Introduction: Tibial plafond fractures constitute one of the most challenging injuries in orthopaedic surgery. Complications are common and clinical outcomes are generally poor. New guidelines for the management of these fractures and modern implants look forward to improving these results.

Material and Methods: 40 tibial plafond fractures treated by open reduction and internal fixation between January 2006 and December 2008 were included prospectively. Fractures were classified according to the AO classification. A CT scan was required in17 intraarticular fractures. Definitive surgery was delayed until soft tissue injury had been healed. Eleven patients underwent provisional external fixation. Mean time to surgery was of 7.5 days (range, 0 to 40 days). 27 fractures were treated by anteromedial plating, 12 with anterolateral plating and in one case two plates were required. Bone grafting was used in 8 cases. Plain radiographs were used to determine axial alignment and time to healing. Reduction of the articular surface was considered anatomical when there was less of 1mm of displacement. The Ankle Osteoarthritis Score (AOS) was analysed for pain and disability. Statistical analysis was performed with the SPSS 12.0 for Windows.

Results: According to the AO classification there were 22 Type A fractures, 9 Type B and 9 Type C. There were 7 open fractures (3 Type I, 3 Type II, 1 Type IIIA). Mean time to healing was of 18.1 weeks (8 to 32). Mean AOS score was of 41.2 points. There were 33 excellent and good results. There were 11 secondary losses of reduction and 5 non-union.

Clinical results were correlated with the quality of the reduction and with secondary displacement (p=1 and p=0.69 respectively). Anatomic reduction was more frequent in Type A (81.8%) and B (88.9%) fractures than in Type C (77.8%). There were not statistically significant differences in the quality of the reduction (p=0.88) or in the appearance of secondary displacement (p=0.46) between anteromedial or anterolateral plating. There were 6 infections (4 following anteromedial plating and 2 after anterolateral plating which was not statistically significant p=0.88). 13 patients developed soft tissue complications. Five requiring soft tissue fiaps.

Conclusion: Anteromedial and anterolateral plating of the distal tibia provide good clinical and radiological results. Infection rate is similar with both approaches. Appropriate timing of surgery can minimize soft tissue complications.

Introduction and Objectives: One of the complications of hip arthroplasty is intraoperative fractures of the femur. In this study, we reviewed the incidence of intraoperative fractures in 118 hip arthroplasty surgeries using a stem from Meridian Howmedica, Rutherford, New Jersey, in an attempt to analyse the risk factors for intra-operative fractures and their relationship to short-term radiographic characteristics of the prosthesis. Our aim is to determine if there are risk factors associated with a higher incidence of intraoperative fractures in the following categories: patient, shape and dimensions of the femur, and relative size of the implant with respect to the medullary cavity. We will also determine if short-term follow up of patients with fractures yields radiographic information to indicate early loosening of the prosthesis.

Materials and Methods: We studied 118 implants from consecutive operations performed from January 1997 to December 2000. The following variables were evaluated: general patient factors; local factors (characteristics of the femur); previous treatments, degree of femoral osteoporosis, type of femur, cervicodiaphyseal angle, femoral flring, “canal flare index”, cortical index, canal width 20mm proximal to the lesser trochanter, at the lesser trochanter, and 20mm distal to the lesser trochanter, pre-operative proximal and distal measurement of the stem, and if this coincides with the actual size of the stem; intraoperative factors: type of anaesthesia, patient positioning, surgical approach, experience of the surgeon, surgical time, the need for transfusion and number of units, the use of prophylactic cerclage, detection and localization of the intraoperative femoral fracture, and treatment of the same when they occurred; postoperative radiographic factors: level of cutting femoral neck, orientation of the stem (varus or valgus), proximal and distal stem size, proximal and distal packing of the canal, and length of the neck of the head of the prosthesis; radiographic factors 12 months postoperatively: stem orientation (varus or valgus), rounding of the calcar, cortical thickening, osteolysis, osteopenia, the presence of a ledge, the presence of lines of sclerosis, sinking of the stem, loosening of the ball, and the type of integration of the stem into the bone.

Results: Of the 118 cases that were studied, intraoperative fractures occurred in 13 cases, representing an incidence of 11.01%, a somewhat higher rate than others have reported. We analyzed the occurrence of fractures in relation to the different variables in our study. We found a higher incidence of fractures in type A femurs (p< 0.05) and in cases of greater proximal filling by the implant (p< 0.05).

Discussion and Conclusions: Though our study is limited in number of patients and length of follow-up time, it has demonstrated that the incidence of intraoperative fractures is associated with a narrow metaphyseal medullary cavity and predominately with a type A femur, which is a femur with low “canal flare index” values. Furthermore, since the risk of fracture is greater when we attempt to significantly adjust the size of the pros-thesis to the metaphysis, the incidence of fractures was higher when proximal filling was higher. However, cases of prosthesis with fractures did not present with radiographic appearance after 12 months that was worse than those femurs that were not fractured.