Aims

Malreduction of the syndesmosis has been reported in up to 52% of patients after fixation of ankle fractures. Multiple radiological parameters are used to define malreduction; there has been limited investigation of the accuracy of these measurements in differentiating malreduction from inherent anatomical asymmetry. The purpose of this study was to identify the prevalence of positive malreduction standards within the syndesmosis of native, uninjured ankles.

The purpose of this study was to compare the accuracy and precision of acetabular component placement in cadavers using conventional techniques and CT-based individualised guides by both orthopaedic trainees and surgeons. Seven cadaveric pelvises underwent a computerised tomography (CT) scan and a three-dimensional virtual model was created. Based on this model, cup orientation was planned for 40 degrees of inclination and 20 degrees of anteversion and an individualised guide was designed. A physical model of the individualised guide was created using a Rapid Prototyping machine (dimension SST, Stratasys, Inc., USA). The pelvises were mounted in the lateral position and covered with a soft tissue envelope exposing only the acetabulum as would be visualised during a lateral approach to the hip. A total of 26 participants (16 orthopaedic surgery residents, 10 orthopaedic surgeons) were asked to use an acetabular cup impactor to place the cup in 40 degrees of inclination and 20 degrees of anteversion. This was first completed for all seven pelvises using conventional placement. Each participant was then instructed on how to use the individualised guide. They were provided with the guide and an individualised acetabular model to practice placement. Once they were comfortable with the system they were then asked to use the individualised guides in each of the seven pelvises. An optoelectronic navigation system was used to evaluate the accuracy of the placement of the acetabular cup. An Optotrak Certus Motion Tracking System (Northern Digital Inc., Waterloo, Canada) was used. An optoelectronic marker was attached to the acetabulum and a combined pair-point and surface matching was performed. After the guide was placed in the acetabulum, a tracked axial pointing device was aligned inside the guidance cylinder and its three-dimensional orientation stored. The angle deviation between the achieved position and the planned cup orientation was calculated. There were no statistically significant differences between trainees and surgeons in either conventional placement or use of the individualised guides. There were no statistically significant differences in anteversion between the groups. The individualised guide showed statistical improvement in the absolute deviation from planned inclination compared to conventional placement (4.2° vs. 9.1°, p< 0.001) as well as a reduction in standard deviation (3.3 vs. 5.9, p< 0.001). The use of individualised guides can improve the accuracy and precision in the placement of acetabular component positioning. The current guide design controls well for inclination, which is a key factor in the function of a total hip arthroplasty. Based on this data, we will implement design changes to better address version of the component. Future work will likely include comparison to computer-assisted cup placement as well

Surgical options in the treatment of acute acromio-clavicular joint (Rockwood Type III and IV) dislocations are many and controversial. We evaluated our technique using TIGHTROPE connecting the base of the coracoid to the proximal fragment of the clavicle. Between March 2006 and December 2006, ten young and active adult patients with acute ACJ dislocations were treated with arthroscopically assisted ARTHREX TIGHTROPE fixation. The dislocation was reduced with traction and manual reduction with the patient in beach-chair position. The base of the coracoid was identified and isolated using a radiofrequency ablator placed through the anterior portal while visualizing through the lateral portal. An ACL guide was placed percutaneously supero-medial to the coracoid over the distal with the inferior end of the ACL guide placed through a posterior portal, approximated against the prepared base of the coracoid. The Arthrex Tightrope braided fibre-wire was introduced through the pre-drilled distal clavicle passed to the base of the coracoid and manually tensioned to achieve stable reduction. Standard rehabilitation protocol was utilised as for internal fixation of distal clavicular fractures. Patients were evaluated clinically using Constant Score, which ranged from 75 to 83 and radiologically at 6 weeks and 3 months. We present the functional results and the technical difficulties faced highlighting on the probable reasons for failure of fixation in two of our early patients who had revision fixations. We also describe the additional intra-operative techniques used in the last few patients to prevent such complications and achieve a secure reduction. We conclude that Arthroscopic Reconstruction of dislocated Acromio-Clavicular joint using TIGHTROPE may require additional repair of the ligaments in carefully selected patients to prevent failure of fixation

Our aim was to evaluate the efficacy of a two-level reconstruction technique using subchondral miniscrews for the stabilisation of comminuted posterior-wall marginal acetabular fragments before applying lag screws and a buttress plate to the main overlying posterior fragment. Between 1995 and 2003, 29 consecutive patients with acute comminuted displaced posterior-wall fractures of the acetabulum were treated operatively using this technique.

The quality of reduction measured from three standard plain radiographs was graded as anatomical in all 29 hips. The clinical outcome at a mean follow-up of 35 months (24 to 90) was considered to be excellent in five patients (17%), very good in 16 (55%), good in six (21%) and poor in two (7%). The use of the two-level reconstruction technique appears to provide stable fixation and is associated with favourable results in terms of the incidence of post-traumatic osteoarthritis and the clinical outcome. However, poor results may occur in patients over the age of 55 years.

A carbonated apatite cement with a high compressive strength was used in the treatment of tibial plateau fractures. There were 41 patients (20 male; 21 female; mean age 59 years). All patients had isolated tibial plateau fractures. There were 15 B2.2, 23 B3.1 and 3 B2.3 fractures. Fractures were fixed with limited internal fixation using a short anterior parapatellar incision. Reduction and fixation were initially achieved. Once this was carried out the void under the elevated plateau was filled using calcium phosphate cement. A buttress plate was used in one case, screws or K-wires in 33 cases and calcium phosphate cement alone in 7 cases. Patients were mobilised partially weight bearing in a hinged knee brace and allowed full weight bearing at 6 weeks. Reductions were anatomic (< 2mm displacement in 32 (78%) cases, satisfactory (3-5mm displacement) in 7 (17%) cases and imperfect (> 5mm) in 2 (5%) patients. Extrusion of some calcium phosphate cement into surrounding soft tissue occurred in one case. This material resorbed with no adverse effects. Loss of reduction was observed in 6 (15%) cases. There were no other significant complications. Thirty-seven patients (90%) had more than 120 degrees of knee flexion at 6 months. Calcium phosphate cement is an alternative to the use of bone grafting in any area of cancellous subject to compressive load. It is ideal for use in tibial plateau fractures with compressed subchondral bone after elevation. It obviates the need for buttress plating and bone grafting and there is no bone graft donor site morbidity. Patients are able to mobilise more rapidly and early discharge is facilitated. Calcium phosphate cement is a promising development in the management of tibial plateau fractures and initial results suggest it may be more effective in maintaining reduction that standard methods of fixation and grafting