Aims. Total hip arthroplasty (THA) is considered the preferred treatment for displaced proximal femoral neck fractures. However, in many countries this option is economically unviable. To improve outcomes in financially disadvantaged populations, we studied the technique of concomitant valgus hip osteotomy and operative fixation (VOOF). This prospective serial study compares two treatment groups: VOOF versus operative fixation alone with cannulated compression screws (CCSs). Methods. In the first series, 98 hip fixation procedures were performed using CCS. After fluoroscopic reduction of the fracture, three CCSs were placed. In the second series, 105 VOOF procedures were performed using a closing wedge intertrochanteric osteotomy with a compression lag screw and lateral femoral plate. The alignment goal was to create a modified Pauwel’s fracture angle of 30°. After fluoroscopic reduction of fracture, lag screw was placed to achieve the calculated correction angle, followed by inter-trochanteric osteotomy and placement of barrel plate. Patients were followed for a minimum of two years. Results. Mean follow-up was 4.6 years (4.1 to 5.0) in the CCS group and 5.5 years (5.25 to 5.75) in the VOOF group. The mean Harris Hip Score at two-year follow-up was 83.85 in the CCS group versus 88.00 in the VOOF group (p < 0.001). At the latest follow-up, all-cause failure rate was 29.1% in the CCS group and 11.7% in the VOOF group (p = 0.003). The total cost of the VOOF technique was 7.2% of a THA, and total cost of the CCS technique was 6.3% of a THA. Conclusion. The VOOF technique decreased all-cause failure rate compared to CCS. The total cost of VOOF was 13.5% greater than CCS, but 92.8% less than a THA. Increased cost of VOOF was considered acceptable to all patients in this series. VOOF technique provides a reasonable alternative to THA in patients who cannot afford a THA procedure. Cite this article: Bone Jt Open 2023;4(5):329–337

Aims. Achilles tendon re-rupture (ATRR) poses a significant risk of postoperative complication, even after a successful initial surgical repair. This study aimed to identify risk factors associated with Achilles tendon re-rupture following operative fixation. Methods. This retrospective cohort study analyzed a total of 43,287 patients from national health claims data spanning 2008 to 2018, focusing on patients who underwent surgical treatment for primary Achilles tendon rupture. Short-term ATRR was defined as cases that required revision surgery occurring between six weeks and one year after the initial surgical repair, while omitting cases with simultaneous infection or skin necrosis. Variables such as age, sex, the presence of Achilles tendinopathy, and comorbidities were systematically collected for the analysis. We employed multivariate stepwise logistic regression to identify potential risk factors associated with short-term ATRR. Results. From 2009 to 2018, the short-term re-rupture rate for Achilles tendon surgeries was 2.14%. Risk factors included male sex, younger age, and the presence of Achilles tendinopathy. Conclusion. This large-scale, big-data study reaffirmed known risk factors for short-term Achilles tendon re-rupture, specifically identifying male sex and younger age. Moreover, this study discovered that a prior history of Achilles tendinopathy emerges as an independent risk factor for re-rupture, even following initial operative fixation. Cite this article: Bone Joint Res 2024;13(7):315–320

Introduction:. Calcaneal fractures are rare but debilitating injuries assumed to affect particular demographic sub groups. This study aimed to relate epidemiological factors (age, gender, smoking status and social deprivation scores) to the incidence of calcaneal fractures requiring operative fixation over a 10-year period. Methods:. Data (age, gender and smoking status) was extracted from a prospective trauma database regarding calcaneal fractures between September 2002 and September 2012. The Rank of Index of Multiple Deprivation (IMD) scores was collated for each patient and data sub-stratified in 20% centiles. 2010 National Census Data was used to formulate patient subgroups and incidences. Resulting data was subjected to statistical analysis through calculation of relative risk (RR) scores with 95% confidence intervals (95% CI). Results:. 101 calcaneal fractures in 95 patients that underwent operative fixation were identified. 3 open fractures in 3 patients were excluded. In males, the annual incidence of calcaneal fractures requiring operative fixation was 5.10 per 100,000 compared to 1.25 per 100,000 in females (RR 1.60, 95% CI 1.45–1.77). The mean age in males was 36.8 years with a peak incidence between 20–29 years old. The mean age of females was 42.5 years with a peak incidence between 30–39 years old. In females, there was a more even spread throughout all ages with a gradual increase in incidence towards post-menopausal ages. 54 (55.1%) fractures requiring operative fixation occurred in smokers compared to 44 (44.9%) in non-smokers, (RR 2.00, 95% CI 1.39–2.88). Rank of IMD scores revealed 34.0 % of all fractures occurred in the top 20% (RR 1.7, 95% CI 1.28–2.26) most deprived areas and 58.5% of fractures in the top 40% most deprived areas. Conclusions:. This study indicates that male gender, smoking status and high rank of multiple deprivation scores are independent characteristics associated with calcaneal fractures requiring operative fixation

Introduction: Operative fixation of unstable ankle fractures is a well-recognised form of management. However controversy exists in the surgical treatment of unstable ankle fractures in the elderly age group, over 80 years. Operative fixation in these cases is challenging and the postoperative mortality and morbidity has discouraged surgical intervention. The literature regarding the prognosis of surgery in this elderly group is limited. The purpose of this study is to document the results of operative fixation of unstable ankle fractures in patients aged over 80 years of age. Methods: Ninety-two consecutive patients aged above 80 underwent open reduction and internal fixation of unstable ankle fractures during the period of January 1998 to August 2007. Five patients’ case records were unavailable for the study and they were therefore excluded. The data was collected retrospectively from the case records and radiographs. The clinical and radiological outcomes following surgery were recorded and analysed in detail. The complications were noted and the risk factors for poor prognosis were analysed. Results: The average age was 85.2 (range 80.1 – 95.1 yrs). The minimum duration of follow up was nine months. The superficial wound infection rate was 5.7% (5 cases). The deep infection rate was 4.6% (4 cases), three required surgical debridement. The 30-day postoperative mortality was 4.6 % (4 cases). 88.1 % (74 out of 84 cases) were able to return to their preinjury mobility at the last follow-up. Diabetes and smoking did not statistically influence the outcome of the surgery. Conclusion: The results of operative fixation of unstable ankle fractures in this age group are encouraging with good functional recovery and return to preinjury mobility status in most cases

Introduction: Operative fixation of unstable ankle fractures is a well recognised form of management. However controversy exists in the surgical treatment of unstable ankle fractures in the very elderly age group of over 80 years. Operative fixation in these cases is challenging and the postoperative mortality and morbidity has discouraged surgical intervention in this population. However, the literature regarding the prognosis of surgery in this elderly group is very limited. The purpose of our study was to describe the results of 85 patients aged above 80 years, who underwent operative fixation for unstable ankle fractures. Methods: 92 consecutive patients aged above eighty years of age had open reduction and internal fixation for unstable ankle fractures during the period of January 1998 – August 2007. The data was collected retrospectively from the case records and radiographs. The mechanism of injury, fracture pattern, and medical co morbidities were recorded. A standard postoperative rehabilitation programme was followed. 5 patients were excluded as complete medical records were unavailable. The clinical and radiological outcomes following surgery were recorded and analysed in detail. The complications were noted and the risk factors for poor prognosis were analysed. Results: There were 71 women and 16 men in the study. The most common fracture pattern was pronation external rotation type. The average age was 85.2 (Range 80.1 – 95.1 yrs). The minimum duration of follow up was 9 months. The superficial wound infection rate was 5.7% (5 cases) which settled with oral antibiotic treatment for 1–2 weeks. The deep infection rate was 4.6% (4 cases) which required surgical debridement and implant removal. The 30 day postoperative mortality was 4.6 % (4 cases). Most patients demonstrated radiological fracture union with medial malleolus possessing slightly a higher risk of non union. 88.1 % (74 out of 84 cases) were able to return back to their pre injury mobility at the last follow-up. Diabetes and smoking did not statistically influence the outcome of the surgery. Conclusion: The results of operative fixation of unstable ankle fractures are very encouraging with good functional recovery and return to pre injury mobility status in most cases. The surgical fixation is technically challenging and careful attention must be given to the osteopenia and soft tissue factors

Introduction: Controversy exists in the surgical treatment of unstable ankle fractures in the very elderly age group of over 80 years. Operative fixation in these cases is challenging and the postoperative mortality and morbidity has discouraged surgical intervention in this population. However, the literature regarding the prognosis of surgery in this elderly group is very limited. The purpose of our study was to describe the results of 92 patients aged above 80 years, who underwent operative fixation for unstable ankle fractures. Methods: 92 consecutive patients aged above eighty years of age had open reduction and internal fixation for unstable ankle fractures during the period of January 1998 – August 2007. The data was collected retrospectively from the case records and radiographs. A standard postoperative rehabilitation programme was followed. The complications were noted and the risk factors for poor prognosis were analysed. Results: There were 80 women and 12 men in the study. The average age was 85.2 (Range 80.1 – 95.1 yrs). The minimum duration of follow up was 9 months. The superficial wound infection rate was 7% (6 cases) and the deep infection rate was 4.6% (4 cases). The 30 day postoperative mortality was 5.4 % (5 cases). 86 % (75 out of 87 cases) were able to return back to their pre injury mobility at the last follow-up. Diabetes, dementia, peripheral vascular disease and smoking were found to be statistically significant risk factors associated with wound complications. Patient with 2 or more risk factors is 5 times more likely to have wound infection. Conclusion: The results of operative fixation of unstable ankle fractures are very encouraging with majority of patients returning to pre injury mobility status

To assess patient following operative fixation of clavicle fractures. In the literature, the incidence of paraesthesia following operative fixation of clavicle fractures is reported to be between 7–29%. This problem can be bothersome to patients and the degree of disability is poorly documented. All clavicle fractures (67) treated operatively at the Alfred Hospital between 01/06/2003 and 01/06/2006 were included in the study. Patients were asked to complete paper based questionnaires assessing satisfaction, presence of numbness and degree of disability following clavicle operation. Additionally, they were followed up clinically to assess the area of numbness and scarring. The response rate was 65% (43/67). Most of the patients were satisfied with the operation and only 15% reported significant problems with the wound. Majority of patients returned to pre-morbid activities and employment. The degree of paraesthesia varied among respondents and it was associated with the type of incision used. There was little difference in patient satisfaction with regard to various surgical devices utilised. It is important to address wound complications such as scarring and paraesthesia when discussing operative treatments for patients with clavicle fractures. The results suggest that wound related problems can be frequent and a significant percentage of operatively managed patient experience long term numbness. It is possibly an under appreciated problem. Additionally our results suggest that vertical incisions achieve a more favourable outcome compared to horizontal incisions

Introduction: The use of an Aircast walking boot following operative fixation of ankle fractures has been shown to significantly improve early patient comfort, post-fracture swelling and time to full rehabilitation. However, the practical implications and in particular the financial impact of this orthosis has not been assessed. The current study, therefore, aims to determine whether use of the removable splint following operative fixation provides an economically viable alternative to the standard below knee cast. Materials and methods: Between May 2006 and January 2007 those patients who underwent operative ankle fixation and who were treated postoperatively with the use of an Aircast walker were identified. A group of age-matched controls were used for comparison. Demographic details and postoperative outcomes including postoperative stay were obtained from the hospital notes and computer records. Results: 12 patients were treated with an Aircast boot during the study period. The mean age of the study group was 43.6 years compared to 43.3 years in the control group. Operative fixation was carried out within 0.83 days and 0.92 days respectively. Patients in the Aircast group were discharged within a mean period of 2.92 days following surgery compared to 3.58 days in the control group. Conclusions: The current study demonstrates that the use of an Aircast walker boot in the postoperative period is clinically comparable to the standard below knee cast. In particular, the orthosis also enables patients to be discharged home earlier, which has positive implications both for patient recovery and the overall cost of treatment

Introduction: Many authors have stated that open reduction and internal fixation of displaced ankle fractures give better results than conservative management (Hughes et al, Clin Orthop 1979; Tunturi et al, Acta Orthop Scand 1983; Philips et al, JBJS 1985 and ). However, there is little information on the long-term outcome of operated ankle fractures. There is inadequate knowledge of patient perception of ankle function following operative treatment of these injuries. Aim: To analyse long-term results following operative treatment of these fractures using a patient centred outcome measure. Methods: 112 patients had undergone operative fixation of isolated, closed bi-malleolar ankle fractures between 1992 and 1996 at Middlesbrough General Hospital. All patients had undergone operative fixation using standard AO principles. An independent assessor ascertained the quality of reduction using standardised radiological parameters (Joy et al JBJS 1974, Sarkisian & Cody J Trauma 1976, Mont et al J Ortop Trauma 1992) to assess the post-operative X-ray films. All postoperative reductions were within the parameters of a good reduction. The modified Olerud & Molander ankle score questionnaire was sent by post to all patients identified living in the region. Results: 66 out of 112 patients responded; 34 (52%) leading a sedentary lifestyle and 32 (48%) a moderate/ active lifestyle. Mean age of the patients was 47 years. The follow-up period ranged from 5 to 11 years (average 7 years). Olerud and Molander scores ranged from 5 to 100, with a mean score of 66.5 (SD 27.6), and median score of 70. Only 9 (13.6%) patients had a score of 100. Comparisons between Olerud and Molander scores were made with regard to: gender, whether metal work was removed at a second operation, Weber classification (B vs C) and patient’s lifestyle. No significant differences were observed. The associations between Olerud and Molander score and the key variables were assessed using non-parametric (Spearman’s) correlation coefficients. None of the variables considered were significantly associated with Olerud and Molander score. Conclusion: The study would suggest that, despite modern fixation techniques, few patients following bi-malleolar ankle fracture have a symptom free ankle. There is no obvious parameter to predict outcome in patients who are managed appropriately for these injuries

Introduction and Aims: A retrospective review of the medical records and radiographs of patients treated with operative fixation of two-part proximal humerus fractures was undertaken to compare the results of different modes of fixation. Comparison was made between ORIF with a blade plate, percutaneous Kirschner wire fixation, and intramedullary nail fixation utilising a Polarus nail. Method: Thirty-six patients were treated with intramedullary fixation, 11 with blade plate fixation and 10 with percutaneous fixation, utilising Kirschner wires. Union rates were 34/36 (94%) for the Polarus nail, 9/10 (90%) for K-wire fixation and 9/11 (82%) for blade plate fixation. Time to union averaged 12.4 weeks for the Polarus nail, 11 weeks for K-wire fixation and 21 weeks for blade plate fixation. Average active shoulder range of motion in forward flexion/abduction were 125/118 degrees for intramedullary nail, 132/132 degrees for the blade plate and 112/111 degrees for patients treated with K-wire fixation. Results: The major discrepancy in comparison of the different modes of fixation was in the complication rate. Ten complications occurred in the group treated with intramedullary fixation. These included one non-union, one painless fibrous non-union and back out of the proximal interlocking screw in eight patients, five of which required screw removal. Seven of 11 patients treated with blade plate fixation experienced complications, including two non-unions, two malunions, two with functionally limiting heterotopic ossification, one arthrofibrosis and one with persistent pain. The complications associated with percutaneous Kirschner wire fixation included one non-union, two malunions, four developed functionally limiting heterotopic ossification, five incidences of early pin removal secondary to pin migration, one arthrofibrosis requiring surgical intervention and one infection requiring surgical irrigation and debridement. Conclusion: Results comparable in all groups. Fewer complications seen with intramedullary fixation. Majority of complications with Polarus nail related to backing out of proximal interlocking screw. Modification of implant to include end cap, which locks the proximal screw seems to eliminate complication. Results indicate that intramedullary nail fixation is superior to blade plate fixation or pecutaneous Kirschner wire fixation for two-part proximal humerus fractures

Opinions is divided among surgeons whether to operatively fix displaced calcaneal fractures in elderly patients and heavy smokers. In a long term follow-up of operatively treated calcaneal fractures, we considered several factors that could affect outcomes and complication rates. Method: 59 calcaneal fractures in 54 patients that underwent operative fixation for displaced intra-articular fractures from April 1995 to January 2006 were reviewed. There were 18 Tongue type and 41 Joint depression fractures on X-rays. Of 38 available CT scans, 25 were Sanders Type II and 13 were Types III and IV fractures. Average interval to surgery was 6 days. Postoperative mobilisation regime was passive range of motion immediately following surgery with non weight bearing for 6 weeks. Weight bearing was started at 6–8 weeks. On follow-up, patients were assessed with clinical and radiological exam, completed Short Form-36 (SF-36), the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hind foot scale and Visual Analogue Scale (VAS) scores. Results: The duration of follow-up was between 6 months to 11.2 years (6.4 years). The pre and post operative Bohler angles were 8° ± 11° and 29° ± 6° respectively. There was significant limitation of subtalar movement on the operated side irrespective of the presence of arthritis. The average AOFAS, SF-36 and VAS scores were 79, 58 and 3 respectively. Good results were associated with age < 50 years, ASA grade I, pre-op Bohler angle of < 5° and Sanders < IIC. 89% of patients returned to their previous level of activity after an average of 6.5 months. Smoking was not associated with early or late complication rates and did not affect outcome. Conclusions: We think that advanced age and smoking are not contraindications for operative fixation of displaced calcaneal fractures

Introduction. Osteochondral defects of the knee may occur following patella dislocation or following direct trauma or twisting injuries to the knee in adolescents. Often a diagnostic and therapeutic challenge, if these lesions are left, posttraumatic osteoarthritis may occur. This retrospective single centre study presents the short-term results following operative fixation of osteochondral fragments of the knee using Omnitech ® screws. Method. All skeletally immature patients presenting with an osteochondral fracture of their femur or patella confirmed on xray and MRI were identified. Arthroscopic evaluation of the osteochondral defect was performed followed by open reduction and internal fixation of the osteochondral fragment using Omnitech ® screws. A standard postoperative rehabilitation protocol was followed. Patients were evaluated at follow-up using a Knee Injury and Osteoarthritis Outcome Score (KOOS). Results. Eight patients were identified. The mean age at time of injury was 15 years (range 14–16) for two girls and 14.4 years (range 13–16) for six boys. The lateral femoral condyle was involved in six cases and patella in two cases. At mean follow up of 14 months (range 1–38) there was no revision for failure and no postoperative complications. The KOOS score (out of 100) at final follow up was subdivided as follows; Pain, 93 (range 81–100), other symptoms, 77 (range 36–100), function in daily living (ADL), 97 (range 84–100), function in sport and recreation, 84 (range 55–100) and knee related quality of life, 79 (range 44–100). Discussion. The short-term results of using Omnitech® screws are promising. Subchondral screw placement with adequate compression of the osteochondral fragment is achievable with Omnitech ® screws. Seven patients are back to their pre-injury sporting activity and one patient is currently undergoing postoperative rehabilitation, one month following surgery

Recent reports suggest that long-term alendronate therapy may result in an unusual pattern of femoral subtrochanteric fracture. We aimed to determine if the presence of a specific radiographic feature in patients on alendronate could be used to predict an impending insufficiency fracture and thereby prevent its occurrence through further investigations and prophylactic fixation in high-risk patients. Sixty-two subtrochanteric fractures treated surgically from 2001 to 2007 were reviewed and radiographs of 25 low-energy fractures were independently evaluated. Incidence of alendronate therapy, clinical data, and other investigations like bone mineral density (BMD) scans were recorded. Seventeen fractures (68%) were associated with alendronate therapy. Hypertrophy of the lateral cortex of the femur with splaying of the fracture ends was noted in 70.1% of patients on alendronate; initial radiographs were not available in 17.6% and 11.8% had stress fractures identified by bone scan. None of the fractures in the non-alendronate group had this pattern. The fracture configuration in the alendronate group suggested that an ellipsoid thickening in the lateral cortex had been present prior to fracture. Indeed, 6 patients on alendronate (35.3%) had pre-existing radiographs as early as 3 years prior to fracture and all had this feature. Four of them had bone scans, which confirmed a stress fracture. Hip pain was often associated with this radiographic sign but may not be specific as patients were already on follow-up for other musculoskeletal conditions. BMD scans were not predictive of an impending fracture as they were mostly in the osteopaenic range. Only 50% with proven stress fractures had prophylactic fixation, while the remainder sustained overt fractures. Alendronate-related subtrochanteric fractures are associated with a specific pre-existing radiographic abnormality. We recommend that all patients on long-term alendronate - particularly those with hip pain or a previous subtrochanteric fracture - be routinely followed-up with plain radiographs of the pelvis. If an ellipsoid feature is noted in the subtrochanteric region, further investigations like bone scan or MRI should be sought. Patients with evidence of stress fracture should be strongly considered for prophylactic operative fixation. We believe this is a cost-effective strategy to prevent subtrochanteric insufficiency fractures in patients on alendronate

Introduction

Considerable controversy exists with regard to the surgical management of displaced intra-articular calcaneal fractures. Protagonists for internal fixation would suggest there is sufficient evidence to expect better functional outcomes with surgery. However, this is not conclusive.

Aim

To identify factors which improved outcome following surgery.

Method

Between 1994–2000, 28 patients with 30 displaced intra-articular fractures of the calcaneum were treated with open reduction and internal fixation at our hospital (mean age 45 years). We reviewed 20 patients within the Shropshire region using four recognised hindfoot scoring systems. Patients were classified according to Sanders’ classification with pre-operative CT scans. The mechanism of injury and post-operative management were recorded. Clinical and radiographic assessments were also made.

Results

Average follow-up was 3.6 years. The overall surgical results were comparable with similar studies based upon the Maryland Foot Score (30% excellent, 35% good, 30% fair, 5% poor). Seventy-five percent of our patients returned to work within six months at an average of five months. Three patients developed a superficial wound infection. Age, energy of injury, time to surgery, time spent in plaster and time to commencing physiotherapy had no significant bearing on functional outcome. However, early weightbearing at six weeks positively influenced outcome with all four scoring systems (p=0.01, 0.01, 0.02, 0.05) with a deterioration of outcome with delayed weightbearing. This was shown to be due to loss of subtalar joint mobility (r=−0.74, p=0.001).

Conclusions

We propose that good results can be obtained from internal fixation of intra-articular calcaneal fractures with a high probability of early return to work. We recommend that patients be encouraged to weightbear at 6 weeks to optimise mobility at the subtalar joint.

Aim: To identify factors which improved outcome following surgery. Method: Between 1994–2000, 28 patients with 30 displaced intra-articular fractures of the calcaneum were treated with open reduction and internal fix-ation at our hospital (mean, 45 years). We reviewed 20 patients within the Shropshire region over a 3.6 average follow-up period using 4 recognised hindfoot scoring systems. Patients were classified according to Sander’s classification with preoperative CT scans. The mechanism of injury and postoperative management was recorded. Clinical and radiographic assessments were also made. Results: Average follow up was 3.6 years. The overall surgical results were comparable of similar studies based upon the Maryland Foot Score (30% excellent, 35% good, 30% fair, 5% poor). 75% of our patients returned back to work within 6 months with an average of 5 months. 3 patients developed a superficial wound infection. Data analysis revealed that neither the age, energy of injury, time to surgery, time spent in plaster nor the time that physiotherapy was commenced had any significant bearing on functional outcome. However, early weightbearing at 6 weeks positively influenced outcome with all 4 scoring systems (p=0.01, 0.01, 0.02, 0.05) with a deterioration of outcome with delayed weightbearing. This was shown to be due to loss of sub-talar joint mobility (r=−0.74, p=0.001). Conclusions: We propose that good results can be obtained from internal fixation of intra-articular calcaneal fractures with a high probability of early return back to work. We recommend that patients be encouraged to weightbear at 6 weeks to optimise mobility at the subtalar joint.

Purpose: To demonstrate that Rush pin is safe and effective in selected fragility ankle fractures.

Introduction: Fragility ankle fracture is increasing proportionately to their age. It produces not only clinical challenge due to multiple co morbidities but also a challenge to heal the fracture and particularly the skin. We found that early minimal intervention by stabilizing the lateral column with a rush nail is safe, beneficial and acceptable practice in selected cases.

Material & Method: Retrospective case notes & X-rays review of fragility ankle fractures between 1st of January 2005 to 31^st of August 2008 selection using the criteria below

✓ Closed Ankle Fracture

Results:

Seven patients found.

All patients had ankle fracture with fragile or damaged skin. All operated within 10 days of injury, including those who were on warfarin or significant medical problems. All underwent closed reduction and or percutaneous medial malleolar fixation and stabilization of the lateral column with Rush Pin through a stab incision under x-ray control. A lightweight plaster was applied for 4–6 weeks. All fracture healed in a acceptable position without any skin complication. One patient who had pre operative ulcer also healed.

Discussion/Conclusion: Minimally invasive treatment has no surgical wound complication. All fracture healed in a satisfactory position. All discharged after mean follow up of 6 month. One death due to unrelated cause after 5 weeks of operation.

Rush pin fixation in fragility fracture is a useful and safe methods of treatment in selected group.

Complications in internal fixation of proximal humeral fractures can lead to an unsatisfactory outcome. We retrospectively reviewed 22 patients at a mean follow-up of 13 months (range 3–30). The average age was 58 years (36–86) in 10 male and 12 female patients. The mechanism of injury involved a simple fall in 17, MCA in 3, assault in 1 and metastasis in 1. The operation was performed at a mean of 11 days after the injury (range 1–29). There were 12 3-part, 6 2-part, 2 4-part fractures, 1 fracture dislocation and 1 pathological fracture. Only 13 out of 22 patients (59%) did not develop any complications. We had hardware problems in 5 patients including hardware pull-out, plate prominence, screw penetration, loosening or breakage. 2 wound infections, 1 axillary nerve palsy and 1 peri-operative death. 3 patients (14%) had reoperations to remove the plate, 1 had revision fixation, 1 MUA, 1 open capsular release and 1 I+D of wound. Radiographic union was achieved in 18 patients (82%). We identified a relatively high rate of complications especially in alcoholic or unfit patients. Better patient selection and familiarity with the implant and operative technique are essential for a good outcome. Pain relief and union rate were satisfactory.

The objective was to compare vastus lateralis muscle splitting verses muscle sparing surgical approach to proximal femur for fixation of intertrochanteric fracture.

Of the 16 patients in this prospective randomised double blind study 8 were randomised to vastus lateralis muscle splitting and rest to muscle sparing group. Main outcome measurement was assessment of status of vastus lateralis muscle at 2 and 6 weeks using nerve conduction study. Preoperative demographics were identical for both the groups.

There was no statistically significant difference between the groups with regards to velocity, latency, and amplitude. The postoperative haemoglobin drop, heamatocrit, position of the dynamic hip screw and mobility status were identical.

Both clinical and neurophysiological outcome suggest that damage done to vastus lateralis either by splitting or elevating appears to be identical.

Introduction: Current Literature is sparse with respect to the optimum surgical approach for fixation of a fractured neck of Femur. A cadaveric study has been performed to determine the pattern of innervation of the Vastus Lateralis muscle. Results indicate that a muscle splitting technique may cause more nerve damage than a muscle reflection technique. The purpose of this study was to determine the clinical and neurophysiological effects of two different surgical approaches to the proximal femur.

Methods: Patients were randomised to receive either a Vastus splitting approach or a Vastus reflecting approach to the fractured femoral neck. The contralateral leg was used as the control for neurophysiological investigation. Needle electromyography was performed on both the operated and unoperated limbs within 2 weeks of surgery.

Results: 25 patients were included in the study randomisation. A total of 17 patients completed neurophysiological investigation, 8 in muscle reflection and 9 in muscle splitting groups. There was a significant reduction in femoral nerve conduction velocity compared to the unoperated control side in the muscle split group. This was also the case for amplitude of response measured in the Vastus muscle. The muscle reflection group showed no significant differences in these parameters compared to the unoperated side.

Conclusion: On the basis of the results of this study we recommend a Vastus Lateralis reflecting approach for proximal Femoral fracture fixation. The functional outcome of a muscle splitting approach remains unclear but could be investigated as part of a larger trial.

Purpose: The optimal timing for surgical stabilization of the fractured spine is controversial. Early stabilization facilitates earlier mobilization and theoretically reduces associated complications.

Method: Consecutive patients requiring stabilization surgery for a spinal fracture, without neurological injury were identified from a prospective institutional database. Patients were stratified by the time to their final surgical stabilization procedure (< 12, 12–24, 24–48, 48–72 and > 72 hours) and outcomes compared. Multivariate analyses were performed to explore potential confounding effects.

Results: 76 patients satisfied the inclusion/exclusion criteria. The median time to final surgical spinal stabilization was 71.8 hours. There were significant differences in complications related to prolonged recumbancy (e.g. respiratory failure, thromboembolism, p = 0.016) between the different time frames. Graphical exploration suggested higher complication rates after 48 hours delay. Comparing patients stabilized after 48 hours compared to those within, there was a 6.9 times (p = 0.0085) greater risk of a complication related to prolonged recumbancy. These effects remained significant after multivariate adjustments for age, comorbidity and ISS. There were trends towards longer lengths of stay and lower function (measured using the FIM) at discharge in the surgical delay group.

Conclusion: This study demonstrates a strong relationship between surgical delay and complications. The cutoff for this delay appears to occur at 48 hours. This study is limited in that the identified relationship may be related to a number of other confounding factors not measured or inadequately adjusted for because of small numbers. Further study, using this study’s developed algorithms in larger datasets, may help resolve some of these issues.