Aims

Ankle fracture fixation is commonly performed by junior trainees. Simulation training using cadavers may shorten the learning curve and result in a technically superior surgical performance.

Abstract. Background. Extracorporeal radiation therapy (ECRT) has been reported as an oncologically safe and effective reconstruction technique for limb salvage in diaphyseal sarcomas with promising functional results. Factors affecting the ECRT graft-host bone incorporation have not been fully investigated. Methods. In our series of 51 patients of primary bone tumors treated with ECRT, we improvised this technique by using a modified V-shaped osteotomy, additional plates and intra-medullary fibula across the diaphyseal osteotomy in an attempt to increase the stability of fixation, augment graft strength and enhance union at the osteotomy sites. We analyzed our patients for various factors that affected union time and union rate at the osteotomy sites. Results. On univariate analysis, age <20 years, metaphyseal osteotomy site, V-shaped diaphyseal osteotomy, extramedullary plate fixation and use of additional plate at diaphyseal ostetomy had a significantly faster time to union while gender, tumor type, resection length, chemotherapy and use of intra-medullary fibula did not influence union time. In multivariate analysis, metaphyseal ostoeotomy, V-shaped diaphyseal osteotomy and use of additional plate at diaphyseal ostetomy were the independent factors with favourable time to union. Although the rate of union was higher with V-shaped diaphyseal osteotomy and use of additional plate and intra-medullary fibula at diaphyseal ostetomy, this difference could not be established statistically. None of the analyzed factors apparently affected the union rate in univariate analysis. Conclusion. Judicious choice of osteosynthesis and augmentation of ECRT graft can enhance incorporation with reduced complications and good functional outcome

Aims

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

Aims

The aim of this study was to investigate whether clinical and radiological outcomes after intramedullary nailing of displaced fractures of the fifth metacarpal neck using a single thick Kirschner wire (K-wire) are noninferior to those of technically more demanding fixation with two thinner dual wires.

Aims

To compare the outcomes for trochanteric fractures treated with a sliding hip screw (SHS) or a cephalomedullary nail.

As the incidence of total hip arthroplasty (THA) rises, an increasing prevalence of peri-prosthetic femur fractures has been reported. This is likely due to the growing population with arthroplasties, increasing patient survival and a more active life-style following arthroplasty. It is the 3rd most common reason for THA reoperation (9.5%) and 5th most common reason for revision (5% with fracture risk after primary THA reported at 0.4%-1.1% and after revision at 2.1%-4%). High quality radiographs are usually sufficient to classify the fracture and plan treatment. Important issues in treatment include stem fixation status and fracture location relative to the stem. Additional comorbidities will also influence treatment choices, of which the most critical is the presence of infection and the quality of bone stock. The most commonly studied, and reported classification system is the Vancouver. Type A are peri-trochanteric fractures with AL at the lesser and AG at the greater trochanter. B fractures are those around the stem with B1 fractures having a well-fixed stem, B2 a loose stem with adequate bone stock, and B3 representing loose stem and inadequate bone stock. C fractures are distal to the stem. Type A) Trochanteric Fractures: These are usually associated with lysis. Displaced fractures can be managed adequately with cerclage fixation and cancellous allograft to fill osteolytic defects. Undisplaced fractures usually heal well with symptomatic treatment. Type B) Fractures Around the Stem: The B1 type has a well-fixed component and is usually treated with extramedullary fixation plus graft. Contemporary plates have been designed specifically for these fractures. Strut allograft may be used to provide a more rigid construct. Spiral and long oblique fractures can be cerclaged while short oblique or transverse fractures require fixation anterior and lateral with cable plates and cortical strut grafts. Screws can be used distal to the implant, and cables used proximally. The B2 type has a loose prosthesis but otherwise good bone stock. In this setting, the fracture line may be extended on the lateral cortex of the femur as an extended osteotomy to provide easy access for cement removal. These fractures can be managed with an extensively coated stem if rotational stability can be obtained in the distal segment. If rotational stability over a 4 cm scratch interference fit of the stem isn't possible, then a fluted tapered modular stem should be used. Strut allografts improve initial stability. The B3 type has both a loose prosthesis and poor bone stock and in the younger patient restoration of bone stock should be a priority. Bulk femoral grafts may be needed. The elderly or low functional demand patient may be treated with a proximal femoral replacement. Because of soft-tissue deficiencies, a constrained acetabular liner may be needed to prevent instability. Type C) Fractures Distal to the Stem: These usually accompany a stable stem and many fixation devices are available. Locking plates have become most popular and should be secured with cerclage wires proximally around the component with screws distally. Retrograde nails may be employed if there is adequate bone distal to the stem tip and above the fracture

Revision knee prostheses are often augmented with intramedullary stems to provide stability following bone loss. However, there are concerns with the use of such stems, including loosening caused by strain-shielding, end-of-stem pain, and removal of healthy bone surrounding the medullary canal. Extracortical fixation plates may present an alternative. The aim of the study was to quantitatively evaluate and compare strain-shielding in the tibia following implantation of a knee replacement component augmented with either a conventional intramedullary stem (design1), or extracortical plates (design2) on the medial and lateral surfaces. Eight composite synthetic tibiae were implanted with one of the two designs, painted with a speckle pattern, loaded in axial compression (peak 2.5 kN) using a materials test machine, and imaged with a 5-megapixel digital image correlation (DIC) system throughout loading. Bone loss was simulated in all models by removing a volume of metaphyseal bone. For four tibiae, the tibial tray was augmented with a cemented stem (∼150 mm). The others were augmented by extracortical plates (maximum 90 mm long) along the medial and lateral surfaces (Fig. 1). Strains were computed using an ARAMIS 5M software system between loaded and unloaded states in the longitudinal direction, for the medial, posterior and lateral surfaces of the tibiae. Strains were checked locally by use of strain gauge rosettes at three levels on medial, lateral and posterior aspects. The bone strains measured on the posterior surfaces were reported in three regions; proximal (0–70 mm, where the medial extracortical plate lies), middle (70–130 mm, the stem is present but not the extracortical plates), and distal (130–200 mm, beyond the stem). Mean longitudinal strains for both implant types were comparable in the distal region, and were greater than in the other regions (Fig 2). The mean strains differed considerably in the middle region: 565–715 μstrain with stemmed components 1050–1155 μstrain with plated components. Strains followed a similar pattern in the proximal region, particularly very close (20 mm) to the tibial tray component, where the stemmed component bones (775 ± 160 μstrain) displayed less surface strain than the plated component bones (1210 ± 180 μstrain). Strain-shielding was observed for both designs. The side plates were shorter than the intramedullary rods, so the region of the bone distal to the plates was not strain-shielded, while the same region was strain-shielded when a stemmed component was implanted. It was also shown that in the region of bone just distal of the tibial tray component, design1 shielded the bone from strain 56% more on average than design2. From these results, it can be speculated that the use of extracortical plate rather than intramedullary stems may lead to improved long-term results of revision TKA, assuming the plates and screws provide adequate stability. The extramedullary fixation system preserves more bone than IM fixation, and has the advantage of allowing use of primary TKA components, cemented over the subframe. Similar components have been developed for the femur

Aims

Our aim, using English Hospital Episode Statistics data before during and after the Distal Radius Acute Fracture Fixation Trial (DRAFFT), was to assess whether the results of the trial affected clinical practice.

Introduction:. Displaced and shortened clavicle shaft fractures can be treated operatively by intra- or extramedullary fixation. The aim of the study was to compare the effectiveness of these two treatment modalities. Methods:. Forty seven patients with acute displaced and shortened clavicle shaft fractures were randomly assigned to either an intramedullary locked fixation group or an anatomically contoured locked plating group. All patients were operated by the same surgeon and had identical post-operative treatment regimes. The effectiveness of both treatment regimens were assessed based on; incision length, operative time and union rate. Disabilities of the Arm, Shoulder and Hand Score (DASH) and Constant Shoulder Score were assessed one year post-operatively. Results:. Twenty-five patients were included in the plating group and twenty-two in the intramedullary fixation group. No differences between the two groups were found for age, gender, fracture comminution and/or displacement. Incision size was significantly (p<0.0001) smaller in the nailing group (38±9 mm) than in the plating group (118±19 mm). In line with this the operating time was also shorter in the nailing group than in the plating groups (43±8 min and 60±19 min, respectively (p=0.0029)). One year postoperatively a 100% union rate was achieved in both groups. Lower DASH scores (2±5 vs 16±18 (p=0.0071)) and higher Constant Shoulder scores (96±6 vs. 90 ± 18 (p=0.0122)), were found in the nailing group. Conclusion:. Both anatomically contoured locked plating and locked intramedullary fixation resulted in successful treatment of displaced and shortened clavicle shaft fractures. Intramedullary fixation however was associated with shorter operating times and smaller incision sizes. In addition, better DASH and Constant Shoulder scores were found in the nailing group one year post operatively. Based on these finding and the absence of prominent subcutaneous hardware necessitating removal of the nail, the intramedullary device is a good alternative to treat displaced clavicle shaft fractures

Patients using a neutral rotation brace post proximal humerus fracture fixation have improved functional outcome and external rotation of the shoulder compared to patients using a standard polysling. Patients who have proximal humerus fracture fixation with extramedullary plates and screws have a risk of reduced range of movement especially external rotation. Gerber et al showed that the average external rotation after fixation of proximal humeral fractures was 39 degrees in their patient cohort compared to a normal range of 80–100 degrees. This can lead to reduced function and poor patient related outcomes. Geiger et al showed that in a cohort of 28 patients, poor functional outcome was noted in 39.3% with an average Constant-Murley Score of 57.9. Current practice is to utilise a polysling holding the shoulder in internal rotation post-shoulder fixation. Patients usually wear the sling for up to 6 weeks. We believe that this increases the risk of adhesion formation with the shoulder in internal rotation in the shoulder joint. Therefore this can cause loss of external rotation in the shoulder joint. We believe that holding the shoulder in a neutral alignment, with a neutral rotation brace post-fixation, will enable an increased rate of external rotation post-operatively thus improving external rotation and functional outcome. There is currently no literature comparing the different slings used post-operatively and we believe that this study would be the first of its kind. It would have a substantial change in the way clinicians manage proximal humeral fractures and will potentially reduce the numbers of re-operations to divide adhesions or perform capsular releases. Secondary benefits include a potential earlier return to full function and work and improved patient satisfaction. Study proposal: Prospective Randomised Controlled Trial of the neutral rotation brace compared to the standard, currently used, polysling post proximal humerus fracture fixation. No blinding of either participants or clinicians. Three surgeons utilising similar fixation techniques via the deltopectoral approach and using Philos plate fixation (Synthes Ltd.). Standardised post-operative rehabilitation protocol for all patients. Follow up: clinical review and postal outcomes for 1 year. Primary outcomes: Post operative functional outcome scores (Oxford, DASH, EQL) obtained at 6 weeks, 9 weeks, 3 months and 1 year). These will be compared to scores taken pre-operatively. Secondary outcomes: Clinical review at 6 weeks, 3 months and 1 year with range of movement measurements. Radiographs also taken at 6 weeks and 3 months to assess union. Patient questionnaire at 1 year (with outcome scores) assessing patient return to work, complications and patient satisfaction. Inclusion criteria: Proximal humeral fractures requiring operative intervention with extramedullary plate fixation (i.e. fractures displaced by 1cm and/or angulated by 45 degrees or more). Age>18. Exclusion Criteria: Patients having intra-operative findings of complete Pectoralis major rupture or if operative exposure requires complete Pectoralis major tenotomy. (These patients need to be held in internal rotation with a standard polysling to allow healing of the Pectoralis major tendon)

Introduction. Debate still exists as to the optimum method of fixation for subtrochanteric femoral fractures. Meta-analysis of studies comparing cephalocondylic nails with extramedullary implants for extracapsular hip fractures have suggested that further investigation is required in this area. We present the outcome of the largest series to date of subtrochanteric fractures treated by both methods and with a minimum of one year follow-up. Methods. 244 patients with a subtrochanteric femur fracture were treated at one centre over a 21 year period were prospectively studied. 75 were treated with an extramedullary fixation implant and 168 with an intramedullary nail. Surviving patients were followed up till one year from injury. Results. The mean age of patients was 74 and 71% were female. Fixation failure requiring revision surgery occurred in 4% of those treated with an extramedullary implant and 6% of those treated with an intramedullary nail, a difference that was not statistically significant. Length of surgery was similar for both operations but transfusion requirements were less for those treated by the intramedullary nail (p<0.0001). No notable differences in other outcomes were found. Discussion. In summary both intramedullary and extramedullary fixation produce comparable outcomes for this fracture

Fractures of the proximal femur at the level of the lesser trochanter (reversed and transverse fracture lines, Evans classification type II, AO classification A3 fractures) are known to have an increased risk of fixation failure. 58 patients with such a fracture were randomised to have the fracture fixed with either an intramedullary nail (220 mm Targon PF nail) or a sliding hip screw (SHS). The mean age of the patients was 82 and 11% were male. All patients were followed up for one year by a research nurse blinded to the treatment groups.

Mean length of surgery was 50 minutes for the nail versus 52 minutes for the SHS. There were no differences between groups in the need for blood transfusion. Operative complications tended to be less for the nail group (1/27 versus 5/26). Mean hospital stay was 18 days for the nail group versus 29 days for those treated with the SHS. The only fracture healing complications were one case of cut-out in the SHS group and two cut-outs in the nail group, two of which required revision surgery. During follow-up those patients treated with the nail reported a tendency to lower pain scores than those treated with the SHS (p=0.04 at two months). This difference persisted even at one year from injury. Mortality and regain of mobility was similar between groups.

These results indicate that for these difficult fractures types both types of fixation produce comparable outcomes.

In a randomised trial involving 598 patients with 600 trochanteric fractures of the hip, the fractures were treated with either a sliding hip screw (n = 300) or a Targon PF intramedullary nail (n = 300). The mean age of the patients was 82 years (26 to 104). All surviving patients were reviewed at one year with functional outcome assessed by a research nurse blinded to the treatment used. The intramedullary nail was found to have a slightly increased mean operative time (46 minutes (sd 12.3) versus 49 minutes (sd 12.7), p < 0.001) and an increased mean radiological screening time (0.3 minutes (sd 0.2) versus 0.5 minutes (sd 0.3), p <  0.001). Operative difficulties were more common with the intramedullary nail. There was no statistically significant difference between implants for wound healing complications (p = 1), or need for post-operative blood transfusion (p = 1), and medical complications were similarly distributed in both groups. There was a tendency to fewer revisions of fixation or conversion to an arthroplasty in the nail group, although the difference was not statistically significant (nine versus three cases, p = 0.14). The extent of shortening, loss of hip flexion, mortality and degree of residual pain were similar in both groups. The recovery of mobility was superior for those treated with the intramedullary nails (p = 0.01 at one year from injury).

In summary, both implants produced comparable results but there was a tendency to better return of mobility for those treated with the intramedullary nail.

Pathological fractures of the humerus are associated with pain, morbidity, loss of function and a diminished quality of life. We report our experience of stabilising these fractures using polymethylmethacrylate and non-locking plates. We undertook a retrospective review over 20 years of patients treated at a tertiary musculoskeletal oncology centre. Those who had undergone surgery for an impending or completed pathological humeral fracture with a diagnosis of metastatic disease or myeloma were identified from our database. There were 63 patients (43 men, 20 women) in the series with a mean age of 63 years (39 to 87).

All had undergone intralesional curettage of the tumour followed by fixation with intramedullary polymethylmethacrylate and plating. Complications occurred in 14 patients (22.2%) and seven (11.1%) required re-operation. At the latest follow-up, 47 patients (74.6%) were deceased and 16 (25.4%) were living with a mean follow-up of 75 months (1 to 184). A total of 54 (86%) patients had no or mild pain and 50 (80%) required no or minimal assistance with activities of daily living. Of the 16 living patients none had pain and all could perform activities of daily living without assistance.

Intralesional resection of the tumour, filling of the cavity with cement, and plate stabilisation of the pathological fracture gives immediate rigidity and allows an early return of function without the need for bony union. The patient’s local disease burden is reduced, which may alleviate tumour-related pain and slow the progression of the disease. The cemented-plate technique provides a reliable option for the treatment of pathological fractures of the humerus.

Fractures of the proximal femur at the level of the lesser trochanter (reversed and transverse fracture lines, Evans classification type II, AO classification 31. A3 fractures) are known to have an increased risk of fixation failure. 53 patients with such a fracture were randomised to have the fracture fixed with either an intramedullary nail (220 mm Targon Proximal Femoral nail) or a Sliding Hip Screw (SHS). The mean age of the patients was 82 and 11% were male. All patients were followed up for one year by a research nurse blinded to the treatment groups.

Mean length of surgery was 51 minutes for the nail versus 53 minutes for the SHS. There were no differences between groups in the need for blood transfusion. Operative complications tended to be less for the nail group (1/27 versus 5/26). Mean hospital stay was 17 days for the nail group versus 29 days for those treated with the SHS (p< 0.0001). The only fracture healing complications were one case of cut-out in each group requiring revision surgery. During follow-up those patient treated with the nail reported significantly lower pain scores than those treated with the SHS (p=0.08). This difference persisted even at one year from injury. In addition there was a tendency to a better regain of mobility in the first nine months from injury for those treated with the nail.

These results indicate that for these difficult fractures types an intramedullary nails produces superior results to the Sliding Hip Screw.

Aim: To report the technique of reverse femoral LISS [Limited Invasive stabilisation system] plate fixation of pathological fractures of proximal femora with pre-existing deformity due to multiple fractures in a patient known to suffer with Osteopetrosis. Design: Osteopetrosis, a rare heterogeneous condition, is a result of failure of the bone remodelling. The orthopaedic presentations of which include, back pain, deformity of long bones and multiple fractures. Historically, most fractures in patients with Osteopetrosis were treated nonsurgically with good results, but at the expense of malunion. Operative treatment is indicated, to avoid disabling deformity or to treat nonunion of the fractures. The conventional onlay or inlay devices for fracture stabilisation are difficult to use due to malunion and obliteration of medullary canal, caused by previous fractures and hardness of the bone. The new LISS is an extramedullary, internal fixation system and its main features are an atraumatic insertion technique, minimal bone contact, and a locked, fixed-angle construction. The LISS plate can be used to stabilize the whole length of a femur with multiple deformities. Subject: A 46-year – old lady who is a known case of autosomal dominant Osteopetrosis sustained 5 left femoral and 4 right femoral pathological fractures, over a period of 25 years. They were treated nonoperatively and the fractures were healed with some malunion. During the recent clinical presentation, her bilateral proximal femoral fractures failed to unite by conservative methods and operative treatment was indicated. We used a bilateral reverse femoral LISS plate as the proximal fragments were short and needed axial and rotational control. Conclusion: The reverse LISS is a useful implant for treatment of femoral fractures, especially when the femur is deformed and the medullary cavity is obliterated as in cases of Osteopetrosis

Aim: To study the management and survival outcome of patients with metastatic long bone deposits referred to a general orthopaedic unit at a district general hospital. Methods and materials: 43 patients with pathological or impending long bone fractures were identified between 1998 and 2001. Details of primary tumor, bony metastatic involvement and management were recorded. Additional data was collected regarding prophylactic versus therapeutic treatment, oncological input, time to death and Mirel’s score, where relevant. Results: The most common areas of long bone metastases were found to be proximal femur 29/43 (67%) and humeral shaft 11/43 (26%). Proximal femoral lesions included subcapital, intertrochanteric and subtrochanteric lesions. Operative stabilisation was carried out in 27/43 (63%), and involved intramedullary fixation (10/27; 37%), extramedullary fixation (15/27; 56%), and arthroplasty (2/27; 7%). Of the initial 43 patients, 14 (33%) presented with impending fractures, with Mirel’s scores ranging from 7 to 11 (average 9). The duration of pre-existing pain in the in the fracture group varied from 3 days to 6 months (average 55 days). None of these patients received oncological input during this time period. Of these 15 patients, 12 subsequently required surgery. Patient survival times in the operated group averaged 3 months (2 days to 9 months) – with the exception of one patient who survived for 36 months. This compared equally with survival times for the unoperated group. Only 2/43 patients received preoperative oncology input. In the postoperative group (27 patients), 16 (59%) received radiotherapy. Of the remaining 11 patients, 9 (33%) did not receive radiotherapy due to significant postoperative complications and died within 8 weeks. Discussion: The main aims of surgery in patients with metastatic bony disease are pain relief, and preservation of stability and function. In view of the low life expectancy, preoperative oncology input is important in determining patient longevity and in deciding if surgery is beneficial. All patients should be considered for postoperative radiotherapy once the wound has healed. This multi disciplinary approach can be difficult to achieve in the setting of a district general hospital where oncology services are limited