BackgroundOpen reduction and internal fixation of distal humerus fractures is standard of care with good to excellent outcome for most patients. However, nonunions of the distal humerus still occur. These are severely disabling problems for the patient and a challenge for the treating physician. Fortunately, a combination of standard nonunion techniques with new plate designs and fixation methods allow even the most challenging distal humeral nonunion to be treated successfully.Questions/PurposesThe purpose of this manuscript is to describe our current technique in treating distal humeral nonunion as it has evolved over the last four decades. We have now follow-up on 62 treated patients.MethodsA few key steps are essential to obtain bone healing while regaining or preserving elbow motion. These include careful planning, extensile exposure, release of the ulnar nerve, capsular release and mobilization of the distal fragment, debridement, and finally stable fixation after alignment with application of bone graft.ResultsThe vast majority of distal humeral nonunions can be treated successfully with open reduction and internal fixation.ConclusionImportant components of the treatment plan are careful preoperative planning, extensile approach, debridement, and solid fixation with—locking—plates and liberal use of bone graft.Electronic supplementary materialThe online version of this article (doi:10.1007/s11420-017-9551-y) contains supplementary material, which is available to authorized users.

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Patients with contained-type OLTs experienced better clinical outcomes than those with uncontained-type OLTs after AOT for the treatment of OLTs. However, the AOT procedure still provided good clinical and MRI outcomes in both contained-type and uncontained-type OLTs at midterm follow-up.

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ObjectiveTo quantify and optimize metal artifact reduction using virtual monochromatic dual-energy CT for different metal implants compared to non-metal reference scans.MethodsDual-energy CT scans of a pair of human cadaver limbs were acquired before and after implanting a titanium tibia plate, a stainless-steel tibia plate and a titanium intramedullary nail respectively. Virtual monochromatic images were analyzed from 70 to 190 keV. Region-of-interest (ROI), used to determine fluctuations and inaccuracies in CT numbers of soft tissues and bone, were placed in muscle, fat, cortical bone and intramedullary tibia canal.ResultsThe stainless-steel implant resulted in more pronounced metal artifacts compared to both titanium implants. CT number inaccuracies in 70 keV reference images were minimized at 130, 180 and 190 keV for the titanium tibia plate, stainless-steel tibia plate and titanium intramedullary nail respectively. Noise, measured as the standard deviation of pixels within a ROI, was minimized at 130, 150 and 140 keV for the titanium tibia plate, stainless-steel tibia plate and titanium intramedullary nail respectively.ConclusionTailoring dual-energy CT protocols using implant specific virtual monochromatic images minimizes fluctuations and inaccuracies in CT numbers in bone and soft tissues compared to non-metal reference scans.

The aim of this study is to describe the number and location of the nutrient foramina in human scapulae which can minimize blood loss during surgery. Methods 30 cadaveric scapulae were macerated to denude the skeletal tissue. The nutrient foramina of 0.51 mm and larger were identified and labeled by adhering glass beads. CT scans of these scapulae were segmented resulting in a surface model of each scapula and the location of the labeled nutrient foramina. All scapulae were scaled to the same size projecting the nutrient foramina onto one representative scapular model. Results Average number of nutrient foramina per scapula was 5.3 (0-10). The most common location was in the supraspinous fossa (29.7%). On the costal surface of the scapula, most nutrient foramina were found directly inferior to the suprascapular notch. On the posterior surface, the nutrient foramina were identified under the spine of the scapula in a somewhat similar fashion as those on the costal surface. Nutrient foramina were least present in the peri-glenoid area. Conclusion Ninety percent of scapulae have more than one nutrient foramen. They are located in specific areas, on both the posterior and costal surface.

PurposeCoracoid fractures represent approximately 3–13% of all scapular fractures. Open reduction and internal fixation can be indicated for a coracoid base fracture. This procedure is challenging due to the nature of visualization of the coracoid with fluoroscopy. The aim of this study was to develop a fluoroscopic imaging protocol, which helps surgeons in finding the optimal insertion point and screw orientation for fixations of coracoid base fractures, and to assess its feasibility in a simulation study.MethodsA novel imaging protocol was defined for screw fixation of coracoid base fractures under fluoroscopic guidance. The method is based on finding the optimal view for screw insertion perpendicular to the viewing plane. In a fluoroscopy simulation environment, eight orthopaedic surgeons were invited to place a screw down the coracoid stalk through the coracoid base and into the neck of 14 cadaveric scapulae using anatomical landmarks. The surgeons placed screws before and after they received an e-learning of the optimal view. Results of the two sessions were compared and inter-rater reliability was calculated.ResultsScrew placement was correct in 33 out of 56 (58.9%) before, and increased to 50 out of 56 (89.3%) after the coracoid tunnel view was explained to the surgeons, which was a significant improvement (p < 0.001).ConclusionsOur newly developed fluoroscopic view based on simple landmarks is a useful addendum in the orthopaedic surgeon’s tool box to fixate fractures of the coracoid base.Electronic supplementary materialThe online version of this article (10.1007/s00276-019-02274-z) contains supplementary material, which is available to authorized users.

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.