Aims. To report the outcomes of patients with a fracture of the distal tibia who were treated with intramedullary nail versus locking plate in the five years after participating in the Fixation of Distal Tibia fracture (FixDT) trial. Methods. The FixDT trial reported the results for 321 patients randomized to nail or locking plate fixation in the first 12 months after their injury. In this follow-up study, we report the results of 170 of the original participants who agreed to be followed up until five years. Participants reported their Disability Rating Index (DRI) and health-related quality of life (EuroQol five-dimension three-level questionnaire) annually by self-reported questionnaire. Further surgical interventions related to the fracture were also recorded. Results. There was no evidence of a difference in patient-reported disability, health-related quality of life, or the need for further surgery between participants treated with either type of fixation at five years. Considering the combined results for all participants, there was no significant change in DRI scores after the first 12 months of follow-up (difference between 12 and 24 months, 3.3 (95% confidence interval -1.8 to 8.5); p = 0.203), with patients reporting around 20% disability at five years. Conclusion. This study shows that the moderate levels of disability and reduced quality of life reported by participants 12 months after a fracture of the distal tibia persist in the medium term, with little evidence of improvement after the first year. Cite this article: Bone Joint J 2023;105-B(7):795–800

The ideal form of fixation for displaced, extra-articular fractures of the distal tibia remains controversial. In the UK, open reduction and internal fixation with locking-plates and intramedullary nailing are the two most common forms of treatment. Both techniques provide reliable fixation but both are associated with specific complications. There is little information regarding the functional recovery following either procedure. We performed a randomised pilot trial to determine the functional outcome of 24 adult patients treated with either a locking-plate (n = 12) or an intramedullary nailing (n = 12). At six months, there was an adjusted difference of 13 points in the Disability Rating Index in favour of the intramedullary nail. However, this was not statistically significant in this pilot trial (p = 0.498). A total of seven patients required further surgery in the locking-plate group and one in the intramedullary nail group. This study suggests that there may be clinically relevant, functional differences in patients treated with nail versus locking-plate fixation for fractures of the distal tibia and differences in related complications. Further trials are required to confirm the findings of this pilot investigation

A series of 3061 patients with fracture of the distal tibia or ankle was studied for a possible link between overweight and failed reduction. The relative body-weight was recorded as the preoperative self-reported body mass index (BMI) of each patient. There were 109 patients (3.6%) with failure of internal fixation or of closed reduction severe enough to necessitate refixation or corrective osteotomy. The mean BMI in all age- and gender-specific groups studied was found to be significantly higher in patients with failed reduction than in those with an uneventful course (p < 0.01). The relative risk of loss of reduction for patients with a BMI greater than 1SD above the BMI of the corresponding age and gender group of the general population was 3.72 for distal tibial fractures and 3.04 for ankle fractures. Overweight should be recognised as a significant factor in predicting a complicated course after a fracture of the lower leg. Awareness of the increased risk of loss of reduction in overweight patients is important in all phases of management

We have reviewed 15 cases of triplane fracture of the distal tibia. The mechanism of injury is lateral rotation and the anatomical pattern of the fracture depends on the state of the growth plate at the time of injury. In seven of our cases the anteromedial part of the growth plate was fused, but in eight children the plate was completely open. In six of these eight children there was a hump or projection of the medial growth plate. It is suggested that this hump stabilises the anteromedial part of the epiphysis in a manner similar to the partial anteromedial fusion seen in older children, and that this accounts for the occurrence of triplane fracture in the presence of an open growth plate

In a series of 126 consecutive pilon fractures, we have described anatomically explicable fragments. Fracture lines describing these fragments have revealed ten types of pilon fracture which belong to two families, sagittal and coronal. The type of fracture is dictated by the energy of injury, the direction of the force of injury and the age of the patient.

The October 2023 Trauma Roundup. 360. looks at: Intramedullary nailing versus sliding hip screw in trochanteric fracture management: the INSITE randomized clinical trial; Five-year outcomes for patients with a displaced fracture of the distal tibia; Direct anterior versus anterolateral approach in hip joint hemiarthroplasty; Proximal humerus fractures: treat them all nonoperatively?; Tranexamic acid administration by prehospital personnel; Locked plating versus nailing for proximal tibia fractures: a multicentre randomized controlled trial; A retrospective review of the rate of septic knee arthritis after retrograde femoral nailing for traumatic femoral fractures at a single academic institution

Osteoid osteoma is a benign bone-forming lesion, characterized by its small size, its clearly demarcated outline and by the usual presence of a surrounding zone of reactive bone formation. It often poses a diagnostic challenge due to its ambiguous presentation. The aetiology of osteoid osteoma is poorly understood. The previous suggestion that osteoid osteoma was not associated with trauma or infection has been challenged by more recent literature raising the possibility that it could be a reactive or healing response or a phenomenon associated with the revascularisation process. This case report describes an unusual presentation of a post-traumatic osteoid osteoma. Two years following a diaphyseal, spiral tibial fracture treated nonoperatively, the patient developed new pain at the previous fracture site. The pain was constant, relieved by non-steroidal analgesia and not associated with systemic upset. It was initially attributed to other more likely diagnoses such as osteomyelitis and neuropathic pain. Multiple investigations and interventions were undertaken prior to the definitive diagnosis being obtained by surgical excision of the lesion and histological studies five years after the injury and three years following the initiation of the discomfort. In both English and foreign language literature there are only seven case reports that document osteoid osteoma following fracture, these are predominantly in the lower limb with no predominance to operative or nonoperative management. This case report should raise the index of clinical suspicion of osteoid osteoma occurring post fracture.

Salter-Harris II fractures of the distal tibia affect children frequently, and when they are displaced present a treatment dilemma. Treatment primarily aims to restore alignment and prevent premature physeal closure, as this can lead to angular deformity, limb length difference, or both. Current literature is of poor methodological quality and is contradictory as to whether conservative or surgical management is superior in avoiding complications and adverse outcomes. A state of clinical equipoise exists regarding whether displaced distal tibial Salter-Harris II fractures in children should be treated with surgery to achieve anatomical reduction, or whether cast treatment alone will lead to a satisfactory outcome. Systematic review and meta-analysis has concluded that high-quality prospective multicentre research is needed to answer this question. The Outcomes of Displaced Distal tibial fractures: Surgery Or Casts in KidS (ODD SOCKS) trial, funded by the National Institute for Health and Care Research, aims to provide this high-quality research in order to answer this question, which has been identified as a top-five research priority by the British Society for Children’s Orthopaedic Surgery. Cite this article: Bone Joint J 2023;105-B(5):471–473

Aim. The aim of this study was to compare the cost-effectiveness of intramedullary nail fixation and ‘locking’ plate fixation in the treatment of extra-articular fractures of the distal tibia. Patients and Methods. An economic evaluation was conducted from the perspective of the United Kingdom National Health Service (NHS) and personal social services (PSS), based on evidence from the Fixation of Distal Tibia Fractures (UK FixDT) multicentre parallel trial. Data from 321 patients were available for analysis. Costs were collected prospectively over the 12-month follow-up period using trial case report forms and participant-completed questionnaires. Cost-effectiveness was reported in terms of incremental cost per quality adjusted life year (QALY) gained, and net monetary benefit. Sensitivity analyses were conducted to test the robustness of cost-effectiveness estimates. Results. Mean NHS and PSS costs were significantly lower for patients treated with an intramedullary nail than for those treated with a locking plate (-£970, 95% confidence interval (CI) -1685 to -256; p = 0.05). There was a small increase in QALYs gained in the nail fixation group (0.01, 95% CI -0.03 to 0.06; p = 0.52). The probability of cost-effectiveness for nail fixation exceeded 90% at cost-effectiveness thresholds as low as £15 000 per additional QALY. The cost-effectiveness results remained robust to several sensitivity analyses. Conclusion. This trial-based economic evaluation suggests that nail fixation is a cost-effective alternative to locking plate fixation. Cite this article: Bone Joint J 2018;100-B:624–33

Introduction. Pilon fractures are complex, high-energy, intra-articular fractures of the distal tibia. Achieving good outcomes is challenging due to fracture complexity and extensive soft tissue damage. The purpose of this study was to determine the long-term functional and clinical outcomes of definitive management with fine wire Ilizarov fixation for closed pilon fractures. Materials and Methods. 185 patients treated over a 14-year period (2004–2018) were included. All patients had Ilizarov frames applied to restore mechanical axis and fine wires to control periarticular fragments. CT scans were performed post operatively to confirm satisfactory restoration of the articular surface. All frames were dynamized prior to removal. Patients' functional outcome was assessed using the validated Chertsey Outcome Score for Trauma (“COST”). Review of clinical notes and imaging was used to determine complications and time to union. Results. The mean functional outcome in the studied cohort was determined to be “average” on the “COST” score. Poorer functional outcomes were associated with younger age at time of injury and multi-fragment fracture patterns. Mean time in frame was 170 days. Complication rates were low. There were no deep infections, no amputations and only 8 patients went on to have ankle fusions. Conclusions. Good functional results and low complication rates can be achieved by managing pilon fractures with fine wire Ilizarov fixation. Nonetheless, at time of injury patients should be counselled as to the severity of the injury and impact on their functional status

Introduction: Unstable fractures of the distal tibia that are not suitable for intramedullary nailing are commonly treated by open reduction and internal þxation and/or external þxation techniques. Treatment of these injuries using minimally invasive plate osteosynthesis (MIPO) techniques may offer the advantage of achieving adequate þxation whilst minimising soft tissue injury and damage to the vascular integrity of the fracture fragments. Purpose: We report our experience using MIPO techniques for the treatment of unstable fractures of the distal tibia. Method: A review of all patients who sustained an unstable fracture of the distal tibia treated by MIPO between 1998 and 2001 was undertaken. Twenty patients were identiþed. The mean age was 38.3 years (17 Ð 71). All fractures were closed, and were classiþed according to the AO system. Intra-articular fracture extensions were classiþed according to RŸedi and Allgšwer. Results: Sixty percent of patients achieved callus by 8 weeks. All patients achieved callus by 3 months. The mean time to full weight bearing was 12 weeks (8 Ð 17). By 6 months 18/20 patients had achieved union. The two remaining patients achieved union by 7 months without further surgery. There were no deep infections and only one malunion. There were no cases of failure of þxation. Conclusion: MIPO appears to offer a reliable method of þxation of fractures of the distal tibia that are unsuitable for intramedullary nailing. Our results suggest that this technique is associated with a lower risk of signiþcant complications than encountered with more traditional methods of þxation of such fractures

The August 2012 Trauma Roundup. 360. looks at: pelvic fractures, thromboembolism and the Japanese; venous thromboembolism risk after pelvic and acetabular fractures; the displaced clavicular fracture; whether to use a nail or plate for the displaced fracture of the distal tibia; the dangers of snowboarding; how to predict the outcome of lower leg blast injuries; compressive external fixation for the displaced patellar fracture; broken hips in Morocco; and spinal trauma in mainland China

Aims: There has been recent interest in the use of external þxation for the treatment of distal peri-articular fractures. The current study was undertaken to evaluate the role of the hybrid external þxation system in the treatment of the distal tibial fractures. Methods: We treated 137 fractures of the distal tibia, of which 46 were treated with hybrid external þxation. The indication for this method of treatment was in the presence of an unstable extra-articular fracture and/or a severe comminution of the distal tibia, as well as an associated severe soft-tissue injury. Routine demographic data, clinical and radiographic þndings as well as reduction, outcomes and complications were recorded. Patients were evaluated with outcome scale of Ovadia and Beals. Results: There were 17 closed fractures and 29 open. Twenty-one extra -and 25 intrarticular fractures were managed with a Hybrid Fixator. All fractures achieved complete healing. Reductions of C-type fractures were within 0-2 mm in 16 and 3–5mm in 56 and > 5mm in 3 patients. The Hybrid External þxator was removed at an average of 17.5 weeks. Full weight bearing was achieved at a mean of 7.8 weeks. There were no intraoperative injuries to nerves or major vessels. Using the outcome scale of Ovadia and Beals, good-excellent results were achieved in 67% (n=31) subjectively and 72% (n=33) objectively. Two poor results occurred in patients with a varus malunion. Conclusion: External þxation is a satisfactory method of treatment for fractures of the distal tibia and is associated with fewer complications than internal þxation, because it limits the amount of soft tissue

We have assessed the proximal capsular extension of the ankle joint in 18 patients who had a contrast-enhanced MRI ankle arthrogram in order to delineate the capsular attachments. We noted consistent proximal capsular extensions anterior to the distal tibia and in the tibiofibular recess. The mean capsular extension anterior to the distal tibia was 9.6 mm (4.9 to 27.0) proximal to the anteroinferior tibial margin and 3.8 mm (−2.1 to 9.3) proximal to the dome of the tibial plafond. In the tibiofibular recess, the mean capsular extension was 19.2 mm (12.7 to 38.0) proximal to the anteroinferior tibial margin and 13.4 mm (5.8 to 20.5) proximal to the dome of the tibial plafond. These areas of proximal capsular extensions run the risk of being traversed during the insertion of finewires for the treatment of fractures of the distal tibia. Surgeons using these techniques should be aware of this anatomy in order to minimise the risk of septic arthritis

Introduction. Fractures of the distal tibia can be challenging to manage. Numerous surgical techniques have been utilised in managing these however there remains debate as to the optimum method of fixation. This study aims to assess the surgical outcomes and PROMs of patients with distal tibial fractures managed with intramedullary-nails or ring fixation. Methods. This is a retrospective study of patients with closed distal tibial fractures managed between 01/01/2013–31/12/2016. Adult patients admitted with closed fracture of the distal tibia fixed with an intramedullary-nail or circular-frame were included in the study. Primary outcomes were time of union, alignment of tibia post-operatively and the results of two validated PROMs (Kujala knee score and Olerud and Molander Ankle Score). Results. 12 patients had circular-frame and 14 patients underwent intramedullary-nailing. PROMS were completed in 9 (75%) of the frame group and 7 (50%) of the nail group. There was no statistically significant difference in age (p=0.095); no statistically significant difference in time to union (medians = frame 29.7 weeks, IM nail 24 weeks, p=0.212); no statistically significant difference in the coronal angulation difference from neutral (medians = frame 1.9 degrees, IM nail 2.0 degrees, p=0.940). There was statistically significant difference in sagittal angulation difference from neutral (Medians = frame 3 degrees, IM nail 0.6 degrees, p=0.041); the proportion of males in the frames groups was statistically significantly higher (p=0.033). There was no statistically significant difference in outcome of ankle scores (medians = frame 92.5, IM nail 75, p=0.132); there was a statistically significant difference in the knee score favouring the frame group (medians = frame 99, IM nail 74.5, p=0.041). Discussion. Our results show distal tibia fractures can be treated with circular-frames or IM-nails. Patients at high-risk of soft tissue complication or to minimise the risk of knee symptoms should be considered for a circular-frame

The aim of this study was to document the outcome following either early or delayed fixation for complex (AO-OTA type 43.C) fractures of the tibial plafond. From our trauma database we identified all patients who sustained a complex intra-articular fracture of the distal tibia over an 11-year period. Demographic data, fracture classification, management, complications and subsequent surgeries were recorded. The primary outcome measure was the development of early complications following surgery. The secondary outcome measure was the long-term patient reported outcome. There were 102 type C pilon fractures in 99 patients with a mean age of 42yrs (16–86) and 75.5% (n=77) were male. 73 (71.6%) patients underwent primary open reduction internal fixation (ORIF), with 20 (19.6%) undergoing primary external fixation with delayed ORIF. 34 complications were recorded in 28 (27.5%) patients. There were 18 (17.6%) infections, with a deep wound infection in 9 (8.8%) patients and a superficial wound infection in 9 (8.8%). Risk factors for developing infection were multiple co-morbidities (p=0.008), an open fracture (p=0.008), and primary external fixation with delayed ORIF (p=0.023). At a mean of 6 years (0.3–13; n=53) post injury the mean FAOS score was 76.2 (0–100), the mean FADI score was 75.7 (0–100), and 72% (n=38) of patients were satisfied. This is the largest series in the literature documenting the outcome following fixation for type C tibial pilon fractures. Despite the severity of these injuries, we have demonstrated a satisfactory outcome using primary early fixation in the vast majority of cases

Aims. To systematically review qualitative studies of patients with distal tibia or ankle fracture, and explore their experience of injury and recovery. Methods. We undertook a systematic review of qualitative studies. Five databases were searched from inception to 1 February 2022. All titles and abstracts were screened, and a subset were independently assessed. Methodological quality was appraised using the Critical Appraisal Skills Programme (CASP) checklist. The GRADE-CERQual checklist was used to assign confidence ratings. Thematic synthesis was used to analyze data with the identification of codes which were drawn together to form subthemes and then themes. Results. From 2,682 records, 15 studies were reviewed in full and four included in the review. A total of 72 patients were included across the four studies (47 female; mean age 50 years (17 to 80)). Methodological quality was high for all studies, and the GRADE-CERQual checklist provided confidence that the findings were an adequate representation of patient experience of distal tibia or ankle fracture. A central concept of ‘being the same but different’ conveyed the substantial disruption to patients’ self-identity caused by their injury. Patient experience of ‘being the same but different’ was expressed through three interrelated themes, with seven subthemes: i) being proactive where persistence, doing things differently and keeping busy prevailed; ii) living with change including symptoms, and living differently due to challenges at work and leisure; and iii) striving for normality, adapting while lacking in confidence, and feeling fearful and concerned about the future. Conclusion. Ankle injuries were disruptive, draining, and impacted on patients’ wellbeing. Substantial short- and longer-term challenges were experienced during recovery. Rehabilitation and psychosocial treatment strategies may help to ameliorate these challenges. Patients may benefit from clinicians being cognisant of patient experience when assessing, treating, and discussing expectations and outcomes with patients. Cite this article: Bone Jt Open 2023;4(3):188–197

Aims

Triplane ankle fractures are complex injuries typically occurring in children aged between 12 and 15 years. Classic teaching that closure of the physis dictates the overall fracture pattern, based on studies in the 1960s, has not been challenged. The aim of this paper is to analyze whether these injuries correlate with the advancing closure of the physis with age.

Aim. A prospective cohort of patients undergoing total ankle arthroplasrty for arthritis following pilon fractures was included in the present study. This group of patients generally have poor soft tissue envelope and have had previous surgical interventions prior to the ankle arthroplasty, making the arthroplasty more difficult as well as prone to complications. Methods. The data collected included patient demographics, American Orthopaedic Foot and Ankle Score (AOFAS) and patient reported outcomes (FAOS, SF-36, patient satisfaction) The data was collected preoperatively and at 1 & 2 years postoperatively. The minimum follow-up period was 2 years post-operatively. Results. A total of 167 total ankle arthroplasties were performed by the senior author between Jan 2006 and June 2010. Of this cohort, the indication for 12 arthroplasties was arthritis following pilon fractures of the distal tibia. The average of the patients at the time of the surgery was 64.2yrs. The average number of previous surgeries prior to the ankle arthroplasty was 1.5. There were significant improvements in the AOFAS scores from an average of 18 to 75 at final review. The WOMAC scores improved from 31 to 71 for pain, stiffness improved from 31 to 60 and function improved from 33 to 63. The improvement of the SF36 and patient satisfaction score is similar to the ones for primary ankle osteoarthritis. The complications were: 1 case of superficial wound infection which settled with antibiotics, one fracture of medial malleolus and one case of undisplaced distal tibial fracture treated conservatively to union. Conclusion. The Indications for TAR can be safely broadened to include younger patients with arthritis following pilon fractures of the tibia. The Outcomes after TAR for patients with arthritis following pilon fractures are comparable to those for primary osteo arthritis of the ankle

Introduction. Intramedullary nailing is gaining popularity for treatment of distal tibial fractures due to short operative time and minimum surgical trauma to soft tissues. Distal tibial fractures are commonly associated with concurrent fibular fractures at, above or below the level of tibial fractures. So far there is no consensus for fixation of fibular fractures. Materials and Methods. Fractures of fibula at or below the level of fracture of tibia were taken into consideration. Fractures of fibula above the tibial level were excluded because they do not add to stability of fracture fixation. Retrospective study was done and distal tibia-fibula fractures were separated into 2 groups based on whether fibula was fixed or not. Measures of angulation were obtained from radiographs taken immediately after the surgery, a second time 3 months later, and at 6-month follow-up. Results. 35 fracture of distal tibia and fibula were included in study. Fibula was not fixed in 21 cases while 14 fibular fixations were carried out either using short plates(8) or intramedullary pins(6). No significant differences were observed for malalignment in fracture of fibula at the level of tibial fractures. However for fractures of fibula at a level lower than its tibial counterpart, fixation of fibula significantly reduced malalignment. Conclusion. Fixation of fibula has a definite role in reducing malunion in cases where fibula was fractured below the level of tibial fracture. Fixation of fibula may increase overall stability of fixation of tibia and reduce malunion

Introduction: The use of Ilizarov frames is contraindicated in patients with psychiatric conditions, thought to be due to non compliance. We present our experience of treating five fractures with Ilizarov frame in four patients who sustained their injuries through parasuicide. Method: Consecutive series of patients treated by a single surgeon at our institution. Five fractures in four patients, (one bilateral fracture) were treated with an Ilizarov fine wire frame. All fractures were comminuted distal tibia (pilon): one was B3.3, two C3.2 and a further two C3.3 using the AO system. Four out of five fractures were open Grade IIIA. Outcome was based on functional score (Olerud and Molander); SF 12 and radiological assessment. Results: There were three females and the mean age was thirty-one years. Of the five fractures, three united successfully, at eight months; one achieved a malunion and one an aseptic non-union at 1 year. Discussion: Our experience suggests complex fractures can be treated favourably with circular frames in parasuicide patients. The patients were generally compliant with frame care and the outpatient monitoring was no different from any other patient with similar injuries

Most high-energy trauma to lower legs, ankles and feet result in severe crush injuries. We performed a retrospective case series study. Eight patients (7M: 1F) with mean age of 28 years (range -18 -35 years) were included. Four had Grade 3 open fractures of the distal tibia and 5 had open foot fractures. Two had neurovascular injuries. Four patients had associated injuries with mean ISS of 9 (range 8-16) and a mean MESS score of 3.5 (3-7). All had undergone some form of internal and external fixation within approximately 24 hours (8 hrs to 4 days). The mean follow-up period was two years (range 1-4 years). At final follow-up patients' health was measured using SF-36 questionnaire. Six patients had their fractures healed at a mean of 4.8 months (4-9 m). Two patients had fully functional foot with occasional complaints of painful ankle. Two patients had CRPS1 undergoing treatment. Two patients are unable to walk due to chronic pain and deformity. Comparison of the SF-36 scores with the age-matched UK normal controls without foot and ankle injuries showed significantly worse scores in physical function (PF: p<0.01) and role physical (RP: p< 0.01) categories. Our surgical instinct dominates decision-making, favouring salvage rather than amputation in these young groups of patient. They gradually suffer a cocktail of crippling disease characterised by psycho-socio-economic and physical disability. Should we be depleting our resources in salvaging these complex limb injuries?

Unstable fractures of the distal tibia are being increasingly treated by open reduction and internal fixation using pre-contoured locking plates. Functional outcome following this type of fixation has not been reported previously. The aim of this study was to functionally assess patients following MIPO fixation of distal tibial fractures. Case notes of 26 patients treated at a single centre were reviewed. The fracture type, fixation technique, complications, time to union and subsequent treatment were documented. All patients returned for functional scoring using the validated American Academy of Orthopedic Surgeons (AAOS) foot and ankle core score. Twenty-six consecutive patients were treated between 2002-2005. The majority were male, and 5 were open fractures. There were 13 AO type A, 4 type B and 9 type C fractures. Mean follow up was 20 months. Average time from injury to surgery was 2.5 days. All fractures were treated by a MIPO technique. A pre-contoured distal locking plate was used for the distal tibial reconstruction. Secondary surgical procedures e.g. 2nd look, delayed primary closure, or skin grafting were necessary in 3 cases. The fibula was plated in 60% of cases. Four patients developed wound infections requiring antibiotics, and all resolved. The commonest rehabilitation regime was 6 weeks non weight bearing in plaster. Mean time to union was 18 weeks. There were 3 cases of delayed union, requiring bone grafting. One patient required removal of the plate due to local irritation, and one required a broken screw to be removed. Mean range of movement was 10 degrees dorsiflexion, 30 plantarflexion. The mean normalised AAOS foot and ankle core score was 41 (SD +/− 8). We conclude that MIPO fixation of distal tibial fractures is a safe and effective method of treatment. Functional outcome does not significantly differ from that of the general population

Pilon fractures of the distal tibia pose a difficult therapeutic problem. Various treatment methods exist. We present encouraging early results with the Medial Tibial LISS plate (LCDCP) for these injuries. Materials and Methods: 7 patients (5 male:2 female); age: 34 (range 26–59); All closed injuries 3 type 1; 3 type 2; 1 type IIIc; Average time from injury to surgery: 6 days (4–12 days). Technique: 4 patients had preliminary joint-spanning fixator; 4 patients had fibular plating through a posterolateral incision; A curved anteromedial incision was used to avoid plate exposure in case of wound breakdown. Medial Tibial LISS plate with inter-fragmentary screws to reduce main fracture fragments. Early, non-weight bearing mobilization. Results: Minimum Follow Up: 6 months (range 6–18 months). Union was obtained in all fractures. Joint reconstruction was graded as anatomical in 3 patients, mildly non-anatomical in 3 patients, and markedly incongruent in 1 patient (Type IIIc3). ROM: average 10° Dorsiflexion and 30° Plantarflexion. Pain: None in 4, mild in 2, and severe in 1. Wound healing problems: 1 minor requiring no surgical intervention, 1 requiring debridement of distal tibial wound. We conclude that this technique offers a viable alternative to other methods in the treatment of these difficult injuries

Aims

Paediatric fractures are highly prevalent and are most often treated with plaster. The application and removal of plaster is often an anxiety-inducing experience for children. Decreasing the anxiety level may improve the patients’ satisfaction and the quality of healthcare. Virtual reality (VR) has proven to effectively distract children and reduce their anxiety in other clinical settings, and it seems to have a similar effect during plaster treatment. This study aims to further investigate the effect of VR on the anxiety level of children with fractures who undergo plaster removal or replacement in the plaster room.

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an llizarov ring fixator. Only patients with intra-articular fracture of the tibial plafond on plain radiographs that corresponded to type III pattern of Ruedi and Allgower were included. There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident. Operative fixation consisted of fracture reduction and stabilisation using the Ilizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided. Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average of 6.3 months). Neither deep infection nor soft tissue complications occurred. Outcomes measured using the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire and our results compare well with other fixation techniques. The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries

This paper describes the outcome of type III pilon fractures of the distal tibia treated primarily with an Ilizarov ring fixator. Only patients with an intra-articular fracture of the tibial plafond on plainradiographs that corresponded to type III pattern with the system of Rfiedi andAllgower were included. There were thirteen patients with a mean age of 45 (range 29–65), twelve males and one female. The mechanism of injury in all the patients was high-speed road traffic accident. Operative fixation consisted of fracture reduction and stabilisation using the llizarov circular frame external fixator and olive tipped wires. Further insult to the already damaged soft tissues was avoided. Bony union was achieved in all cases. Treatment in the frame lasted between 3 and 10 months (average 6. 3 months). Neither deep infection nor soft tissue complications occurred. Outcome measurements included the Olerud ankle score, modified Ovadia and Beals radiological criteria, and the SF-36 Health Questionnaire. Wound and deep infections were successfully avoided and bony union was achieved in all our patients. This compares well with other fixation techniques. The use of the llizarov circular frame external fixator without any additional internal reduction or fixation procedures is a definite option for the treatment of these high-energy injuries

Purpose: To evaluate the outcome of salvage surgery with external fixation in these rare and severe lower limb injuries. Methods: Eight patients (7M: 1F) with mean age of 28 years (range −18 −35 years) were included. Four had Grade 3 open fractures of the distal tibia and 5 had open foot fractures. Two had neurovascular injuries. Four patients had associated injuries with mean ISS of 9 (range 8–16) and a mean MESS score of 3.5 (3–7). All had undergone some form of internal and external fixation within approximately 24 hours (8 hrs to 4 days). The mean follow up period was two years (range 1 – 4 years). At final follow-up patient’s health was measured using SF-36 questionnaire. Results: Six patients had their fractures healed at a mean of 4.8 months (4–9 m). Two patients had fully functional foot with occasional complaints of painful ankle. Two patients had CRPS1 undergoing treatment. Two patients are unable to walk due to chronic pain and deformity. Comparison of the SF -36 scores with the age-matched UK normal controls without foot and ankle injuries showed significantly worse scores in physical function (PF: p< 0.01) and role physical (RP: p< 0.01) categories. Conclusions: Our surgical instinct dominates the decision-making favoring salvage with external fixation primarily rather than amputation in these young groups of patient. Should we be depleting our resources in salvaging these complex limb injuries?

Fractures of distal tibia are common and often present with dilemma of appropriate and safe management. The use of locking plates has changed the way these fractures have been managed as it avoids extensive soft tissue dissection and periosteal stripping. The aims of this study were to look at the results of stabilization and analyse the complications of fractures of distal tibia treated with Locked plates. We carried out a retrospective study of patients who underwent surgical treatment for distal tibial fractures using MIPO (Minimally invasive Percutaneous Osteosynthesis) technique. The data was gathered from theatre data base. We studied a period between Nov 2006 to May 2009. We collected patient demographics as well as the type of fractures, mechanism of injury, radiological union and associated complications. There were no open fractures in the study. The limb was splinted for two weeks after surgery in a back slab. The patients were followed up at 6 weeks, 3, 6, 9 and 12 months after surgery. There were 45 patients in the study with 29 males & 16 females between ages of 20 – 87 (avg. 49 yrs). 24 patients sustained injury due to a fall, 12 were involved in RTA and the remaining 9 were sports related injuries. The mean time to surgery was 3.15 days (1 – 7) and surgery was carried either by the consultant or their direct supervision. The mean hospital stay was 7 days (2 – 35) and mean time to radiological evidence of callus was 9 weeks. All patients eventually returned to their preinjury employment. 76% showed radiological union at 6 months and 90% at 9 months. There were 3 superficial wound infections, 2 deep infections whilst 2 needed bone grafting and 1 implant failure. 2 patients developed mild form of CRPS which resolved at 12 months. 11 patients had metal discomfort of which 9 had removal of hardware. All these patients had the tip snapped off. MIPO with LCP is a reliable and reproducible technique in treatment of closed unstable fracture of distal tibia. Patients must be counselled about implant removal after fracture union. Avoid snapping the tip of the LCP

Purpose: To give the review of the foot deformities in the patients with myelomeningocele (MMC), their relationship to the level of the neurological lesion and therapeutic possibilities. Material & Methods: Since 1998 till 2004 there were 20 patients with myelomeningocele treated in our clinic, in 19 patients was noted the foot deformity (total 34 feet). The deformity was unilateral in 4 patients, asymmetric in 2 patients (equinovarus + calcaneovalgus or planovalgus). The most frequent was equinovarus deformity (16 feet, 47%), next planovalgus deformity (9 feet, 26,5%), calcaneovalgus (7 feet, 20,6%) and equinovalgus (2 feet, 5,9%). In 28 feet the surgery was done. For the correction of the various deformities of the feet were used soft tissue releases or tendons transfer, in the older patient or after failed soft tissue release the bony operation was done (tarsal osteotomy, talo-calcaneal stabilisation, artrodesis). Results: The aim of every type of surgery was to achieve the acceptable foot shape, with plantigrade step and possibility of weigh bearing, with minimal risk of the pressure necrosis. In the most patients the purpose was achieved, although some of them passed several surgeries. In 18 deformities only one surgery obtained the correction of the deformity, the but for the 10 feet subsequent surgery was required because of the residual or relapsing deformity. In 3 patients was noted the pressure necrosis, in 1 patient appeared the fracture of the distal tibia (epiphyseolysis) after the removal the postoperative plaster. Conclusion: The orthopaedic care about the patients with MMC is only a part of the interdisciplinary approach of several specialists. The procedures for the correction of the neurogenic deformities of the feet, belong to the delicate surgery and is necessary very careful indication in relation with the type of deformity, which is dependent on the high of the lesion, and with the expectancy of walking. In the patients with good prognosis of walking is necessary to choose the procedure which guarantee weight-bearing and plantigrade step without the risk of ischemic skin defects

Aims

A pilon fracture is a severe ankle joint injury caused by high-energy trauma, typically affecting men of working age. Although relatively uncommon (5% to 7% of all tibial fractures), this injury causes among the worst functional and health outcomes of any skeletal injury, with a high risk of serious complications and long-term disability, and with devastating consequences on patients’ quality of life and financial prospects. Robust evidence to guide treatment is currently lacking. This study aims to evaluate the clinical and cost-effectiveness of two surgical interventions that are most commonly used to treat pilon fractures.

Entre Janvier 1998 et Février 2001, 39 patients avec une fracture du 5e distal du tibia furent traités primaire-ment à l’aide d’un enclouage centromédullaire vérouillé statique. La population étudiée est composée de 24 hommes et 15 femmes, âgés de 40 ans en moyenne. Le suivi moyen est de 12,9 mois. Une union osseuse a été obtenue pour toutes les fractures. Le temps moyen de consolidation fut de 21,5 semaines (incluant un cas à 68 semaines). Quatre patients on présenté un retard d’union, et une chirurgie additionnelle fut requise chez trois d’entre eux. Deux patient ont présenté une malunion. Ces deux cas étaient associés à une fracture du péroné distal qui n’avait pas été ostéosynthésée. Les fractures du tibia distal demeurent un défi thérapeutique pour le chirurgien orthopédique. L’enclouage centromédullaire alésé verrouillé statique est une méthode d’ostéosynthèse sécuritaire et efficace pour ces fractures, tel que démontré dans notre série. L’enclouage centromédullaire est désormais considéré comme la méthode d’ostéosynthèse la plus appropriée dans le traitement des fractures déplacées de la diaphyse tibiale. Son usage s’est étendu aux fractures des tiers proximaux et distaux du tibia. Par contre, beaucoup moins de preuves sur l’efficacité d’un tel traitement existent. Les fractures du tibia distal demeurent un défi thérapeutique pour le chirurgien orthopédique. L’enclouage centromédullaire alésé verrouillé statique est une méthode d’ostéosynthèse sécuritaire et efficace pour ces fractures, tel que démontré dans notre série. Le montage offre une stabilité suffisante pour la mobilisation et la mise en charge précoce. L’adhérence à une technique minutieuse est requise et permet d’éviter une malunion. Notre série confirme la place de l’enclouage centromédullaire comme méthode d’ostéosynthèse primaire des fractures du 1/5 distal du tibia. Entre Janvier 1998 et Février 2001, 39 patients avec une fracture du 5e distal du tibia furent traités primaire-ment à l’aide d’un enclouage centromédullaire vérouillé statique. La population étudiée est composée de 24 hommes et 15 femmes, âgés de 40 ans en moyenne (16 à 79 ans). Le suivi moyen est de 12,9 mois (7 à 24 mois). Une union osseuse a été obtenue pour toutes les fractures. Le temps moyen de consolidation fut de 21,5 semaines (incluant un cas à 68 semaines). Quatre patients on présenté un retard d’union, et une chirurgie additionnelle fut requise (dynamisation du clou) chez trois d’entre eux. Deux patient ont présenté une malunion, soit 5o de varus dans un cas et 7o de valgus dans un cas. Ces deux cas étaient associés à une fracture du péroné distal qui n’avait pas été ostéosynthésée. Aucune perte de réduction n’a été notée en postopératoire. Cinq complications furent notées, soit un bris de matériel (vis de verrouillage n’entrainant pas de séquelle foinctionnelle et ne requérant pas de réopération), deux syndromes du compartiment et deux atteintes neurologiques (sciatique poplité externe). Aucune infection ni problème cutané ne sont survenus. En moyenne, la mise en charge fut autorisée à 5,8 semaines postopératoire. Financement: Aucun

Aims

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.

The treatment of high energy fractures of distal tibia by internal fixation is followed by a high rate of soft tissue complications. The result estimation of these fractures in a two stage treatment, bridging the ankle by Ex-Fix with/without internal fixation of the fibula and internal fixation of the tibia after soft tissue recovery. In a 4 year period (2005–8), 15 patients, average of 42 years were treated. The AO fracture classification was followed. The soft tissue damage estimation (Osternn-Tscherne and Gustillo classification), the fracture pattern of the fibula and the injury mechanism consisted of the choice method criteria. The majority of the injuries was classified Tscherne II & III, and 3 open fractures Gustillo II. Fracture reduction was performed by bridging Ex-Fix of the ankle with/without plating the fibula with a 1/3 or DCP 3.5 mm plate. Definite internal fixation of the tibia by locking plate was performed from 8th –14th postoperative day after soft tissue recovery. Preoperatively CT scan was performed with grate significance, defining the soft tissue condition, the surgical approach and the osteosynthesis type. Follow up average 14 months. None of the patients developed infection. All wounds were healed in one stage. Superficial skin necrosis was conservatively treated in two patients. Soft tissue complications, after internal fixation of high energy fractures of the distal tibial, usually appear. Two stages treatment allows better preoperative planning, immediate patient mobilization and reduce complication rate

Introduction. We describe a minimally invasive technique that permits intra-focal bone graft of non-union sites with minimal disturbance of soft tissues and vascularity, and present the results of this technique. Materials and Methods. 10 patients with established tibia fracture non-union were judged suitable for the technique, and were treated in our limb reconstruction unit between January 1995 to June 2007. Eight patients were male, 2 were females with a mean age of 37.4 years (27–64). Five fractures were in the distal tibia and five were diaphyseal fractures. Five fractures were as a result of high velocity and 6 fractures were open. Average number of previous operations were 3 (range 1–7). Time lapse between injury to trephine grafting procedure was mean of 34 (6–168 months). 5 patients had a sedentary job, 2 were labourers and 2 were not working. There were 5 smokers and 2 obese patients. Six cases were of infected non-unions. Operative technique. Under general anaesthesia, the graft(s) was first obtained from the iliac crest using a guide wire centred trephine. A stab incision was made at the non-union site under image control. A core was taken across the non-union, taking care to breach both bone fragments. A trephine core was rolled in Bone Morphogenetic Protein (BMP-7). This was then introduced through the trephine in to the non-union site and pushed with the plunger into the defect created by the cylindrical plug taken from the site. After this, the trocar with the stylet in place was gradually withdrawn with small oscillating motions to fill in the path of the trocar. This was repeated about 3–4 times at the non-union site. The stab wound were closed with interrupted Nylon. Results. 10 patients underwent treatment for complex non-union after initial operation (average number 3) at the referring centre. Treatment in a circular fixator ranged from 10–33 months (20.7 months) with reapplication in 2 patients. Average number of procedures were 4 (range 1–7). Trephine grafting was performed in all cases; BMP was used in 4 cases along with iliac crest bone graft. All patients attained clinical and radiological union with CT confirmation required in 2 patients. 4 patients with sedentary job returned to work, manual workers returned to low demand occupation. Conclusion. The technique described is a safe and effective treatment method for this complex problem with limited donor site morbidity and avoids prolonged hospital stay

Aim: Distal extra articular fractures of femur and tibia are difþcult to treat by conventional nails because of inability to use distal locking screws. The aim of this study is to analyse the effectiveness of this new I.M. Nail that does not require the use of distal locking screws for rotational stability. Methods & Material: Since 1994 we have treated a total of 68 such cases. Of these 40 were fractures of distal tibia and 28 were that of femur. Age range was from 11– 92. After insertion of the nail in the usual way, a ÒTrio WireÒ was introduced through the nail. This wire fans out in the distal segment which maintains rotational stability. Patients were mobilised with partial weight bearing within 3 weeks. Results: Most of the fractures were united without any signiþcant problem. Delayed union occurred in 2 cases. Breakage of the trio wire occurred in one case and 1 patient with supra-condylar fracture of femur needed revision for persistent varus deformity. Conclusion: We conclude that this I.M. Nail can be used effectively for þxation of these difþcult fractures. This is does not require X-ray exposure for distal locking. Operative time is thus minimised. This also saves surgeonñs hands from direct exposure to radiation. The þxation also allows for dynamisation of the fracture to promote early union

Aims

The aim of this study was to describe the technique of distraction osteogenesis followed by arthrodesis using internal fixation to manage complex conditions of the ankle, and to present the results of this technique.

We studied 11 patients with checkrein deformities of the hallux who underwent surgical treatment. Six had lengthening of the flexor hallucis longus tendon by Z-plasty in the midfoot, and five underwent release of adhesions and lengthening of the tendon by Z-plasty at the musculotendinous junction at the fracture site.

All six patients who underwent Z-plasty at the midfoot showed complete correction of the deformity without recurrence. Of the five who had release of adhesions and Z-plasty of the tendon at the fracture site, two showed partial and one showed complete recurrence.

Controversy continues to surround the management of patients with an open fracture of the lower limb and an associated vascular injury (Gustilo type IIIC). This study reports our 15-year experience with these fractures and their outcome in 18 patients (15 male and three female). Their mean age was 30.7 years (8 to 54) and mean Mangled Extremity Severity Score (MESS) at presentation was 6.9 (3 to 10). A total of 15 lower limbs were salvaged and three underwent amputation (two immediate and one delayed). Four patients underwent stabilisation of the fracture by external fixation and 12 with an internal device. A total of 11 patients had damage to multiple arteries and eight had a vein graft. Wound cover was achieved with a pedicled flap in three and a free flap in six. Seven patients developed a wound infection and four developed nonunion requiring further surgery. At a mean follow-up of five years (4.1 to 6.6) the mean visual analogue scale for pain was 64 (10 to 90). Depression and anxiety were common. Activities were limited mainly because of pain, and the MESS was a valid predictor of the functional outcome. Distal tibial fractures had an increased rate of nonunion when associated with posterior tibial artery damage, and seven patients (39%) were not able to return to their previous occupation.

Using human cadaver specimens, we investigated the role of supplementary fibular plating in the treatment of distal tibial fractures using an intramedullary nail. Fibular plating is thought to improve stability in these situations, but has been reported to have increased soft-tissue complications and to impair union of the fracture. We proposed that multidirectional locking screws provide adequate stability, making additional fibular plating unnecessary. A distal tibiofibular osteotomy model performed on matched fresh-frozen lower limb specimens was stabilised with reamed nails using conventional biplanar distal locking (CDL) or multidirectional distal locking (MDL) options with and without fibular plating. Rotational stiffness was assessed under a constant axial force of 150 N and a superimposed torque of ± 5 Nm. Total movement, and neutral zone and fracture gap movement were analysed.

In the CDL group, fibular plating improved stiffness at the tibial fracture site, albeit to a small degree (p = 0.013). In the MDL group additional fibular plating did not increase the stiffness. The MDL nail without fibular plating was significantly more stable than the CDL nail with an additional fibular plate (p = 0.008).

These findings suggest that additional fibular plating does not improve stability if a multidirectional distal locking intramedullary nail is used, and is therefore unnecessary if not needed to aid reduction.

Cite this article: Bone Joint J 2014;96-B:385–9.

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders’ classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale.

There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler’s angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders’ classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler’s angle.

We have managed 21 patients with a fracture of the tibia complicated by bone and soft-tissue loss as a result of an open fracture in 10, or following debridement of an infected nonunion in 11, by resection of all the devitalised tissues, acute limb shortening to close the defect, application of an external fixator and metaphyseal osteotomy for re-lengthening. The mean bone loss was 4.7 cm (3 to 11). The mean age of the patients was 28.8 years (12 to 54) and the mean follow-up was 34.8 months (24 to 75).

All the fractures united with a well-aligned limb. The mean duration of treatment for the ten grade-III A+B open fractures (according to the Gustilo-Anderson classification) was 5.7 months (4.5 to 8) and for the nonunions, 7.6 months (5.5 to 12.5). Complications included one refracture, one transient palsy of the peroneal nerve and one equinus contracture of 10°.