Current dogma is that a programme of anatomic repositioning with rigid internal fixation of fractures will lead to successful healing. Failures are attributed to failures in technique, not in instruments, implants, or concepts. Current basic science research shows that in the osteoporotic skeleton, bone trabeculae, once lost, are not replaced. This is true in fractures. In a series of cases, the author will show that lost bone is indeed not replaced, and the unsuccessful clinical outcome is caused by adherence to concepts that do not solve the problem of fracture repair in the elderly. Five specific case examples will be shown to demonstrate this problem. Despite an abundance of bone graft substitutes, bone morphogenic protein preparations, and cancellous bone autografting, the problem of dependable fracture repair in the elderly skeleton still needs to be solved.

Aims: The objectives of this study are to determine the feasibility of the endoscopic þxation of the anterior pelvis. Material and Methods: Twenty adult cadavers were studied. A þve hole plate was introduced and þxed by balloon and C02 dilatation of the space of Retzius. After plating, the cadavers were dissected to analyze plate and screw position, and presence of damage on the surrounding tissues related to the procedure. Results: Plate and screws were seen to be in good position in all cases. No damage to vital structures was identiþed. Case Report: 33 y/o male sustained an open book external rotation AO/OTA type 61-B3.1 pelvic fracture. EFAP was performed successfully. Postoperative x rays showed good reduction and implants position. Discussion and conclusion: Open approaches to the anterior pelvis are not free of complications. Endoscopy allows clear visualization of the space of Retzius and it is a valuable aid for pelvis fracture þxation. Extraperitoneal endoscopy of the anterior pelvis is a safe and commonly performed surgical procedure. This paper shows that plate and screws þxation of the symphysis pubis can also be performed using this minimally invasive approach.

We reviewed 1085 consecutive compound limb fractures treated in 914 patients at the University of Louisville over a nine-year period. Of these fractures, 240 (group 1) received only systemic antibiotic prophylaxis and 845 (group 2) were managed by the supplementary local use of aminoglycoside-polymethylmethacrylate (PMMA) beads. There were no significant differences in age, gender, fracture type, fracture location or follow-up between the two groups. All had copious wound irrigation, meticulous debridement and skeletal stabilisation, but wound management and the use of local antibiotic depended on the surgeon's individual preference and there was no randomisation. In group 1 there was an overall infection rate of 12% as against 3.7% in group 2 (p < 0.001). Both acute infection and local osteomyelitis showed a decreased incidence in group 2, but this was statistically significant only in Gustilo type-IIIB and type-IIIC fractures for acute infection, and only in type-II and type-IIIB fractures for chronic osteomyelitis. Our review suggests that the adjuvant use of local antibiotic-laden PMMA beads may reduce the incidence of infection in severe compound fractures.