Aim: The open tibial fracture is an increasingly common injury. In those with severe soft tissue damage (i.e., Gustilo type III), it is still controversial how to primarily stabilise the bony structure. This study aims to compare the use of the unreamed interlocking tibial nail (URTN) with external fixation (Ex-Fix) in the treatment of patients with grade III open tibial fractures.

Methods: A Medline literature search identified 21 studies. Only those comparing URTN with Ex-Fix for the treatment of grade III open tibial fractures, in adults, were included. Non-comparative studies were excluded. The quality of each study was assessed and relevant data extracted.

Results: Total number of patients in studies included was 53 in the URTN group and 54 in the Ex-Fix group. Non-union occurred in 10.7% of patients treated with URTN compared to 25.2% in the Ex-Fix group. Mal-union and malrotation were much lower in the URTN group than in the Ex-Fix group, 26.5% vs. 41.7% and 8.7% vs. 21.7%, respectively. Time to union was shorter with URTN (31.9 weeks) compared to Ex-Fix (37 weeks). Time to full weight bearing was significantly shorter with URTN compared to Ex-Fix, 16.6 weeks vs. 28.7 weeks, respectively. Infection rate was higher with Ex-Fix (29.1%) compared to URTN (11.5%), and nerve injury also occurred more with Ex-Fix, 16.7% vs. 9.8%. Re-operation rate was high in both groups (40% URTN, 35.9% Ex-Fix).

Conclusions: The unreamed interlocking tibial nail is superior to external fixation in the treatment of grade III open tibial fractures. It is a safe, effective technique with comparably low complication rates. Management of concomitant soft tissue injuries is consistently easier, and patients have a significantly shorter time to full weight bearing. External fixation, however, still has a role in the immediate stabilisation of these fractures, especially in the critically ill unstable patient.

Antero-posterior (AP) pelvis and lateral x-rays are routinely prescribed for the positional diagnosis of proximal femoral fractures, however; the usefulness of the lateral x-ray has not been previously presented in the literature. In addition, the clinical advantage of internally rotated AP views has also not been tested. This study aims to define the value of the lateral x-ray, and the internally rotated AP view, in the assessment and treatment planning of proximal femoral fractures.

X-rays from 359 consecutive patients with proximal femoral fractures were divided into: ‘un-positioned’ AP (greater trochanter overlying the lateral femoral neck), clear neck AP (internally rotated to show the lateral femoral neck), and lateral views. Three blinded reviewers independently assessed the x-rays in sequence and noted the positional diagnosis and displacement. This was then compared with the intra-operative diagnosis used as gold standard.

The addition of a lateral x-ray to an AP view significantly increased the rate of the correct diagnosis made by the reviewers when compared to an AP view alone, in intracapsular fractures only (p < 0.013), but not for extracapsular fractures (p = 0.27).

The use of clear neck AP views did not increase the rate of correctly diagnosing the type of fracture when compared to unpositioned AP views. This applies for both intracapsular (p = 0.57), and extracapsular fractures (p < 0.823).

Although orthopaedic rote dictates that every fracture should be visualised in two views, this study has shown with that for the majority of hip fractures one view is adequate and safe. The lateral x-ray is only required for intracapsular fractures that appear undisplaced on the AP view and should not be performed routinely. Specially positioned AP views are not required and should be avoided due to the unnecessary pain caused and the needless cost.

Purpose: To investigate the validity of previous observations that meniscal repair has a better success rate when associated with ACL reconstruction.

Methods and Results: The case notes of 170 patients who underwent meniscal repair between May 1999 and May 2007 were analysed for causes of re-operation and relation to status of the ACL. Mean age at the time of surgery was 28 years.

41 patients underwent re-operation at a mean time interval of 21 months (range 2 weeks - 87 months). 79 patients (Group A) had isolated meniscal tears. 44 patients (Group B) had meniscal repair at the same time as elective ACL reconstruction and underwent brace-free, accelerated rehabilitation. 47 patients (Group C) had meniscal repair in association with ACL disruption and underwent staged ligament reconstruction.

In Group A, 23 patients underwent re-operation (Indications; meniscal symptoms 21, stiffness 1, infection 1). Nineteen repairs (23.8%) were found to have failed. In Group B, 15 patients underwent re-operation (Indications; meniscal symptoms 12, stiffness 1, revision ACL 2). Twelve (27.2%) repairs were found to have failed. In Group C, Nine (19.6%) repairs were found to have failed. 6 at the time of staged ACL reconstruction and 3 subsequently, at further arthroscopy. There was no statistical difference between the groups with respect to the incidence of failed meniscal repairs.

Analysis of possible predictive factors including age, gender, location of lesion and the type of repair did not show statistical significance.

Conclusions: Reoperation rate following meniscal repair is high. Meniscal repair for tears associated with ACL disruption in this group did not appear to have a higher success rate compared to isolated tears. This raises questions regarding the current practice of ignoring meniscal repair and instituting brace-free, early, aggressive rehabilitation following concomitant ACL reconstruction.