Aims. The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs). Methods. All patients with PDFF primarily treated with DP, SP, or DFA between 2008 and 2022 at a university teaching hospital were included in this retrospective cohort study. The primary outcome was revision surgery for failure following DP, SP, or DFA. Secondary outcome measures included any reoperation, length of hospital stay, and mortality. All basic demographic and relevant implant and injury details were collected. Radiological analysis included fracture classification and evaluation of metaphyseal and medial comminution. Results. A total of 111 PDFFs (111 patients, median age 82 years (interquartile range (IQR) 75 to 88), 86% female) with 32 (29%) Su classification 1, 37 (34%) Su 2, and 40 (37%) Su 3 fractures were included. The median follow-up was 2.5 years (IQR 1.2 to 5.0). DP, SP, and DFA were used in 15, 66, and 30 patients, respectively. Compared to SP, patients treated with DP were more likely to have metaphyseal comminution (47% vs 14%; p = 0.009), to be low fractures (47% vs 11%; p = 0.009), and to be anatomically reduced (100% vs 71%; p = 0.030). Patients selected for DFA displayed comparable amounts of medial/metaphyseal comminution as those who underwent DP. At a minimum follow-up of two years, revision surgery for failure was performed in 11 (9.9%) cases at a median of five months (IQR 2 to 9): 0 DP patients (0%), 9 SP (14%), and 2 DFA (6.7%) (p = 0.249). Conclusion. Using a strategy of DP fixation in fractures, where the fracture was low but there was enough distal bone to accommodate locking screws, and where there is metaphyseal comminution, resulted in equivalent survival free from revision or reoperation compared to DFA and SP fixation. Cite this article: Bone Jt Open 2024;5(6):489–498

Aims

Proper preoperative planning benefits fracture reduction, fixation, and stability in tibial plateau fracture surgery. We developed and clinically implemented a novel workflow for 3D surgical planning including patient-specific drilling guides in tibial plateau fracture surgery.

Introduction and Objective. Plating of geriatric distal femoral fractures with Locking Compression Plate Distal Femur (LCP–DF) often requires augmentation with a supplemental medial plate to achieve sufficient stability allowing early mobilization. However, medial vital structures may be impaired by supplemental medial plating using a straight plate. Therefore, a helically shaped medial plate may be used to avoid damage of these structures. Aim of the current study was to investigate the biomechanical competence of augmented LCP–DF plating using a supplemental straight versus helically shaped medial plate. Materials and Methods. Ten pairs of human cadaveric femora with poor bone quality were assigned pairwise for instrumentation using a lateral anatomical 15-hole LCP–DF combined with a medial 14-hole LCP, the latter being either straight or manually pre-contoured to a 90-degree helical shape. An unstable distal femoral fracture AO/OTA 33–A3 was simulated by means of osteotomies. All specimens were biomechanically tested under non-destructive quasi-static and destructive progressively increasing combined cyclic axial and torsional loading in internal rotation, with monitoring by means of optical motion tracking. Results. Initial axial stiffness and torsional stiffness in internal and external rotation for straight double plating (548.1 ± 134.2 N/mm, 2.69 ± 0.52 Nm/° and 2.69 ± 0.50 Nm/°) was significantly higher versus helical double plating (442.9 ± 133.7 N/mm, 2.07 ± 0.32 Nm/° and 2.16 ± 0.22 Nm/°), p≤0.04. Initial interfragmentary axial displacement and flexural rotation under 500 N static loading were significantly smaller for straight plating (0.11 ± 0.14 mm and 0.21 ± 0.10°) versus helical plating (0.31 ± 0.14 mm and 0.68 ± 0.16°), p<0.01. However, initial varus deformation under this loading remained not significantly different between the two fixation methods (straight: 0.57 ± 0.23°, helical: 0.75 ± 0.34°), p=0.08. During dynamic loading, within the course of the first 4000 cycles the movements of the distal fragment in flexion were significantly bigger for helical over straight plating (1.03 ± 0.33° versus 0.40 ± 0.20°), p<0.01. However, no significant differences were observed between the two fixation methods in terms of varus, internal rotation, axial and shear displacements at the fracture site, and number of cycles to failure. Conclusions. Augmented lateral plating of unstable distal femoral fractures with use of supplemental helically shaped medial plate was associated with more elastic bone-implant construct behavior under static and dynamic loading compared to straight double plating. Both fixation methods resulted in comparable number of cycles to failure. From a biomechanical perspective, the more elastic helical double plating may be considered as useful alternative to straight plating, potentially reducing stress risers at the distal bone-implant interface due to its ameliorated damping capacities

Aims

We investigated patient characteristics and outcomes of Vancouver type B periprosthetic fractures treated with femoral component revision and/or osteosynthesis.

Introduction. The incidence of distal femoral fractures in the geriatric population is growing and represents the second most common insufficiency fracture of the femur following fractures around the hip joint. Fixation of fractures in patients with poor bone stock and early mobilisation in feeble and polymorbide patients is challenging. Development of a fixation approach for augmentation of conventional LISS (less invasive stabilization system) plating may result in superior long-term clinical outcomes and enhance safe weight bearing. Objectives. The aim of this study was to investigate the biomechanical competence of two different techniques of augmented LISS plating for treatment of osteoporotic fractures of the distal femur in comparison to conventional LISS plating. Materials & methods. Unstable distal femoral fracture AO/OTA 33-A3 was set in artificial femora with low density simulating osteoporotic bone. Three study groups, consisting of 10 specimens each, were created for instrumentation with a 9-hole LISS plate, a LISS plate with an additional 3D-printed polyactide cylindrical intramedullary graft, as well as a LISS plate plus a medial 3.5mm LCP (locking compression plate) - double plating. All specimens were non-destructively tested under axial (20–150N) and torsional (0–4Nm) quasi-static loading. Each construct was tested with two different working length (WL) configurations (long and short) of the LISS plate. Relative movements between the most medial superior and inferior osteotomy aspects were investigated via three-dimensional motion tracking analysis. Results. Interfragmentary displacement along the femur axis (mm) under 150N axial loading was 2.03±0.23/1.65±0.27 for LISS with long/short WL, 0.18±0.06/0.18±0.04 for double plating with long/short WL, and 0.40±0.05/0.30±0.05 for LISS plus graft with long/short WL. Shear interfragmentary displacement (mm) under 4Nm torsional loading in internal rotation was 1.16±0.17/0.92±0.11 for LISS with long/short WL, 0.40±0.10/0.43±0.07 for double plating with long/short WL, and 1.09±0.13/0.82±0.11 for LISS plus graft with long/short WL. Double plating revealed significantly smaller longitudinal and shear displacement compared to the other two techniques for long and short WL, respectively (P≤0.010). In addition, LISS plus graft fixation was with significantly less longitudinal displacement in comparison to conventional LISS plating for long and short WL, respectively (P≤0.001). Long WL resulted in significantly higher longitudinal and shear displacement compared to short WL for LISS and LISS plus graft (P≤0.032), but not for double plating (P=1.000). Conclusion. Intramedullary grafting resulted in significantly increased fracture stability under axial loading in comparison to conventional LISS plating. However, it was not efficient enough to achieve comparable stability to double plating

Periprosthetic joint infection (PJI) is one of the most feared and challenging complications following total knee arthroplasty. We provide a detailed description of our current understanding regarding the management of PJI of the knee, including diagnostic aids, pre-operative planning, surgical treatment, and outcome.

Cite this article: Bone Joint J 2015;97-B(10 Suppl A):20–9.

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

Despite our best efforts, occasionally, certain patients will have multiply operated, failed reconstructions after TKA. There are situations where further attempts at arthroplasty are unwise, for example, chronic infections with multiple failed staged reconstructions. A careful pre-operative evaluation of the patient is critical to guide decision-making. An assessment of medical comorbidity, functional demands, and expectations is important. Regarding the extremity, the severity of bone loss, soft tissue defects, ligamentous competency, and neurovascular status is important. The next step is to determine whether the knee is infected. The details of such a workup are covered in other lectures, however, the author prefers to aspirate all such knees and obtain C reactive protein and sedimentation rates. For equivocal cases, PCR may be helpful. If no infection is present, complex reconstruction is considered. Segmental megaprosthesis and hinged prostheses may be helpful. Often, soft tissue reconstruction with an extensor mechanism allograft or muscle flap is required. Obviously, these are massive undertakings and should be done by experienced surgeons. If a prosthesis is not a good option, other options include definitive resection, knee arthrodesis, or above knee amputation. A careful discussion with the patient about the pros and cons is necessary to allow them to partner with the surgeon in the decision-making. Definitive resections are reserved for minimal to non-ambulators with significant comorbidity that do not desire an AKA. AKA is often the best option, however, it should be noted that the majority of these patients will never ambulate with a prosthesis due to the energy requirements necessary to do so. High complication rates and reoperation rates have been reported with AKA after TKA. Functional outcome studies have generally shown better function with arthrodesis than with AKA. Arthrodesis can be effective and can be accomplished with several methods. If active infection is present, an external fixator is typically chosen. If no infection is present then plating or long intramedullary nailing is considered. Plating requires healthy anterior soft tissues due to the bulk associated with double plating techniques. The highest union rates have been reported with long nails. The author therefore prefers to use long nails after eradicating infection with a staged procedure (interval spacer) rather than to use an external fixator. Union rates are higher with nails, but the risk of re-infection is slightly higher as well. Careful attention to detail is necessary to minimise complications

Despite our best efforts, occasionally, certain patients will have multiply operated, failed reconstructions after TKA. There are situations where further attempts at arthroplasty are unwise, for example, chronic infections with multiple failed staged reconstructions. A careful preoperative evaluation of the patient is critical to guide decision-making. An assessment of medical comorbidity, functional demands, and expectations is important. Regarding the extremity, the severity of bone loss, soft tissue defects, ligamentous competency, and neurovascular status is important. The next step is to determine whether the knee is infected. The details of such a workup are covered in other lectures, however, the author prefers to aspirate all such knees and obtain C reactive protein and Sedimentation Rates. For equivocal cases, PCR may be helpful. If no infection is present, complex reconstruction is considered. Segmental megaprosthesis and hinged prostheses may be helpful. Often, soft tissue reconstruction with an extensor mechanism allograft or muscle flap is required. Obviously, these are massive undertakings and should be done by experienced surgeons. If a prosthesis is not a good option, other options include definitive resection, knee arthrodesis, or above knee amputation. A careful discussion with the patient about the pros and cons is necessary to allow them to partner with the surgeon in the decision-making. Definitive resections are reserved for minimal to non-ambulators with significant co-morbidity that do not desire an AKA. AKA is often the best option, however, it should be noted that the majority of these patients will never ambulate with a prosthesis due to the energy requirements necessary to do so. High complication rates and reoperation rates have been reported with AKA after TKA. Functional outcome studies have generally shown better function with arthrodesis than with AKA. Arthrodesis can be effective and can be accomplished with several methods. If active infection is present, and external fixator is typically chosen. If no infection is present then plating or long intramedullary nailing is considered. Plating requires healthy anterior soft tissues due the bulk associated with double plating techniques. The highest union rates have been reported with long nails. The author therefore prefers to use long nails after eradicating infection with a staged procedure (interval spacer) rather than to use an external fixator. Union rates are higher with nails, but the risk of re-infection is slightly higher as well. Careful attention to detail is necessary to minimise complications

The April 2014 Trauma Roundup³⁶⁰ looks at: is it safe to primarily close dog bite wounds?; conservative transfusion evidence based in hip fracture surgery; tibial nonunion is devastating to quality of life; sexual dysfunction after traumatic pelvic fracture; hemiarthroplasty versus fixation in displaced femoral neck fractures; silver VAC dressings “Gold Standard” in massive wounds; dual plating for talar neck fracture; syndesmosis and fibular length easiest errors in ankle fracture surgery; and dual mobility: stable as a rock in fracture.

Background. To establish relative fixation strengths of a single lateral locking plate, a double locking plate, and a tibial nail in treatment of proximal tibial extra-articular fractures. Methods. Three groups of composite tibial synthetic bones consisting of 5 specimens per group were included; lateral plating (LP) using a LCP-PLT (locking compression plate-proximal lateral tibia), double plating (DP) using a LCP-PLT and a LCP-MPT (locking compression plate-medial proximal tibia), and intramedullary nailing (IN) using an ETN (expert tibial nail). To simulate a comminuted fracture model, a gap osteotomy measuring 1 cm was cut 8 cm below the joint. For each tibia, a minimal preload of 100N was applied before loading to failure. A vertical load was applied at 25mm/min until tibia failure. Results. For axial loading, fixation strength of DP (14387.3N, SD=1852.1) was 17.5% greater than that of LP (12249.3N, SD=1371.6), and 60% less than that of IN (22879.6N, SD=1578.8) (p<0.001). For ultimate displacement in axial loading, similar results were observed for LP (5.74mm, SD=1.01) and DP (4.45mm, SD=0.96), with a larger displacement for IN (5.84mm, SD=0.99). Conclusion. In biomechanical testing of a comminuted proximal tibial fracture model, DP proved stronger than LP in terms of ultimate strength. IN proved strongest; however, DP may be an acceptable alternative for minimally invasive osteosynthesis, which may be technically difficult to fix using a nail

Background. The aim of the study was to assess the outcome of internal fixation using two ordinary plates with autogenous bone grafting in the management of non-union of femoral shaft fractures over a period of eleven years. Method. A retrospective study of double plating and autogenous bone grafting for un-united femoral shaft fractures performed by the two Senior Authors between 1996 and 2007. During this period, twenty-one cases were carried out. Details of preoperative, intra-operative, and postoperative findings were assessed. Postoperative follow up was recorded over a period of minimum two years. The procedure was performed using two ordinary plates; a broad lateral and narrow anterior plates. Autogenous cancellous grafts from iliac crest were used in all of the cases, and in some, half fibulas were inserted through the medullary canal of the femur. Results. A total of twenty-one patients were included in the study. All of them received previous treatment. The primary treatment was by intramedullary nailing in thirteen patients, uni-plating in four, external fixator in three, and traction in one. The average age was 32 (range from 16 to 52). The average interval between the initial fracture and the treatment of the non-unions was 13 months (range from 6 to 28 months). All wounds, both at fracture site and the graft donor site, healed primarily except one. That was at an iliac crest graft donor site, where superficial infection occurred, and was treated with antibiotics and healed 6 weeks later. All patients achieved union on an average of 16 weeks (range from 12 to 28 weeks). There has been no failure in implants. The average lower limb shortening was 0.75 cm (range from 0.5 to 1.0 cm). No one requested shoe raise. All the patients regained the preoperative range of motion at the hip and knee joints except four, who had limited flexion to 100 degrees. Conclusion. We conclude that double plating with autogenous bone grafting is not only a convenient method to treat non-union of femoral shaft fractures as it requires minimal instrumentation and equipment, but it should also be considered as a safe and accepted treatment method as postoperatively patients can be discharged early on crutches, with a high success rate. It is less expensive, an important consideration in developing countries

Objectives

We aimed to further evaluate the biomechanical characteristics of two locking screws versus three standard bicortical screws in synthetic models of normal and osteoporotic bone.

The safety and efficacy of bone-healing enhancement with Bone Morphogenetic Protein-7 (BMP) has been studied in the clinical setting of persistent post-traumatic and post-partum pelvic instability. Prospective collection and analysis of all cases with pelvic ring instability after trauma or childbirth, treated with reconstruction and local application of BMP-7. Patient demographics, hospitalisation, operative interventions before and after the BMP-7 grafting, and follow-up data were recorded and evaluated. The median follow-up period was 1 year (range 12 to 18 months). Over a two-year period (March 2005 – January 2007) nine patients (8 females) with median age of 39 years (31–62) were operated for persistent pelvic instability and pain. The mean number of previous operations was 1,6 procedures. Reconstruction of the pelvic ring included 4 cases of post-partum pubic symphysis instability, 2 traumatic non-unions of pubis symphysis and 3 sacroiliatis (1-septic and 2-aseptic). Reconstruction included double plating of pubis symphysis (4-cases), external pelvic fixation (2-cases), sacroiliac screw fixation (1-case) and anterior sacroiliac plating (2-cases). In 4 cases BMP-7 was used alone; in 5 it was used together with iliac crest autograft. All patients were mobilizing with a wheelchair for a period of 8 weeks (6–12) before progressing to full weight bearing. Clinical and radiological union occurred in 8/9 cases at a median time of 14 weeks (range 12–20). One female patient with post-partum pubic symphysis instability and a chronic psychiatric disorder is still complaining of pain despite the radiological evidence of progress of fusion. The rest reported resolution of symptoms. No local or systemic complications or adverse events associated with the use of BMP-7 were recorded. The application of BMP-7 alone or supplementing autografting has been proven to be radiologically 100% and clinically 90% successful and safe following pelvic ring reconstruction as seen in this series of patients

The aim of this study was to review the number of patients operated on for traumatic disruption of the pubic symphysis who developed radiological signs of movement of the anterior pelvic metalwork during the first post-operative year, and to determine whether this had clinical implications. A consecutive series of 49 patients undergoing internal fixation of a traumatic diastasis of the pubic symphysis were studied. All underwent anterior fixation of the diastasis, which was frequently combined with posterior pelvic fixation. The fractures were divided into groups using the Young and Burgess classification for pelvic ring fractures. The different combinations of anterior and posterior fixation adopted to stabilise the fractures and the type of movement of the metalwork which was observed were analysed and related to functional outcome during the first post-operative year.

In 15 patients the radiographs showed movement of the anterior metalwork, with broken or mobile screws or plates, and in six there were signs of a recurrent diastasis. In this group, four patients required revision surgery; three with anterior fixation and one with removal of anterior pelvic metalwork; the remaining 11 functioned as well as the rest of the study group.

We conclude that radiological signs of movement in the anterior pelvic metalwork, albeit common, are not in themselves an indication for revision surgery.

Purpose: Proximal tibia fractures present a difficult treatment challenge with historically high complication rates. The purpose of this study is to report the clinical outcome of proximal tibial fractures treated with of a variable-axis locking plate. Patients and Methods: Between 2004 and 2007, 42 patients (23 males) with a mean age of 50 (21–67) with a total of 42 proximal tibia fractures were included in this prospective documented study. Fractures were classified according to the OTA system. All fractures were treated with the polyaxial locked-plate fixation system (DePuy, Warsaw, Indiana). Besides radiography, CT scanning was obtained for type B and C fractures. Clinical and radiographic data, including fracture pattern, changes in alignment, local and systemic complications, hardware failure and time to union were recorded. Functional outcome was measured using the Knee Society Score. Malalingment was defined the presence of more than 5°angulation in any plane at the post-op X-ray and at the final F.U. The mean follow up was 11 months (6–36). Results: According to the OTA classification, there were 7 41-A, 11 41-B and 24 41-C fractures. There were 6 open and 36 closed fractures. The majority were isolated injuries 38/42. 19 cases required bone grafting. Fractures were treated percutaneously in 30% of the cases (MIPO). Double plating was utilised in 8 cases. All fractures but 2 progressed to union at a mean time of 3.8 months (3–5). The two fractures who failed to unite were complicated by deep sepsis and required further intervention. One patient required fasciotomies for compartment syndrome. Superficial infection was treated successfully with a short course of antibiotics in 2 cases. There was no evidence of varus collapse as a result of polyaxial screw failure. No plate fractured, and no screw cut out was noted. There was 1 case of lateral joint collapse (more than 10o) in a patient with open bicondylar plateau fracture. The mean Knee society score at the time of final follow-up was 89 points (59 – 100) and the mean functional score was 83 points. Conclusion: The polyaxial locking plates provided stable fixation of extra-articular and intra-articular proximal tibia fractures and good functional outcomes with a low complication rate. These plates offer more fixation options without an apparent increase in mechanical complications or loss of reduction

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

We retrospectively evaluated eight patients who underwent arthrodesis of the knee using cannulated screws. There were six women and two men, with a mean age of 53 years. The indications for arthrodesis were failed total knee arthroplasty, septic arthritis, tuberculosis, and recurrent persistent infection. Solid union was achieved in all patients at a mean of 6.1 months. One patient required autogenous bone graft for delayed union. One suffered skin necrosis which was treated with skin grafting. The mean limb-length discrepancy was 3.1 cm. On a visual analogue scale, the mean pain score improved from 7.9 to 3.3. According to the Knee Injury and Osteoarthritis Outcome score quality of life items, the mean score improved from 38.3 pre-operatively to 76.6 at follow-up. Cannulated screws provide a high rate of union in arthrodesis of the knee with minimal complications, patient convenience, and a simple surgical technique.