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Letters to the Editor to:

Scientific Articles:
Joaquin Sanchez-Sotelo, Michael E. Torchia, and Shawn W. O'Driscoll
Complex Distal Humeral Fractures: Internal Fixation with a Principle-Based Parallel-Plate Technique
J Bone Joint Surg Am 2007; 89: 961-969 [Abstract] [Full text] [PDF]
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Electronic letters published:

[Read Letter to the Editor] Complex Distal Humeral Fractures: Internal Fixation with a Principle-Based Parallel-Plate Technique
Shawn W. O'Driscoll, Ph.D., M.D., Joaquin Sanchez-Sotelo, M.D., Ph.D; Michael E. Torchia, M.D.   (27 June 2007)
[Read Letter to the Editor] More technical tips for parallel plating of distal humerus
Bhavuk Garg, Rajesh Malhotra, Arvind Jayaswal, P P Kotwal   (27 June 2007)

Complex Distal Humeral Fractures: Internal Fixation with a Principle-Based Parallel-Plate Technique 27 June 2007
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Shawn W. O'Driscoll, Ph.D., M.D.,
Professor of Orthopedic Surgery
Mayo Clinic,
Joaquin Sanchez-Sotelo, M.D., Ph.D; Michael E. Torchia, M.D.

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Re: Complex Distal Humeral Fractures: Internal Fixation with a Principle-Based Parallel-Plate Technique

odriscoll.shawn{at}mayo.edu Shawn W. O'Driscoll, Ph.D., M.D., et al.

We thank the authors for taking the time to share their experience and additional technical tips concerning the principle-based parallel- plate technique for fixing complex distal humerus fractures that we published.

We agree, wholeheartedly, with the recommendations offered and some of them represent details for which there was simply not enough room to permit their inclusion in the article. In fact, one of the illustrations that had to be deleted was an illustration showing compression across the articular fragments with a reduction clamp, as recommended in their first comment.

We agree with their recommendation for fixing coronal plane fractures with mini screws, but we specifically recommend that those not be inserted until all of the distal screws that go through the plates across to the other side of the distal humerus have been inserted. This permits those small mini screws to interdigitate with the metal structure in the distal humerus and to offer rigid stability of the coronal shear fractures. It is also important that the lateral coronal shear fractures be captured by the screws coming from the medial side before any mini screws are inserted.

Locking screws have become a current topic of great interest. We would like to emphasize that locking screws are not necessary to achieve rigid stability in the distal humerus if the principles and technical objectives outlined in this article are rigorously adhered to. Obviously the authors of this letter have found the same.

We agree that varus/valgus alignment must be carefully assessed, while reducing the distal segment to the shaft and confirmed to be correct before supracondylar compression, which is step 4.

The authors of the letter indicate that they also saw loosening of screws in the distal portion in many patients postoperatively, while being mobilized. I do not know whether they are referring to patients who had been operated on using the technique described in this paper or traditional techniques that we refer to as having been inadequate for some of these complex fractures. I presume it was the latter, as we have not seen this using the current recommended technique.

Finally, we appreciate the immediate response of authors with experience who have found that this principle-based approach of so-called parallel plating and intensive postoperative rehabilitation does provide excellent results in these very complicated fractures.
More technical tips for parallel plating of distal humerus 27 June 2007
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Bhavuk Garg,
Orthopaedic surgeon
All India Institute of Medical Sciences,
Rajesh Malhotra, Arvind Jayaswal, P P Kotwal

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Re: More technical tips for parallel plating of distal humerus

drbhavukgarg{at}gmail.com Bhavuk Garg, et al.

Dear editor, We read with great interest the article entitled "Complex Distal Humeral Fractures: Internal Fixation with a Principle-Based Parallel-Plate Technique". We are following this technique for last three years and would like to add some technical tips: 1. Compression across articular fragments should be achieved by reduction forceps and preferably no lag screw should be put as it tends to compress the fragments. As a result of which, olecranon fossa may get narrower, resulting in loss of extension postoiperatively.This also justifies the use of fully threaded screws as mentioned by authors. 2. Secondly, we should always look for fractures in coronal plane particularly of trochlea and capitellum and use of mini screws is very useful in this situation. The trochlea is very important for a good function as well as for stability. 3.We also recommend not to use locking screws as it is very difficult to change the direction of screws as interdigitation is needed for the stability of the construct and fixed direction of locking screw may hinder putting up the next locking screw. 4.A careful notice of varus and valgus alignment is also essential while putting screws in proximal portion of plate, attaching distal fragment to proximal fragment. 5. In our cases, we also saw an additional complication of loosening of screws in distal portion in many patients postoperatively, while being mobilized. These were managed by removal of screw under local anaesthesia in OPD setup.

The combined use of TRAP approach, parallel plating of distal humerus and aggressive postoperative rehabillitation does provide an excellent outcome.

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.