Ankle fractures are one of the most common bony injuries presenting to the trauma surgeon. The more severe ones result in disruption of the tibiofibular syndesmosis and hence worse outcome. The outcome depends on accurate reduction of syndesmosis. The two main options in managing these injuries are syndesmotic screws or tightrope. The aim of this study is to compare the rate of complications between these two techniques and their radiographic results.

Retrospective data from 62 patients between September 2009 and March 2011 who had fixation of syndesmosis was obtained from theatre logbooks. 46 patients had syndesmotic screws inserted while 16 had tightrope. The average age was comparable in both groups (51 years v/s 41). 25 of the 46 syndesmotic screws inserted were removed. No tightropes had to be removed for any reason. 2 patients with syndesmotic screws had wound complications while 1 patient which tightrope insertion had a persistent diastasis.

There were no differences in radiological outcome between the two groups with regards to reduction of syndesmosis (measured by talofibular clear space minus medial clear space) (p-value 0.283). The difference between the talocrural angles was also of no significance (p-value 0.344). Our results indicate that tightropes achieve radiologically similar reduction of syndesmosis as screws without any significant difference in complications. The need for a second operation is significantly lower with tightrope fixation.

The aim of this study was to find out whether distal radius fractures treated by K wire fixation loose reduction after wire removal and analyze the variables may influence this. Patients who underwent K wire fixation for unstable fractures of distal radius over a period of 3 years were included in this retrospective study. Fractures were classified according to AO classification. Radiographs taken just prior to removal of K wires and radiographs taken at least 1 month after wire removal were analyzed to study three radiological parameters; Palmar or dorsal tilt, radial inclination and ulnar variance. Loss of these angles was analyzed statistically against variables like age, sex, AO classification, type of K wires used, delay in fixation and duration of fixation. 59 fractures were analyzed with mean age of 56 years and male to female ratio of 1:2. Average loss of radial tilt was 2.6 deg, loss of palmar tilt was 2.6 deg and loss of ulnar variance was 1.3 mm. We found that distal radius fractures treated by percutaneous K wire fixation, do not suffer significant loss of reduction of fracture position after removal of wires. This remains true regardless of age, sex, fracture type according to AO type, type of wires used, delay in fixation or duration of wire fixation.

Arthrodesis of the ankle joint gives satisfactory short and medium-term results; however, in the longer term, it frequently leads to sub-talar and mid-tarsal osteoarthritis which is difficult to treat. Use of mobile bearings have significantly improved the results of ankle replacement. This a mid term follow up (1 to 5 years)of Buechel-Pappas ankle replacements performed by the senior author.34 total ankle replacements performed by one surgeon from October 1999 to May 2004 were reviewed retrospectively. Pre and post operative VAS scores, AOFAS scores were evaluated to find patient satisfaction and outcome. Tourniquet time as recorded in operation notes showed the learning curve for the procedure. Males : Females- 1:1.4. Mean age was 65 years (range : 33 to 83). Indication for surgery was primary osteoarthritis in 13, post traumatic arthritis in 14 and rheumatoid arthritis in 8. Average VAS score was 8.2 pre operative and improved to 2.0 at follow-up. AOFAS score improved from 39.1 to 72. Operating time averaged 113 minutes in 1999 and 85 in 2004. Significant complications were medial impingement (8) out of which 3 patients needed further surgery, intra-operative malleolar fractures (medial 4, lateral 1 and posterior 1, all healed successfully) and injury to cutaneous nerves (4) 3 patients had superficial infection which settled with antibiotics, but there were no cases of deep infection. 58 % were very happy, 32.5 % were happy, 9.5 % were not happy with the result. 2 patients had ankle fusion on the opposite side earlier, both were happier with the replaced side. Ankle replacements appear to offer a good alternative to fusion in selected patients. There is a significant risk of minor complications. Medial impingement may need further debridement at a later stage.

Ankle replacements appear to offer a good alternative to fusion in most arthritic conditions. Use of mobile bearings have significantly improved results of ankle replacement. These have a significant minor complication rate including nerve injury, fractures. One of the significant complications noted in our series was medial impingement. 34 Buechel-Pappas total ankle replacements performed by the senior author from October 1999 to May 2004 were reviewed retrospectively. Mean follow up of 2.8 years. 8 patients reported medial impingment symptoms at follow up. 3 patients underwent repeat surgery for this problem. One patient underwent arthroscopic debridement of scar tissue and impinging bone by another surgeon which gave good symptomatic relief. Two other patients had tibialis posterior tendonitis and underwent surgical decompression of the tendon. Both were found to be having degenerative tendons with partial tears. We discuss the findings, literature review and other complications of ankle replacements as well. Whether medial impingement is due to implant design or inherent pathology of ankle has to be studied further. Other implant designs like Agility may treat arthritis in medial and lateral gutters but can still cause soft tissue impingement. Whether these are due to implant design, residual arthritis in medial recess or soft tissue pathology is uncertain. This may be caused by the cylindrical shape of talar component (the physiologic talus has a cone shape with smaller radius on medial side). This has not been proven yet, but has been addressed in newer designs like Salto and Hintegra prostheses.

Use of allograft in orthopaedic surgery is a well-established procedure. Ethylene Oxide sterilization is still controversial in bone banking because of its effect on osteoinductive properties of bone graft. Freeze drying is considered to be the best technique for allograft preparation and storage. High cost of equipment and its maintenance makes this method not feasible option in developing countries like India. This study involved setting up of a bone bank for the first time in JIPMER institute, Pondicherry, India. Cancellous bone was collected from 40 patients (femoral heads removed during joint replacements). They were cleaned thoroughly, chemically processed and sterilized with ethylene oxide gas and stored doubly packed. These were implanted at 11 patients with 14 non-unions, which required cancellous bone grafts. Patients were followed up clinically looking for infection and radiologically for graft incorporation. 85.7 % of grafted sites were united at the end of 12 months. Non-unions took average of 44.8 weeks for the union. Radiological union achieved by 12 months with average time of graft incorporation 44.8 weeks. In 8 cases the allografts were used to pack cavities. Healing occurred at an average of 29 weeks. In 4 patients with arthrodesis following excision of tumor one site failed to unite, one deep infection, which did not resolve with regular chemotherapy had an amputation. The rest of the sites healed at an average 54.8 weeks. This study shows ethylene oxide sterilized cancellous allograft suitable for packing cavities in treatment of benign bone lesions as well as in treatment of non-union. The osteoconductive property of bone allograft may not be affcted by the ethylene oxide sterilization. Achivement of union and a low rate of infection confirms efficacy of ethylene oxide as cost effective and reliable option for bone allograft sterilization.

The aim of the study was to find out the relationship between delay in fixation of ankle fractures and incidence of wound complications like wound dehiscence, necrosis of margins, infection. Ankle fractures are fixed either on the day of injury or delayed for up to 7 days in view of the swelling. We reviewed 51 patients with ankle fractures retrospectively (exclusions- children, open fractures, co-morbid conditions like diabetes, steroid use) looking for delay in surgical fixation and wound complications. Out of 19 patients operated within 24 hours of injury, only one had a wound complication. This was 8 out of 20 for patients operated anywhere between 24 hours and 7 days. 12 patients had their fractures fixed after 7days, out of which 4 developed wound problems. (p value- < 0.05). This suggests that delay in ankle fracture fixation increases the rate of wound related problems. Review of case notes suggested that most patients in the second group (24 hours to 7 days) were waiting for the available slot in the trauma list. Based on these observations we suggest that ankle fractures should be prioritized in trauma lists and fixed within 24 hours of injury.

The purpose of this study was to find out whether routine post operative check radiographs after DHS (Dynamic Hip Screw) fixations are contributing to patient management. In a random selection of 50 NHS hospitals in England, 18 orthopaedic units were found to be ordering formal check radiographs after DHS. In our department check radiographs were routinely being done even though image pictures were printed in theatre. We reviewed 174 DHS fixations, assessed adequacy of image intensifier pictures and compared them with post operative radiographs. 115 stable fractures showed no change in position of fracture or screw. In 59 unstable fractures 14 showed medialisation of femoral shaft. 132 case notes were reviewed and none of these patients have had a change in post operative mobilization status based on check radiographs. The 14 unstable fractures which showed change in position too continued with mobilization.

We conclude that routine check radiographs are unnecessary after DHS fixations if adequate image pictures are obtained at surgery. It has important implications like manpower and cost, patient discomfort and unnecessary radiation.