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To clarify the factors affecting functional results of fracture-dislocations of the proximal interphalangeal (PIP) joint treated by open reduction and internal fixation (ORIF), 60 patients, including 38 patients with a dorsal fracture-dislocation and 22 with a pilon fracture, were analysed. The mean ratio of articular surface involvement was 48.5% and a depressed central fragment existed in 75.3% of the cases. ORIF was performed in 47 patients through a lateral approach using Kirschner wires and in 13 through a palmar approach using a plate or screws. The mean flexion, extension and range of motion (ROM) of the PIP joint was 89.5°, 11.5° and 78.0°, respectively. Stepwise regression analysis revealed that a delayed start of active motion exercise after surgery, elderly age and ulnar ray digit were factors affecting functional outcomes. Although ORIF allows accurate restoration of the articular surfaces, an early start of motion exercise is essential for good results.

The purpose of this scoping review was to identify and describe the current body of evidence on internal fracture fixation devices that require compression screws. Electronic literature searches were conducted and 665 unique studies were included. Investigations on avulsion fractures represented a small proportion of these studies (45 studies), the remainder being those on patients with fractures with vascular compromise risk. The most common type of avulsion injury investigated was tibial avulsion fractures, followed by fifth metatarsal and calcaneal avulsions. For vascular compromised fractures, greater than half of the studies were on femoral neck injuries while scaphoid injury studies also represented a substantial proportion of this evidence base. Most of the studies were case series and there was limited randomized clinical trial evidence. A total of 429 studies provided sufficient information on the devices used in their investigation; DePuy-Synthes and Acumed ranked as the top two companies in cumulative publications over the last decade. There is a large body of evidence on internal fixation compression screw devices used in the management of fractures; however, the literature is generally dominated by non-comparative research studies. Opportunities to improve the evidence base are large. Manufacturer priority on evidence-based product development is key to ongoing research inquiry.

The objective of this work is to develop a first level approximation hybrid model that predicts the rate of reduction of the elastic modulus for a composite internal fixation plate. The first level model combines a modified composite theory in which the bioresorbable constituent moduli and volume fractions are time-dependent, with predictions from a Finite Element (FE) model, but ignores viscoelastic effects. The FE model is used to predict relationships between geometrical constraints (material interfaces), while a theoretical combined elastic modulus is determined using the Reuss model. The composite internal fixation device design comprises Poly-L-lactide and Hydroxyapatite (HA/PLLA) and Titanium. The geometrical relationships established by the FE static model are combined with the theoretical mathematical model in order to predict the rate of decrease of the elastic modulus of the composite device. The first level model predicts that the composite plate modulus decreases at a rate that appropriately compensates for the increasing modulus of the healing bone during fracture healing. This suggests that the proposed composite fixation plate has a strong potential for improved fracture healing through the reduction of stress shielding while the fracture heals, and the elimination of stress shielding after fracture healing.

The aim of this paper is to compare the biomechanical characteristics of a newly designed assembly locking compression plate (NALCP) and traditional locking compression plate (LCP) for internal fixation of femoral-shaft comminuted fractures. A femoral-shaft wedge fracture model (AO classification 32-C2.1) was created in six pairs of femoral specimens ($n=12$) randomly divided into two equal groups. Biomechanical properties were tested with axial and torsional loading tests. The relative maximum displacement of fracture blocks and strain was recorded. A strain diagram was made; the fatigue test results of NALCP specimens under axial load were recorded. Under axial load, the relative maximum displacement of fracture blocks in the $X$, $Y$, and $Z$ axes was smaller in NALCP specimens than in LCP specimens ($P<0.05$ and 0.01, respectively). Under torsional load, the relative maximum displacement of fracture blocks in the $X$ and $Z$ axes in NALCP specimens was less than that in LCP specimens ($P<0.01$) but no statistically significant difference in the $Y$ axes ($P>0.05$) was found. In both cases, the main NALCP strain was higher than the LCP strain ($P<0.01$) but no statistically significant difference in mean strain ($P>0.05$) was found. Our NALCP provides strong mechanical stability for comminuted femoral fractures and can effectively avoid stress concentration, reduce stress shielding, and facilitate bone healing.

This study investigated the effect of two surgical treatment schemes on complex proximal humeral fractures. We included 60 patients with complex proximal humeral fractures admitted to the People’s Hospital of Zhongjiang County, China, from May 2016 to May 2017. The patients were randomly divided into group A (30 cases; intramedullary nail fixation) or group B (30 cases; plate internal fixation) to compare the therapeutic effects. We used Neer’s scoring system to calculate an acceptability ratio and assess pain six weeks after surgery. The acceptability ratio was 80.0% in group A and 93.3% in group B, and the ratio did not differ between the groups ($P>0.05$). In groups A and B, 56.7% and 50% of patients were without pain, respectively; this rate did not differ between the groups ($P>0.05$). Our results indicate that both methods are suitable for treating complex proximal humeral fractures. However, in practice, surgeons should select the most appropriate treatment method based on the actual fracture to ensure the best postoperative outcome with the least amount of pain.

Metacarpals are unique bones that support the finger to aid hand function. Metacarpals are also the commonest bones to get fractured in the hand. Historically, most metacarpal fractures were managed conservatively. Due to increased patient expectations as well as advancements in diagnosis and osteosynthesis, various surgical options are now available for metacarpal fractures. The goal of operative management of metacarpal management is no longer limited to achieving clinical or radiological union. To restore hand function to a preinjury level, the surgeon must achieve adequate anatomical reduction and stable fixation with minimal soft tissue damage. Similar to tendon repair, to start early active motion should be the goal after metacarpal fracture fixation. Intraoperative consideration should also include minimizing soft tissue damage and avoiding tendon, ligament or capsular entrapment. The aim of this article is to explain the principles of surgical management, the different options available for metacarpal fractures, the techniques, pearls, advantages and disadvantages of each technique, so the surgeon can choose the ideal option to achieve the best result.

Background: Volar locking plates have provided the capability to repair both simple and complex fractures. However, complications related to the inability to fix or to maintain the fixation of some fracture patterns have been reported with volar locking plates. The purpose of this study was to evaluate the results of dorsal plating treatment for specific pattern of fractures.

Methods: Patients with distal radius fractures were retrospectively evaluated. Inclusion criteria for this study were those related to the patient and treatment (adult patients, internal fixation with dorsal plating, a minimum follow-up of 12 months), and those related to the fracture pattern (displaced central articular fragment, volar distal fracture line not enough to allow volar fixation, displaced dorsal-ulnar fragment, dorsal partial fractures, combination of these patterns). Clinical outcome information including active range of motion, radiographs, PRWE and DASH questionnaires were collected. Complications were recorded.

Results: During a 6-year period, 679 distal radius fractures were treated with open reduction and internal fixation. Of these, 27 patients fulfilled the inclusion criteria. Patients were examined at a median of 34 months’ follow-up. All but pronation, supination, and radial deviation had a statistically significant difference compared to the opposite side. The median score on the DASH was 4.5 and 3.2 on the PRWE. No patient suffered loss of reduction during the follow-up nor were tendon ruptures recorded.

Conclusions: Although most of the distal radius fractures can be treated with volar locking plates, almost 5% of them present specific patterns that are amenable to treatment with dorsal fixation, without postoperative loss of reduction. These specific patterns are: (1) displaced central articular fragment, (2) volar distal fracture with less of 1cm distance from the distal volar edge of the radius, (3) displaced dorso-ulnar fragment, (4) Barton’s fracture, (5) combination of these patterns.

Background: Open reduction and internal fixation with a plate is one of the alternative treatments for fracture–dislocation of the proximal interphalangeal (PIP) joint. However, it does not always lead to satisfactory results. The aim of this cohort study is to describe the surgical procedure and discuss the factors affecting the treatment results.

Methods: We retrospectively reviewed 37 cases of consecutive unstable dorsal fracture–dislocation of the PIP joint treated using a mini-plate. The volar fragments were sandwiched with a plate and dorsal cortex, and screws were used as subchondral support. The average rate of articular involvement was 55.5%. Five patients had concomitant injuries. The mean age of the patients was 40.6 years. Mean time between injury and operation was 11.1 days. The average postoperative follow-up duration was 11 months. Active ranges of motion, % total active motion (TAM) were evaluated postoperatively. The patients were divided into two groups according from Strickland score and Gaine score. Fisher’s exact test, Mann–Whitney U test and a logistic regression analysis were used to evaluate the factors affecting the results.

Results: The average active flexion, flexion contracture at the PIP joint, and % TAM were 86.3°, 10.5° and 80.6%, respectively. Group I included 24 patients who had both excellent and good scores. Group II included 13 patients who had neither excellent nor good scores. When the groups were compared, there was no significant relationship between the type of fracture–dislocation and the extent of articular involvement. There were significant associations between outcomes and patient age, period from injury to surgical intervention and presence of concomitant injuries.

Conclusions: We concluded that meticulous surgical technique leads to satisfactory results. However, factors, including the patient’s age, time from injury to surgery and the presence of concomitant injuries needing adjacent joint immobilisation, contribute to unsatisfactory outcomes.

Level of Evidence: Level IV (Therapeutic)

Background: This study introduces a novel method for the management of closed metacarpal neck fractures. Kirschner wires (K-wire) are introduced in a retrograde and the wires withdrawn through skin proximally at the base of the metacarpal. The fracture is reduced using traction and the reduction is maintained by antegrade advancement of the K-wires. The aim of this study is to report the outcomes of this technique.

Methods: A total of 36 patients with severely angulated closed metacarpal neck fractures underwent reduction and fixation using this novel method from January 2017 to December 2020 in centres in Ireland and Saudi Arabia. We performed a retrospective review of these patients’ clinical data examining their outcomes.

Results: Six months postoperatively, all fractures demonstrated bony union and correction of angulation. All patients exhibited excellent range of motion (ROM) with no significant impairment of hand function.

Conclusions: The method detailed here is a simple, minimally invasive and reliable technique that has not previously been described. It is suitable for use in the management of closed metacarpal neck fractures of the fourth and fifth metacarpal, with dorsal angulation greater than 60°.

Level of Evidence: Level IV (Therapeutic)

Background: Intra-articular fractures of the proximal interphalangeal joint (PIPJ) can result in poor outcomes if inadequately treated. Dynamic external fixation and internal fixation with plates and/or screws are two treatment options. The role of combining these two methods is unclear. The aim of this study is to determine the outcomes of patients with intra-articular fractures of the PIPJ treated with a combination of dynamic external fixation with a plate and/or screws.

Methods: A retrospective review was conducted on 18 consecutive cases of intra-articular fractures of the PIPJ treated with pins and rubber band traction system (PRTS) combined with dorsal internal fixation with plates and/or screws. The patients’ average age was 51 years (range: 20–81 years). The fracture patterns were volar-type (n = 2), dorsal-type (n = 4) and pilon-type (n = 12). Data with regard to time to surgery, interphalangeal joint range of motion, grip strength, VAS for pain, Quick DASH score, complications, duration of follow-up and return to work were collected.

Results: The levels of articular involvement were stable (n = 1), tenuous (n = 5) and unstable (n = 12). The average time to surgery was 9 days, and the average follow-up period was 15 months. The fracture was fixed with a dorsal plate and screws in 10 patients and with only screws in eight patients. All patients had PRTS. All patients returned to their original occupation and the fractures united in good alignment. The average grip strength was 86% of that of the unaffected side. The average active PIPJ motion was 85° (range: 50°–106°), and the average active distal interphalangeal joint (DIPJ) motion was 48° (range: 10°–90°).

Conclusions: Our results show that a combination of PRTS and open reduction and fixation with plate and/or screws achieved a good range of motion and articular reduction.

Level of Evidence: Level IV (Therapeutic)

Comminuted fractures of the radial head still present significant technical and surgical challenges. In this article, we describe a novel fixation of comminuted radial head fractures with the help of an intramedullary nail. Experiments with solid, conventionally machined intramedullary nails showed some major drawbacks in the fixation of radial head fractures. Several design and manufacturing procedures were proposed. The general idea behind the new design was the concept of a nail which would eliminate the need for prefabricated bores. Experiments with a selective laser sintered thin-walled nail, designed with the help of CT images, fulfilled expectations. This thin-walled proximal radius nail thus offers a stable fixation of the radial head fracture fragments, with the ability to preserve the existing vascular supply to the radial head fragments, and therefore not just use the reconstructed radial head as a bioprosthesis.

Implant failure due to inadequate bone screw fixation, particularly in the osteoporotic bone, is a frequent complication. Studies showed a significant improvement in screw stability of external fixation treatments when employing hydroxyapatite (HA) coated screws. We studied whether coating screws with osteoconductive materials could similarly improve screw stability in internal fixation. Forty-eight AO/ASIF cortical screws were divided into Group A: stainless steel; Group B: HA-coated stainless steel; and Group C: titanium (Ti)-coated Ti screws which were implanted randomly into the femurs and tibiae of six sheep. Insertion torque was 2,000 N/mm. At one and three months Group A’s extraction torque was lower than its insertion torque (p<0.001) while Group B and D’s extraction torque was higher than their insertion torque (p<0.001). Screws coated with osteoconductive materials provided higher stability than standard screws and should be used to improve fixation stability and reduce postoperative complications caused by screw instability.