Aims

The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size.

The radiological evidence of implant failure following plate fixation of traumatic pubic symphysis diastasis can be up to 75%. We report the complications following symphyseal double orthogonal plating in patients with pubic symphysis diastasis over a period of 2.5 years. Patient records and radiographs of 38 consecutive patients were reviewed with mean follow up of 12.5 months. 5 patients (13%) had radiological evidence of implant failure with one patient (2.6%) requiring revision surgery. There was no evidence of wound complications. We conclude that our lower rate of revision surgery and metal work failure is attributed to double orthogonal plating.

Background

Tightrope fixation has been suggested as an alternative to screw stabilisation for distal tibiofibular joint diastasis that provides stability but avoids the problems of rigid screws across the joint. Recent case series (of 6 and 16 patients) have however, reported soft tissue problems and infections in 19–33% of patients. This study aims to review treatment and complications of distal tibiofibular diastasis fixation in our unit with the use of Tightrope or diastasis screws.

Circumferential pelvic binders have been developed to allow rapid closure of the pelvic ring in unstable fracture patterns. Despite evidence to support the use of pelvic binders, there is a paucity of clinical data regarding the effect of binder position on symphyseal diastasis reduction. All patients presenting to the UK's military hospital in Afghanistan who survived and underwent pelvic radiography were reviewed. Cases were identified by retrospective assessment of all digital plain pelvic radiographs performed between January 2008 and July 2010. All radiographs and CT images were assessed to identify the presence of any pelvic fracture. Patients were grouped into three categories according to the vertical level of the buckle: superior to the trochanters (high), inferior to the trochanters (low) and at the level of the trochanters (troch). Diastasis reduction was measured in patients with Anterior-Posterior Compression (APC) grades II and III, or Combined Mechanical Injuries(CMI). Comparison of diastasis reduction between the high and troch groups was assessed by an independent samples Student's t-test. We identified 172 radiographs where the metallic springs in the buckle of a SAM Pelvic Sling. ™. were clearly visible. The binders were positioned at the trochanteric level in 50% of radiographs. A high position was the commonest site of inaccurate placement (37%). In the patients with fractures and an open diastasis, the mean pelvic diastasis gap was 2.75 times greater in the high group compared to the trochanteric level (mean difference 22 mm) (p < 0.01). Application of pelvic binders superior to the greater trochanters is commonplace and associated with inadequate fracture reduction, which is likely to delay cardiovascular recovery in these significantly injured casualties

Introduction

Syndesmosis injuries are significant injuries and require anatomical reduction. However, stabilisation of these injuries with syndesmosis screws carries specific complications and many surgeons advocate a second operation to remove the screw. Primary Tightrope suture fixation has been shown to be an effective treatment for syndesmotic injuries and avoids the need for a second operation.

Objectives

Overlap between the distal tibia and fibula has always been quoted to be positive. If the value is not positive then an injury to the syndesmosis is thought to exist. Our null hypothesis is that it is a normal variant in the adult population.

The aim of this study was to assess the accuracy of placement of pelvic binders and to determine whether circumferential compression at the level of the greater trochanters is the best method of reducing a symphyseal diastasis.

Patients were identified by a retrospective review of all pelvic radiographs performed at a military hospital over a period of 30 months. We analysed any pelvic radiograph on which the buckle of the pelvic binder was clearly visible. The patients were divided into groups according to the position of the buckle in relation to the greater trochanters: high, trochanteric or low. Reduction of the symphyseal diastasis was measured in a subgroup of patients with an open-book fracture, which consisted of an injury to the symphysis and disruption of the posterior pelvic arch (AO/OTA 61-B/C).

We identified 172 radiographs with a visible pelvic binder. Five cases were excluded due to inadequate radiographs. In 83 (50%) the binder was positioned at the level of the greater trochanters. A high position was the most common site of inaccurate placement, occurring in 65 (39%). Seventeen patients were identified as a subgroup to assess the effect of the position of the binder on reduction of the diastasis. The mean gap was 2.8 times greater (mean difference 22 mm) in the high group compared with the trochanteric group (p < 0.01).

Application of a pelvic binder above the level of the greater trochanters is common and is an inadequate method of reducing pelvic fractures and is likely to delay cardiovascular recovery in these seriously injured patients.

Introduction: Ankle diastasis injury occurs in up to 20% of ankle fractures. Various techniques have been used to treat syndesmosis injuries, but controversy remains and outcome is variable. In light of some recent cases of substandard syndesmosis fixations requiring revision, an audit of our results was undertaken.

Method: Study type: Retrospective audit of radiographs and patient records

Data collection: patients were selected using an orthopaedic database search for operations coded as distal tib/fib ORIF or ankle ORIF.

Study period: 12 months, July 2008 to July 2009 (currently data has been analyzed on the first 6 months only, the remaining 6 months will follow)

Audit questions to be answered: How is ankle diastasis injury being managed? Are we reducing syndesmosis correctly? Should there be a revision to local policy?

Audit standard: Syndesmoses should be adequately reduced and fixation techniques employed should be in accordance with recommendations in standard Orthopaedic reference texts (Rockwood & Green, AO fixation manual 3)

Results: 76 ankle ORIFs in July to December 2008 inclusive. Out of these, 16 had diastasis fixation (21%). 2 of the patients had a syndesmosis width over 6 mm indicating an inadequate reduction of the syndesmosis 1. Both of these required revision surgery. In total 70% of the post operative x-rays showed inadequate syndesmosis fixation or reduction.

Discussion: The single most predictive indicator of a favourable function is accurate reduction of the syndesmosis 2. Substandard fixations are associated with poor long term outcomes. This raises the potential for litigation and the requirement for education and policy change. We have produced policy guidelines for theatre and circulated the information to all surgeons. A further audit will be carried out to assess the effectiveness of this in 6 months time. (The data will be available from this re-audit for presentation at the conference.)

The purpose of this study was to assess the stability of a developmental pelvic reconstruction system which extends the concept of triangular osteosynthesis with fixation anterior to the lumbosacral pivot point. An unstable Tile type-C fracture, associated with a sacral transforaminal fracture, was created in synthetic pelves. The new concept was compared with three other constructs, including bilateral iliosacral screws, a tension band plate and a combined plate with screws. The pubic symphysis was plated in all cases. The pelvic ring was loaded to simulate single-stance posture in a cyclical manner until failure, defined as a displacement of 2 mm or 2°. The screws were the weakest construct, failing with a load of 50 N after 400 cycles, with maximal translation in the craniocaudal axis of 12 mm. A tension band plate resisted greater load but failure occurred at 100 N, with maximal rotational displacement around the mediolateral axis of 2.3°.

The combination of a plate and screws led to an improvement in stability at the 100 N load level, but rotational failure still occurred around the mediolateral axis. The pelvic reconstruction system was the most stable construct, with a maximal displacement of 2.1° of rotation around the mediolateral axis at a load of 500 N.

Between October 2006 and September 2007, eight consecutive patients with syndesmotic diastasis of the ankle had Tight Rope suture –endobutton fixation. We present our early results following this fixation. There were 3 males and 5 females with a mean age of 42 years (range 21 – 67). All were followed up for a mean of 7 months. Five patients had right side involvement. Majority were twisting injuries. These patients were compared with a cohort group (10 patients) who had diastasis screw fixation for similar fractures during the same period.

Results: The mean post operative Olerud & Molander ankle subjective score was 86 points. The tourniquet time was significantly less in endobutton group compared to the diastasis screw group(mean of 56 minutes vs. 72 minutes). There was some difference in time to mobilisation between the two groups (mean of 10 days). The endobutton group patients were able to return to work and leisure activities earlier (mean of 4 weeks) compared to the diastasis group. Range of motion was similar in both groups. There were fewer complications in both groups with superficial infection and stiffness being the most common. Both groups were satisfied with the fixation.

Advantages of Tight rope fixation: The tourniquet time was reduced; there was no need for 2nd operation with its attendant risks. Earlier mobilisation was possible leading to early return to work and leisure activities.

We recommend the use of this new suture endobutton fixation for ankle diastasis with promising early functional results. Further prospective studies are needed to evaluate this new type of fixation device.

We reviewed retrospectively 45 patients (46 procedures) with bladder exstrophy treated by bilateral oblique pelvic osteotomy in conjunction with genitourinary repair.

The operative technique and post-operative management with or without external fixation are described. A total of 21 patients attended a special follow-up clinic and 24 were interviewed by telephone. The mean follow-up time was 57 months (24 to 108).

Of the 45 patients, 42 reported no pain or functional disability, although six had a waddling gait and two had marked external rotation of the hip. Complications included three cases of infection and loosening of the external fixator requiring early removal with no deleterious effect. Mid-line closure failed in one neonate managed in plaster. This patient underwent a successful revision procedure several months later using repeat osteotomies and external fixation.

The percentage pubic approximation was measured on anteroposterior radiographs pre-operatively, post-operatively and at final follow-up. The mean approximation was 37% (12% to 76%). It varied markedly with age and was better when external fixation was used. The wide range reflects the inability of the anterior segment to develop naturally in spite of close approximation at operation.

We conclude that bilateral oblique pelvic osteotomy with or without external fixation is useful in the management of difficult primary closure in bladder exstrophy, failed primary closure and secondary reconstruction.

Which of several osteotomies described for approximation of the pubic bones in wide congenital diastasis of the pelvis best facilitates closure is controversial. This paper describes the benefits of the horizontal innominate osteotomy in approximation of the pubic bones when there is wide congenital diastasis.

Between 1994 and 2000, 11 children, ranging in age from one week to eight years, were treated by horizontal innominate osteotomies. Six children had exstrophy of the bladder. There were ischiophagus tetrapus twins and cases of duplication of the genitalia and sacral teratoma. The follow-up time ranged from six months to six years.

General surgical procedures were followed by bilateral innominate osteotomies to facilitate approximation of the pubic bones for bladder, genitalia and anterior abdominal wall repair. The ilium was exposed subperiosteally with the patient supine. A Salter-type osteotomy was performed, dividing the innominate bone from the sciatic notch to just above the anterior inferior iliac spine. The distal fragments were rotated medially, the pubic bones approximated in the midline, and the surgical soft tissue procedures completed. Postoperatively, children were maintained in gallows traction for two weeks and immobilised in plaster for four further weeks.

All osteotomies healed well. Abdominal wound infections occurred in two children, resulting in separation of the pubis. One child had repeat osteotomies one year later and healed well. Abdominal wall hernia occurred in one child. The gap between the pubic bones in the remaining patients ranged from 1cm to- 5 cm. Internal rotation of the hip improved in all patients.

Horizontal iliac osteotomies enable complex pelvic malformations to be corrected without turning the patient. The approximation of the pubis relieves the tension for reconstruction of the bladder, urethra, genitalia and anterior abdominal wall. The procedure is quick and permits single stage closure.

1. Two cases of congenital diastasis of the inferior tibio-fibular mortise are described.

2. No previous description of this condition has been found in the literature.

3. it is suggested that the cause is osteochondrosis of the distal tibial epiphysis associated with a club foot.

Dr J. Robert Close has been good enough to point out a misquotation from his article, "Some Applications of the Functional Anatomy of the Ankle Joint"(Journal of Bone and Joint Surgery, 1956, 38-A, 761) in a later contribution by Mr M. G. H. Smith entitled "Inferior Tibio-fibular Diastasis Treated by Cross-screwing (Journal of Bone and Joint Surgery, 1963, 45-B, 737). Dr Close, in referring to tibio-fibular diastasis and deltoid ligament rupture with low fractures of the fibula, wrote (p. 780), "Treating diastasis therefore frequently means treatment for the deltoid lesion. When one realises that a certain amount of spreading apart of the malleoli and a certain amount of rotation of the fibula about the tibia are anatomical requirements for normal ankle motion the necessity for later removal of such internal fixation becomes obvious. Screws thus placed have been known to break during normal walking after the fractures have healed." In his paper Mr M. G. H. Smith, making mention of tibio-fibular movement, wrote, "This small range of movement of the fibula at the inferior tibio-fibular joint caused Close (1956) to recommend that screws placed across the joint to maintain reduction of diastasis be removed before weight bearing and movement were commenced. He stated that screws had broken when left in position." Further abbreviation by editorial staff led to the statement actually printed p. (737): "Close (1956) recommended the removal of screws that had been placed across the joint to maintain reduction of diastasis before movement was allowed, because the screws broke when left in position." The inadvertent change in sense unfortunately escaped attention, and we very much regret that Mr Close was thus misquoted

1. Twenty-three patients were treated by cross screwing for diastasis of the tibia and fibula in fractures at the ankle.

2. It is suggested that limitation of ankle dorsiflexion after this treatment was caused by the presence of a mechanical block to dorsiflexion by spur formation at the margins of tibia and talus.

3. An ordinary bone screw controlled the diastasis satisfactorily in twenty patients.

4. The screw did not interfere with movement at the inferior tibio-fibular joint because bone resorption about that part of the screw in the fibula allowed a small range of movement.

5. Discomfort from the screw was relieved by its removal.

1. Partial diastasis of the tibio-fibular syndesmosis is believed to be common, but it is often overlooked as a cause of recurrent sprains of the ankle.

2. The treatment of recurrent sprains of the ankle by stabilising the inferior tibio-fibular joint with a lag screw is described. The method has been used in seventy-five patients aged between sixteen and sixty-five years. The longest follow-up has been six years.