Severely impacted valgus proximal humeral fractures : surgical technique

Background: The functional results associated with nonoperative treatment of severely impacted valgus fractures of the proximal part of the humerus are poor, and these injuries are difficult to treat with minimally invasive percutaneous fixation techniques. The aim of this study was to review the functional and radiographic results and complications of a new operative technique in a series of twenty-five patients.

Methods: Over a two-year period, we treated twenty-nine patients with a severely impacted valgus fracture of the proximal part of the humerus. Three patients were lost to follow-up and one died, leaving twenty-five patients who were available for the study. In all of the fractures, the head-shaft angle had been tilted into > or = 160 degrees of valgus and the greater tuberosity was displaced by >1 cm. All patients were treated with open reduction of the fracture, and the space created behind the humeral head was filled with Norian Skeletal Repair System (SRS) bone substitute. The fractures were stabilized with either screws or buttress plate fixation. Associated rotator cuff tears were repaired. All patients underwent functional outcome assessment with use of the Constant, DASH (Disabilities of the Arm, Shoulder and Hand), and SF-36 (Short Form-36) scores at one year, and twelve patients were followed for two years.

Results: All fractures united within the first year, all reductions were maintained, and no patient had signs of osteonecrosis of the humeral head on the latest follow-up radiographs. At one year, the median Constant score was 80 points and the median DASH score was 22 points. The functional results continued to be satisfactory in the twelve patients who were followed for two years. The results in our series were better than those achieved in studies of nonoperative treatment of similar fracture configurations. There were six clinically relevant complications, although none required a reoperation and all six patients had a satisfactory short-term functional outcome.

Conclusions: Internal fixation of severely impacted valgus fractures of the proximal part of the humerus, supplemented by Norian SRS bone substitute to fill the proximal humeral metaphyseal defect, produces good early functional and radiographic outcomes. Additional follow-up will be required to assess whether these initially satisfactory outcomes are maintained over the longer term.

Biomechanical studies: science (f)or common sense?

 Introduction: It is our impression that many biomechanical studies invest substantial resources studying the obvious: that more and larger metal is stronger. The purpose of this study is to evaluate if a subset of biomechanical studies comparing fixation constructs just document common sense. Methods: Using a web-based survey, 274 orthopaedic surgeons and 81 medical students predicted the results of 11 biomechanical studies comparing fracture fixation constructs (selected based on the authors' sense that the answer was obvious prior to performing the study). Sensitivity, specificity, and accuracy were calculated according to standard formulas. The agreement among the observers was calculated by using a multirater kappa, described by Siegel and Castellan. Results: The accuracy of predicting outcomes was 80% or greater for 10 of 11 studies. Accuracy was not influenced by level of experience (i.e., time in practice and medical students vs. surgeons). There were substantial differences in accuracy between observers from different regions. The overall categorical rating of inter-observer reliability according to Landis and Koch was moderate (k = 0.55; standard error (SE) = 0.01). Conclusion: The results of a subset of biomechanical studies comparing fracture fixation constructs can be predicted prior to doing the study. As these studies are time and resource intensive, one criterion for proceeding with a biomechanical study should be that the answer is not simply a matter of common sense. © 2014 Elsevier Ltd. All rights reserved.

Interobserver reliability of coronoid fracture classification : two-dimensional versus three-dimensional computed tomography

Purpose : This study tests the hypothesis that 3-dimensional computed tomography (CT) reconstructions improve interobserver agreement on classification and treatment of coronoid fractures compared with 2-dimensional CT.

Methods : A total of 29 orthopedic surgeons evaluated 10 coronoid fractures on 2 occasions (first with radiographs and 2-dimensional CT and then with radiographs and 3-dimensional CT), separated by a minimum of 2 weeks. Surgeons classified fractures according to the classifications of Regan and Morrey and of O'Driscoll et al., identified specific characteristics, recommended the most appropriate treatment approach, and made treatment recommendations. The kappa multirater measure (κ) was calculated to estimate agreement between observers.

Results : Regardless of the imaging modality used, there was fair to moderate agreement for most of the observations. Three-dimensional CT improved interobserver agreement in Regan and Morrey's classsication (κ3-dimensional = 0.51 vs κ2-dimensional = 0.40; p < .001) and O'Driscoll et al.'s classifications (κ3-dimensional = 0.48 vs κ2-dimensional = 0.42; p = .009). There were trends toward better reliability for 3-dimensional reconstruction in recognition of coronoid tip fractures (κ3-dimensional = 0.19, κ2-dimensional = 0.03; p = .268), comminution (κ3-dimensional = 0.41 vs κ2-dimensional = 0.29; p = .133), and impacted fragments (κ3-dimensional = 0.39 vs κ2-dimensional = 0.27; p = .094), and in surgeons' opinions on the need for something other than screws or plate for surgical fixation (κ3-dimensional = 0.31 vs κ2-dimensional = 0.15; p = .138). Interobserver agreement on treatment approach was better with 2-dimensional CT (κ3-dimensional = 0.27, κ2-dimensional = 0.32; p = .015).

Conclusions : Three-dimensional CT reconstructions improve interobserver agreement with respect to fracture classification compared with 2-dimensional CT.

Prospective randomized controlled trial comparing dynamic hip screw and screw fixation for undisplaced subcapital hip fractures

Background
Neck of femur fractures (NOFFs) are a common cause of morbidity and mortality in our community. Minimally displaced intracapsular fractures are treated with internal fixation by a two-hole dynamic hip screw (DHS) or three partially threaded cancellous screws. Data to support the superiority of one are limited. This prospective randomized controlled trial compares outcomes with these two fixation methods.

Methods
We prospectively recruited patients over 50 years, with an acute fracture subcapital NOFF, who walked and lived independently, and were cognitively intact. They were randomized into DHS or cancellous screw groups and followed up for 2 years (overall 75.9%). Outcomes of mortality, revision, loss of fixation, avascular necrosis, surgical complications, WOMAC, Harris hip score and SF-12 were measured.

Results
We recruited 62 patients (31 DHS, 29 cancellous screws, 2 failed consent). Six deaths (19.3%) were seen in each group. A total of 3.2% of DHS (1 out of 31) and 10.3% (3 out of 29) of cancellous screw patients required re-operation (P = 0.272). There was no statistical significant difference in patient satisfaction, quality of life (QoL), radiological union or osteonecrosis. There are trends towards better functional scores and QoL in cancellous screws, particularly at 1 year (P = 0.0061), but with a higher re-operation rate. There was a combined mortality and transition to institutional care of 40.0% (24 out of 60) at 2 years.

Conclusions
This study found no difference in outcomes between DHS and cancellous screws in the treatment of subcapital NOFFs in a fit, independent population, but we found a high level of physical decline in previously fit, independently ambulating patients. A large, multicentre trial will be required to differentiate between these two fixation methods.

Complications associated with operative fixation of acute midshaft clavicle fractures

The aim of this study was to review the complication rate and profile associated with surgical fixation of acute midshaft clavicle fracture in a large cohort of patients treated in a level I trauma centre.Patients and methods: We identified all patients who underwent surgical treatment of acute midshaft clavicle fracture between 2002 and 2010. The study group consisted of 138 fractures (134 patients). There were 107 males (78%) and 31 females (22%) and median age of 35 years (IQR 24-45). The most common mechanism of injury was a road traffic accident (78%). Sixty percent (n = 83) had an injury severity score of ≥ 15 indicating major trauma. The most common fracture type (75%) was simple or wedge comminuted (2B1) according to the Edinburgh classification. The median interval between the injury and operation was 3 days (IQR 1-6). Plate fixation was performed in 110 fractures (80%) and intramedullary fixation was performed in 28 fractures (20%). There were 85 males and 25 females in the plate fixation group with median age of 35 years (IQR: 25-45) There were 22 males and 6 females in intramedullary fixation group with median age of 31 years (IQR 24-42 years). Statistical analysis was performed using Independent sample t-test, Mann-Whitney test, and Chi-square test. Significant P-value was < 0.05.Results: The overall incidence of complication was 14.5% (n = 20). The overall nonunion rate 6%. Post operative wound infection occurred in 3.6% of cases. The incidence of complication associated with plate fixation was 10% (11 of 110 cases) compared to 32% associated with intramedullary fixation (9 of 28 cases) (P = 0.003). Thirty five percent of complications were related to inadequate surgical technique and potentially avoidable. Symptomatic hardware requiring removal occurred in 23% (n = 31) of patients. Symptomatic metalware was more frequent after plate fixation compared to intramedullary fixation (26% vs 7%, P = 0.03).Conclusions: Intramedullary fixation of midshaft clavicle fracture is associated with higher incidence of complications. Plate fixation is associated with a higher rate of symptomatic metalware requiring removal compared to intramedullary fixation. Approximately one in three complications may be avoided by attention to adequate surgical technique.

Effect of the manufacturing process on the interlaminar fracture toughness of 2/2 twill weave fabric carbon/epoxy composites

A 2/2 twill weave fabric carbon fibre reinforced epoxy matrix composite MTM56/CF0300 was used to investigate the effect of different manufacturing processes on the interlaminar fracture toughness. Double cantilever beam tests were performed on composites manufactured by hot press, autoclave and 'Quickstep' processes. The 'Quickstep' process was recently developed in Perth, Western Australia for the manufacture of advanced composite components. The values of the mode I critical strain energy release rate (G1d were compared and the results showed that the composite specimens manufactured by the autoclave and the 'Quickstep' process had much higher interlaminar fracture toughness than the specimen produced by the hot press. When compared to specimens manufactured by the hot press, the interlaminar fracture toughness values of the Quickstep and autoclave samples were 38% and 49% higher respectively. The 'Quickstep' process produced composite specimens that had comparable interlaminar fracture toughness to autoclave manufactured composites. Scanning electron microscopy (SEM) was employed to study the topography of the mode I interlaminar fracture surface and dynamic mechanical analysis (DMA) was performed to investigate the fibre/matrix interphase. SEM micrography and DMA spectra indicated that autoclave and 'Quickstep' produced composites with stronger fibre/matrix adhesion than hot press.

Characterization and analysis of delamination fracture and nanocreep properties in carbon epoxy composites manufactured by different processes

Delamination resistance and nanocreep properties of 2/2 twill weave carbon epoxy composites manufactured by hot press, autoclave, and Quickstep^TM process are characterized and analyzed. Quickstep is a fluid filled, balanced pressure heated floating mold technology, which is recently developed in Perth, Western Australia for the manufacture of advanced composite components. Mode I and Mode II interlaminar fracture toughness tests, and nanoindentation creep tests on matrix materials show that the fast ramp rate of the Quickstep process provides mechanical properties comparable to that of autoclave at a lower cost for composite manufacturing. Low viscosity during ramping process and good fiber wetting are believed to be the reasons that this process produces composites with high delamination and creep-resistant properties. Nanocreep properties are analyzed using a Kelvin–Voigt model.

Equal channel angular pressing of metal matrix composites: effect on particle distribution and fracture toughness

An Al6061-20%Al₂O₃ powder metallurgy (PM) metal matrix composite (MMC) with a strongly clustered particle distribution is subjected to equal channel angular pressing (ECAP) at a temperature of 370 °C. The evolution of the homogeneity of the particle distribution in the material during ECAP is investigated by the quadrat method. The model proposed by Tan and Zhang [Mater Sci Eng 1998;244:80] for estimating the critical particle size which is required for a homogeneous particle distribution in PM MMCs is extended to the case of a combination of extrusion and ECAP. The applicability of the model to predict a homogeneity of the particle distribution after extrusion and ECAP is discussed. It is shown that ECAP leads to an increase of the  uniformity of the particle distribution and the fracture toughness.

Manufacturing influence on the delamination fracture behavior of the T800H/3900-2 carbon fiber reinforced polymer composites

'Torayca' T800H/3900-2 is the first material qualified on Boeing Material Specification (BMS 8-276) which utilizes the thermoplastic-particulate interlayer toughening technology. Two manufacturing processes, the autoclave process and the fast heating rated Quickstep™ process, were employed to cure this material. The Quickstep process is a unique composite production technology which utilizes the fast heat transfer rate of fluid to heat and cure polymer composite components. The manufacturing influence on the mode I delamination fracture toughness of laminates was investigated by performing double cantilever beam tests. The composite specimens fabricated by two processes exhibited dissimilar delamination resistance curves (R-curves) under mode I loading. The initial value of fracture toughness GIC-INIT was 564 J/m2 for the autoclave specimens and 527 J/m2 for the Quickstep specimens. However, the average propagation fracture toughness GIC-PROP was 783 J/m2 for the Quickstep specimens, which was 2.6 times of that for the autoclave specimens. The mechanism of fracture occurred during delamination was studied under scanning electron microscope (SEM). Three types of fracture were observed: the interlayer fracture, the interface fracture, and the intralaminar fracture. These three types of fracture played different roles in affecting the delamination resistance curves during the crack growth. More fiber bridging was found in the process of delamination for the Quickstep specimens. Better fiber/matrix adhesion was found in the Quickstep specimens by conducting indentation-debond tests.

Effect of susceptibility to interfacial fracture on fatigue properties of spot-welded high strength sheet steel

While advanced high strength steels (AHSS) have numerous advantages for the automotive industry, they can be susceptible to interfacial fracture when spot-welded. In this study, the susceptibility of interfacial fracture to spot-weld microstructure and hardness is examined, as well as the corresponding relationships between fatigue, overload performance, and interfacial fracture for a TRIP (transformation induced plasticity) steel. Simple post-weld heat-treatments were used to alter the weld microstructure. The effect on interfacial fracture of diluting the weld pool by welding the TRIP material to non-TRIP steel was examined, along with the effect of altering the base material microstructure. Results show that weld hardness is not a good indicator of either the susceptibility to interfacial fracture, or the strength of the joint, and that interfacial fracture does not necessarily lead to a decrease in strength compared to conventional weld-failure mechanisms, i.e. button pullout. It was also found that while interfacial fracture does affect low cycle to failure behavior, there was no effect on high cycle fatigue.

The effect of osteoporotic vertebral fracture of predicted spinal loads in vivo

he aetiology of osteoporotic vertebral fractures is multi-factorial, and cannot be explained solely by low bone mass. After sustaining an initial vertebral fracture, the risk of subsequent fracture increases greatly. Examination of physiologic loads imposed on vertebral bodies may help to explain a mechanism underlying this fracture cascade. This study tested the hypothesis that model-derived segmental vertebral loading is greater in individuals who have sustained an osteoporotic vertebral fracture compared to those with osteoporosis and no history of fracture. Flexion moments, and compression and shear loads were calculated from T2 to L5 in 12 participants with fractures (66.4 ± 6.4 years, 162.2 ± 5.1 cm, 69.1 ± 11.2 kg) and 19 without fractures (62.9 ± 7.9 years, 158.3 ± 4.4 cm, 59.3 ± 8.9 kg) while standing. Static analysis was used to solve gravitational loads while muscle-derived forces were calculated using a detailed trunk muscle model driven by optimization with a cost function set to minimise muscle fatigue. Least squares regression was used to derive polynomial functions to describe normalised load profiles. Regression co-efficients were compared between groups to examine differences in loading profiles. Loading at the fractured level, and at one level above and below, were also compared between groups. The fracture group had significantly greater normalised compression (p = 0.0008) and shear force (p < 0.0001) profiles and a trend for a greater flexion moment profile. At the level of fracture, a significantly greater flexion moment (p = 0.001) and shear force (p < 0.001) was observed in the fracture group. A greater flexion moment (p = 0.003) and compression force (p = 0.007) one level below the fracture, and a greater flexion moment (p = 0.002) and shear force (p = 0.002) one level above the fracture was observed in the fracture group. The differences observed in multi-level spinal loading between the groups may explain a mechanism for increased risk of subsequent vertebral fractures. Interventions aimed at restoring vertebral morphology or reduce thoracic curvature may assist in normalising spine load profiles.

Manufacturing process effects on the mode I interlaminar fracture toughness and nanocreep properties of CFRP

Quickstep ™ is a fluid filled floating mould technology which was recently developed by an Australian company of the same name. The Quickstep and conventional autoclave manufacture of composites were compared by investigating the mode I interlaminar fracture toughness and nanocreep propeties of HexPly914 carbon epoxy composites. It was found that composites cured using the Quickstep technology had significantly higher fracture toughness (1.8 times) than the composites cured via autoclave for this system. DMTA (dynamic mechanical thermal analysis) results showed a higher Tg (glass transition temperature) for the material manufactured by the Quickstep than that cured by the autoclave. FTIR (Fourier transform infrared spectroscopy) spectra did not indicate any difference in cure chemistry between the two processes. Nanocreep experiments were performed to explore the viscoelastic properties of the epoxy matrix of composites. The KelvinVoigt three-element model was applied to analyse the indentation creep behaviour of both composites.