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Regarding “Optimizing stability in distal humeral fracture fixation”
ARTICLE IN PRESS J Shoulder Elbow Surg (2009) -, e1-e2
www.elsevier.com/locate/ymse
LETTER TO THE EDITOR Regarding ‘‘Optimizing stability in distal humeral fracture fixation’’ TO THE EDITOR: I have read with great interest the article by O’Driscoll3 concerning how to optimize stability in distal humeral fractures. In this article O’Driscoll illustrates in detail how to locate the screws along the distal humerus to accomplish at the same time maximum fixation of the bony fragments and restoration of articular geometry. I have carefully analyzed the figures of the article showing the technical objectives. In the past I used traditional plates according to AO/ ASIF, whereas I have recently started to successfully use the anatomic precontoured bone plates shown in the O’Driscoll article to treat elbow fracture in elderly patients.
Certainly the peculiar anatomic morphology of these last bone implants improves anatomic reduction and synthesis, allowing at the same time the screws to be oriented according to the surgeon’s needs, leading to better synthesis of the fracture. From my personal point of view, elderly and often osteoporotic patients can present plurifragmentary humeral palette fractures that are very difficult to treat with a high number of screws in the epiphyseal region because osteoporotic bone weakens the purchase of the internal fixation devices. Moreover, placing too many screws in these patients with a poor-quality incompetent bone could be an obstacle to bone healing in the course of fracture treatment.1 To this end, I have tried to develop a different synthesis model that uses 9 screws instead of 13 screws. The essence of the proposed screw placement method, that I have named ‘‘Doublework Screw Technique,’’ lies in using 2 fewer
Figure 1 In the proposed ‘‘Doublework Screw Technique,’’ the bone plates are linked by means of a single screw (numbered 1, 2, 3, 4), instead of 2 separate screws, that is fixed to the opposite plate with a screwable-in metallic cap that acts as a counter-nut. It should thus be possible to increase compression stability with 9 screws rather than 13.
1058-2746/2009/$36.00 - see front matter Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2007.07.026
COR 5.0 DTD ymse1362 21 February 2009 10:42 pm ce 43
ARTICLE IN PRESS e2
Letter to the Editor
Figure 2 Because of the peculiar helicoidal profile morphology of the compressive screw, an appropriate counter-nut is screwed along the screw profile to obtain a compressive effect. A single screw is needed to achieve stability with consequent bone saving.
screws in the bony region above the olecranon fossa and 2 fewer screws in the bony region below the olecranon fossa. Each of these screws (numbered in the Figure as 1, 2, 3, and 4) does double duty because it replaces the screw that was once located on the opposite plate, now missing, and is fixed to the opposite plate by means of a metallic cap that acts as a counter-nut (Figure 1). This technique saves bone and at the same time maintains the small bony fragments in place, guarantees columnar stability, and obtains impacted reduction of the bony fragments. To do that, the manufacturers of these plates and screws need to create a metallic cap or counternut (Figure 2) that, due to the peculiar morphology of the helicoidal profile of the screw, can be ‘‘screwed in the screw’’ with a screwdriver to achieve a compressive effect
of the plate against the bone and a ‘‘double compressive effect’’ of the bony plates to each other. The modified technique I propose satisfies all of the 8 technical objectives O’Driscoll explained in the article.3 In particular, technical objective 2 is enhanced, and technical objective 3 becomes ‘‘lighter.’’ In fact, every screw in the distal fragment is anchored not only in a fragment on the opposite side that is fixed by a plate but also to the opposite plate by means of the metallic cap. Fewer screws are placed in the distal fragments to diminish or avoid the possible collapse of bone fragments because of the decreased holding power of the screws in osteoporotic bone.2 In my opinion, this technique should be reserved for elderly patients because it simultaneously permits enough strength and stiffness to resist the breaking and bending forces that cause the implant loosening that is typical in osteoporotic bone due to screw toggling.4 Andrea Emilio Salvi, MD [email protected] Mellino Mellini Hospital Trust Civil Hospital of Iseo (Brescia, Italy) Orthopaedics and Traumatology Department Via Cipro 30 25124 Brescia, Italy
References 1. Cantu RV, Koval KJ. The use of locking plates in fracture care. J Am Acad Orthop Surg 2006;14:183-90. 2. Cornell CN. Internal fracture fixation in patients with osteoporosis. J Am Acad Orthop Surg 2003;11:109-19. 3. O’Driscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg 2005;14(1 suppl S):186S-94. 4. Sommer C, Babst R, Muller M, Hanson B. Locking compression plate loosening and plate breakage: a report of four cases. J Orthop Trauma 2004;18:571-7.
COR 5.0 DTD ymse1362 21 February 2009 10:42 pm ce 43
www.elsevier.com/locate/ymse
LETTER TO THE EDITOR Regarding ‘‘Optimizing stability in distal humeral fracture fixation’’ TO THE EDITOR: I have read with great interest the article by O’Driscoll3 concerning how to optimize stability in distal humeral fractures. In this article O’Driscoll illustrates in detail how to locate the screws along the distal humerus to accomplish at the same time maximum fixation of the bony fragments and restoration of articular geometry. I have carefully analyzed the figures of the article showing the technical objectives. In the past I used traditional plates according to AO/ ASIF, whereas I have recently started to successfully use the anatomic precontoured bone plates shown in the O’Driscoll article to treat elbow fracture in elderly patients.
Certainly the peculiar anatomic morphology of these last bone implants improves anatomic reduction and synthesis, allowing at the same time the screws to be oriented according to the surgeon’s needs, leading to better synthesis of the fracture. From my personal point of view, elderly and often osteoporotic patients can present plurifragmentary humeral palette fractures that are very difficult to treat with a high number of screws in the epiphyseal region because osteoporotic bone weakens the purchase of the internal fixation devices. Moreover, placing too many screws in these patients with a poor-quality incompetent bone could be an obstacle to bone healing in the course of fracture treatment.1 To this end, I have tried to develop a different synthesis model that uses 9 screws instead of 13 screws. The essence of the proposed screw placement method, that I have named ‘‘Doublework Screw Technique,’’ lies in using 2 fewer
Figure 1 In the proposed ‘‘Doublework Screw Technique,’’ the bone plates are linked by means of a single screw (numbered 1, 2, 3, 4), instead of 2 separate screws, that is fixed to the opposite plate with a screwable-in metallic cap that acts as a counter-nut. It should thus be possible to increase compression stability with 9 screws rather than 13.
1058-2746/2009/$36.00 - see front matter Ó 2009 Journal of Shoulder and Elbow Surgery Board of Trustees. doi:10.1016/j.jse.2007.07.026
COR 5.0 DTD ymse1362 21 February 2009 10:42 pm ce 43
ARTICLE IN PRESS e2
Letter to the Editor
Figure 2 Because of the peculiar helicoidal profile morphology of the compressive screw, an appropriate counter-nut is screwed along the screw profile to obtain a compressive effect. A single screw is needed to achieve stability with consequent bone saving.
screws in the bony region above the olecranon fossa and 2 fewer screws in the bony region below the olecranon fossa. Each of these screws (numbered in the Figure as 1, 2, 3, and 4) does double duty because it replaces the screw that was once located on the opposite plate, now missing, and is fixed to the opposite plate by means of a metallic cap that acts as a counter-nut (Figure 1). This technique saves bone and at the same time maintains the small bony fragments in place, guarantees columnar stability, and obtains impacted reduction of the bony fragments. To do that, the manufacturers of these plates and screws need to create a metallic cap or counternut (Figure 2) that, due to the peculiar morphology of the helicoidal profile of the screw, can be ‘‘screwed in the screw’’ with a screwdriver to achieve a compressive effect
of the plate against the bone and a ‘‘double compressive effect’’ of the bony plates to each other. The modified technique I propose satisfies all of the 8 technical objectives O’Driscoll explained in the article.3 In particular, technical objective 2 is enhanced, and technical objective 3 becomes ‘‘lighter.’’ In fact, every screw in the distal fragment is anchored not only in a fragment on the opposite side that is fixed by a plate but also to the opposite plate by means of the metallic cap. Fewer screws are placed in the distal fragments to diminish or avoid the possible collapse of bone fragments because of the decreased holding power of the screws in osteoporotic bone.2 In my opinion, this technique should be reserved for elderly patients because it simultaneously permits enough strength and stiffness to resist the breaking and bending forces that cause the implant loosening that is typical in osteoporotic bone due to screw toggling.4 Andrea Emilio Salvi, MD [email protected] Mellino Mellini Hospital Trust Civil Hospital of Iseo (Brescia, Italy) Orthopaedics and Traumatology Department Via Cipro 30 25124 Brescia, Italy
References 1. Cantu RV, Koval KJ. The use of locking plates in fracture care. J Am Acad Orthop Surg 2006;14:183-90. 2. Cornell CN. Internal fracture fixation in patients with osteoporosis. J Am Acad Orthop Surg 2003;11:109-19. 3. O’Driscoll SW. Optimizing stability in distal humeral fracture fixation. J Shoulder Elbow Surg 2005;14(1 suppl S):186S-94. 4. Sommer C, Babst R, Muller M, Hanson B. Locking compression plate loosening and plate breakage: a report of four cases. J Orthop Trauma 2004;18:571-7.
COR 5.0 DTD ymse1362 21 February 2009 10:42 pm ce 43