The question of whether to reconstruct an ACL-deficient knee as early as possible following injury or to delay surgery remains unanswered. Early reconstruction potentially reduces the risk of secondary damage. However, there is also concern regarding the risk of arthrofibrosis if surgery is undertaken too soon. The aim of this study was to investigate whether injury-to-surgery delay determines ACL-reconstruction outcomes at up to 2years post-operatively.

A retrospective analysis of prospectively collected data from 211 knees with isolated primary ACL ruptures was performed. Patients were examined preoperatively, at 6months, 1 year, and 2 years post-operatively using International Knee Documentation Committee (IKDC) and Lysholm scores. Side to side differences in knee laxity were also measured with a KT1000 arthrometer. Spearman's rho correlations were used to associate injury-to-surgery delay with outcome scores.

Outcomes scores significantly increased for both IKDC (p<0.05) and Lysholm (p<0.05) questionnaires. Significant positive correlations (p<0.05) were also found between injury-to-surgery delay and IKDC and Lysholm subjective scores. Strongest correlation coefficients were noted at the 2yr follow-up for both IKDC and Lysholm scores (r = 0.79 and 0.8 respectively). Side-to-side laxity measures also showed significant positive correlations with injury-to-surgery delay at 1 year (r = 0.17) and 2 year (r = 0.41) follow ups. The positive correlation suggests that delayed surgery is positively related to subjective outcomes, as well as objective measures of knee laxity.

However, this relationship also suggests that other factors such as the patient's functional status at time of surgery may play a role in their post-operative function. For example, those who can compensate for the ruptured ligament may function well following delayed surgery. These findings highlight the need for more detailed investigation of the interaction between functional status, injury-to-surgery delay and post-operative recovery.

Supracondylar fractures of the humerus in children are among the most common paediatric fractures, and yet present one of the greatest technical challenges for management. Traditionally treated as surgical urgencies, recent literature calls that belief into question. The purpose of this study was to determine the influence of the elapsed time from injury to surgery of Gartland Type III supracondylar fractures on operative time and quality of reduction.

A retrospective review of all Gartland Type III supra-condylar factures treated by closed reduction and percutaneous pinning at our hospital between January 2003 and April 2006 was performed. Subjects in this consecutive series underwent a formal chart review to extract necessary data. The intra-operative fluroscopic images were utilised to assess the quality of reduction. All images were analyzed by three independent blinded reviewers on two separate occasions. Parameters measured on the AP images included: Baumann’s Angle, Humerocapitellar angle, Gordon Index, Griffet Index one and two.

Of the one hundred and forty-one charts reviewed, twenty-nine were excluded for various criteria. Of the remaining sample (N=112), sixty-one patients were treated in less than eight hours (Group one), and fifty-one treated after eighthours (Group two). There were sixty-one girls and fifty-one boys, with a mean age of six yrs. There were no cases of compartment syndrome. No subjects required conversion from closed to open reduction. The mean time from injury to surgery was six hundred and seventy minutes (min = 128, max = 3117). The mean for Group one was three hundred and forty-one minutes and one thousand and sixty-five minutes for Group two. The mean operative time was 33.29 minutes, (min=ten, max =eighty-two). The mean operative time in Group one was 33.13 minutes and 33.38 minutes in Group two. Two t-tailed t-test demonstrates no significant difference between the two groups. Radiographic analysis revealed the following means: Baumann’s angle (m = 70.26), humero-capitellar angle (m= 36.19), Gordon Index (m=33.78), Griffet Index 1 (m=0.88) and Griffet Index 2 (m=2.55). Comparison of the radiographic parameters and indices demonstrated no significant difference between the two groups.

This study demonstrates delaying surgery beyond eight hours led to no difference in operative time or quality of reduction. Previous studies have demonstrated no difference in rate of compartment syndrome, presence of complications or need for open reduction between these two groups. Our findings combined with previous retrospective studies support the need for further prospective study and support the surgeon’s clinical judgment in determining the urgency of surgical intervention in this patient population.

Aims

The aim of this study was to determine whether early surgical treatment results in better neurological recovery 12 months after injury than late surgical treatment in patients with acute traumatic spinal cord injury (tSCI).

Aim. Pelvic osteomyelitis following pressure ulceration results in substantial patient morbidity. Previous studies have reported a heterogenous approach to diagnosis and medical management by physicians, suggesting equipoise on key clinical questions. This study hypothesised that the same equipoise exists amongst Orthopaedic surgeons. Method. An 18-question multiple-choice questionnaire was designed through an iterative feedback process until the final version was agreed by all authors. Likert-type scale responses were used with graded responses (e.g., never/fewer than half of patients/around half of patients/more than half of patients/every patient). The online survey was sent to members of the Musculoskeletal Infection Society (MSIS), the European Bone and Joint Infection Society (EBJIS), and the ESCMID Study Group for Implant-Associated Infections (ESGIAI). No incentive for participation was provided. Results. Amongst respondents, 22/41 were based in Europe and 10/41 from the USA. The majority (29/41) had been in clinical practice between 5—24 years. There was a high priority placed on bone biopsy histology, culture-positive bone sampling, and palpable bone without periosteal covering for diagnosis. Multidisciplinary team approach with plastic surgery involvement at the index procedure was advocated. The strongest indications for surgical intervention were source control for sepsis, presence of an abscess/collection, and prevention of local osteomyelitis progression. Physiological/psychological optimisation and control of acute infection were the primary determinants of surgical timing. There was low utilisation of adjunctive surgical therapies. Local/regional primary tissue transfer or secondary healing with/without VAC were the preferred techniques for wound closure. Recurrent osteomyelitis was the most common reason for prolonged antimicrobial therapy. The majority received bedside advice from an infectious disease-specialist but a quarter of respondents preferred telephone advice. Conclusions. Amongst an international cohort of Orthopaedic Surgeons there was a heterogenous diagnostic and therapeutic approach to pressure-related pelvic osteomyelitis

Aim. In the context of total knee arthroplasty (TKA), trauma with perigenicular fracture fixation or oncological surgical treatment, soft tissue defects can expose critical structures such as the extensor apparatus, the knee joint, bone or implants. This work compares soft tissue reconstruction (STR) between a classical pedicled gastrocnemius (GC) muscle flap and a pedicled chimeric sural artery perforator (SAP) musculocutaneous GC flap in complex orthoplastic scenarios. Method. A retrospective study was conducted on prospectively maintained databases in three University Hospitals from January 2016 to February 2021 after orthopaedic, traumatological or oncological treatment. All patients with a perigenicular soft tissue defect and implant-associated infection were included undergoing STR either with a pedicled GC flap or with a pedicled chimeric SAP-GC flap. The outcome analysis included successful STR and flap related complications. The surgical timing, preoperative planning and surgical technique are discussed together with the postoperative rehabilitation protocol. Results. 43 patients were included (22 GC muscle flaps, 21 SAP-GC musculocutaneous flaps). The GC and SAP-GC patient group were comparable in terms of age, comorbidities, defect size and follow-up. The incidence of flap related complications was comparable among the two groups. Specifically, in the SAP-GC group 1 wound dehiscence at the recipient site occurred as well as 1 distal muscle flap necrosis, 1 distal skin flap necrosis, 1 donor site infection and 1 donor site wound dehiscence. Furthermore, the donor site was closed in 9 patients while a skin graft was used in 12 patients. A significant difference was recorded with regard to re-raising the flap for further orthopaedic treatment: In the SAP-CG group (re-raise in 11 patients) no problems occurred while in the GC group (re-raise in 14 patients) in 6 patients the soft tissue did not heal completely. Conclusions. According to our clinical experience, the pedicled chimeric SAP-CG musculocutaneous flap is a relevant further development of the classical GC workhorse flap for perigenicular STR, in multiple staged procedures

Evaluate the complications and outcomes of off-hours spinal metastasis surgery. Retrospective analysis of a prospective collected data. Preoperative, operative and post-operative data were collected as well as the complications and Frankel score at all time checkpoints. Off-hours surgery was defined as surgery starting between 17:00 and 8:00 the following day or surgery during the weekend. p < 0 .05 was defined as statistical significance threshold. 376 patients were included with an incidence of off-hours surgery of 32%. There was an increase of neurologic complication in the off hours group. This was associated with a higher ASA score and older population group. Oddly, there was decreased operative time with off-hours surgery with no difference in bleeding and number of fusion levels. Nonetheless, there was a higher percentage of neurologic improvement with off hours surgery compared to in-hours surgery. Finally, there were no effect on patients' survival in this patient population. To our knowledge, this is the first report of the effect of off-hours surgery on complications and outcomes of spinal metastasis. Greater neurological compromise and higher age and ASA scores were associated with higher incidence of off-hours surgery. It is associated with decreased surgical time with higher percentage of neurological improvement. Finally, there is no effect of surgical timing on survival rates

Distal radius fractures (DRF) are very common injuries. National recommendations (British Orthopaedic Association, National Institute for Health and Care Excellence (NICE)) exist in the UK to guide the management of these injuries. These guidelines provide recommendations about several aspects of care including which type of injuries to treat non-operatively and surgically, timing of surgery and routine follow-up. In particular, current recommendations include considering immobilizing patients for 4 weeks in plaster for those managed conservatively, and operating on fractures within 72 hours for intra-articular injuries and 7 days for extra-articular fractures. With increased demands for services and an ageing population, prompt surgery for those presenting with distal radius fractures is not always possible. A key factor is the need for prompt surgery for hip fracture patients. This study is an audit of the current standard of care at a busy level 2 trauma unit against national guidelines for the management of DRFs. This retrospective audit includes all patients presenting to our emergency department from June to September 2018. Patients over 18 years of age with a diagnosis of a closed distal radius fracture and follow-up in our department were included in the study. Those with open fractures were excluded. Data was retrieved from clinical coding, electronic patient records, and IMPAX Client (Picture archiving and communication system). The following data was collected on patients treated conservatively and those managed surgically:- (1)Time to surgery for surgical management; (2)Period of immobilization for both conservative and operative groups. 45 patients (13 male, 32 female) with 49 distal radius fractures (2 patients had bilateral injuries) were included. Patients had mean age 63 years (range 19 to 92 years) 30 wrists were treated non-operatively and 19 wrists treated surgically (8 K-wires, 10 ORIF, 1 MUA). Mean time to surgery in the operative group was 8 days (range 1 – 21 days, median 7 days). Mean time to surgery for intra-articular fractures was 7 days (range 1 – 21) and 12 days for extra-articular fractures (range 4 – 20). Mean immobilization period in those treated in plaster is 6 weeks (range 4 – 13 weeks, median 5.6 weeks). At busy level 2 trauma units with limited theatre capacity and a high volume of hip fracture admissions, time to surgery for less urgent injuries such as wrist fractures is often delayed. National guidelines are useful in helping to guide management however their standards are often difficult to achieve in the context of increasing populations in urban areas and an ageing population

The April 2013 Trauma Roundup. 360 . looks at: ankle sprains; paediatric knee haemarthroses; evidence to support a belief; ‘Moonboot’ saves the day; pamphlets and outcomes; poor gait in pilons; lactate and surgical timing; and marginal results with marginal impaction

Hip fracture is a common injury with a high associated mortality. Many recommendations regarding timing of operative intervention exist for patients with such injuries. The Best Practice Tariff was introduced in England and Wales in 2010, offering financial incentives for surgery undertaken within 36 hours of admission. The England and Wales National Institute for Health and Clinical Excellence (NICE) Guidance states that surgery should be performed on the day or day after admission. Due to lack of clear evidence, this recommendation is based on Humanitarian grounds. NICE have called for further research into the effect of surgical timing on mortality. We utilised data from the National Hip Fracture database prospectively collected between 2007 and 2015, comprising 413,063 hip fractures. Using 11 variables, both Cox and Logistic regression analysis was used to establish the effect on mortality of each 12 hour interval from admission to surgery. For each 12 hour time frame from admission to surgery a trend for improved 30 day survival was demonstrated the earlier the surgery was performed. However, this did not reach significance until beyond 48 hours (Hazard ratio of 1.12, 95% CI: 1.04–1.20). Surgery after 48 hours suffered significantly higher chance of mortality compared to surgery done within 12 hours. This is the largest analysis undertaken to date. Lowest mortality rates are found within the 0–12 hour window. After 48 hours there is a significant increased risk of mortality compared to the 0–12 hour time frame. As such, expeditious surgery within 48 hours can be justified both on humanitarian and survivorship grounds. Hip fracture surgery performed within 48 hours is associated with reduced mortality when compared to that beyond this time. This is in agreement with Blue Book recommendations and extends the currently recommended NICE and Best Practice Tariff targets of 36 hours

Aims

The modern prevalence of primary tumours causing metastatic bone disease is ill-defined in the oncological literature. Therefore, the purpose of this study is to identify the prevalence of primary tumours in the setting of metastatic bone disease, as well as reported rates of pathological fracture, postoperative complications, 90-day mortality, and 360-day mortality for each primary tumour subtype.

Initial treatment of traumatic spinal cord injury remains as controversial in 2023 as it was in the early 19th century, when Sir Astley Cooper and Sir Charles Bell debated the merits or otherwise of surgery to relieve cord compression. There has been a lack of high-class evidence for early surgery, despite which expeditious intervention has become the surgical norm. This evidence deficit has been progressively addressed in the last decade and more modern statistical methods have been used to clarify some of the issues, which is demonstrated by the results of the SCI-POEM trial. However, there has never been a properly conducted trial of surgery versus active conservative care. As a result, it is still not known whether early surgery or active physiological management of the unstable injured spinal cord offers the better chance for recovery. Surgeons who care for patients with traumatic spinal cord injuries in the acute setting should be aware of the arguments on all sides of the debate, a summary of which this annotation presents.

Cite this article: Bone Joint J 2023;105-B(4):347–355.

Aims

The effects of remnant preservation on the anterior cruciate ligament (ACL) and its relationship with the tendon graft remain unclear. We hypothesized that the co-culture of remnant cells and bone marrow stromal cells (BMSCs) decreases apoptosis and enhances the activity of the hamstring tendons and tenocytes, thus aiding ACL reconstruction.

Supracondylar fractures of the humerus have historically been treated as an emergency case and operated on at the earliest opportunity. We undertook a study to examine whether surgical timing affects the need for open reduction or peri-operative complications in the type III injuries. Between August 1995 and August 2004, 534 patients presented and were referred to our unit with these fractures. Those with closed, type III injuries without vascular compromise were selected (171 patients). These were divided into 2 groups: those undergoing surgery less than 8 hours from presentation (126 patients) and those undergoing surgery more than 8 hours from presentation (45 patients). The two major differences between the two groups were: the delayed group were more likely to undergo open reduction (33.3% v 11.2%, p<0.05) and the mean length of the surgical procedure was increased (105.1 minutes v 69.2 minutes, p<0.05). Delay in treatment of the type III supracondylar fractures is associated with an increased need for open reduction and a longer procedure. We would recommend treating these injuries at the earliest opportunity

Late presentation and rapid progression of Dupuytren's contracture significantly increases operating time, complications and likelihood of incomplete correction; however, surgical timing is usually more a function of waiting list length than of clinical criteria. We sought to measure the rate of progress of Dupuytren's contracture. All patients with Dupuytren's contracture referred to the sole Consultant Hand Surgeon for Highland Region between June 1997 and February 2003 were prospectively included. Fixed flexion deformities at each finger joint and thumb-index angle to the point of firm resistance to extension were recorded by a single observer (QGNC) at presentation and immediately pre-operatively. Of 151 participants 37% had a family history. There was a male predominance of 5:1, with bilaterality in 77% at presentation. Five percent had diabetes, 3% had epilepsy, 52% acknowledged tobacco habits and 24% regular alcohol in excess of recommended limits. Angular deterioration was observed in 52% of digits, over one quarter of this occurred at the small finger joints, where 58% of PIPJs progressed. Mean delay from presentation to surgery was 11 months (2-55.5). Mean age at presentation of 62 (16-86) years did not correlate with angular deformity at presentation or with velocity of deterioration or with manual/non-manual employment. Mean severity of deformity at presentation for manual (34°) was double non-manual workers (17°) although angular deterioration was faster in the non-manual group (3.8 cf 0.7°/month respectively). Similar speeds of deterioration were seen at MCPJ and PIPJ, speed of deterioration was 2.2°/month for each of the three ulnar digits. Speed of deterioration correlated (r=0.7) with severity of deformity at presentation for ring and small fingers. This study offers the first quantification of rate of deterioration in Dupuytren's contracture. This could be used as a waiting list tool to predict the delay before a digit is likely to pose increased surgical risk

Purpose: The purpose of this study was to review our results in patients with pilon fractures treated with ORIF in which surgical planning involved multiple skin incisions, ensuring that the distance incisions overlapped was less than the distance between them. We hypothesized that soft-tissue complications would be minimal despite incisions placed < 7-cm apart. Method: A retrospective chart review identified 37 pilon fractures in 32 patients treated by three orthopedic traumatologists at The Ottawa Hospital between August 2000 and February 2007. Follow-up included measurements of incision placement and functional outcome measures. Results: There were nine OTA type B and 28 OTA type C fractures; 28 were closed and nine were open. The mean age was 46.5 ±14.5 years, and average follow-up was 3.2 ±1.7 years. Of the patients reviewed, the average number of incisions was 3.7 ±1.1. The average overlap between incisions was 4.6-cm ±1.9 and the average skin bridge between incisions was 5.9-cm ±1.9, with 80% of the skin bridges < 7-cm. Average ROM was 4.3° ±7.1 dorsiflexion and 39.1° ±11.6 plantarflexion. The mean AMA lower extremity impairment score was 18.9% ±12.4, and mean SIP ambulation score was 9.6 ±8.8. Complications included two superficial infections, one deep infection, and three non-unions. There were no cases of wound dehiscence or necrosis, or cases requiring revision soft-tissue coverage. These outcomes were comparable to recent reports with similar injuries. Conclusion: With careful planning and good soft-tissue management, incisions can be placed to maximize articular exposure based on fracture lines. It does not appear that the dogma of keeping incisions > 7-cm apart must be followed in most cases. Prudent surgical timing and meticulous soft-tissue handling can allow for multiple incisions to be placed as necessary for fracture reduction and optimal fixation while maintaining a low rate of complications

Purpose: Treatment of knee dislocations remains challenging and controversial. Several strategies for the management of multiple ligament knee injuries have been described and there are multiple unresolved questions. These include the indications for surgery, repair versus reconstruction, surgical timing and graft selection. The aim of this survey was to identify areas of agreement and controversy, to define the current standard of care and help generate research questions. Method: Using the standard techniques for survey development we presented six clinical scenarios of acute knee dislocations (at least three ligaments) to all orthopaedic surgeons affiliated with Canadian medical schools. The scenarios were designed to cover the common combinations of knee dislocations in both a 25 year old active individual and a 50 year old sedentary individual. The responses were divided into three groups. Group A consisted of those with fellowship training, or practices focused on, sports knee. Group B was comprised of surgeons with trauma fellowship or a sub-specialty trauma practice. Group C were the remaining surgeons without these subspecialty foci. We report on the responses of groups A and B. Results: An average of ten different treatment algorithms were reported for each scenario but there was agreement on the need for early surgical management in the young active individual with a knee dislocation and all dislocations involving a lateral sided injury. Conversely, there was a lack of consensus regarding the need for surgical treatment of the 50 year old individual with bi-cruciate injury and medial collateral ligament. The most common combinations of reconstruction and repair are reported for each clinical scenario. Surgeons strongly favor early surgical intervention, within three weeks of injury, except for the 50 year old sedentary individual with a bi-cruciate plus medial sided injury. Allograft was the most popular choice to reconstruct the PCL and lateral ligament. For the ACL graft there was a near equal distribution between hamstrings, patellar tendon and the use allograft tissue. Conclusion: In the absence of higher level evidence, the information from this survey helps define the standard of care in Canada and identifies areas of controversy which would be a priority for a multi-centre prospective trial

Aims: To compare open and closed surgery in supracondylar fractures (SCHF) of the children and evaluate the complications with delayed surgical timing. Methods: 99 children with displaced extension-type SCHF were treated surgically. Between July 1996 and May 1997 all of the SCHF were treated with open reduction through a posteromedial incision (44 patients, mean age 10.7). This goup didnñt have closed reduction attempt previously. Between May 1997 and July 1998 most of the SCHF were treated with closed reduction and percutaneous crossed pin þxation (55 patients, mean age 7.6). The patients were followed radiologically and clinically 35 months (27–46) for the open and 21 months (16–27) for the closed reduction group. They were evaluated with complications, the clinical and radiological valgus, ßexion and extension degrees compared with the contr-lateral normal elbow. The average period between the injury and the operation was 15 (11–48) hours for open and 17 (10–72) hours for closed group. Results: Valgus degree loss was 5.1û (0û Ð 20û) for open surgical group and, 3.6û (0û Ð 23û) for closed group against the contrlateral elbow. Flexion deþciency was 8.61û (0û Ð 20û) for open and 5.25û (0û Ð 15û) for closed group. Extension gap was 6.23û (0û Ð 22û) at the open group, while closed group had a loss of 0.6û (0û Ð 12û). Conclusions: Open and closed groups did not have statistically signiþcant difference for ßexion range and valgus angles. Extension gap was signiþcantly better for closed treatment group. A reasonable delay of the treatment does not increase the risk of complications

Patient postoperative outcome can be accurately predicted by the patient’s preoperative HHS or WOMAC score. Prospective, cohort studies of one hundred and seventy-five THAs. SF-36, WOMAC and Harris Hip Score (HHS)questionnaires were used to determine pre-operative and two year final outcome. Student’s t-test, 95% confidence intervals, receiver operator characteristic curves, simple regression analysis and probability were measured. Patients with a HHS = sixty-five pre-operatively had a 100% probability of having an excellent result postoperatively. A preoperative HHS value of thirty-four, and preoperative WOMAC (physical function) value of fifty were the best cutoff points to attain a significantly better postoperative functional outcome. Total hip arthroplasty (THA) has been well documented to enhance patient function, but patient outcome is dependant on preoperative statuts. The exact timing of surgery to optimize patient outcome after THA remains unknown. This study determines the ideal timing for surgery to obtain the best possible functional outcome. Prospective, multicenter, cohort studies of one hundred and seventy-five identical, cemented THAs. General health (SF-36) and disease specific (WOMAC and Harris Hip Score(HHS)) questionnaires were used to determine preoperative and two year final outcome. Student’s t-test, 95% confidence intervals, receiver operator characteristic curves, simple regression analysis and probabilty were measured. All functional scores were improved significantly postoperatively (p< 0.001). Patients with a HHS = sixtyfive preoperatively had a 100% probability of having an excellent result postoperatively. A preoperative HHS value of thirty-four, and preoperative WOMAC (physical function) value of fifty were the best cutoff points to attain a significantly better postoperative functional outcome. Patient postoperative outcome can be accurately predicted by the patient’s preoperative HHS or WOMAC score. Optimization of surgical timing, by prioritizing wait lists or deciding to treat the arthritis operatively, based on these preoperative score guidelines will help ensure an excellent outcome post THA

Purpose: The glenoid labrum is a significant passive stabiliser of the shoulder joint. However, its microstructural form remains largely unappreciated, particularly in the context of function. An understanding of the labral structure leads to mechanical hypotheses, and therefore functional role in stability and load distribution, will aid an educated approach to surgical timing and repair. Method: Fresh frozen cadaveric shoulders were grossly harvested via an extended Deltopectoral incision. The Glenohumeral joint was arthroscoped using a modification of Snyders (1989) routine in order to determine the specific anatomy of the capsulolabral complex. The glenoid fossa was then osteotomised before using micro-surgical loupes to section the labrum. Specimens were analysed using Scanning and Transmission Electron Microscopy and Confocal microscopy. Standard processing procedures were used to examine TEM specimens and the data was quantified by computational analysis. Specimens for SEM were cryofractured and Extracellular Matrix removed using a cell maceration technique to expose collagen fibre networks. Images were evaluated qualitatively. Sliced specimens for confocal were serially analysed along their z-axis, and post-processed to form 3-D reconstructions of collagen fibres. Results: Two distinct homogenous areas were identified: (1) a superficial tight meshwork of fibrils and (2) a deep layer with a densely packed fibrous braid which were circumferential in orientation. A third area showed varying distribution of loosely arranged collagen fibres ranging from small fibres apposing area 1 to larger interleaved groupings near area 2. In radial transverse section, both normal and abnormal (stellate and spiral) fibrils were identified. Conclusion: Contrary to published evidence, our results suggest the glenoid labrum is subjected a number of mechanical environments. Possibly distinct regions of the labrum contribute to load sharing; a well vascularised hydrated compressive zone and a tensile component distributing circumferential hoop stress, whilst both braiding and region interfaces suggest shear conditions

This prospective observational study was designed to report the soft tissue complications after fixation of tibial plafond fractures in an effort to challenge the current recommendation that a seven centimeter skin bridge represents the minimum safe distance between surgical incisions. Our hypothesis was that many of the skin bridges would be less than seven centimeters and that this would not result in an increased incidence of wound complications. All injuries received surgical treatment using a minimum of two surgical approaches for the tibial plafond and the associated fibula fracture (if applicable). Forty-two adult patients with forty-six tibial plafond fractures were enrolled in the study between July 1, 2004 and Dec 30, 2005. There were 1 A1, 3 B1, 2 B3, 6 C1, 6 C2 and 28 C3 fractures. Forty-four plafond fractures had an associated fibular fracture. There were thirty-six closed and ten open fractures. High energy injuries were managed using a two staged approach consisting of fibular ORIF through a posterolateral approach combined with spanning external fixation, followed by tibial ORIF when soft tissue swelling subsided (forty-four fractures). The surgical approaches used, the length of the incisions, the distance between the incisions (size of the skin bridge), and the overlap between the incisions was recorded. The surgical wounds were followed until healing and for a minimum of three months. Two surgical approaches were used in thirty-two fractures and three approaches were used in fourteen. These one hundred and six surgical incisions produced sixty skin bridges. The approaches used included pos-terolateral (forty-four), anterolateral (thirty-nine), medial (eleven), anteromedial (eight), and posteromedial (four). The mean skin bridge size was 5.9 cm. Only 15% of the skin bridges were > 7 cm, while 70% were 5–7 cm, and 15% were < 5 cm. The mean overlap between incisions in the study was 7.9 cm. One hundred two incisions healed uneventfully. Healing of two anterolateral incisions was complicated by eschars that resolved with local wound care. One posterolateral fibular incision failed to heal until the fibular plate was removed. One patient required subsequent surgical procedures for infection. Despite a measured skin bridge of less than seven centimeters in 85% of instances, the soft tissue complication rate was low in this group of patients. With careful attention to soft tissue management and surgical timing, incisions for plafond fractures may be placed less than seven centimeters apart, allowing the surgeon to optimise exposures based on the pattern of the injury