a nerve palsy should alert the clinician to the possibility of nerve compression that may benefit from urgent decompression.


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