Background:

Pilon fractures are complex intra-articular fractures of the tibial plafond associated with significant short and long morbidity. Minimising surgical complications is essential.

Aim

Our aim was to compare the Wilkins'-modified Gartland classification and AO classifications of supracondylar humeral fracture with respect to: -Inter-observer reliability; Association of fracture-grade with radiological quality of reduction; Association of fracture-grade with complications.

Printed plain radiographs have traditionally been the method of image transfer between hospitals, but the advent of digital imaging has revolutionised modern day radiology. It is now commonplace for compact discs to be used as the transport media for digital images, the theoretical advantages being ease of transport and storage, integration with PACS systems and the ability to perform image manipulation. However, in our tertiary referral centre for pelvic and acetabular trauma, we noted problems with digital image transfer using this method.

We examined the last 25 compact discs sent to our unit for functionality on 3 separate computers. Only 17/25 discs loaded on all computers, and 2 discs failed to load on any computer. 9 of the remaining 23 discs did not allow image manipulation, and 1 disc would not allow retrieval of all the contained images. 5 of the 23 discs took longer than 5 minutes to retrieve the contained images. In summary, we classed 10 of the 25 discs as acceptable. Patient transfer to our unit was not delayed, but 4 patients underwent repeat CT scans due to incomplete imaging

Digital technology has made great advances into medical imaging. Standardisation using the DICOM format for image creation has attempted to eliminate issues of compatibility, but variation in software used to produce and view images can still vary from these standards. Technical errors in the creation of discs should be eliminated at source, and it is mandatory that referring units check the functionality of discs before they are sent. In this way, the potential for delay to transfer and subsequent repeat exposure to ionising radiation can be avoided.

Sub-muscular plating is an established technique in the management of long-bone fractures and reconstruction. In the femur, the presence of the vascular structures medially favours the lateral approach and as such, the technique of medial femoral sub-muscular plating has not, to the authors knowledge, been previously described.

We report a series of 5 patients employing the medial approach to femoral sub-muscular plating. The indications and limitations of the technique are discussed with particular reference to reducing external fixation times, avoidance of stress risers and areas of previously traumatised or infected tissues. The surgical technique for medial femoral sub-muscular plating with emphasis on the role of vastus medialis in the protection of the vascular structures, together with cross sectional anatomy is described.

Medial femoral sub-muscular plating is a useful technique in specific indications and can be performed safely with an understanding of the relevant anatomy.

Introduction: The subtrochanteric area of the femur is subject to large tensile and compressive forces. The rate of nonunion following operative fixation of such fractures is about 7–20%. Revision surgery to obtain union is difficult because of the small size of the proximal fragment, muscle forces acting in 2 planes, and bone loss.

We present the results of a series of 9 consecutive patients with subtrochanteric non-unions treated by double plates.

Methods: Retrospective analysis of 9 consecutive subtrochanteric nonunions treated with double plates and additional osteoinduction (bone graft, or BG+BMP-7).

Results: There were 5 male and 4 female patients, with ages from 50–82 years (mean 65). All were treated in a single-stage procedure by implant removal, a lateral plate and a separate anterior plate. One patient had had a previous unsuccessful revision procedure with an intra-medullary device.

One patient with liver cirrhosis died 5 days postoperatively. Two patients are currently 8 weeks post surgery. All the others healed in a mean of 5.1 months (range 4–6 months).

Two patients underwent distal femoral lengthening to compensate for bone loss.

Discussion: The high muscle forces around the proximal femur require a sound mechanical environment for bone healing to occur. This is particularly marked in nonunions. The small size of the proximal fragment can result in suboptimal fixation. The addition of the anterior plate provides better fixation and also neutralizes the sagittal forces.

We believe that double plating neutralizes all the forces around the proximal femur, providing the best mechanical environment. Given the limits of the small numbers and the retrospective nature of the study, we believe that this method of treatment offers a sound surgical strategy, reflected by our success rate.

Purpose of study: To study the effect of an additional locking screw on fracture strain and stability in tibias undergoing intramedullary nailing.

Methods: An additional locking hole was drilled into four tibial nails, 185 mm from the proximal end of the 8 mm x 315 mm solid tibial nails. The nails were locked proximally and distally into a triple strain-gauged sawbone. An osteotomy was created distal to the additional hole, and the construct loaded axially, in flexion and extension, and in torsion with and without the extra locking screw. With the additional locking screw in place, strain increased at the proximal strain gauge site during loading in neutral by 17% (139 mϵ, 91–198) (p=0.01) and flexion by 8% (65 mϵ, 60–73) (p< 0.005). Strain decreased on loading in extension by 10% (141 mϵ, 62–243) (p=0.0497). The extra locking screw decreased strain at the gauge closest to the osteotomy site in all loading positions. Strain showed an overall increase with axial loading of 14% (47 mϵ, 4–105) (p=0.16), an increase with loading in flexion of 2% (9 mϵ, −38 to 62) (p=0.75) but a decrease of 47% (254 mϵ, 6–549) (p=0.18) with loading in extension. A significant reduction in angular motion at the osteotomy site occurred with the addition of the extra locking screw (21° at 34.5 Nm without the screw, 13° at 34.5 Nm with the screw, p=0.001). Additional hole in the shaft of the nail lead to increase the stress from 29 – 48 mPa (29 – 48 N/mm2) but did not fail when vertically loaded with 450 Newtons applied at rate of 5Hz sinusoidal waves for 2 million cycles.

Conclusion: Nails with additional locking options, by altering strain and motion at the fracture site, may have the clinical potential to affect fracture healing with relatively low risk of implant failure.

Objective The hypothesis of this study is that the flexibility of idiopathic scoliosis curves as measured by traction radiography performed under general anaesthetic (TUA) will be superior to supine bending radiography. Subsequently, this may aid in determining the surgical approach, sparing patients anterior release surgery, and show greater correlation with the postoperative result. This is a new technique, not previously reported in the literature.

Design A prospective comparison between TUA and supine bending radiography to determine curve flexibility, and examine their relationship with anterior release surgery and postoperative correction.

Subjects This study was based on 21 patients with a diagnosis of idiopathic scoliosis, admitted for corrective surgery at our unit.

Outcome measures The amount of correction achieved by each of the two methods on the preoperative curve was examined using a paired t-test. The influence of the TUA on the decision for anterior release surgery was noted, along with the correlation of each method with postoperative correction.

Results On statistical analysis with a paired t-test, TUA showed significantly greater curve flexibility than that shown by supine bending radiographs (p< 0.001) irrespective of curve classification or magnitude. Of the 11 patients planned for anterior release surgery with posterior fusion, the use of TUA obviated this in 9 (82%) by demonstrating greater preoperative curve flexibility. Excluding thoracolumbar curves, TUA showed significantly greater postoperative correlation than supine bending radiography (R=0.79, R=0.61 respectively).

Conclusion In our unit, traction radiography performed under general anaesthetic is superior to supine bending radiography in assessing curve mobility prior to surgery. Performing TUA has significant benefits to patients in avoiding unnecessary anterior release surgery, and has greater correlation with postoperative correction. In studying fulcrum bending radiographs, Cheung1 showed similar benefits in avoiding anterior release and we therefore recommend the use of these methods by other institutions.