• Clinics in Shoulder and Elbow
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• v.27 no.1
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• pp.32-38
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• 2024

Background: Open reduction and internal fixation (ORIF) with a locking plate is a popular surgical treatment for proximal humeral fractures (PHF). This study aimed to assess the occurrence of complications in elderly patients with PHF treated surgically using ORIF with a locking plate and to investigate the potential differences between patients treated by shoulder surgeons and non-shoulder surgeons. Methods: A retrospective study was conducted using a single-center database to identify patients aged ≥70 years who underwent ORIF for PHF between January 1, 2011, and December 31, 2021. Data on the Neer classification, follow-up, occurrence of avascular necrosis of the humeral head, implant failure, and revision surgery were also collected. Statistical analyses were performed to calculate the overall frequency of complications according to the Neer classification. Results: The rates of implant failure, avascular osteonecrosis, and revision surgery were 15.7%, 4.8%, and 15.7%, respectively. Complications were more common in patients with Neer three- and four-part fractures. Although the difference between surgeries performed by shoulder surgeons and non-shoulder surgeons did not reach statistical significance, the rate of complications and the need for revision surgery were nearly two-fold higher in the latter group. Conclusions: PHF are highly prevalent in the elderly population. However, the ORIF surgical approach, as demonstrated in this study, is associated with a considerable rate of complications. Surgeries performed by non-shoulder surgeons had a higher rate of complications and a more frequent need for revision surgery. Future studies comparing surgical treatments and their respective complication rates are crucial to determine the optimal therapeutic options. Level of evidence: III.

• Clinics in Shoulder and Elbow
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• v.27 no.1
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• pp.72-78
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• 2024

Background: Clinical outcomes after fixation of distal humerus intraarticular fractures are directly related to the quality of reduction. The use of three-dimensional (3D)-printed fracture models can benefit preoperative planning to ensure good reduction. This review aims to determine if surgery performed with 3D printing assistance are faster and result in fewer complications and improved clinical outcomes than conventional methods. We also outline the benefits and drawbacks of this novel technique in surgical management of distal humerus fractures. Methods: A systematic literature search was carried out in various electronic databases. Search results were screened based on title and abstract. Data from eligible studies were extracted into spreadsheets. Meta-analysis was performed using appropriate computer software. Results: Three randomized controlled trials with 144 cases were included in the final analysis. The 3D-printed group had significantly shorter mean operating time (mean difference, 16.25 minutes; 95% confidence interval [CI], 12.74-19.76 minutes; P<0.001) and mean intraoperative blood loss (30.40 mL; 95% CI, 10.45-60.36 mL; P=0.005) compared with the conventional group. The 3D-printed group also tended to have fewer complications and a better likelihood of good or excellent outcomes as per the Mayo elbow performance score, but this did not reach statistical significance. Conclusions: Three-dimensional-printing-assisted surgery in distal humerus fractures has several benefits in reduced operating time and lower blood loss, indirectly decreasing other complications such as infection and anemia-related issues. Future good-quality studies are required to conclusively demonstrate the benefits of 3D printing in improving clinical outcomes.

• Clinics in Shoulder and Elbow
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• v.27 no.1
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• pp.39-44
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• 2024

Background: Displaced olecranon fractures constitute a challenging problem for elbow surgeons. The purpose of this study is to evaluate the role of suture anchor fixation for treating patients with displaced olecranon fractures. Methods: A retrospective review was performed for all consecutive patients with displaced olecranon fractures treated with suture anchor fixation with at least 2 years of clinical follow-up. Surgical repair was performed acutely in all cases with nonmetallic suture anchors in a double-row configuration utilizing suture augmentation via the triceps tendon. Osseous union and perioperative complications were uniformly assessed. Results: Suture anchor fixation was performed on 17 patients with displaced olecranon fractures. Functional outcome scores were collected from 12 patients (70.6%). The mean age at the time of surgery was 65.6 years, and the mean follow-up was 5.6 years. Sixteen of 17 patients (94%) achieved osseous union in an acceptable position. No hardware-related complications or fixation failure occurred. Mean postoperative shortened disabilities of the arm, shoulder, and hand (QuickDASH) score was 3.8±6.9, and mean Oxford Elbow Score was 47.5±1.0, with nine patients (75%) achieving a perfect score. Conclusions: Suture anchor fixation of displaced olecranon fractures resulted in excellent midterm functional outcomes. Additionally, this technique resulted in high rates of osseous union without any hardware-related complications or fixation failures.

• Clinics in Shoulder and Elbow
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• v.26 no.3
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• pp.287-295
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• 2023

Background: Posterolateral rotatory instability (PLRI) is a common mechanism of recurrent elbow instability. While the essential lesion is a deficiency in the lateral ulnar collateral ligament (LUCL), there are often associated concomitant bony lesions, such as an Osborne-Cotterill lesions (posterior capitellar fractures) and marginal radial head fractures, that compromise stability. Currently, there is no standard treatment for posterior capitellar deficiency associated with recurrent PLRI. Methods: We conducted a retrospective review of five patients with recurrent PLRI of the elbow associated with a posterior capitellar impaction fracture engaging with the radial head during normal range of motion. The patients were treated surgically with LUCL reconstruction or repair and off-label reconstruction of the capitellar joint surface using a small metal prosthesis designed for metatarsal head resurfacing (HemiCAP toe classic). Results: Five patients (three adolescent males, two adult females) were treated between 2007 and 2018. At a median follow-up of 5 years, all patients had complete relief of their symptomatic instability. No patients had pain at rest, but two patients had mild pain (visual analog scale 1-3) during physical activity. Three patients rated their elbow as normal, one as almost normal, and one as greatly improved. On short-term radiographic follow-up there were no signs of implant loosening. None of the patients needed reoperation. Conclusions: Recurrent PLRI of the elbow associated with an engaging posterior capitellar lesion can be treated successfully by LUCL reconstruction and repair and filling of the capitellar defect with a metal prosthesis. This treatment option has excellent clinical results in the short-medium term. Level of evidence: IV.

• Clinics in Shoulder and Elbow
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• v.26 no.4
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• pp.397-405
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• 2023

Background: A precontoured plate rarely fits properly within the patient's clavicle and must be bent intraoperatively. This study aimed to determine whether anatomical reduction could be achieved using a plate bent before surgery. Methods: This study included 87 consecutive patients with displaced mid-shaft clavicle fractures who underwent plate fixation and were followed-up for a minimum of 1 year. After exclusions, 39 consecutive patients underwent fixation with a precontoured plate bent intraoperatively (intraoperative bending group), and 28 underwent fixation with the plate bent preoperatively (preoperative bending group). Using free software and a three-dimensional (3D) printer, ipsilateral clavicle 3D-printed models were constructed. Using plain radiographs, the distance between the edge of the lateral inferior cortex and the medial inferior cortex was measured. The angle between the line connecting the inferior cortex edge and the line passing through the flat portion of the superior cortex of the distal clavicle was measured. Results: Mean length differences between the ipsilateral and contralateral clavicle were smaller on both anteroposterior (AP; P=0.032) and axial images (P=0.029) in the preoperative bending group. The mean angular differences on both AP (P=0.045) and axial images (P=0.008) were smaller in the preoperative bending group. No significant differences were observed between the two groups in functional scores at the last follow-up. Conclusions: Smaller differences in length and angle between the ipsilateral and contralateral clavicle, indicative of reduction, were observed in the preoperative bending group. Using the precontoured technique with low expense, the operation was performed more effectively as reflected by a shorter operation time. Level of evidence: III.

• Archives of Craniofacial Surgery
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• v.25 no.4
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• pp.161-170
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• 2024

Background: The eyes are the central aesthetic unit of the face. Maxillofacial trauma can alter facial proportions and affect visual function with varying degrees of severity. Conventional approaches to reconstruction have numerous limitations, making the process challenging. The primary objective of this study was to evaluate the application of three-dimensional (3D) navigation in complex unilateral orbital reconstruction. Methods: A prospective cohort study was conducted over 19 months (January 2020 to July 2021), with consecutive enrollment of 12 patients who met the inclusion criteria. Each patient was followed for a minimum period of 6 months. The principal investigator carried out a comparative analysis of several factors, including fracture morphology, orbital volume, globe projection, diplopia, facial morphic changes, lid retraction, and infraorbital nerve hypoesthesia. Results: Nine patients had impure orbital fractures, while the remainder had pure fractures. The median orbital volume on the normal side (30.12 cm³; interquartile range [IQR], 28.45-30.64) was comparable to that of the reconstructed orbit (29.67 cm³; IQR, 27.92-31.52). Diplopia improved significantly (T(10)= 2.667, p= 0.02), although there was no statistically significant improvement in globe projection. Gross symmetry of facial landmarks was achieved, with comparable facial width-to-height ratio and palpebral fissure lengths. Two patients reported infraorbital hypoesthesia at presentation, which persisted at the 6-month follow-up. Additionally, five patients developed lower lid retraction (1-2 mm), and one experienced implant impingement at the infraorbital border. Conclusion: Our study provides level II evidence supporting the use of 3D navigation to improve surgical outcomes in complex orbital reconstruction.

• Journal of Chest Surgery
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• v.43 no.3
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• pp.285-291
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• 2010

Background: Thoracic trauma is one of the leading causes of morbidity and mortality in developing countries. A rib fracture that is secondary to blunt thoracic trauma is an important indicator of the severity of the trauma. The purpose of study was to determine the morbidity and mortality rates and the management of rib fractures. Material and Method: We performed a retrospective study that involved all the blunt trauma patients with rib fractures, excluding those that were transferred to other hospital within 3 days, that were seen at our hospital between May 2002 and December 2008. Of the 474 admitted patients, 454 met the inclusion criteria. There were 356 male and 98 females, and their overall mean age was 53 years (range: 5~90 years). The outcome parameters included the mechanism of injury, the number of fractured ribs, the length of stay in the ICU, the Injury Severity Score (ISS), the length of the hospital stay, the pulmonary complications and the mortality. Result: The mechanism of trauma included traffic accidents in 189 (41.7%) cases, slipping down in 103 (22.7%) cases, falls in 85 (18.7%) cases, cultivator accidents in 30 (6.6%) cases, industrial accidents in 32 (7.0%) cases and assault in 15 (3.3%) cases. Intrathoracic injury was noted such as hemothorax in 269 (59.3%) cases, pneumothorax in 144 (31.7%) cases, pulmonary contusion in 95 (20.9%) cases, subcutaneous emphysema in 29 (6.4%) cases and great vessel injury in 5 (0.1%) cases. Conservative treatment was administered to most of the patients. Tube thoracostomy was administered in 234 (51.5%) cases, whereas thoracotomy was performed in 18 (4.0%) cases. The mean duration of thoracostomy was $5.2{\pm}6.2$ days. Most of the cases with rib fracture were treated in wards and their mean duration of hospital stay was $22.5{\pm}20$ days. The mean Injury Severity Score (ISS) was $14.8{\pm}10.9$ (range: 3~75). The mortality rate was calculated to be 4.8% (n=22). The main factors correlated with an adverse outcome were the number of ribs fractured, the duration of thoracostomy and pulmonary disease. Industrial insurance affected the length of hospitalization. Pulmonary contusion and the Injury Severity Score (ISS) affected the mortality. Conclusion: Rib fractures are a indicator of severe injury. Because of the complication and associated injuries, we believe these patients should be admitted for evaluation and treatment. Recent studies on the impact of rib fractures after blunt trauma have shown that patients as young as 40 years of age demonstrate increased morbidity and mortality with similar injuries as compared to that of older patients. The ISS and pulmonary contusion influenced the mortality rate. Patients with isolated rib fractures should be hospitalized if the number of fractured ribs is one or more.

• Archives of Craniofacial Surgery
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• v.17 no.1
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• pp.9-13
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• 2016

Background: Position of the facial foramina is important for regional block and for various maxillofacial surgical procedures. In this study, we report on anthropometry and morphology of these foramina using three-dimensional computed tomography (3D-CT) data. Methods: A retrospective review was performed for all patients who have undergone 3D-CT scan of the facial skeleton for reasons other than fracture or deformity of the facial skeleton. Anthropometry of the supraorbital, infraorbital, and mental foramina (SOF, IOF, MF) were described in relation to facial midline, inferior orbital margin, and inferior mandibular margin (FM, IOM, IMM). This data was analyzed according to sex and age. Additionally, infraorbital and mental foramen were classified into 5 positions based on the anatomic relationships to the nearest perpendicular dentition. Results: The review identified 137 patients meeting study criteria. Supraorbital foramina was more often in the shape of a foramen (62%) than that of a notch (38%). The supraorbital, infraorbital, and mental foramina were located 33.7 mm, 37.1 mm, and 33.7 mm away from the midline. The mean vertical distance between IOF and IOM was 13.4 mm. The mean distance between MF and IMM was 21.0 mm. The IOF and MF most commonly coincided with upper and lower second premolar dentition, respectively. Between the sex, the distance between MF and IMM was significantly higher for males than for female. In a correlation analysis, SOF-FM, IOF-FM and MF-FM values were significantly increased with age, but IOF-IOM values were significantly decreased with age. Conclusion: In the current study, we have reported anthropometric data concerning facial foramina in the Korean population, using a large-scale data analysis of three-dimensional computed tomography of facial skeletons. The correlations made respect to patient sex and age will provide help to operating surgeons when considering nerve blocks and periosteal dissections around the facial foramina.

• Journal of Chest Surgery
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• v.43 no.6
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• pp.675-680
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• 2010

Background: The aim of this study was to identify the distinguishing clinicoradiologic findings of traumatic tracheobronchial injury. Material and Method: Between January 2003 and December 2009, six patients who underwent surgical repair for traumatic tracheobronchial injury due to blunt trauma were included in this study. We evaluated the mechanism of the injury, the coexisting injuries, the time until the making diagnosis and treatment, the diagnostic methods, the anatomic location of the injury and the surgical outcomes. Result: The mechanisms of injury were traffic accident and crushing forces. The frequent symptoms were subcutaneous emphysema, dyspnea and pain, and the common radiologic findings were pneumothorax, mediastinal emphysema, rib fracture and lung contusion. Only 2 patients were diagnosed by chest CT and the others were not diagnosed preoperatively. The location of injury was the trachea in 2 patients and the bronchial tree in 4 patients. There was no postoperative mortality or anastomotic leak; however, vocal cord palsy occurred in one patient. The most distinguishing sign was persistent lung collapse even though the chest tube was connected with negative pressure. Conclusion: Although it was not easy to diagnose traumatic tracheobronchial injury without a clinical suspicion, the distinguishing clinical symptoms and CT findings could help to make an early diagnosis without performing bronchoscopy.

• Archives of Craniofacial Surgery
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• v.16 no.3
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• pp.119-124
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• 2015

Background: The Kirschner wire (K-wire) technique allows stable fixation of bone fragments without periosteal dissection, which often lead to bone segment scattering and loss. The authors used the K-wire fixation to simplify the treatment of laborious comminuted zygomatic bone fracture and report outcomes following the operation. Methods: A single-institution retrospective review was performed for all patients with comminuted zygomatic bone fractures between January 2010 and December 2013. In each patient, the zygoma was reduced and fixed with K-wire, which was drilled from the cheek bone and into the contralateral nasal cavity. For severely displaced fractures, the zygomaticofrontal suture was first fixated with a microplate and the K-wire was used to increase the stability of fixation. Each wire was removed approximately 4 weeks after surgery. Surgical outcomes were evaluated for malar eminence, cheek symmetry, K-wire site scar, and complications (based on a 4-point scale from 0 to 3, where 0 point is 'poor' and 3 points is 'excellent'). Results: The review identified 25 patients meeting inclusion criteria (21 men and 4 women). The mean age was 52 years (range, 15-73 years). The mean follow up duration was 6.2 months. The mean operation time was 21 minutes for K-wire alone (n=7) and 52 minutes for K-wire and plate fixation (n=18). Patients who had received K-wire only fixation had severe underlying diseases or accompanying injuries. The mean postoperative evaluation scores were 2.8 for malar contour and 2.7 for K-wire site scars. The mean patient satisfaction was 2.7. There was one case of inflammation due to the K-wire. Conclusion: The use of K-wire technique was associated with high patient satisfaction in our review. K-wire fixation technique is useful in patient who require reduction of zygomatic bone fractures in a short operating time.