PURPOSE OF THE STUDY To improve the important torsional, bending and compressive stability in femoral neck fixation, locking plates have been the latest contribution. However, increased strength by restricted fracture motion may come at expense of an altered load distribution and failure patterns. Within locking plate technology, the important intermediate fracture compression may principally be achieved by multiple sliding screws passing through a sideplate fixed to the femur or connected to an interlocking plate not fixed to the femur laterally, sliding "en bloc" with the plate. While biomechanical studies may deliver the short-time patient safety requirements in implant development, no adequate failure evaluation has been performed with interlocking devices ex vivo in this setting. In the present biomechanical study, we analysed if a novel femoral neck interlocking plate with pins could improve fixation performance by changing the parameters involved in the failure mechanism in terms of fixation strength, fracture motion, load distribution and failure pattern. MATERIAL AND METHODS Sixteen pairs of human femurs with stable subcapital osteotomies were fixated by 2 pins or 3 pins interlocked in a plate using a paired design. Femurs were loaded non-destructively to 10° torsion around the neck axis, 200 N anteroposterior bending and 500 N vertical compression in 7° adduction with 1 Hz in 20 000 cycles, and were subsequently subjected to destructive compression to evaluate failure patterns. Bending stiffness, compressive stiffness and displacement from compressive testing reflected fracture motion. Torque and compression to failure replicated known failure mechanisms and defined strength. To evaluate load distribution, associations between biomechanical parameters and measured local bone mineral measurements by quantitative CT were analysed. RESULTS Interlocked pins increased mean strength 73% in torsion and 39% in compression (p = 0.038). Strength was related to all 4 regional mineral masses from the femoral head to subtrochanterically with interlocking (r = 0.64-0.83, p = 0.034), while only to mineral masses in the femoral head in compression and to the head, neck and trochanterically in torsion with individual pins (r = 0.67-0.78, p = 0.024). No difference was detected in fracture motion or failure pattern. DISCUSSION Within the last decade, angular stable implants have expanded our therapeutic arsenal of femoral neck fractures. Increased stability at the expense of altered devastating failure patterns was not retrieved in our study. The broadened understanding of the effect of interlocking pins by an isolated plate as in the current study involved the feature to gain fixation strength. By permitting fracture compression, and through a significant change of correlations between mechanical parameters and local bone mineral factors, a lateral redistribution of load with interlocked pins from the fragile bone medially to the more solid lateral bone was demonstrated. Regarding the long-term patient safety of interlocked pins and healing complications of non-union and segmental collapse of the femoral head, a definite conclusion may be premature. However, the improved biomechanics of an interlocking plate must be considered a favourable development of the pin concept. CONCLUSIONS Interlocked pins may improve fixation performance by a better load distribution, not by restricting fracture motion with corresponding altered failure patterns. This is encouraging and a challenge to complete further studies of the interlocking plate technology in the struggle to find the optimal treatment of the femoral neck fracture. Key words: femoral neck fracture, biomechanics, cadaver bone, bone mineral, internal fixation, locking plate, interlocked pins.

交锁髓内钉治疗胫骨骨折是近十几年来逐渐兴起并发展迅速的一种新的治疗方法.交锁髓内钉是在标准髓内钉上横行打孔并插入横向螺丝钉,将骨折近端或(和)远端与髓内钉锁在一起,用于控制骨折的短缩和旋转等移位.它通过横穿的锁钉与胫骨骨皮质相嵌,使髓内钉与整个胫骨连成一个整体,具有最大稳定性[1].因此,交锁髓内钉适用范围广,不仅可以固定简单的胫骨中下1/3横形或短斜形骨折,而且可以用来治疗各种类型的粉碎性胫骨骨折,如胫骨近端1/3处的骨折,胫骨干骨折,邻近踝关节的胫骨骨折.我院2001年下半年开始应用交锁髓内钉治疗各种胫、腓骨骨折26例,均取得满意疗效.

ObjectiveThis study aims to evaluate the costs and health outcome for surgical and conservative treatment of displaced proximal humeral fractures.DesignThis study is a randomised controlled trial.ParticipantsThis study included 50 patients aged 60 or older admitted to hospital with a severely displaced three- or four-part fracture.InterventionsThe patients were treated surgically with an angular stable interlocking implant (25 patients) or conservative treatment (25 patients).Main outcome measureThe outcomes measured included quality-adjusted life years (QALYs) and societal costs.ResultsAt 12 months’ follow-up, the mean difference in the number of QALYs was 0.027 (95% confidence interval (CI)=−0.025, 0.078) while the mean difference in total health-care costs was €597 in favour of surgery (95% CI=−5291, 3777).ConclusionThere was no significant difference in QALYs or costs between surgical and conservative treatment of severe displaced proximal humeral fractures.

Background: Some observations indicate a difference in nutritional factors between elderly patients suffering different type of fractures in the proximal femur. To elucidate this we performed over a two months period a cross sectional study of 39 elderly patients admitted to Aker university Hospital due to a fracture in the hip. Methods: Patients admitted to Aker University hospital HF, during a 2 months time period, with a proximal femur fracture needing surgery were included in the project. At time of fracture, the patients were weighed using a class 3 chair scale. Length was measured with a tape measure at bed rest. At the follow up, 3 months later, this was confirmed by standing measurement. Body Mass Index (BMI) was calculated. Activity of daily living, ADL, was recorded by the investigator 3 days postoperatively. A trained nutritionist carried out a Mini Nutrition Assessment at 3 months check up, the ADL was reassessed and Harries hip score recorded. Body composition: Bone Mineral Density (BMD) Bone Mineral Content (BMC), Lean Body Mass (LBM) and Fat Content (FC) was measured using dual X-Ray Absorptiometry (DEXA). Nine healthy patients, aged and sex matched, without a fracture history were examined as a control group. Results: Thirty-nine patients were included in the study. Both groups tended to be free living in their homes, 83% and 100%, respectively. Fifty nine percent of the patients broke their hip at home. The persons in the control group were healthier then the patient group. The control group scored better on Harries Hip score. No difference could be observed in ADL between the two groups. Comparing ADL at admission to hospital with ADL at 3 months check up, showed a declining trend. The mean BMI of the control group was higher than for the patient group. Although not significant at this stage in the project, the trend was also for the control group to score higher in mean BMD. The larger difference between BMD and BMC values between the groups indicated the BMC value to be more representative for Bone quality.1 The controls scored better in both Lean Body Mass (LBM) and Fat-content (FC). The patients with trochanteric fractures showed better nutritional values than the patients with medial fractures. The neck group scored on average low in the Mini Nutrition Assessment, indicating the patients being mal nourished. The trochanteric group scored lower then the control group indicating this group being at risk for malnutrition. BMI in the trochanteric group of patients was higher than for the neck group. There was no difference in BMD, BMC, LBM or FC between these two groups. Discussion: This study seems to confirm the assumption that malnutrition is a significant factor in proximal femoral fractures in the elderly and that there is a difference between patients with different fracture types in body composition.

Osteoporosis, or loss of bone mass and microarchitectural deterioration of bone tissue, does not only enhance risk of fracture but also represents a problem in osteofixation of fractures in fracture treatment. Aging of the western population changes the epidemiology of fractures. An increasing socioeconomic interest in geriatric traumatology makes the need for much urgent study in the field of osteoporotic fractures self evident. It is no longer the province of only one medical group to look for fragmented solutions in the treatment of osteoporotic fractures. Efforts have to be united across professional boundaries to meet the challenge of this problem. Assessment of bone mineral may be used in evaluation of fracture risk but also in the choice of implant as well as in the design of implants used in fracture treatment. The differences in mechanical properties of different types of bone in the same individual have to be respected. Changes in the pattern of fractures and problems with implant anchorage in bone, due to a demographic increase in patients with osteoporosis remain problems requiring new solutions. Still basic principals in fracture treatment may not be eclipsed by new fixation devices.

Objective: To assess short-term functional results in 2 types of syndesmotic fixation, comparing the traditional rigid quadricortical syndesmotic screw fixation with a more dynamic tricortical screw fixation.Design: Prospective, randomized clinical study.Setting: University clinic, level 1 trauma center.Patients: Sixty-four patients with closed ankle fractures in which the syndesmosis was found to be unstable intraoperatively.Intervention: The unstable syndesmoses were fixed with either one 4.5-mm cortical screw through both tibial cortices (n = 30) or two 3.5-mm cortical screws engaging only 1 cortex of the tibia (n = 34). The quadricortical screws were routinely removed after 2 months, whereas the tricortical screws were removed only in the case of discomfort. Rehabilitation was the same in both groups.Results: The Olerud Molander functional score (0-100) was significantly higher in the tricortical group (77 points) compared with the quadricortical group (66 points) (P = 0.025) at 3 months. After I year, however, the functional score was not significantly higher (P = 0.192) in the tricortical group (92.6 points) compared with the quadricortical group (85.7 points). Pain was significantly lower in the tricortical group (P = 0.017) after 3 months, but there was no significant difference after 1 year. There was no significant difference in dorsiflexion between the groups at any point of time. No losses of fixation were detected. The tricortical screws were removed in 2 patients due to migration.Conclusions: Syndesmosis fixation with 2 tricortical screws is safe and improves early function. After 1 year, however, there were no significant differences between the 2 groups in functional score, pain, and dorsiflexion.

On the basis of previous studies showing good correlations between the structural strength of the femur and bone mass as assessed by single energy quantitative computed tomography, this study was scheduled to analyze the mode of failure of an oblique osteotomy in the distal femur in geriatric cadavers stabilized by an AO condylar plate and Grosse-Kempf locked intramedullary nail in axial eccentric loads and to relate the mode of failure to bone mineral content. A pilot study of two pairs of osteotomized, internally fixed femora were loaded axially and the loads correlated with bone mineral content. These correlations were used to calculate estimated failure load in 12 pairs of osteotomized femora (12 plated and 12 nailed specimens) which then were sustained to a cyclic eccentric axial load of 50% of the estimated failure load. The failure patterns in the two groups were different. Fixation failure occurred in all specimens in the plated group at the site of the osteotomy, while in the nailed group the fixation failures in 50% of the specimens were unrelated to the site of the osteotomy. The study suggests that locked intramedullary nailing of a distal femoral fracture in osteoporotic bone gives more secure fracture retention than fixation with a 95-degrees AO/ASIF condylar plate. Furthermore, it shows that bone mineral assessment by densitometric methods can be used to predict the mechanical strength of a bone/implant construct.

We performed a prospective registration of primary soft tissue injuries and perioperative soft tissue complications the first 3 months after surgery in ankle fractures treated by open reduction and internal fixation. Open fractures and polytraumatized patients were excluded. The 154 consecutive patients (90 women) with an average age of 54.5 (S.D. 18.3) years were registered. Primary soft tissue injuries according to Tscherne's classification were noted in 22 patients (14.2%). Major perioperative soft tissue complications requiring revision occurred in five patients (3.2%). Minor perioperative soft tissue complications treated non-operatively occurred in 29 patients (18.8%). A significantly higher incidence of perioperative soft tissue complications occurred in alcohol abusers (P=0.043), after high-energy trauma (P=0.043), and after primary soft tissue injuries (P=0.004). Other possible risk factors such as age, gender, fracture type, diabetes, arteriosclerosis, coronary heart disease, and hypothyroidism had no statistically significant influence on the incidence of perioperative soft tissue complications.

In a prospective, randomised trial, we compared the use of three Ullevaal hip screws with that of two Hansson hook-pins in 278 patients with fractures of the femoral neck. Background factors were similar in both groups. Follow-up was for two years. There were no significant differences between the groups in length of time of surgery, hospital stay, general complications, mortality, pain or walking ability. Likewise, the rates of early failure of fixation, nonunion, and the need for reoperation did not differ significantly between the groups. The use of hook-pins was associated with less drill penetrations of the femoral head during surgery (odds ratio 2.6, p= 0.05) and a lower incidence of necrosis of the femoral head (odds ratio 3.5, p = 0.04). There was a strong relationship between poor reduction and fixation of the fracture and subsequent reoperation (p = 0.0005 and p = 0.0001, respectively). Likewise, peroperative drill penetration of the femoral head was associated with a greater risk of reoperation (p = 0.038). Both methods gave favourable results. In total, 22% of the patients needed a major reoperation (usually hemiarthroplasty), while in 7% of the cases the fixation device needed to be removed. Osteosynthesis as the sole method for operation of all fractures of the femoral neck was thus successful in 78% of patients. With selective treatment most of the remaining patients would have benefited if treated by a primary arthroplasty. Accurate selection requires the development of better prognostic methods.

In a prospective, randomised trial, we compared the use of three Ullevaal hip screws with that of two Hansson hook-pins in 278 patients with fractures of the femoral neck. Background factors were similar in both groups. Follow-up was for two years.There were no significant differences between the groups in length of time of surgery, hospital stay, general complications, mortality, pain or walking ability. Likewise, the rates of early failure of fixation, nonunion, and the need for reoperation did not differ significantly between the groups. The use of hook-pins was associated with less drill penetrations of the femoral head during surgery (odds ratio 2.6, p = 0.05) and a lower incidence of necrosis of the femoral head (odds ratio 3.5, p = 0.04). There was a strong relationship between poor reduction and fixation of the fracture and subsequent reoperation (p = 0.0005 and p = 0.0001, respectively). Likewise, peroperative drill penetration of the femoral head was associated with a greater risk of reoperation (p = 0.038). Both methods gave favourable results. In total, 22% of the patients needed a major reoperation (usually hemiarthroplasty), while in 7% of the cases the fixation device needed to be removed. Osteosynthesis as the sole method for operation of all fractures of the femoral neck was thus successful in 78% of patients. With selective treatment most of the remaining patients would have benefited if treated by a primary arthroplasty. Accurate selection requires the development of better prognostic methods.

The influence of perioperative Soft tissue complications on the functional outcome after open reduction and internal fixation of closed ankle fractures was Investigated. Eighty-eight consecutive patients were followed 3.7 years (SD +/- 0.6) after the injury. Two major and 21 minor soft tissue complications were registered. Average dorsal extension was 29.9 degrees (range four to 54, SD +/- 9.5) of the fractured ankles and 37.2 degrees (range eight to 60, SD +/- 9.1) of the non-fractured ankles. The average subjective functional score was 84.6 (range 40 to 100, SD +/- 14.9). A significant difference was found with respect to the subjective functional score (p = 0.048, Kruskal-Wallis test) but not with respect to dorsal extension (0.358, Kruskal-Wallis test) when comparing groups of minor, major and no soft tissue complications. This study suggests that major soft tissue complications have a negative effect on the long-term functional outcome after surgical repair of an ankle fracture. Minor soft tissue complications, primary skin problems, the timing of primary surgery and fracture types according to AO/ASIF have no or minor influence on the long-term functional result. This study confirms previous reports that the presence of osteoarthritis is frequently associated with a reduced functional outcome.

BACKGROUND AND AIMSOpen reduction and internal fixation of an extensively swollen ankle may lead to wound closure problems, blistering, wound edge necrosis and infection. Accordingly, internal fixation should be accomplished either before or after the period of critical soft tissue swelling. The object of the study was to investigate if the timing of surgery had any influence upon soft tissue complications and hospital stay.PATIENTS AND METHODSThe clinical course of the first 6 postoperative weeks of 84 closed ankle fractures treated by open reduction and internal fixation were reviewed. Seventeen patients were not operated on early due to lack of operative capacity and were thus operated on after 5 days or more. These patients were compared to the patients operated on within 8 hours (n = 67). The groups were comparable with respect to age, gender and fracture types.RESULTSDespite a higher incidence of primary soft tissue injuries in the early group, the patients operated on delayed had a higher incidence of wound infections (17.6% vs. 3.0%) and hospital stay was prolonged with 12.4 days compared to early surgery. All wound infections were found in grossly displaced fractures despite adequate closed reduction immediately after arrival in the hospital.CONCLUSIONSDelayed surgery of closed ankle fractures increases the risk of soft tissue complications and prolongs hospital stay. Immediate surgery is particularly indicated in the severely displaced ankle fracture, and if not achievable, temporary reduction and immobilization is recommended.

The end result after open reduction and internal fixation in distal leg fractures is jeopardized by soft tissue complications. Functional conservative treatment of the same type of fractures often results in delayed and non-union, malunion or non-optimal functional result concerning ankle mobility. Mini-invasive plateosteosynthesis was performed in ten patients with sustained juxta or intra-articular fractures of the distal tibia. In all patients, stable osteo-fixation could be achieved and soft tissue complications did not affect the final result in any of the patients. Mini-invasive plateosteosynthesis seems to be a good treatment alternative in extra- or intraarticular fractures of the distal leg.

The charts of 118 consecutive ankle fractures were reviewed. The patients' age, sex, energy of trauma, hospital stay, need for traction therapy, syndesmosis fixation and soft-tissue problems were related to the various types of fractures according to the AO classification. An interobserver check study revealed an agreement of 0.61 (kappa), which is considered good. The age of the patients with A-fractures was 33 years (SD +/- 13), B-fractures 56 years (SD +/- 18), and C-fractures 48 years (SD +/- 16). The age differences within these groups were highly significant (P < 0.005). The highest average ages were found in the patients with B2 and B3 type fractures, 57 and 61 years, respectively. Women were significantly older than men (P < 0.0001), and 61% of the patients were women. Perioperative problems, such as wound margin necrosis and infections, were significantly related to fracture types B2 and B3. Preoperative traction therapy was necessary in the least stable fractures, of which all but one C1 fracture were B2/3 type fractures. The energy of trauma was not related to perioperative problems. The period of hospitalisation was significantly longer in the patients with B2/B3 type fractures (P < 0.001). Judging by the significantly higher incidence of perioperative complications, longer hospital stay, and predominance of instability and skin damage in the AO B2 and B3 type fractures, these fractures may benefit from more attentive and urgent care.

The charts of 118 consecutive ankle fractures were reviewed. The patients’ age, sex, energy of trauma, hospital stay, need for traction therapy, syndesmosis fixation and soft-tissue problems were related to the various types of fractures according to the AO classification. An interobserver check study revealed an agreement of 0.61 (kappa), which is considered good. The age of the patients with A-fractures was 33 years (SD ± 13), B-fractures 56 years (SD ± 18), and C-fractures 48 years (SD ± 16). The age differences within these groups were highly significant (P < 0.005). The highest average ages were found in the patients with B2 and B3 type fractures, 57 and 61 years, respectively. Women were significantly older than men (P < 0.0001), and 61% of the patients were women. Perioperative problems, such as wound margin necrosis and infections, were significantly related to fracture types B2 and B3. Preoperative traction therapy was necessary in the least stable fractures, of which all but one C1 fracture were B2/3 type fractures. The energy of trauma was not related to perioperative problems. The period of hospitalisation was significantly longer in the patients with B2/B3 type fractures (P < 0.001). Judging by the significantly higher incidence of perioperative complications, longer hospital stay, and predominance of instability and skin damage in the AO B2 and B3 type fractures, these fractures may benefit from more attentive and urgent care.

The subject of this report is the evaluation of 46 comminuted displaced intraarticular calcaneal fractures in 40 patients treated by open reduction and internal fixation. The results were validated by a score based on objective findings and a subjective gradation obtained by a visual analyzing score (VAS). The results were excellent or good in 30 treated fractures, while the results in 9 fractures were validated as satisfactory and in 7 as unsatisfactory. The results concerning disability and need for workman's compensation were promising in patients who had suffered fractures known to result in a high disability and compensation rate.