Background. Ankle fractures associated with diabetes experience more complications following standard Open-Reduction-Internal-Fixation (ORIF) than those without diabetes. Augmented fixation strategies namely extended ORIF and hind-foot-nail (HFN) may offer better results, and early weightbearing in this group. The aim of this study was to define the population of patients with diabetes undergoing primary fixation for ankle fractures. Secondarily, to assess the utilisation of standard and augmented strategies and the effect of these choices on surgical outcomes including
Introduction. Distal femur fractures have traditionally been stabilized with either lateral locking plate or retrograde intramedullary nail. Dual-plates and nail-plate combination fixation have the theoretical biomechanical advantage, faster union and allows patients to weight bear immediately. The aim of this study is to compare single vs combination fixation, and evaluate outcomes and complications. Method. We retrospectively reviewed all patients over 60, admitted to Christchurch Hospital, between 1st Jan 2016 and 31st Dec 2022, with an AO 33A/33B/33C distal femur fracture. Patient demographics, fracture characteristics, operation details, and follow up data were recorded. Primary outcomes are union rate, ambulatory status at discharge, and surgical complications. Secondary outcomes include quality of reduction, operation time and rate of blood transfusions. Results. 114 patients were included. (92 single fixation, 22 combination fixation). Baseline demographic data and fracture characteristics did not differ between the cohorts. There was no difference in the rate of union or time to union between the two cohorts. Combination fixation patients were allowed to weight-bear as tolerated significantly more than single fixation patients (50% vs 18.9%, p=0.003). There was no difference in length of hospital stay, transfusion, complication and mortality rates. Medial translation of the distal articular block was significantly lower in the combination fixation cohort (1.2% vs 3.4%, p=0.021). Operation time was significantly longer in the combination fixation cohort (183mins vs 134mins, p<0.001). Discussion. The results show no difference in achieving union or time to union, despite better quality of fracture reduction with dual fixation. This differs to previously published literature. The clear benefit of combination fixation is immediate weight-bearing. As expected, operation times were longer with combination fixation, however this did not translate to more complications. Conclusion. Combination fixation allows
Stable Weber B fractures are typically treated non-operatively without complications but require close monitoring due to concerns over potential medial deltoid ligament injuries and the risk of delayed talar shift. Following recent evidence suggesting this is unlikely, a functional protocol with
Atypical femoral fracture non-union (AFFNU) is both, rare (3–5 per 1000 proximal femur fractures) and difficult to treat. Lack of standardised guidelines leads to a variability in fixation constructs, use of bone grafting and restricted weight bearing protocols, which are not evidence based. We hypothesised that there is no change in union rates without the use of bone grafting and immediate weight bearing post-operatively does not lead to increased complications. Materials & Methods. A retrospective review of all consecutively treated AFFNU cases between March 2015 to December 2019 was carried out. 9 patients with a mean age of 63.87 years and M:F ratio of 7:2 met the inclusion criteria. Primary outcome variable was radiographic union at 12 months after revision surgery. All surgeries were carried out by a single surgeon. Fixation construct, neck-shaft angle, use of bone graft and immediate postoperative weight bearing protocols were recorded. Results. Radiographic union was achieved in 7 of 9 patients (78%) after first revision surgery. 1 patient achieved union after 2nd revision surgery and 1 patient died in the early post-operative period due to pulmonary embolism. No bone grafting was used in any of the patients and weight-bearing as tolerated was allowed from the first post-operative day. The mean neck-shaft angle after non-union surgery was 136 degrees. Conclusions. In this case series, the union rate was comparable to those reported in literature previously and achieved without any form of bone grafting. To our knowledge, this is the only case series where no bone grafting was used in the management of AFFNU. Limited by a small sample size and retrospective study design, still, this study brings into question the efficacy of practice of bone grafting and restricted weight-bearing in the management of AFFNU. Bone grafting is associated with the risk of infection at donor site, postoperative pain, and morbidity, while
PFFs are an increasing burden presenting to the acute trauma services. The purpose of this study is to show that cemented revision for Vancouver B2/B3 PFFs is a safe option in the geriatric population, allows
Introduction and Objective. Management of gap non-union of the tibia, the major weight bearing bone of the leg remains controversial. The different internal fixation techniques are often weighed down by relatively high complication rates that include fractures which fail to heal (non-union). Minimally invasive techniques with ring fixators and bone transport (distraction osteogenesis) have come into picture as an alternative allowing alignment and stabilization, avoiding a graduated approach. This study was focused on fractures that result in a gap non-union of > 6 cm. Ilizarov technique was employed for management of such non-unions in this case series. The Ilizarov apparatus consists of rings, rods and kirschner wires that encloses the limb as a cylinder and uses kirschner wires to create tension allowing
Despite multiple published reviews, the optimum method of correction and stabilisation of Blount's disease remains controversial. The purpose of this study is to evaluate the clinical and radiological outcomes of acute correction of late-onset tibial vara by percutaneous proximal tibial osteotomy with circular external fixation using two simple rings. This technique was developed to minimise cost in a context of limited resources. This study was conducted between 2016 and 2020. We retrospectively reviewed the clinical notes and radiographs of 30 patients (32tibiae) who had correction of late-onset tibia by proximal tibial osteotomy and Ilizarov external fixator. All cases were followed up to 2 years. The mean proximal tibial angle was 65.7° (±7.8) preoperatively and 89.8° (±1.7) postoperatively. The mean mechanical axis deviation improved from 56.2 (±8.3) preoperatively to 2.8 (±1.6) mm postoperatively. The mean femoral-tibial shaft angle was changed from – 34.3° (±6.7) preoperatively to 5.7° (±2.8) after correction. Complications included overcorrection (9%) and pin tract infection (25%). At final follow up, all patients had full knee range of motion and normal function. All cases progressed to union and there were no cases of recurrence of deformity. This simple procedure provides secure fixation allowing
The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols. A biomechanical model of distal metaphyseal tibial fractures was created using a fourth-generation composite bone model. Three fracture patterns were tested: spiral, oblique, and multifragmented. Each fracture extended to within 4 cm to 5 cm of the plafond. The models were nearly-anatomically reduced and stabilized with an intramedullary nail and three distal locking screws. Cyclic loading was performed to simulate normal gait. Loading was completed in compression at 3,000 N at 1 Hz for a total of 70,000 cycles. Displacement (shortening, coronal and sagittal angulation) was measured at regular intervals.Aims
Methods
Acetabular fractures in the elderly are associated with high levels of morbidity and mortality and are becoming more common. Treatment is complicated by osteoporosis and multiple comorbidities. We present the early results of the use of a coned hemi-pelvis component and total hip arthroplasty in the primary treatment of these injuries. We have prospectively monitored a series of seventeen patients (18 cases) with a mean follow-up of sixteen (4–36) months. They have been reviewed clinically and radiographically. The mean patient age was 78 (64–87), and they had a mean ASA score of 3.3 (3–5). There were (Letournel classification) three elementary fractures, and 15 associated fractures. Mean operative time was 94 (61–134) minutes. There were seven minor post-operative complications. One patient suffered a pre-operative bilateral sciatic nerve injury, partially resolved. Sixteen of 17 patients were allowed to mobilise full weight bearing day one post-operatively. Mean length of hospital stay was 12 (5–27) days. Mortality at 30 days was 0%, and at one year 8%. There have been no thromboembolic events, dislocations or deep infections and no cases of prosthesis migration.
Introduction. Plate fixation for distal femoral fractures is a commonly used method of fracture stabilisation. Many orthopaedic surgeons traditionally do not allow their patients to weight bear for the first 6 weeks after surgery, fearing of loss of fracture reduction and metalwork failure. The aim of this study is to investigate whether the post-operative weight bearing status after plate fixation influences the outcome in terms of loss of reduction and metalwork failure. Materials & Methods. A retrospective data collection from all patients who treated in our hospital surgically for distal femoral fractures, from January 2015 until June 2017. Inclusion criteria were the operative treatment of these fractures with plate fixation. Patients who were treated with retrograde nail, primary total knee replacement or screw fixation were excluded from the study. Patient, injury and surgery demographic data was collected. The immediate post-operative weight bearing status of these patients was noted. Weight bearing status was divided into two groups – Group 1 (Non and touch weight bear – the non-weight bearing group) and Group 2 (Weight bear as tolerated / Full weight bear – the weight bearing group). Radiological data about fracture displacement or metalwork failure was collected at the six weeks and three months follow up after the operation, using a standardised measurement for displacement performed independently by two authors (EI, TA). Results. Of 70 patients, a total of 51 fractures treated with plate fixation were included to the study. The mean age of the cohort was 64.3 ±20.7 years with the majority of the patients being female (63%). Most of the patients (40%) had a complete articular distal femoral fracture, AO Type 33C. Thirty-nine patients (76%) were treated with one lateral distal femoral plate. The total number of the patients in group 1 was 32 (68%); with 17 patients (32%) in group 2. The weight bearing status did not correlate with the fracture type or the fixation type (p>0.05). None of the 6 weeks follow up radiographs revealed fracture displacement in both study groups. Four of the patients from the non-weight bearing group had >1mm displacement at the 3 months' follow-up radiographs. Fisher's exact test revealed no statistically significant difference between the two study groups in both follow-up time points (p=0.55). Two of the patients in the non-weight bearing group had their plate broken at the 3 months follow up and required revision fixation. Conclusion. By reviewing the outcomes in terms of fracture displacement and metalwork failure following plate fixation of distal femoral fractures,
Despite its intrinsic ability to regenerate form and function after injury, bone tissue can be challenged by a multitude of pathological conditions. While innovative approaches have helped to unravel the cascades of bone healing, this knowledge has so far not improved the clinical outcomes of bone defect treatment. Recent findings have allowed us to gain in-depth knowledge about the physiological conditions and biological principles of bone regeneration. Now it is time to transfer the lessons learned from bone healing to the challenging scenarios in defects and employ innovative technologies to enable biomaterial-based strategies for bone defect healing. This review aims to provide an overview on endogenous cascades of bone material formation and how these are transferred to new perspectives in biomaterial-driven approaches in bone regeneration. Cite this article: T. Winkler, F. A. Sass, G. N. Duda, K. Schmidt-Bleek. A review of biomaterials in bone defect healing, remaining shortcomings and future opportunities for bone tissue engineering: The unsolved challenge.
With increasing burden of revision hip arthroplasty, one of the major challenge is the management of bone loss associated with previous multiple surgeries. Proximal femoral replacement (PFR) has already been popularised for tumour surgeries. The inherent advantages of PFR over allograft –prosthesis system, which is the other option for addressing severe bone loss include,
Introduction. Osteoporotic intertrochanteric fracture (ITF) is frequent injuries affecting elderly, osteoporotic patients leading to significant morbidity and mortality. Successful prognosis including union and alignment is challenging even though initial successful reduction with internal fixation. Although many factors are related to the patient's final prognosis. Well reduction with stable fracture fixation is still the goal of treatment to improve the quality of life and decrease morbidity in patients with hip fractures, but this in turn depends on the type of fracture and bone quality. Poor bone quality is responsible for common complications, such as failure of fixation, varus collapse and lag screw cut-out, in elderly patients. Kim et al. found that the complication rate when using conventional DHS in unstable ITFs can be as high as 50% because of screw cut-out. We used the dynamic hip screws (DHS) strengthened by calcium phosphate cement (CPC) for treatment femoral intertrochanteric fracture and review the prognosis of our patients. Materials and Methods. From January of 2011 to January of 2014, 42 patients with femoral intertrochanteric fracture underwent surgery with DHS strengthened by CPC. Comparisons were made between the DHS plus CPC group with the other patients with only DHS used in our department. All patients were followed up for an average time of 14.8(6 to 24) months. X-ray was reviewed for the conditions of union and implant failure. Results. In DHS group, fixation failure happened in 3 case, delayed union and coax varus deformity in 2 cases. IN DHS plus CPC group, all fractures healed uneventfully, there is no non-union or malunion in this group. There is only 1 fixation cut-out and 1 secondary lag screw sliding was noted, however, union was still well over fracture site in this case, the patient had no clinical symptoms. Discussion. Residual bony defects present after DHS fixation in intertrochanteric fracture may lead to postoperative complications, including nonunion or implant failure. DHS strengthened by CPC is reliable fixation for old patients with intertrochanteric fracture, We demonstrated that augmentation of the bony defect with dynamic hip screw by reinforced calcium phosphate cement significantly improved the strength of osteoporotic bone, prevent screw loosening, and promote early healing of fracture. The patients can be decreased the risk of refracture and allow
Introduction. In THA of DDH cases, sometimes shortening and/or derotational subtrochanteric osteotomy is required, for cases with high hip center and/or high anteversion. Initial fixation is one of the most important problems after subtrochanteric osteotomy. To prevent rotational displacement V-osteotomy or step osteotomy is often used. Even though until the osteotomy part unites, additional fixation is required. When a stem with distal load transfer was used body weight can be transferred to healthy part, so
The December 2015 Foot &
Ankle Roundup. 360 . looks at: The midfoot fusion bolt: has it had its day?; Ankle arthroplasty: only for the old?; A return to the Keller’s osteotomy for diabetic feet?; Joint sparing surgery for ankle arthritis in the context of deformity?; Beware the subtalar fusion in the ankle arthrodesis patient?; Nonunion in the foot and ankle a predictive score; Cast versus
Introduction. The number of total hip replacements taking place across the UK continues to grow. In an ageing population, with people living longer and placing greater strain on their prostheses, the number of peri-prosthetic femoral fractures is increasing. We studied the economic impact this has on a large university teaching hospital. Method. All patients with a peri-prosthetic femoral fracture between 24/11/2006 and 31/5/2014 were identified using theatre databases. Radiographic and case note analysis was performed for each case. Costings from finance department for implants and in-patient stay were obtained. Results. 90 cases were identified, 58 female and 32 male, with a mean age of 76 (range: 38–91). 86 fractures occurred around total hip replacements, 4 around hemi-arthroplasties. 89 of the cases were managed surgically, 66% undergoing revision and 33% receiving open reduction and internal fixation (ORIF). According to the Vancouver Classification, 3% were Type A, 79% Type B and 18% Type C. The mean length of stay for all fractures was 43 days, ranging from 5 – 179. The mean overall cost of management was £31,370 (range: £6885 – £112,327). Patients with type C fractures had the highest mean length of stay at 53 days and highest overall mean cost of £33,417. Conclusion. When including rehabilitation costs, our study illustrated a mean cost of £31370, roughly four times the NHS tariff of £8552 and significantly greater than the £3702 per case recovered by one UK teaching hospital. This equates to an average £22000 shortfall per case for peri-prosthetic fractures alone at our institution. Although implant costs are greater, treatment with revision where appropriate allows
Early weight-bearing of patients with ankle fractures is associated with good outcomes. There are a number of potential advantages to early mobilisation including reduced hospital stay and earlier return to work and regular daily activities. However, many surgeons have not incorporated this into their routine ankle fracture protocol, particularly for patients managed operatively; potentially due to concerns regarding loss of reduction. We hypothesised that ankle fractures managed fully weight-bearing would have good outcomes and a low rate of loss of reduction. All ankle fractures presenting to our department over a 15-month period were studied prospectively. Patients were instructed to mobilise fully weight-bearing as able, either immediately postoperatively (for those fractures considered unstable that underwent operative intervention), or at the first fracture clinic review (if stable and managed conservatively). Only patients with syndesmotic injuries and those with neuropathy or psychiatric illness were excluded. The effectiveness of this management protocol was assessed by clinical and radiographic review following fracture union. 847 patients were included, of whom 25% were over the age of 65. 33% of fractures were unstable and therefore managed operatively, 66% were stable and therefore managed in casts or with functional bracing. In every case the radiographs showed maintenance of anatomical mortise and fracture reduction at the time of union, good patient reported outcomes were also recorded. Early weight-bearing of patients with ankle fractures, whether managed conservatively or operatively, results in very low rates of loss of reduction and should be considered routine management for the majority of patients.
