The purpose of this study is to determine the re-operation rate following plate fixation of the olecranon with contoured anatomic plates. Plate fixation of the olecranon allows for management of different fracture patterns as well as osteotomies with anatomic reduction and stable fixation for early elbow mobilization. However, olecranon hardware prominence can be troublesome. Our hypothesis was with the newer generation of low profile contoured anatomic plates, the rate of hardware removal should be lower compared to previously described literature. Retrospective review for patients treated with operative fixation of the olecranon between 2010 and 2015 in the Edmonton zone was identified using population level administrative data. Radiographic screening of these patients was then carried out to identify those who received plate fixation. Fracture patterns were also characterized. Chart reviews followed to determine the indications for re-operation and other post-operative complications. Main outcome measures were re-operation rate and their indications, including hardware prominence. During the screening process, 600 surgically treated olecranon patients were identified and 321 patients were found to have plate fixation of the olecranon. Chart review determined 90 patients had re-operations demonstrating a 28% re-operation rate. Re-operation due to hardware prominence was found to be 15.6%. Other indications included hardware failure (5.3%), infection (2.8%), or contracture (2.8%). Compared to patients that did not require re-operation, the re-operation group had a higher incidence of Type III olecranon fractures (17.4% vs 8.4%, p = 0.036) and Monteggia pattern injuries (13.5% vs 4.9%, p = 0.008). Recent heteregenous data suggests the hardware removal rate related to implant prominence is between 17–54%. Compared to the literature, this study demonstrated a lower rate at 15.6% with contoured anatomic plating. Also, those with more complex fracture patterns were more likely to require re-operation

Aims. It is unclear whether acute plate fixation facilitates earlier return of normal shoulder function following a displaced mid-shaft clavicular fracture compared with nonoperative management when union occurs. The primary aim of this study was to establish whether acute plate fixation was associated with a greater return of normal shoulder function when compared with nonoperative management in patients who unite their fractures. The secondary aim was to investigate whether there were identifiable predictors associated with return of normal shoulder function in patients who achieve union with nonoperative management. Methods. Patient data from a randomized controlled trial were used to compare acute plate fixation with nonoperative management of united fractures. Return of shoulder function was based on the age- and sex-matched Disabilities of the Arm, Shoulder and Hand (DASH) scores for the cohort. Independent predictors of an early recovery of normal shoulder function were investigated using a separate prospective series of consecutive nonoperative displaced mid-shaft clavicular fractures recruited over a two-year period (aged ≥ 16 years). Patient demographics and functional recovery were assessed over the six months post-injury using a standardized protocol. Results. Data from the randomized controlled trial consisted of 86 patients who underwent operative fixation compared with 76 patients that united with nonoperative treatment. The recovery of normal shoulder function, as defined by a DASH score within the predicted 95% confidence interval for each respective patient, was similar between each group at six weeks (operative 26.7% vs nonoperative 25.0%, p = 0.800), three months (52.3% vs 44.2%, p = 0.768), and six months post-injury (86.0% vs 90.8%, p = 0.349). The mean DASH score and return to work were also comparable at each timepoint. In the prospective cohort, 86.5% (n = 173/200) achieved union by six months post-injury (follow-up rate 88.5%, n = 200/226). Regression analysis found that no specific patient, injury, or fracture predictor was associated with an early return of function at six or 12 weeks. Conclusion. Return of normal shoulder function was comparable between acute plate fixation and nonoperative management when union was achieved. One in two patients will have recovery of normal shoulder function at three months, increasing to nine out of ten patients at six months following injury when union occurs, irrespective of initial treatment. Cite this article: Bone Jt Open 2021;2(7):522–529

Introduction: Weber B fractures are one of the most common fractures of the ankle. Unstable fractures are treated with lateral plating and a lag screw. Another method of fixation is antiglide plating, this concept was first introduced by Brunner and Weber in 1982. Manoli and Schaeffer in 1987, showed that fixation by antiglide plate demonstrated superior static biomechanical properties compared to lateral plating. However there are some shortcomings in their study and hence we decided to perform our biomechanical study. The shortcomings of the Manoli study are. They did not use an interfragmentary lag screw for lateral plate fixation. It was a cadaveric study where the bone does not accurately represent the live bone. The quality of the bone ranging from normal to osteoporotic bone varies from cadaver to cadaver and hence there is no uniformity between the samples. Materials and Methods: We used 4th generation composite bone models validated to closely simulate human bone characteristics for fracture toughness, tensile strength, compressive strength, fatigue crack resistance and implant subsidence. 4th generation composite bone model provides uniformity of test samples which is not achievable in cadaveric studies. These bones were custom made for the experiment. We used two sets of bones, one representative of normal bone (Set A n=10) and the other of osteoporotic bone quality (Set B n=10). Each of the sets A & B will have two types of fixations for artificially created Weber B Fractures. Lateral plate with interfragmentary lag screw. Antiglide plate with interfragmentary lag screw. The strength of the fixation was measured by restressing the bone until the fixation failed using an Instron machine which simultaneously applied torque and compressive forces to the fibular construct. The resulting data was analysed on a computer and statistical analysis was performed. Results: When the two fixation constructs were stressed to failure, the lateral plate construct demonstrated less stiffness (3–5Nm/degree) and failed at lower energy levels (250Nm). Similar values obtained for the antiglide system were, stiffness of 12–16Nm/degree and energy absorbed to failure 350–450Nm. Antiglide plating was significantly more stable in the osteoporotic fibula. Conclusion: Antiglide plating with lag screw is much more stable than lateral plating. It is suitable for treatment without plaster cast post operatively. It results in a more stable fixation in osteoporotic bone

The choice of whether to perform antegrade intramedullary nailing (IMN) or plate fixation (PF) poses a conundrum for the surgeon who must strike the balance between anatomical restoration while reducing elbow and shoulder functional impairment. Most humeral middle third shaft fractures are amenable to conservative management given the considerable acceptable deformity and anatomical compensation by patients. This study is concerned with the patient reported outcomes regarding shoulder and elbow function for IMN and PF respectively. A prospective cohort study following up all the cases treated surgically for middle third humeral fractures from 2016 to 2022 at a single centre. Telephonically an analogue pain score, an American Shoulder and Elbow Society (ASES) score for shoulder function and the Oxford Elbow score (OES) for elbow function were obtained. One hundred and three patients met the inclusion criteria. Twenty four patients participated in the study, fifteen had IMN (62.5%) and nine had PF (37.5%.). The shoulder function outcomes showed no statistical difference with an average ASES score of sixty-six for the IMN group and sixty-nine for the PF group. Women and employed individuals expressed greater functional impairment. Hand dominance has no impact on the scores of elbow and shoulder function post operatively. The impairment of abduction score post antegrade nailing was higher in the antegrade nailing group than the plated group. The OES demonstrated greater variance in elbow function in the PF group with the IMN group expressing greater elbow disfunction. This study confirms that treatment of middle third humerus shaft fractures by plate fixation is marginally superior to antegrade intramedullary nailing in preserving elbow function and abduction ability

Background. Plate fixation is one of several options available to surgeons for the management of pediatric femur fractures. Recent literature reports distal femoral valgus can be a complication following lateral plate fixation of femur fractures. We report on a case of extreme distal femoral valgus deformity and a lateral dislocation of the patella four years after having plate fixation of a left distal femoral fracture. Method. A single case was anonymised and retrospectively reviewed through examination of clinical and radiographic data. Results. A 15 year old male presented with 35 degree femoral valgus deformity, one inch leg length discrepancy, painful retained hardware and a lateral dislocation of the patella four years after undergoing lateral plate fixation of a left distal femur fracture. The fracture site healed after plate insertion, but later the patient reported worsening in alignment of lower extremity and complained of pain in the limb. Antero-posterior and lateral radiographs of the femur revealed 35 degrees of left distal femoral valgus. The previous femoral plate migrated proximally and was encased in bone. Due to plate migration, screws that were originally in the distal femoral metaphysis were protruding through the femoral shaft into soft tissues of the medial thigh. Successful treatment involved removal of prominent distal screws and use of a Taylor Spatial external fixator frame to correct the deformity. Lateral soft tissue release was performed to allow patellar relocation. At 12 weeks follow up leg alignment was restored, pain resolved and the patient was mobilising. Conclusion. Femoral valgus is a possible complication of lateral plate fixation in up to 30% of pediatric distal femur fractures. With this patient's combination of deformities as an example, we suggest early hardware removal after fracture union, preventing deformities developing. If plate removal is not chosen, then continued close monitoring of the patient is necessary until skeletal maturity. Level of Evidence. Type 4 (case report)

We report the results of anterior plate fixation for symptomatic, mid-shaft clavicle non-union. The superior surface is most commonly used for plate fixation. To the best of our knowledge, there are no clinical reports where anterior plate fixation of the clavicle was used. We included 12 consecutive patients, with symptomatic mid-shaft clavicular non-union, aged between 23 and 56 years during a four-year period (1998-2002). The injury was secondary to RTA in 6 cases, sports-related in 5 and skiing in one. In three patients, the non-union was secondary to superior plating using one third tubular plate, in acute fractures. The most common complaint was anterior shoulder pain (12 cases) followed by brachialgia (4 patients). The operation was performed through an anterior approach. A 3.5mm reconstruction plate was contoured and fixed onto the anterior surface of the clavicle. Bone graft was used in all cases. The average follow up was 22 months. All 12 patients achieved union at an average union time of seventeen weeks. Compared to superior plating, anterior plating has the distinct advantage that the longer screws can be used (as the clavicle is a flat bone, and the AP diameter is larger compared to superoinferior diameter) thus improving the stability of fixation. Our results show that anterior clavicle fixation is safe and effective in achieving union, even in cases following failed superior plate fixation. We therefore recommend anterior plate fixation and bone grafting in symptomatic nonunions of mid third clavicle fractures

Operative management of clavicle fractures is increasingly common. In the context of explaining the risks and benefits of surgery, understanding the impact of incisional numbness as it relates to the patient experience is key to shared decision making. This study aims to determine the prevalence, extent, and recovery of sensory changes associated with supraclavicular nerve injury after open reduction and plate internal fixation of middle or lateral clavicle shaft fractures. Eighty-six patients were identified retrospectively and completed a patient experience survey assessing sensory symptoms, perceived post-operative function, and satisfaction. Correlations between demographic factors and outcomes, as well as subgroup analyses were completed to identify factors impacting patient satisfaction. Ninety percent of patients experienced sensory changes post-operatively. Numbness was the most common symptom (64%) and complete resolution occurred in 32% of patients over an average of 19 months. Patients who experienced burning were less satisfied overall with the outcome of their surgery whereas those who were informed of the risk of sensory changes pre-operatively were more satisfied overall. Post-operative sensory disturbance is common. While most patients improve, some symptoms persist in the majority of patients without significant negative effects on satisfaction. Patients should always be advised of the risk of persistent sensory alterations around the surgical site to increase the likelihood of their satisfaction post-operatively

The aim of this prospective randomized controlled trial was to compare patient reported and functional outcomes, complications and costs for displaced olecranon fractures managed with either tension band wire (TBW) or plate fixation. We performed a registered prospective randomized, single blind, single centre trial in 67 patients aged between 16–74 years with an acute isolated displaced fracture of the olecranon. Patients were randomised to either TBW (n=34) or plate fixation (n=33). The primary outcome measure was the Disability Arm Shoulder and Hand (DASH) score at one-year. The baseline demographic and fracture characteristics of the two groups were overall comparable. The one-year follow-up was 85percnt;. There was a significant improvement in elbow function over the 12 months following injury in both groups (p<0.001). At one-year following surgery the DASH for the TBW group was not statistically different to the plate fixation group (12.8 vs 8.5; p=0.315). There was no significant difference between groups in terms of range of movement, Broberg and Morrey Score, Mayo Elbow Score or the DASH at all assessment points over the one-year following injury (all p≥0.05). Complication rates were significantly higher in the TBW group (63percnt;vs38percnt;; p=0.042), predominantly due to a significantly higher rate of symptomatic metalwork removal (50percnt;vs22percnt;; p=0.021). In active patients with an isolated displaced fracture of the olecranon, no difference was found in the patient reported outcome between TBW and plate fixation at one year following surgery. The complication rate is higher following TBW fixation due to a high rate of symptomatic metalwork removal

Aims. The optimal management of posterior malleolar ankle fractures, a prevalent type of ankle trauma, is essential for improved prognosis. However, there remains a debate over the most effective surgical approach, particularly between screw and plate fixation methods. This study aims to investigate the differences in outcomes associated with these fixation techniques. Methods. We conducted a comprehensive review of clinical trials comparing anteroposterior (A-P) screws, posteroanterior (P-A) screws, and plate fixation. Two investigators validated the data sourced from multiple databases (MEDLINE, EMBASE, and Web of Science). Following PRISMA guidelines, we carried out a network meta-analysis (NMA) using visual analogue scale and American Orthopaedic Foot and Ankle Score (AOFAS) as primary outcomes. Secondary outcomes included range of motion limitations, radiological outcomes, and complication rates. Results. The NMA encompassed 13 studies, consisting of four randomized trials and eight retrospective ones. According to the surface under the cumulative ranking curve-based ranking, the A-P screw was ranked highest for improvements in AOFAS and exhibited lowest in infection and peroneal nerve injury incidence. The P-A screws, on the other hand, excelled in terms of VAS score improvements. Conversely, posterior buttress plate fixation showed the least incidence of osteoarthritis grade progression, postoperative articular step-off ≥ 2 mm, nonunions, and loss of ankle dorsiflexion ≥ 5°, though it underperformed in most other clinical outcomes. Conclusion. The NMA suggests that open plating is more likely to provide better radiological outcomes, while screw fixation may have a greater potential for superior functional and pain results. Nevertheless, clinicians should still consider the fragment size and fracture pattern, weighing the advantages of rigid biomechanical fixation against the possibility of soft-tissue damage, to optimize treatment results. Cite this article: Bone Jt Open 2024;5(3):227–235

Introduction. Plate fixation for distal femoral fractures is a commonly used method of fracture stabilisation. Many orthopaedic surgeons traditionally do not allow their patients to weight bear for the first 6 weeks after surgery, fearing of loss of fracture reduction and metalwork failure. The aim of this study is to investigate whether the post-operative weight bearing status after plate fixation influences the outcome in terms of loss of reduction and metalwork failure. Materials & Methods. A retrospective data collection from all patients who treated in our hospital surgically for distal femoral fractures, from January 2015 until June 2017. Inclusion criteria were the operative treatment of these fractures with plate fixation. Patients who were treated with retrograde nail, primary total knee replacement or screw fixation were excluded from the study. Patient, injury and surgery demographic data was collected. The immediate post-operative weight bearing status of these patients was noted. Weight bearing status was divided into two groups – Group 1 (Non and touch weight bear – the non-weight bearing group) and Group 2 (Weight bear as tolerated / Full weight bear – the weight bearing group). Radiological data about fracture displacement or metalwork failure was collected at the six weeks and three months follow up after the operation, using a standardised measurement for displacement performed independently by two authors (EI, TA). Results. Of 70 patients, a total of 51 fractures treated with plate fixation were included to the study. The mean age of the cohort was 64.3 ±20.7 years with the majority of the patients being female (63%). Most of the patients (40%) had a complete articular distal femoral fracture, AO Type 33C. Thirty-nine patients (76%) were treated with one lateral distal femoral plate. The total number of the patients in group 1 was 32 (68%); with 17 patients (32%) in group 2. The weight bearing status did not correlate with the fracture type or the fixation type (p>0.05). None of the 6 weeks follow up radiographs revealed fracture displacement in both study groups. Four of the patients from the non-weight bearing group had >1mm displacement at the 3 months' follow-up radiographs. Fisher's exact test revealed no statistically significant difference between the two study groups in both follow-up time points (p=0.55). Two of the patients in the non-weight bearing group had their plate broken at the 3 months follow up and required revision fixation. Conclusion. By reviewing the outcomes in terms of fracture displacement and metalwork failure following plate fixation of distal femoral fractures, early weight bearing of these patients do not jeopardise the outcome of the operation

Purpose. Open reduction and plate fixation of displaced mid-shaft clavicle fractures has gained significant popularity following a recent multi-center randomized control trial. The purpose of this study is to describe the incidence of reoperation following plate fixation of displaced mid-shaft clavicle fractures. The secondary objective is to determine if plate design influences the incidence of reoperation. Method. A retrospective search of our hospital database was performed to identify subjects treated with plate fixation for a displaced clavicle fracture between 2001 and 2009. Radiographs and medical records were used to identify demographic data, fracture classification, plate design, and reoperation events. Only mid-shaft (AO/OTA 15-B) fractures treated with either a Low-Contact Dynamic Compression (LCDC) plate or Pre-contoured Locking (PCL) plate were included. Results. 144 subjects were included in the study. The mean age was 36 years (95% CI 33 38 years) and the mean duration of follow-up was 60 weeks (95% CI 46 74 weeks). 60% of included fractures were wedge pattern (15-B2), followed by 35% simple (15-B1) fractures, and 5% complex (15-B3) fracture patterns. Pre-contoured locking plates were used in 92 cases (64%) and LCDC plates were used in the remaining 52 subjects (36%). 21 subjects (15%) underwent reoperation: 17% of subjects treated with LCDC plates and 13% of subjects treated with PCL plates (p=0.62). Indications for reoperation included painful hardware (86%), hardware failure (9%), and refracture (5%). There was no association between reoperation and age (p = 0.23), gender (p = 0.56), fracture type (p = 0.53), or plate design (p = 0.49). Conclusion. This study represents a large series of displaced clavicle fractures treated with open reduction and plate fixation. Reoperation following plate fixation is relatively common and is primarily due to painful hardware. No difference in reoperation rates between LCDC and pre-contoured plates could be detected in the current sample size

Distal radius fractures (DRF) are the most common fracture type in all age groups combined. Unstable DRF may be surgically managed with volar or dorsal plate fixation. Dorsal plating has traditionally been associated with decreased range of motion (ROM). However, this assumption has not been recently assessed to determine whether functional ROM is achievable (approximately 54o of flexion and 60o of extension) with recent advances in lower profile dorsal plate design. The aim of this study was therefore to compare ROM and patient reported outcome measures between volar and dorsal plating methods for DRF. A meta-analysis was performed to directly compare ROM and DASH scores between dorsal and volar plate fixation for DRF. Separate literature searches for each plating method were performed using MedLine and EMBase on January 28, 2018. Exclusion criteria consisted of non-English articles, basic science articles, animal/cadaver studies, case studies/series, combined operative approaches, papers published more than 20 years ago and paediatric studies. Only articles with at least one year patient follow-up and a) ROM and AO distal radius fracture classification, or b) DASH scores were included. Raw data was extracted from all articles that met inclusion criteria to compile a comprehensive dataset for analysis. Descriptive statistics with z-score comparison for AO classification or a two-tailed independent samples t-test for ROM and DASH scores for dorsal versus volar plating were performed. Significance was defined as p < 0 .05. After rigorous screening, 6 dorsal plating and 43 volar plating articles met inclusion criteria for ROM/AO classification versus 6 dorsal plating and 44 volar plating articles for DASH scores. The weighted means of flexion (dorsal 54.9o, SD 9.3, n=257, volar 61.3o, SD 11.5, n=1906) and extension (dorsal 60.0o, SD 12, n=257, volar 62.8o, SD 11.4, n=1906) were statistically significantly different (both p < 0 .001) between the two plating methods. The volar plating group had a significantly higher proportion of AO type C fractures (dorsal 0.5, n =169, volar 0.6, n=1246, p < 0 .001). The weighted means of reported DASH scores were not significantly different between dorsal (14.01, SD 14.8) versus volar (13.6, SD 12.8) plating (p=0.54). Though mean wrist flexion and extension were statistically different between the dorsal versus volar plating methods, the difference between group means was less than 5o, which is unlikely to be clinically significant. Additionally, we did not find a significant difference in DASH scores between the two plating methods. Taken together, these findings imply that the statistical difference in ROM outcomes are likely not clinically significant and should therefore not dictate choice of plating method for fixation of DRF

Fractures repair by two mechanisms; direct fracture healing and indirect fracture healing via callus formation. Research concerning the effects of bisphosphonate on fracture repair has solely assessed indirect fracture healing. Patients with osteoporosis on bisphosphonates continue to sustain fragility fractures. A proportion of osteoporotic fractures require plate fixation. Bisphosphonates impair osteoclast activity and therefore, may adversely affect direct fracture healing that predominates with plate fixation. Five skeletally mature Sprague-Dawley rats received daily subcutaneous injections of 1mg/kg Ibandronate (IBAN). Similarly, five control rats received saline (CONTROL). Three weeks following commencement of injections a tibial osteotomy was rigidly fixed with compression plating similar to that seen in routine clinical practice. Fracture healing was monitored with radiographs. Six weeks post plate fixation, animals were sacrificed. Radiographs were performed of the extricated tibiae following plate removal. The visibility of the osteotomy site was scored as totally visible, partially visible or absent as previously described. Mechanical testing was conducted on the healing osteotomies via 4-point bending. Fractures healed without visible external callus. In the IBAN group three animals had totally visible osteotomy lines and two had partially visible osteotomy lines. The CONTROL group had three animals with absent osteotomy lines and two with partially visible osteotomy lines. The mean (±SD) stress at failure for the healing tibial osteotomies at 6 weeks was 28.8 (±23.97)MPa in the IBAN group and 37.4(±29.20) MPa in the CONTROL group (p=0.62). Our results indicate that Ibandronate adversely affected direct fracture repair as demonstrated by the radiographic density of the fracture line. The strength of the repair was reduced but this did not reach statistical significance. Our results suggest that a sample size of 220 animals is required to detect a 15% difference (alpha 0.05, beta 0.2) which suggests the effect of bisphosphonates on direct fracture repair may be small

Distal radius fractures (DRF) are the most common fracture type in all age groups combined. Unstable DRF may be surgically managed with volar or dorsal plate fixation. Dorsal plating has traditionally been associated with decreased range of motion (ROM). However, this assumption has not been recently assessed to determine whether functional ROM is achievable (approximately 54 degrees of flexion and 60 degrees of extension) with recent advances in lower profile dorsal plate design. The aim of this study was therefore to compare ROM and patient reported outcome measures between volar and dorsal plating methods for DRF. A meta-analysis was performed to directly compare ROM and Disabilities of Arm, Shoulder and Hand (DASH) scores between dorsal and volar plate fixation for DRF. Separate literature searches for each plating method were performed using MedLine and EMBase on January 28, 2018. Exclusion criteria consisted of non-English articles, basic science articles, animal/cadaver studies, case studies/series, combined operative approaches, papers published more than 20 years ago and paediatric studies. Only articles with at least one year patient follow-up and a) ROM and AO-OTA distal radius fracture classification, or b) DASH scores were included. Raw data was extracted from all articles that met inclusion criteria to compile a comprehensive dataset for analysis. Descriptive statistics with z-score comparison for AO-OTA classification or a two-tailed independent samples t-tests for ROM and DASH scores for dorsal versus volar plating were performed. Significance was defined as p < 0 .05. After rigorous screening, six dorsal plating and 43 volar plating articles met inclusion criteria for ROM/AO-OTA classification versus six dorsal plating and 44 volar plating articles for DASH scores. The weighted means of flexion (dorsal 54.9 degrees, SD 9.3, n=257, volar 61.3 degrees, SD 11.5, n=1906) and extension (dorsal 60 degrees, SD 12, n=257, volar 62.8 degrees, SD 11.4, n=1906) were significantly different (both p < 0 .001) between the two plating methods. The volar plating group had a significantly higher proportion of type C fractures (dorsal 0.5, n =169, volar 0.6, n=1246, p < 0 .001). The weighted means of reported DASH scores were not significantly different between dorsal (14, SD 14.8) versus volar (13.6, SD 12.8) plating (p=0.54). Though mean wrist flexion and extension were statistically different between the dorsal versus volar plating methods, the difference between group means was less than 5-degrees, which is unlikely to be clinically significant. Additionally, there was no significant difference in DASH scores between the two plating methods. Taken together, these findings imply that the statistical difference in ROM outcomes are likely not clinically significant and should therefore not dictate choice of plating method for fixation of DRF

Background. Surgical management of calcaneus fractures is demanding and has a high risk of wound complications. Traditionally these fractures are managed with splinting until swelling has subsided. We describe a novel protocol for the management of displaced intra-articular calcaneus fractures utilising a temporizing external fixator and staged conversion to plate fixation through a sinus tarsi approach. The goal of this technique is to allow for earlier treatment with open reduction and internal fixation, minimise the amount of manipulation required at the time of definitive fixation and reduce the wound complication rate seen with the extensile approach. Methods. The records of patients with displaced calcaneus fractures from 2010–2014 were retrospectively reviewed. A total of 10 patients with 12 calcaneus fractures were treated with this protocol. All patients underwent ankle-spanning medial external fixation within 48 hours of injury. Patients underwent conversion to open plate fixation through a sinus tarsi approach when skin turgor had returned to normal. Time to surgery, infection rate, wound complications, radiographic alignment, and time to radiographic union were recorded. Results. The average Bohler's angle improved from 13.2 (range −2 to 34) degrees preoperatively to 34.3 (range 26 to 42) degrees postoperatively. The average time from external fixation to conversion to internal fixation was 4.8 (range 3 to 7) days. There were no immediate post-surgical complications. The average time to weight bearing was 8.5 weeks. The average time to radiographic union was 9.5 (range 8 to 12) weeks. There were no infections or wound complications at the time of last follow-up. Conclusions. Early temporizing external fixation for the acute management of displaced calcaneus fractures is a safe and effective method to reduce and stabilise the foot and may decrease the time to definitive fixation. In our series there were no complications related to the use of the external fixator. Level of Evidence. IV Retrospective case series

Tension band wire fixation continues to be the most popular method of fixation for displaced olecranon fractures despite several biomechanical studies questioning the validity of the tension band concept. Our aim was to compare the outcome of the tension band wire (TBW) method with plate fixation. 58 consecutive olecranon fractures underwent internal fixation in 58 patients between September 2000 and December 2004. There were 30 male and 28 female with a mean age at the time of surgery of 52.5 years for the TBW group (range 19 to 88) and 46.1 for the plate group (range 19 to 72). Patients were excluded if they were less than 16 years of age. Choice of fixation was based on surgeon preference, fracture pattern and presence of associated injuries. 43 patients were managed with the AO tension band technique and 15 with plate fixation. Clinical assessment and functional analysis was performed using Helm’s scoring system. Radiographic assessment was performed to assess the quality of reduction. All fractures were displaced and classified according to Colton’s classification. Mean follow up was 13 months (range 6 to 18) and similar for the two groups. For the TBW group 41 (95 %) had a fair or good result. 27 (62.8%) patients had symptomatic metal prominence requiring implant removal. In the plate fixation group 14 (94%) had a fair or good functional result despite having more complex fractures. Only 2 (18%) patients required implant removal for symptomatic metalwork, including one failure due to a technical problem. Similar functional results were seen with plating and tension band wiring of displaced olecranon fractures. Despite meticulous technique, tension band wire fixation still has an unacceptably high complication rate with symptomatic metal prominence requiring further surgery. To avoid this problem, we recommend plating, even for the more simple olecranon fractures

Purpose: Nonunion of the humeral shaft is an uncommon complication of diaphyseal fractures. The rate of nonunion reported in the literature is nevertheless very variable, ranging from 1 to 10%. There are many causal and favouring factors often related to a technical error or poor therapeutic indication. There are several ways to treat humeral shaft fractures (orthopaedic treatment, locked centromedullary nail, ascending pinning, plate fixation, external fixation). Rigorous technique and rigorous indications are the key to success. Material and methods: We reviewed 35 patients with aseptic nonunion of the humeral shaft between 1995 and 2000. The nonunion resulted from imperfect initial treatment in 24. Mean age was 44 years; fracture of the mid third of the shaft was oblique or transverse in general; all types of initial treatments had been used but ascending pins predominated (16 cases). All patients were reoperated for external plate fixation with a cancellous or corticocancellous bone graft after identifying the radial nerve. Results: All patients achieved consolidation within a mean delay of 15 weeks with good shoulder (mean elevation 135°) and elbow (mean 10–130°) amplitudes. There were two cases of transient radial paresis with spontaneous recovery. Only two patients experienced mild arm pain that did not required long-term antalgesic treatment. There were no injuries to the femorocutaneous nerve at the site of graft harvesting. Discussion: Plate fixation for nonunion of the humerus is widely described in the literature. The main complications with this method include radial paralysis and infection. For this reason, several recent reports have advocated locked nailing or external fixation of the Ilizarov type. These methods are technically difficult and are not free of their own complications. We thus recommend screw plate fixation (eight cortical screws on either side of the nonunion) associated with cancellous bone grafts. The results in our series with almost no complications favour this option

Debate surrounds the optimum operative treatment of periprosthetic distal femoral fractures (PDFFs) at the level of well fixed femoral components; lateral locking plate fixation (LLP-ORIF) or distal femoral replacement (DFR). To determine which attributed the least peri-operative morbidity and mortality we performed a retrospective cohort study of 60 consecutive unilateral PDFFs of Su types II (40/60) and III (20/60) in patients ≥60 years; 33 underwent LLP-ORIF and 27 underwent DFR. The primary outcome measure was reoperation. Secondary outcomes included perioperative complications and functional mobility status. Kaplan Meier survival analysis was performed. Cox multivariable regression analysis identified risk factors for reoperation after LLP-ORIF. Mean length of follow-up was 3.8 years (range 1.0–10.4). One-year mortality was 13% (8/60). Reoperation rate was significantly higher following LLP-ORIF: 7/33 vs 0/27, p=0.008. For the endpoint reoperation, five-year survival was better following DFR: 100% compared to 70.8% (51.8 to 89.8 95%CI) (p=0.006). For the endpoint mechanical failure (including radiographic loosening) there was no difference at 5 years: ORIF 74.5% (56.3 to 92.7); DFR 78.2% (52.3 to 100), p=0.182). Reoperation following LLP-ORIF was independently associated with medial comminution: HR 10.7 (1.45 to 79.5, p=0.020). Anatomic reduction was protective against reoperation: HR 0.11(0.013 to 0.96, p=0.046). When inadequately fixed fractures were excluded differences in survival were no longer significant: reoperation (p=0.156); mechanical failure (p=0.453). Reoperation rates are higher following LLP-ORIF of low PDFFs compared to DFR. Where adequate reduction, proximal fixation and augmentation of medial comminution is used there is no difference in survival between LLP-ORIF and DFR

There are many management solutions for the fixation of Periprosthetic fractures with intact stem of Hip and shoulder arthroplasties. The Bio Mechanics of single plate application are unlikely to be strong enough to commence mobilisation and its effectiveness against torsional strain with an osteoporotic bone quality is of concern. Double plate fixation as discussed at the last South African Orthopaedic Congress by Mr Floyd et al is another option but this again may have some biomechanical concerns and biological compromise at the fracture site due to periosteal stripping. Implant revision with a longer stem is a bigger surgical insult to a potentially frail group of patients with questionable bone quality. We report a short series of 16 peri-prosthetic fractures with intact stem that are managed with Zimmer cable plate fixation System. The results were very satisfactory and we consider this an attractive option to be considered in the management of this difficult presentation. This is a retrospective study. We present the results of 13 Periprosthetic Femoral Shaft fractures and 3 humeral periprosthetic fractures in 16 patients treated with cable plate fixation system. Majority of the patients were over 60 years with an ASA rating of 3–4. The procedures were performed in a district general hospital in the UK between August 2001 to December 2005. The patients presented with in 1–20 years following initial Arthroplasty. All the fractures were fixed with Zimmer cable plate fixation system. An 8 hole plate was most commonly used for femoral fractures through the lateral approach for TYPE 2 fractures. The proximal end of the plate was secured with 3–4 cable ties. Early partial weight bearing was encouraged. The majority of the patients were discharged within 12 weeks. Of the 3 humeral fractures union was achieved at 12 weeks in 2. There was 1 case of implant failure due to a further fracture noted in a manic depressive patient, who was not compliant. All proximal femoral fractures showed evidence of clinical and radiological union by 6 months. The majority (7/13) had united within 20 weeks. There were no complications noted. We recommend this effective method should seriously be considered in the management of this difficult and increasingly occurring complication in a frail population

Background: First MTP joint arthrodesis is a well established and very common procedure for painful arthrosis. Plate fixation method has been used with successful outcome (97–100%) by few authors but it is yet to be accepted universally for fear of complications. Aim: To evaluate clinical and radiological outcome of first MTP fusion using low profile Acumed plate. Methods: We retrospectively reviewed 125 patients who had 1st MTP arthrodesis (over 6 year period) for painful Hallux Rigidus not relieved by conservative means and for rheumatoid forefoot reconstruction. The preoperative evaluation included a subjective questionnaire, physical exam, AOFAS hallux score and radiographic measurements. Post-operatively, all patients were mobilised with heel weight bearing shoes for six weeks. All patients had follow up of minimum 6 months(range 6 months to 6 years). At the final follow-up all patients had answered a questionnaire which evaluated any limitations of daily activity and restrictions in footwear. Radiological measurements included union of the arthrodesis and various angles (valgus, intermetatarsal and dorsiflexion). Results: Of the 125 patients we had final reviews for 103 patients. The mean AOFAS improved from 40 to 82. The individual components of AOFAS i.e. pain, walking ability and alignment improved significantly. All patients but one had radiological evidence of fusion at mean of 6 weeks (range 6–8weeks) allowing them to walk with normal footwear. The mean dorsiflexion angle was 15° (range 13 °–18 °). The patient with non-union had re-arthrodesis with bone grafts using the revision plate. Two patients with rheumatoid arthritis required removal of plate for infection and wound breakdown. No plate failure occurred in any of the patients. Conclusion: The plate fixation is a reliable method for 1st MTP joint fusion that allows for a predictable fusion in a satisfactory alignment with low complication rate. The stability of the fixation allows for early mobilization without need for plaster immobilization and early return to functional activities