Purpose: Treatment of complex diaphyseal malunions is challenging. It requires extensive preoperative planning and precise operative technique. A single technique has not been generalizable secondary to the limitations of each type of osteotomy. A simpler method was developed to manage these deformities.

Method: Ten patients with complex diaphyseal mal-unions (4 femoral, 6 tibial) underwent a clamshell osteotomy. Indications for surgery included pain at adjacent joints and deformity. Preoperative evaluation included deformity characterization. The malunited segment was identified on biplanar radiographs. After exposure the malunited segment was transected perpendicular to the normal diaphysis proximally and distally. The transected segment was again osteotomized about its long axis and wedged open with a lamina spreader, similar to opening a clamshell. The surgical approach was sealed to retain the subsequent reamings. The proximal and distal segments of the diaphysis were aligned using the intramedullary nail as an anatomic axis template and the opposite extremity as a length and rotation template. Partial weight-bearing mobilization with crutches began immediately and progressed based on clinical and radiographic evaluation. Followup ranged from 6–52 months.

Results: Radiographic angular corrections were complete in each case and ranged from 2–20 degrees in the coronal plane, 0–32 degrees in the sagittal plane, and 0–25 degrees in the axial plane (rotation). Correction of length ranged from 0–5 centimeters, restoring leg length to within 2 centimeters in all cases. All osteotomies were healed both clinically and radiographically by 6 months. All patients were ambulatory without assistive devices by the time of the most recent followup.

Conclusion: The proposed osteotomy provides a generalizable way to correct many forms of diaphyseal mal-unions by acting as a bypass in realigning the anatomic axis of the long bone using a reamed intramedullary nail as a template.

This study was designed to answer the question “Is there a difference in outcome following operative management of AO type C distal humerus fractures for patients with associated injuries compared to those with isolated injuries?” Our hypothesis was that patients with associated injuries would have worse outcomes compared to those with isolated injuries.

Fifty-eight patients with fifty-eight fractures managed with ORIF were included. Hospital records, clinic notes and radiographs of these patients were retrospectively reviewed. MFA and DASH scores were prospectively obtained after patients were identified (mean 37.4 months post injury, range 6–74 months).

Thirty-two patients had isolated distal humeral fractures while twenty-six patients had distal humeral fractures with associated injuries. The mean MFA of patients with isolated injuries was significantly lower than for patients with associated injuries (27.2 vs 41.7, p = 0.01). There was no difference in DASH scores between the two groups (23.7 vs 29.1, p = 0.34). The mean postoperative arc of motion was one hundred and seven degrees for isolated injuries and seventy-five degrees for patients with associated injuries (p=0.006). Surgical release for stiffness was required for two patients (6%) in the isolated group and ten patients (38%) in the associated injuries group (p=0.003).

Outcomes for isolated distal humeral fractures in this study were comparable to previously published literature. Patients who sustain associated injuries at the time of distal humeral fracture have more stiffness and a worse outcome on a global outcome score, but a similar outcome on a limb specific outcome score.

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.