Traditionally, unstable anterior pelvic ring injuries have been stabilised with an external fixator or by internal fixation. Recently, a new percutaneous technique of placement of bilateral supraacetabular polyaxial screws and subcutaneous connecting bar to assemble an “internal fixator” has been described. We present the surgical technique and early clinical results of using this technique in twenty-five consecutive patients with a rotationally unstable pelvic ring injury and no diastasis of the symphysis pubis treated between April 2010 and December 2013. Additional posterior pelvic stabilisation with percutaneous iliosacral screws was used in 23 of these patients. The anterior device was routinely removed after three months. Radiological evidence of union of the anterior pelvic ring was seen in 24 of 25 patients at a minimum 6 month follow-up. Thirteen patients developed sensory deficits in the lateral femoral cutaneous nerve (five bilateral) and only one fully recovered. The anterior pelvic internal fixator is a reliable, safe and easy percutaneous technique for the treatment of anterior pelvic ring injuries, facilitating the reduction and stabilisation of rotational displacement. However, lateral femoral cutaneous nerve dysfunction is common. The technique is recommended in cases with bilateral or unilateral pubic rami fractures and no diastasis of the symphysis pubis

Introduction: Increasing number of osteoporotic fractures of the femur, especially upper part of the femur creates everyday problem of health services. Treatment of these fractures has been improving markedly during the past 25 years. DHS, gamma nail and some other implants are very useful in everyday surgery. However some of complications still can not be resolved like cut out. Osteoporotic fractures in subtrochanteric area represent even bigger challenging. Diaphyseal fractures are also difficult to be treated. The main problem is quality of osteoporotic bone. Plate with parallel screws doesn’t provide reliable fixation. Intramedulary nails, because of wide channel in distal femur area also don’t provide desirable fixation stability. Material and Method: We analysed results of using of one new device: selfdynamisable internal fixator (SIF) in the series of 389 patients treated because of upper femur fractures. That device has possibilities of spontaneous dynamisation in two axes: along the femoral neck axis and along the diaphyseal axis. Spontaneous dynamisation in the diaphyseal axis is very important if diaphyseal or subrtochanteric fracture or comminuted fracture of the upper femur with subtrochanteric extension treated. For activation of axial dynamisation it not necessary to do any action from outside the body. This feature is activated spontaneously if there is no progress in fracture union within 6–8 weeks. This device provides three-dimensional fixation using clams and rod onto the lateral surface of the femur. The age of patients was from 59 to 87 years. This internal fixator is applied using minimally invasive method – by one or two small incisions. Results: During the treatment it has been confirmed working of self-dynamisation concept. Spontaneous dynamisation in the long axis of the femur has been proven in 21% of patients with subtrochanteric and diaphyseal fractures and it has been proven radiologically that sliding happened between 1–4 mm (average 2.5 mm). Such dynamisation together with 3D configuration of screws resulted in relatively quick fracture healing. Follow up was 19 months (6–60). Altogether 97.6% fractures healed within normal healing time. There were 1 infection, 2 cut out, 1 mechanical complication, 4 delay unions and one non-union. Conclusion: According to results obtained, it can bee concluded that new biological internal fixator is suitable for minimally invasive technique, without opening of fracture site

Despite its clinical significance, metaphyseal fracture healing has received little attention in research and experimental models have been limited. In particular it is not known to what extent the mechanical environment plays a role in metaphyseal fracture healing. Recently, a new murine internal fixation plate has been developed to stabilise fractures in the distal femur under highly standardised conditions. Goal of the current study was to modify this design, in order to be able to evaluate the influence of the fixator bending stiffness on metaphyseal fracture healing in mice.

Adapting the existing single body design, resulting in low flexibility fixation, two new plates were developed with a decreased bending stiffness of approximately 65% and 45% of the original implant (100%). Pilot experiments were performed on 54 animals, whereas the mice were sacrificed and fracture healing assessed radiologically and biomechanically after 14 and 28 days.

MicroCT evaluation confirmed that the osteotomy was created in the trabecular, metaphyseal bone of the distal mouse femora. All bones showed progressive fracture healing over time, with decreased implant stiffness leading to increased periosteal callus formation.

These implants represent an important new research tool to study molecular and genetic aspects of metaphyseal fracture healing in mice under standardized mechanical conditions, in order to improve clinical treatment in challenging situations, such as in osteoporotic bone.

Purposes of study: To design and introduce into clinical practice a more effective fixation method for condylar and supracondylar fractures of the distal femur, which provides secure fixation and permits the use of a minimally invasive surgical technique.

Methods and results: We have designed a novel implant for secure internal fixation of condylar and supracondylar fractures of the distal femur.

This involves a retrograde intramedullary nail with a unique “cruciate” configuration of distal locking bolts which stabilise the fractured condyles in relation to the shaft.

The optimal geometrical configuration of the distal locking bolts has been developed using cadaver studies. Following finalisation of the design, mechanical bench testing of the implant and clinical trials have been completed according to a protocol agreed with the UK Medical Devices Agency.

So far 36 patients have been treated using the implant which has proved to be effective and easy to use. Much less soft tissue dissection is required than when using conventional blade plates or DHS, or even newer “percutaneous” plating methods.

Conclusions: Mechanical testing on simulated specimens of both segmental defects and intercondylar “T” fractures has shown that the retrograde “cruciate” nail compares favourably with fixation with a DHS screw/plate implant.

Following completion of clinical trials, the Medical Devices Agency has granted approval for general use of the implant. It is anticipated that this will greatly facilitate the management of distal femoral fractures particularly those involving intercondylar fracture patterns.

Aim: Prospective study to evaluate the results and the technique of 63 proximal femoral osteotomies in 39 cerebral palsy patients performed with the new Fixclipª biological internal þxator system. Methods: Thirty nine cerebral palsy patients with dislocated or painful subluxing hips, who underwent upper femoral osteotomy from 2 different centres in the last 7 years were included in the study. Results: The average age of patients at operation was 12.7 years (range 3 Ð 60 years). All the patients were followed up until union. Some had removal of the implant. Postoperative splintage was normally used when soft tissue procedures were performed along with femoral osteotomy. Three patients needed revision surgery for readjustment of the device and 2 patients had superþcial infections. All osteotomies healed by 12–16 weeks apart from one. There was no malunions, or avascular necrosis. One patient had a non-union that united after revision surgery. Conclusion: The Fixclips system is modular and easily adjustable. The system lies off the bone with minimal disturbance to the periosteal blood supply. Compared to other implants, Fixclips are biologically and mechanically very effective with low complications and well suited in cerebral palsy patients where rigid þxation can cause extensive loss of bone mass. This is the þrst study reporting the use of ÔFixclipsñ system for upper femoral osteotomy.

Abstract. Introduction. Intra-articular distal humerus OTA type C fractures are challenging to treat. When osteosynthesis is not feasible one can choose to do a primary arthroplasty of elbow or manage non-operatively. The indications for treatment of this fracture pattern are evolving. Objectives. We present our outcomes and complications when this cohort of patients was managed with either open reduction internal fixator (ORIF), elbow arthroplasty or non-operatively. Methods. Retrospective study to include OTA type C2 and C3 fracture distal humerus of 36 patients over the age of 50 years managed with all the three modalities. Patient's clinical notes and radiographs were reviewed. Results. Between 2016 and 2022, 21 patients underwent ORIF – group 1, 10 patients were treated with arthroplasty – group 2 and 5 were managed conservatively- group 3. The mean age of patients was 62 years in group 1, 70 years in group 2 and 76 years in group 3. The mean range of movement (ROM) arc achieved in the group 1 & 2 was 103 while group 3 was 68. At least follow up was 6 months. 5 patients in group 1 underwent metalwork removal and 2 patients in group 3 under arthroplasty. Conclusion. The outcomes of arthroplasty and ORIF are comparable, but reoperation rates and stiffness were higher in ORIF and conservative group. Surgeon choice and patient factors play important role in decision towards choosing treatment modality. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Locking plates have led to important changes in bone fracture management, allowing flexible biological fracture fixation based on the principle of an internal fixator. The technique of locking plate fixation differs fundamentally from conventional plating and has its indications and limitations. Most of the typical locking plate failure patterns are related to basic technical errors, such as under-sizing of the implant, too short working length, and imperfect application of locking screws. After analysis of the fracture morphology and intrinsic stability following fracture reduction, a meticulous preoperative planning is mandatory under consideration of the principles of the internal fixator technique to avoid technical errors and inaccuracies leading to early implant failure

Since the early nineties clinical experience were gained with locking plates to stabilize long bone fractures. Firstly with a Point Contact Fixator, a device making the step from a conventional plate to an internal fixator, than with pure precontured internal fixators for the periaticular regions or nowadays with plates giving the option for the placement of locking or conventional cortical screws and are so called Locked Compression Plate (LCP). Almost every new development for extraarticular fracture stabilization reflects this development. Despite today’s broad, worldwide acceptance of the fixation technique, someone should be very clear about the benefits and the underlying concept to avoid failures, complications and unnecessary costs. Clear clinical benefits have been proven in complex fractures of the metaphysis and joints, furthermore the fixation of highly osteoporotic and/or periprosthetic fractures became more reliable. Also the technique of minimally invasive plating – the so-called biological plating –, where the fracture zone is only bridged and therefore the fracture often is not exposed any more, was facilitated with the new internal fixators. However, the process should not be overused, particularly in cases of insufficient surgical experience, because the technical demanding minimally invasive procedures can have detrimental effects on the fracture alignment and therefore on the later outcome. Not to forget the extended use of intraoperative x-ray exposure to control the reduction and implant fixation. Applying locking plates, the surgeon should never forget that bone healing requires still prerequisites in respect to stability and, of course, of other biological stimuli. This reflects the ongoing discussion, how a simple long bone fracture, should be optimal stabilized with an internal fixator, the amount of bone/implant fixations contacts and the timing for necessary further operations in present of delayed healing. The opportunity to combine both stabilization options – conventional screw and locking screw placement – within one implant needs a clear understanding of the underlying fixation issues and requires a clear teaching concept to avoid unfavorable combination of the different screws. In this lecture a broad, critical overview about the worldwide impact of locking plates in long bone fracture treatment will be given including proven advantages as well as discussing detected disadvantages using literature evidence and clinical examples

The paper present our results in application of new method for nonunion treatment of the femoral diaphysis. The internal fixator has been applied with 36 patients. Bone graft substitution is used with 11 (30,5%) patients. The method of placement and results of the work according to the modified system of the Karlstrom-Olerud method have been presented. Excellent condition was found with 25 (69,4%) patients, satisfactory with 8 (22,2%) and poor with 3 (8,3%) patients. Average healing time is 57 weeks. The method in which the internal fixator is applied provides complete stability of the nonunion and makes possible spontaneous-biological dinamization of the nonunion. It doesn’t damage the periosteal and medullary bone vascularization which favors healing process

Purpose of the study:. To determine the outcomes of cases converted from an external fixator to an internal fixation device in the management of limb reconstructions and deformity corrections. Method:. A retrospective review of 18 patients, that underwent a conversion procedure to internal fixation following long term external fixation use, was done. This comprised 24 limbs. Inclusion criteria: All cases of long term external fixator use converted to internal fixation over a 5 year period. Average external fixation time, pin site care, conversion timing, surgical device used as well as outcome were documented. Results:. The mean treatment time in an external fixator was 185 days (61–370). The reasons for conversion included patient dissatisfaction, pin tract sepsis and a refracture. The conversion procedures included 8 intramedullary nail fixations and 16 plate and screw fixations. An acute conversion was identified as an internal fixation that was done in the same sitting as external fixator removal. A delayed conversion was any internal stabilisation that was done thereafter. In total, the complication rate associated with conversion to internal fixation following long term external fixation was 25%, mainly due to persistent non-union or sepsis. In the 8 conversions to intramedullary nails, 7 were acute: 4 had good outcomes with sepsis free union being achieved. 3 had poorer outcomes with a non-union and 2 amputations being documented. The single delayed nailing achieved union. In the 16 conversions to plate fixation, 13 achieved union. 10 were acute conversions and 3 were delayed. The remaining 3 that developed complications included 2 acute conversions with septic non-unions and a single delayed conversion which resulted in sepsis. Conclusion:. Conversion of an external fixator to an internal fixator in a non-acute reconstructive setting has a 75% success rate. In the acute conversion group (19 cases), plate and screw fixation had a superior outcome. In the delayed conversion group (5 cases), intramedullary fixation was favoured

In recent years, plate osteosynthesis in metaphyseal and diaphyseal long bone fractures has been increasingly applied in a minimally invasive fashion. Several clinical studies describe a beneficial effect of the smaller additional soft tissue damage, resulting in satisfying fracture and soft tissue healing. However, is the surgical soft tissue damage really evidently smaller and the recovery faster?. A trauma model with severe, circumferential soft tissue damage to the distal right thigh and a distal multifragmentary (AO type C) femur fracture was carried out on 24 male sheep. After five days temporary external fixation, an internal fixator was placed either by a conventional open lateral approach or by minimally invasive technique. To assess the soft tissue damage and its recovery within the first 14 days, local compartment pressure monitoring as well as daily measurements of systemic markers (Creatin Kinase, CK and Lactate Dehydrogenase, LDH) in blood were performed. The local monitoring with a special probe (Neurovent PTO, Raumedic AG, Germany) within the quadriceps muscle allowed the measurement of compartment pressure (CP), as well as temperature. The CK and LDH levels responded to the severe trauma with high peaks within the first 48 hours post trauma. After the internal fixator operations CK levels illustrate a significantly lower increase (p< 0.05) in the minimally invasive group compared to the open approach group in the first two days postoperatively. LDH levels show lower values for the minimally invasive group (p=0.06). The values of CP present an initial increase after the trauma and then higher values (p=0.08) after the open plating operation. For the intracompartmental temperature no statistical differences were found, too (p=0.17). These results, with reduced additional soft tissue damage and faster recovery in the minimally invasive approach group, reflect the clinical experience and expectations. However, while minimally invasive plate osteo-synthesis is certainly a desired option for fracture fixation, good surgical skills are required to insure that the reduced surgical trauma is in line with optimal fracture healing. The influence of the two different approaches on the bone healing per se, as well as the influence on soft tissue functionality, has yet to be demonstrated

Introduction: Proximal tibial fractures continue to be problematic for orthopaedic surgeons. Continued problems in their managment include infection, soft tissue problems, failure of fixation and joint stiffness. Combining the concept of “biological plating” and locked internal fixators, the LISS (Less Invasive Stabilization System) has been developed. Material and methods: The Lis-system is an extramedullary internal fixator that proposes the advantage of indirect reduction and percutaneous, submuscular implant placement. The Lis-system is indicated for fractures of the proximal tibia that involve both the medial and lateral columns. They include AO/OTA Type A2, A3, C1, C2, C3 and type B in selected cases. For the reduction, we put the lower limb in the calcaneal-traction. For intra-articular fractures the prime objective is to achieve anatomic reconstruction of the joint. This study is a prospective evluation of the Lis-System for the treatment of high-energy tibial plateau and proximal tibial fractures treated between October 2002 and Febrary 2004. Twenty-five patient (18 male and 7 female) were treated. The fracture were classified according to the AO classification. The follow-up period between 3 months and 16 months (mean 8.9 months). Results: The fractures treated were 10 intrarticular (AO 41C or 41B) and 15 metaphyseal (AO 41 A); two of these fractures presented with open soft tissue damage. The average age of the patients was 43 years. There were five cases of polytraumatized and four patinetsa with multiple fractures. The mean range of motion was 2 degree (R= 0–13) to 110 degree (R= 80–150). The mean time to full weight-bearing was 16.2 weeks (R= 10–19). There where no non-union. In one case, there was a valgus malunion of about 5 degree, in 2 case a valgus malunion of less of 5 degree and anyone of more of 5 degree. The tecnique of osteosyntesis with the LISS allows a minimally invasive approach, minimizing additional trauma to the soft tissue. There were no cases of varus malunion, of failure or of loss of reduction. One patient developed superficial infection that we treat with antibiotics terapy. No syndrome compartiment were see. Conclusion: In conclusion with the new methods of percutaneus plate osteosyntesis we see decreased soft tissue complication and the time of healing. The Less Invasive Stabilizzation System in our opinion is the goal standard for multisegmentary or comminnuted fractures of the proximal tibia with distal long extensions in patients with politrauma. The early clinical result optain in our experiance indicate that the Less invasive Stabilizzation System combine efficent bone stabilization with the advantage of minimally invasive operative technique

Total hip arthroplasty following pelvic or femoral trauma presents the joint surgeon with challenges not dissimilar to that of revision surgery. Careful preoperative evaluation and planning, and realistic assessment of risks and expectations is necessary. Complex acetabular fractures present the surgeon with a variety of challenges in conversion to total hip replacement (THR). Bone stock is the critical factor in achieving a stable acetabular reconstruction, particularly with regard to the posterior column. In patients who have undergone prior open reduction and internal fixation, routine radiographic examination will often be inconclusive as to the status of healing of fractures due to the presence of metal, and CAT scans will be similarly obfuscated by metal artefact. Therefore, the surgeon must be prepared for the possibility of bone stock deficiency at the time of reconstruction. Subclinical infection following ORIF is possible; all patients should be screened for this possibility with preoperative determination of the ESR and C-reactive protein. If these studies are elevated, aspiration of the hip under x-ray or ultrasound guidance should be considered. At the time of surgery, it is suggested that cultures be obtained prior to the administration of systemic antibiotics, and consideration given to intraoperative frozen section examination of tissue if infection is suspected. Removal of internal fixation devices, debridement, and second stage reconstruction after appropriate antibiotic therapy will be necessary in these cases. Exposure of the hip will be complicated by scar tissue. Particular care is required to avoid sciatic nerve injury during the exposure and hardware removal. Extension of the hip and knee during posterior exposure of the acetabulum and internal fixation devices will aid in retraction and avoidance of neuropraxic sciatic injury. Stainless steel screws and plates should not contact titanium alloy implants in order to avoid the possibility of fretting wear and corrosion of dissimilar metals. Intraarticular exposure of screws or plates mandates removal of the device. In the absence of such exposure, hardware may be left in place. Post-traumatic hip arthritis is frequently associated with avascular necrosis of the femoral head. It is not unusual to see advanced bone loss and collapse of the femoral head, with associated limb shortening. If internal fixation has been performed in the proximal femur, consideration of the appropriate femoral component length is necessary to bypass any stress risers. Calcar replacement implants will be necessary in the face of proximal femoral deficiency. The risk of dislocation following THR in the setting of post-traumatic arthrosis is increased in the presence of soft tissue defects, abductor dysfunction, or neuromuscular deficit. Postoperative bracing may be necessary to assure stability of the reconstruction. The use of a THR orthosis set at 10–15° abduction, 30–60° flexion for 12 weeks following surgery has been successful in preventing dislocation in the setting of abnormal soft tissues

Aim. Radiologic signs such as radiolucent lines around the implant, hardware fracture or displacement and periosteal reaction have been considered suggestive of implant-associated infection. The goal of this study is to assess the correlation of these signs with confirmed internal fixation-associated infection evaluated in a prospective cohort. Method. We evaluated the radiologic appearance of preoperative standard x-ray images in 421 surgeries performed in 380 patients with internal fixation device in place (56.8% male, mean age 53 ± 17 years). This prospective study was performed in a large single center for musculoskeletal surgery from 2013–2017. Infection was suspected preoperatively in only 23.8% of the surgeries. The most common indications for surgeries in which infection was not suspected were nonunion (84 cases) and symptomatic hardware (57 cases). All removed implants were sent to sonication for biofilm removal and detection. In addition, several peri-implant tissue samples were collected. Radiographs were analyzed in a blinded fashion for signs of radiolucent lines around the implant before removal, hardware fracture or displacement, and soft periosteal reactions suggestive of infection. Diagnosis was established according to the IDSA criteria for PJI. Contingency tables were constructed to determine sensitivity and specificity, and to perform Chi-square tests to compare the presence of infection with radiological signs of infection. Results. Radiologic signs suggestive for infection were uncommon, including radiolucent lines in 48 cases (11.4%); hardware breakage in 542cases (12.4%); hardware displacement in 45 cases (10.7%); periosteal reaction in 30 cases (7.1%). Infection was confirmed in 27.6% of the surgeries, and radiological signs of infection were only marginally more common in this group. Only the presence of radiolucent lines (p = 0.47; OR = 1.86 [95% CI 1.00 – 3.38]) and periosteal reaction (p = 0.15; OR = 2.48 [1.17 – 5.26]) were significantly associated with confirmed infection. Sensitivity of radiolucent lines and periosteal reaction were low (16,4% and 12,1%, respectively), while specificity remained acceptable (90.5%and 94.8%, respectively). Conclusions. Radiologic signs of infection are uncommon, even in the context of a confirmed infection. Radiolucency surrounding the implant and the presence of a soft periosteal reaction were significantly associated with the presence of infection, though sensitivity of the signs remained very low

Aim. Unexpected positive infections are distinct entity in prosthetic revision surgery. The prevalence and characteristics of unexpected positive cultures in internal fixation are however less established. The aim of this study was to describe the prevalence and characteristics of unexpected diagnosis of infection in a prospective cohort of revision surgeries following internal fixation. Method. We reviewed the microbiological results following 356 surgeries that included partial or complete removal of internal fixation, performed in 328 patients (54% male, mean age 53 ± 17 years), in which infection was not initially suspected. This prospective study was performed in a large single center for musculoskeletal surgery from 2013–2017. The implants most commonly removed were plate and/or screws (281 cases, 78,9%), followed by intramedullary nails (64 cases, 18,0%). The main indications for surgery were nonunion (89 cases, 25%) and symptomatic hardware (70 cases, 19,7%). All removed implants were sonicated, and tissue cultures were obtained depending on the surgeon's criteria. Diagnosis of infection was established by the presence of 2 or more positive tissue cultures (1 with a highly virulent microorganism), or ≥ 50 colony-forming units found in the sonication fluid. Results. Infection was confirmed in 47 cases (13,2%); diagnosis was obtained with tissue cultures in 5 cases (1,4%), sonication in 14 cases (3,9%) and a combination of both sonication and tissue samples in 28 cases (7,9%). In another 24 cases (6,7%), ≥ 50 CFU of low-virulence microorganisms were isolated in the sonication fluid, but no tissue samples were available to confirm the diagnosis. Low-virulent microorganisms such as Propionibacterium acnes (22 cases / 46,8%) or coagulase-negative Staphycoccci (13 cases, 27,7%) were most commonly isolated. Sonication was key for the diagnosis of 61,7% of unexpected-positive surgeries. Nearly half of the patients received a new implant (internal fixation in 40,4%; arthroplasty in 6,4%), but only 34% of the patients were treated with antibiotics on discharge. Conclusions. Unexpected diagnosis of infection occurs in approximately 13,2% of revision surgeries following internal fixation, most commonly due to low-virulent microorganisms. Sonication was key for the diagnosis of the majority of these infections. The clinical relevance of these infections remains unclear, though the insertion of new implants raises concern. We recommend sonication of all internal fixation devices removed, especially if new implants are inserted in the revision surgery

Introduction. Fracture around the knee can lead to posttraumatic osteoarthritis (PTOA) of the knee. Malunion, malalignment, intra-articular osseous defects, retained internal fixation devices, and compromised soft tissues may affect the outcome of total knee replacement (TKR). On average, the posttraumatic patient subsets were 10.4 years younger than those for primary knee OA. Recently, there were several studies reporting the outcome of THA for posttraumatic OA hip. However, no current literature defines the comparative functional outcome between PTOA and primary OA knee. The purpose of our study was to compare the midterm outcomes of patients undergoing TKR following periarticular knee fractures/ligamentous injuries versus primary osteoarthritis (PO) of the knee. Materials and methods. Retrospective chart reviews of patients underwent TKR between 2008 and 2013 were identified. 136 patients underwent open reduction and internal fixation with plate and screws or ligament reconstruction while 716 patients were primary OA. Mean follow up time was comparable in both groups. Demographic data, medical comorbidities, WOMAC, visual analogue scale, and complications were recorded. Results. There were significantly different in age (56.5 vs 63.8 years, p<0.0001), gender (48.5% vs 63.1% of female, p=0.0014), and obese (62.3% vs 76.0%, p=0.025) between PTOA and PO groups, respectively. The PO group had higher comorbidities than PTOA group including anticoagulant usage (51% vs 30.9%, p=0.0002), number of disease ≥ 4 (69.6% vs 45.3%, p<0.0001), ASA class ≥3 (38.8% vs 21.6%, p<0.0001), and Charlson Comorbidity Index (3.6 vs 2.8, p<0.0001). The PTOA group had longer operative time (110.9 vs 100.1 minutes, p<0.0001) than PO group. Preoperatively anatomical axis of the knee was approximately valgus in PTOA but varus alignment in PO group (p<0.0001). However, postoperatively anatomical and mechanical axis was comparable in both groups. Postoperative VAS (1.8 vs 1.2, p=0.002) at 1 year follow up and pain component of WOMAC (77.8 vs 85.7, p=0.013) in PTOA group was worse than PO group, respectively. On the contrary, there was no difference in postoperative complication and readmission rate between groups. Conclusion. Total knee replacement for Post-traumatic OA was associated with poorer functional outcome compared to those for primary osteoarthritis in midterm follow up

Accurate implant size estimation for internal fixation of long bone fractures can reduce intra-operative errors, operative time and radiation exposure. With the advent of pre-packed sterile implants, the exponential increase in the number of internal fixation devices and the lack of standard templates for them on PACS systems, templating has become increasingly difficult. This often results in the opening up of wrong implants leading to increased costs both in terms of increased operative time and additional implants. We describe a technique to determine implant size preoperatively using sterile implant boxes. Post anaesthesia and positioning, the pre packed implant box of approximate size is placed over the limb across the fracture site. An X-ray is then taken using the C-arm. In case of a plate, the number of holes desired on either side of the fracture, the shape of the implant and planned placement of screws are seen. Different implant boxes with the contained implant are placed and once the most appropriate implant for the particular fracture is reached, the box is opened and implant is kept ready for insertion. This technique has been found to be accurate, easy, reproducible and effective for estimating the implant size thereby decreasing the chances of opening wrong implants and saving the intra operative time substantially

Acetabular fracture treatment outcomes have improved over the past two decades due to the more accurate identification of common fracture patterns, the development of more adequate surgical approaches, and the creation of improved methods for reduction and repair. However, certain cases have a distinctly lower likelihood of a favorable outcome, and in this setting primary arthroplasty as part of the open reduction and internal fixation (ORIF) may provide the best solution. Acute primary total hip arthroplasty (THA) provides primary stability and immediate pain relief, permits graded weight-bearing and early pain-free mobilization, and may also treat pre-existing hip arthritis. Removal of the femoral head improves exposure making fracture reduction and fixation easier without the need for more extensile approaches. Open reduction and internal fixation to obtain stability of the anterior and posterior columns is followed by placement of a multi-holed acetabular shell which serves as a supplementary internal fixation device. The femoral head can be used as bulk bone graft to replace and reinforce the reconstruction. These complex procedures are best undertaken by a surgical team with substantial experience with both acetabular trauma and hip arthroplasty. Despite improvements in outcomes with ORIF, THA is commonly required following failed treatment. Scarring, heterotopic ossification, bone defects, residual deformity, devitalised bone fragments and previous implants can make the procedure challenging. If the patient has undergone previous ORIF it is important to rule out low grade sepsis with appropriate blood tests (ESR + CRP) and further work-up as warranted. Surgical exposure must be carefully planned so as to be able to access all aspects of the acetabulum, including removal of hardware which may interfere with acetabular component placement. Bone stock loss, malunion and/or non-union must be evaluated with appropriate radiographs or CT scans may be required. Acetabular replacement in the face of deformity from previous trauma encompasses three main problems; bony defects, the presence of bone in places where it is not normally encountered, such as surrounding and incarcerating the femoral head, or substantially anterior or lateral to the center of the acetabulum, and movement of the acetabulum from its normal relationship to the remainder of the pelvis to a new location, such as a higher or more medialised hip center. Intraoperative landmarks may be obscured and therefore placement of reamers and the component may be confusing. THA after acetabular fracture is technically demanding and generally is accompanied by results more typical of revision than primary arthroplasty for degenerative disease

Introduction. In most cases of stable type medial femoral neck fracture and some cases of dislocated medial femoral neck fracture, internal fixation was undertaken. Dual SC Screw (DSCS) System is an internal fixation device which has sliding mechanism and preventing mechanism of back out of the screw. The purpose of this study is to evaluate the results and complication of medial femoral neck fracture treated with DSCS. Methods. Fifty two patients operated for fractures of the medial femoral neck with DSCS were identified as the study population. All patients followed up at least 2years. Outcome measures included the period of bone union, revision surgery, operating times and clinical symptoms and complication. Results. The average operation time was 37 minutes and 49 cased achieved union. Moreover all patients could regain the pre-injury walking ability. Three patient did not achieve union and two patients suffered displacement of reduced fracture and three patients had avascular necrosis of the femoral head. However, the cases of subtrochanteric femral fracture or the back out of the screws were not found. The mechanical tests using imitation bone showed the strength of DSCS. Conclusion. Operative treatment with internal fixation using DSCS in femoral neck fracture gives favorable results because of its strong fixation and holding function of the screw. The operative technique was simple and the DSCS thought to be a useful tool for femoral neck fracture

Introduction. Various methods to manage medial tibial defects in primary total knee arthroplasty (TKA) have been described. According to Vail TP, metal augmentation is usually indicated for defect depth of >10 mm of the medial tibial plateau. The outcomes of metal augmentation have been described as excellent. Nevertheless, we believe that it is mandatory to preserve as much of the bone as possible for future revision surgeries. Therefore, we performed autologous impaction bone grafting even for large bone defects (defect depth of ≥10 mm) in primary TKA. The objectives of this study are to describe our bone grafting technique in detail and to assess the radiological outcomes of the grafted bone. Methods. Between 2003 and 2011, 26 TKAs with autologous impaction bone grafting for ≥10 mm medial tibial defects were performed. The preoperative diagnoses were osteoarthritis in 17 knees, rheumatoid arthritis in 2 knees, osteonecrosis of the medial tibial condyle in 6 knees, and Charcot's joint in 1 knee. The average mediolateral width and depth of the medial tibial defects, measured after the horizontal osteotomy of the tibial articular surface, were 17.8 mm (range, 10–25 mm) and 12.0 mm (range, 10–23 mm), respectively. The average patient age at surgery was 73.2 years (range, 56–85 years). The patients were followed up for an average of 55 months (range 27–109 months). Bone grafting technique: Multiple drill holes (white arrow) were made on the floor of the defect (A) and a morselized cancellous bone was impacted using the grip end of a metal hammer (white asterisk) and firm manual pressure to fill the defect. Thus, the firm impaction prevented bone cement from entering the space between the graft and the tibial host bed. An assistant's index finger (black asterisk) was used as a bank (B). The tibial component was fixed on the grafted bone (white asterisk) with bone cement (C). Internal fixation devices were not required, and stem extension was used in only Charcot's joint (defect depth=23 mm). Aftertreatment was the same as that for the usual TKAs without bone defects. Results. In terms of clinical outcomes, no patient showed disturbances in walking ability at final follow-up. The average knee flexion angle was 114° (range, 95°–130°). The grafted bone was kept at the grafted area on the radiograms throughout the follow-up period. No absorption or collapse of the grafted bone was observed on the radiograms at the final follow-up. Usually, the grafted bone showed osteosclerotic changes around 2–3 months after TKA. Then, the osteosclerosis became weakened and the bony trabeculae could be detected in the grafted area. Finally, the grafted bone completely incorporated into the host bone in all knees with evidence of bony trabeculae crossing the interface by up to 1 year after surgery. The margin of the grafted area resembled bony cortex in 19 TKAs (73.1%). Conclusions. Our technique is easy, economic, and reproducible. It is an acceptable alternative to metal augmentation for large medial tibial defects in primary TKA