Strategies in Trauma and Limb Reconstruction

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2013 | April | Volume 8 | Issue 1

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David M. Rose, Toby O. Smith, Dominic Nielsen, Caroline B. Hing

Expandable intramedullary nails in lower limb trauma: a systematic review of clinical and radiological outcomes

[Year:2013] [Month:April] [Volume:8] [Number:1] [Pages:12] [Pages No:1 - 12]

Keywords: Tibial fracture, Femoral fracture, Expandable nail

   DOI: 10.1007/s11751-013-0156-9  |  Open Access |  How to cite  | 


This study systematically reviews the evidence-base for the use of expandable nails in the treatment of acute diaphyseal fractures of the lower limb. Both electronic and hand searches were undertaken of the published and grey literature to 1 December 2011. A total of 154 citations were identified, of which 15 were deemed suitable and assessed with the Critical Appraisals Skills Programme tool. A total of 625 nailing procedures were performed in 620 patients: 279 femoral and 346 tibial nails. The expandable nail was found to be significantly quicker to insert than interlocked nails (p < 0.05), and the total incidence of non-union or other complication was 13 and 14 % for expandable femoral and tibial nails, respectively. Notable complications with the expandable nail included fracture propagation on nail inflation in 2.5 % and post-operative shortening in 3.3 %. Device failure secondary to problems with the expansion mechanism was seen in 2.9 %. The rate of non-union and infection following expandable nailing was 3.1 and 1.4 %, respectively. Despite promising initial results, there remains a paucity of good quality studies to support the use of expandable nails over interlocked nails for the treatment of acute diaphyseal fractures of the lower limb.


Original Article

Guido Antonini, R. Giancola, D. Berruti, E. Blanchietti, P. Pecchia, V. Francione, P. Greco, T. C. Russo, L. Pietrogrande

Clinical and functional outcomes of the PCCP study: a multi-center prospective study in Italy

[Year:2013] [Month:April] [Volume:8] [Number:1] [Pages:8] [Pages No:13 - 20]

Keywords: Functional recovery, Percutaneous compression plate, Intertrochanteric femoral fracture, Reduced blood loss, Reduced transfusions, Femoral fixation

   DOI: 10.1007/s11751-013-0159-6  |  Open Access |  How to cite  | 


The standard surgical management of hip fractures is associated with tissue trauma and bleeding which are added to the fracture injury. The percutaneous compression plate (PCCP) is a minimally invasive device that has been demonstrated in previous studies to reduce postoperative complications and blood loss. This prospective, multi-center, observational study assessed clinical and functional outcomes with PCCP as treatment for trochanteric fractures. Patients with a stable or unstable proximal femoral fracture of type AO 31.A1 or 31.A2 were enrolled in eight hospitals in Italy. The primary outcome of interest was the recovery of the pre-fracture functional status at 1-year follow-up; secondary outcomes of interest included blood transfusions, surgical time, complications, and mortality. A total of 273 patients were enrolled. The ASA score was 3 or 4 in 72.5 % of patients. The mean surgical time was 44.1 min; the mean post-surgery blood transfusions was 0.9 units. At 1 year, 48 patients (17.6 %) died, 28 (10.2 %) were lost to follow-up, 4 patients (1.5 %) were excluded, hence 193 patients (70.3 %) were available for final evaluation. At the 1-year follow-up visit, 51.9 % of patients recovered or improved their pre-fracture modified Harris Hip Score, 49.1 % of patients improved or maintained their walking abilities, and 66.6 % of patients residing at home pre-surgery maintained their domicile. The overall mortality rate was 17.6 %. Major complications included two fracture collapses, one excessive sliding of the cephalic screw leading to a partial fracture collapse and one back-out of the diaphyseal screw. This study demonstrates that treatment of trochanteric fractures with PCCP gives good outcomes and significant advantages such as low blood loss, short surgical time, low risk of complications, and good functional recovery in the majority of the patients.


Original Article

Jens Christian Werlinrud, Kirstin Petersen, Jens Lauritsen, Søren Larsen, Henrik Schrøder

A prospective randomized study of conservative versus surgical treatment of unstable palmar plate disruption in the proximal interphalangeal finger joint

[Year:2013] [Month:April] [Volume:8] [Number:1] [Pages:4] [Pages No:21 - 24]

Keywords: Conservative versus surgical intervention, Hyperextension injury, Palmar ligament, PIP, Prospective randomized study, Proximal interphalangeal joint, Palmar fibrocartilage, Palmar plate

   DOI: 10.1007/s11751-013-0154-y  |  Open Access |  How to cite  | 


The aim of this study was to assess the effect of conservative versus operative treatment for unstable palmar plate disruption in the proximal interphalangeal (PIP) joint of the fingers with respect to preservation of joint stability, mobility, and pain. The study was conducted as a prospective study in which 83 patients were randomly assigned into 2 groups: (1) conservative treatment with a rigid splint for 2 weeks, (2) surgical reattachment of the palmar plate in local anesthesia followed by 2 weeks of immobilization in a plaster cast. Both groups were thereafter treated by taping to the neighboring finger for 3 weeks. With regard to hyperextension instability, stiffness, and pain, there is no significant difference in outcome between patients with traumatic palmar plate lesions and hyperextension instability treated with surgical repair and patients treated conservatively with a splint. We do not recommend primary surgical repair of unstable isolated palmar plate lesions in the proximal interphalangeal joints of the 4 ulnar fingers. Type of study/level of evidence Therapeutic, Level II.


Original Article

T. Monni, F. F. Birkholtz, P. de Lange, C. H. Snyckers

Conversion of external fixation to internal fixation in a non-acute, reconstructive setting: a case series

[Year:2013] [Month:April] [Volume:8] [Number:1] [Pages:6] [Pages No:25 - 30]

Keywords: External fixation, Internal fixation, Conversion, Limb reconstruction, Scoring system, Consolidation phase

   DOI: 10.1007/s11751-013-0157-8  |  Open Access |  How to cite  | 


The aim of the study is to determine the outcomes in patients who underwent conversion from an external fixator to an internal fixation device. This is a retrospective review of 18 patients (24 limbs) who underwent conversion from external to internal fixation. The patients had external fixators applied for traumatic bone defects or congenital deformities. Conversion to internal fixation was performed for reasons of patient dissatisfaction with external fixation, pin track sepsis, persistent non-union or refracture. The complexity of cases was graded using Paley's level of difficulty score. Patients were either converted acutely or delayed. Internal fixation devices were either intramedullary nails or plate and screws. Outcome was regarded as excellent if the patients were fully weight-bearing and pain-free on a mechanically well-aligned limb and without need for further surgery: good if the patient required subsequent surgery to achieve union and poor if irreversible complications occurred. Acute conversions (fixator removal and introduction of internal fixation device at same surgery) were done in 19 limbs and delayed conversion (interval between fixator removal and internal fixation) in 5. In the acute group, 17 limbs (89.4 %) had at least a good outcome, 16 of these limbs had an excellent result. Two limbs (10.6 %) had a poor result and required amputation. Both cases were after acute conversion to intramedullary nails; the original presenting diagnosis was of an infected non-union of the tibia and both had Paley scores above 7. In the delayed conversion group, all limbs (100 %) had at least a good outcome, with 4 limbs (80 %) having an excellent result. The mean external fixator time was 185 days (61–370). Both the cases with poor outcomes had longer external fixation times. This series supports the practice of conversion of external fixation to internal fixation with the majority of patients attaining good results. It identifies that plate devices appear to produce fewer deep sepsis complications, as compared to intramedullary nails, particularly when the original presenting diagnosis is a septic non-union.


Original Article

Mahmoud A. El-Rosasy, Sameh A. El-Sallakh

Distal tibial hypertrophic nonunion with deformity: treatment by fixator-assisted acute deformity correction and LCP fixation

[Year:2013] [Month:April] [Volume:8] [Number:1] [Pages:5] [Pages No:31 - 35]

Keywords: Tibia, Nonunion, Deformity, Internal fixation

   DOI: 10.1007/s11751-012-0150-7  |  Open Access |  How to cite  | 


Distal tibial hypertrophic nonunion with angular deformity has been successfully treated by circular external fixator. The inconvenience of the bulky external fixator and frequent pin tract infection would not be accepted in certain cases. This study included thirteen patients (mean age 39 years) with angular deformity of the distal dia-/metaphyseal tibial shaft. Five patients were originally treated by interlocking nail, three were treated by plate and screws fixation, four treated conservatively and one had deformity secondary to fracture of a lengthening regenerate. All patients were treated by osteotomy and acute correction of the deformity using temporary unilateral fixator and internal fixation by a locking compression plate (LCP). The external fixator was removed at the end of surgery. The results were evaluated both clinically and radiologically. All osteotomies healed within 3 (2–4) months. All patients were able to work within an average of 2.3 months. The function of the upper ankle joint was unrestricted in twelve cases, and in 1 case there was a mild functional deficit. The mean follow-up was 60 months (24–120). The frontal plane alignment parameters (the mechanical axis deviation, the lateral distal tibial angle and the medial proximal tibial angle) and the sagittal alignment parameters (the posterior proximal tibial angle and the anterior distal tibial angle) were within normal values postoperatively. No cases of deep infection or failure of fixation were encountered. Acute correction of distal tibial shaft hypertrophic nonunion with deformity and LCP fixation is a reliable option in well-selected cases.


Original Article

Mauricio Leal Mongon, Felipe Alberto Piva, Sylvio Mistro Neto, Jose André Carvalho, William Dias Belangero, Bruno Livani

Cortical tibial osteoperiosteal flap technique to achieve bony bridge in transtibial amputation: experience in nine adult patients

[Year:2013] [Month:April] [Volume:8] [Number:1] [Pages:6] [Pages No:37 - 42]

Keywords: Amputation, Surgical technique, Tibia, Fibula, Flap

   DOI: 10.1007/s11751-013-0152-0  |  Open Access |  How to cite  | 


Amputation, especially of the lower limbs, is a surgical procedure that gives excellent results when conducted under the appropriate conditions. In 1949 Ertl developed a technique for transtibial osteomyoplastic amputation which restored the intraosseous pressure through canal obliteration and expanded the area of terminal support through a bony bridge between the fibula and distal tibia. The aim of this study was to investigate the effectiveness of a modification of the original Ertl's technique in which a cortical osteoperiosteal flap created from the tibia is used to form a bony bridge during transtibial amputation in adults. Nine patients underwent leg amputations with the cortical tibial osteoperiosteal flap technique for reconstruction of the stump. The average duration of follow-up was 30.8 (range, 18–41) months. The post-surgery examination included a clinical examination and radiography. A 6-min walk test (Enright in Respir Care 48(8):783–785, 2003) was performed in the 32nd week after amputation. At 24th week post-surgery, all patients had stumps that were painless and able to bear full weight through the end. The creation of a cortical osteoperiosteal flap from the tibia to the fibula during transtibial amputation is a safe and effective technique that provides a strong and painless terminal weight-bearing stump. This constitutes a useful option for young patients, athletes, and patients with high physical demands.


Original Article

Alex Trompeter, Rohit R. Gupta

The management of complex periprosthetic humeral fractures: a case series of strut allograft augmentation, and a review of the literature

[Year:2013] [Month:April] [Volume:8] [Number:1] [Pages:9] [Pages No:43 - 51]

Keywords: Periprosthetic, Fracture, Humerus, Allograft, Strut, Reverse geometry

   DOI: 10.1007/s11751-013-0155-x  |  Open Access |  How to cite  | 


There is little published discussion on the management of postoperative periprosthetic humeral fractures where rotator cuff function is poor, the bone stock is dwindling or both. This is a phenomenon increasingly seen in the older, more osteoporotic population and presents an interesting challenge especially in when faced with these patients with poor bone quality. We present the treatment of three fractures with the use of long-stem reverse geometry arthroplasty and other surgical techniques more commonly reserved for periprosthetic fractures of the proximal femur such as cortical strut allograft augmentation. We believe revision to reverse geometry long-stem implant with cortical strut allograft augmentation to be safe and appropriate in the management of these complex injuries, although technically challenging, and has excellent initial and medium-term results.



Shabir A Dhar, Sharief Ahmed Wani, Tahir Ahmed Dar, Shahid Hussain, Reyaz Ahmed Dar, Abdul Rouf Malik

Open management of neglected inferior dislocation of the shoulder with proximal humeral fracture in an adolescent

[Year:2013] [Month:April] [Volume:8] [Number:1] [Pages:3] [Pages No:53 - 55]

Keywords: Fracture, Inferior dislocation, Bone shortening

   DOI: 10.1007/s11751-012-0151-6  |  Open Access |  How to cite  | 


Neglected dislocation of the shoulder is a rare condition with some cases of anterior and posterior dislocation being reported. We report a case with a fracture dislocation of the proximal humerus with the dislocated head lying inferior to the glenoid. We also report on the surgical management of a case with this extremely rare condition which required shortening of the distal fragment to reduce tissue tension.



K. Thomason, K. J. Burkhart, K. Wegmann, L. P. Müller

The sequelae of a missed Essex-Lopresti lesion

[Year:2013] [Month:April] [Volume:8] [Number:1] [Pages:5] [Pages No:57 - 61]

Keywords: Essex-Lopresti, Radial head fracture, Radial head resection, Complication, One bone forearm

   DOI: 10.1007/s11751-013-0153-z  |  Open Access |  How to cite  | 


Radial head fractures are the most common type of elbow fracture in adults. Unrecognised disruption of the intraosseous membrane at the time of injury can lead to severe wrist pain from proximal radial migration especially if the radial head is excised. In this case, despite anatomical reduction and internal fixation of the radial head fracture, longitudinal forearm instability developed after delayed radial head resection was performed 7 months post-injury. A Suave-Kapandji procedure was performed due to ongoing wrist pain. Because of the previous radial head resection, this led to a floating forearm that could only be solved by creating a one-bone forearm, sacrificing all forearm rotation to achieve a stable lever arm between the elbow and wrist joint.



Konstantinos N. Malizos, Maria Ioannou, Vasileios Kontogeorgakos

Ancient schwannoma involving the median nerve: a case report and review of the literature

[Year:2013] [Month:April] [Volume:8] [Number:1] [Pages:4] [Pages No:63 - 66]

Keywords: Benign neural sheath tumors, Ancient schwannoma, Neurilimoma, Median nerve

   DOI: 10.1007/s11751-013-0158-7  |  Open Access |  How to cite  | 


Ancient schwannomas are benign long standing schwannomas of the neural sheaths. Histological findings are these seen as in conventional schwannomas, but ancient schwannomas additionally demonstrate cystic hemorrhagic changes and degenerative nuclei with pleomorphism and hyperchromasia. Due to the nuclear atypia, and cystic degeneration, ancient schwannomas might be confused with malignant tumors on histology and imaging, leading to a radical surgical approach. The median nerve is rarely affected. We present a rare case of an ancient schwannoma involving the median nerve at the mid humerus. The tumor slowly grew up within ten years and become symptomatic with local pain, mild numbness in the distribution of the median nerve in the palm and Tinel's test. The tumor was successfully removed by separating it from the nerve fascicles to negative margins. Post-operatively local symptoms relieved but minor sensory loss in the median nerve distribution in the palm was noticed which improved in the following six months. Ancient schwannomas can be misdiagnosed as sarcomas due to specific imaging and histologic findings. Patients’ physical examination, history and fine radiologic and pathology features should be cautiously interpreted in order to achieve correct diagnosis and avoid unnecessary wide tumor excisions.


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