Introduction and Objective. Plating of geriatric distal femoral fractures with Locking Compression Plate Distal Femur (LCP–DF) often requires augmentation with a supplemental medial plate to achieve sufficient stability allowing early mobilization. However, medial vital structures may be impaired by supplemental medial plating using a straight plate. Therefore, a helically shaped medial plate may be used to avoid damage of these structures. Aim of the current study was to investigate the biomechanical competence of augmented LCP–DF plating using a supplemental straight versus helically shaped medial plate. Materials and Methods. Ten pairs of human cadaveric femora with poor bone quality were assigned pairwise for instrumentation using a lateral anatomical 15-hole LCP–DF combined with a medial 14-hole LCP, the latter being either straight or manually pre-contoured to a 90-degree helical shape. An unstable distal femoral fracture AO/OTA 33–A3 was simulated by means of osteotomies. All specimens were biomechanically tested under non-destructive quasi-static and destructive progressively increasing combined cyclic axial and torsional loading in internal rotation, with monitoring by means of optical motion tracking. Results. Initial axial stiffness and torsional stiffness in internal and external rotation for straight double plating (548.1 ± 134.2 N/mm, 2.69 ± 0.52 Nm/° and 2.69 ± 0.50 Nm/°) was significantly higher versus helical double plating (442.9 ± 133.7 N/mm, 2.07 ± 0.32 Nm/° and 2.16 ± 0.22 Nm/°), p≤0.04. Initial interfragmentary axial displacement and flexural rotation under 500 N static loading were significantly smaller for straight plating (0.11 ± 0.14 mm and 0.21 ± 0.10°) versus helical plating (0.31 ± 0.14 mm and 0.68 ± 0.16°), p<0.01. However, initial varus deformation under this loading remained not significantly different between the two fixation methods (straight: 0.57 ± 0.23°, helical: 0.75 ± 0.34°), p=0.08. During dynamic loading, within the course of the first 4000 cycles the movements of the distal fragment in flexion were significantly bigger for helical over straight plating (1.03 ± 0.33° versus 0.40 ± 0.20°), p<0.01. However, no significant differences were observed between the two fixation methods in terms of varus, internal rotation, axial and shear displacements at the fracture site, and number of cycles to failure. Conclusions. Augmented lateral plating of unstable distal femoral fractures with use of supplemental helically shaped medial plate was associated with more elastic bone-implant construct behavior under static and dynamic loading compared to straight double plating. Both fixation methods resulted in comparable number of cycles to failure. From a biomechanical perspective, the more elastic helical double plating may be considered as useful alternative to straight plating, potentially reducing stress risers at the distal bone-implant interface due to its ameliorated damping capacities

The extended lateral approach offers a safe surgical approach in the fixation of calcaneal fractures. Lateral plating of the calcaneum could put structures on the medial side at risk. The aim was to identify structures at risk on the medial side of the calcaneum from wires, drills or screws passed from lateral to medial. Ten embalmed cadaveric feet were dissected. A standard extended lateral approach was performed. The DePuy perimeter plate was first applied and 2mm K-wires were drilled through each of the holes. The medial side was now examined to determine the structures at risk through each hole. The process was repeated with the Stryker plate. The calcaneum was divided into 6 zones, by two vertical lines, from the margins of the posterior facet and a transverse line along the axis of the bone through the highest point of the peroneal tubercle. The DePuy and the Stryker plates have 12 screw positions, 5 of which are common. With both systems, screw positions in zone 1 risk injury to the medial plantar nerve and zone 3 the lateral plantar nerve. A screw through zone 2 compromises the medial plantar in both. Screws through zone 4 risk the lateral plantar nerve with the DePuy plate. Screws through zone 5 of the DePuy plate risk the medial calcaneal nerve. Zone 5 of the Stryker plate and Zone 6 of both are safe. There is significant risk to medial structures from laterally placed wires, drills or screws. Subtalar screws have the highest risk and have to be carefully measured and placed. The Stryker plating system is relatively safer than the DePuy perimeter plate with three safe zones out of six

Introduction and Objective. Distal femoral fractures are commonly treated with a straight plate fixed to the lateral aspects of both proximal and distal fragments. However, the lateral approach may not always be desirable due to persisting soft-tissue or additional vascular injury necessitating a medial approach. These problems may be overcome by pre-contouring the plate in helically shaped fashion, allowing its distal part to be fixed to the medial aspect of the femoral condyle. The objective of this study was to investigate the biomechanical competence of medial femoral helical plating versus conventional straight lateral plating in an artificial distal femoral fracture model. Materials and Methods. Twelve left artificial femora were instrumented with a 15-hole Locking Compression Plate – Distal Femur (LCP-DF) plate, using either conventional lateral plating technique with the plate left non-contoured, or the medial helical plating technique by pre-contouring the plate to a 180° helical shape and fixing its distal end to the medial femoral condyle (n=6). An unstable extraarticular distal femoral fracture was subsequently simulated by means of an osteotomy gap. All specimens were tested under quasi-static and progressively increasing cyclic axial und torsional loading until failure. Interfragmentary movements were monitored by means of optical motion tracking. Results. Initial axial stiffness was significantly higher for helical (185.6±50.1 N/mm) versus straight (56.0±14.4) plating, p<0.01. However, initial torsional stiffness in internal and external rotation remained not significantly different between the two fixation techniques (helical plating:1.59±0.17 Nm/° and 1.52±0.13 Nm/°; straight plating: 1.50±0.12 Nm/° and 1.43±0.13Nm/°), p≥0.21. Helical plating was associated with significantly higher initial interfragmentary movements under 500 N static compression compared to straight plating in terms of flexion (2.76±1.02° versus 0.87±0.77°) and shear displacement under 6 Nm static rotation in internal (1.23±0.28° versus 0.40±0.42°) and external (1.21±0.40° versus 0.57±0.33°) rotation, p≤0.01. In addition, helical plating demonstrated significantly lower initial varus/valgus deformation than straight plating (4.08±1.49° versus 6.60±0.47°), p<0.01. Within the first 10000 cycles of dynamic loading, helical plating revealed significantly bigger flexural movements and significantly lower varus/valgus deformation versus straight plating, p=0.02. No significant differences were observed between the two fixation techniques in terms of axial and shear displacement, p≥0.76. Cycles to failure was significantly higher for helical plating (13752±1518) compared to straight plating (9727±836), p<0.01. Conclusions. Although helical plating using a pre-contoured LCP-DF was associated with higher shear and flexion movements, it demonstrated improved initial axial stability and resistance against varus/valgus deformation compared to straight lateral plating. Moreover, helical plate constructs demonstrated significantly improved endurance to failure, which may be attributed to the less progressively increasing lever bending moment arm inherent to this novel fixation technique. From a biomechanical perspective, helical plating may be considered as a valid alternative fixation technique to standard straight lateral plating of unstable distal femoral fractures

Summary Statement

Objectifying postoperative recovery of patients with comminuted tibial plateau fractures treated with a unilateral plate trough the use of a gait analysis system.

Aims. Dual plating of distal femoral fractures with medial and lateral implants has been performed to improve construct mechanics and alignment, in cases where isolated lateral plating would be insufficient. This may potentially compromise vascularity, paradoxically impairing healing. This study investigates effects of single versus dual plating on distal femoral vascularity. Methods. A total of eight cadaveric lower limb pairs were arbitrarily assigned to either 1) isolated lateral plating, or 2) lateral and medial plating of the distal femur, with four specimens per group. Contralateral limbs served as matched controls. Pre- and post-contrast MRI was performed to quantify signal intensity enhancement in the distal femur. Further evaluation of intraosseous vascularity was done with barium sulphate infusion with CT scan imaging. Specimens were then injected with latex medium and dissection was completed to assess extraosseous vasculature. Results. Quantitative MRI revealed a mean reduction of 21.2% (SD 1.3%) of arterial contribution in the lateral plating group and 25.4% (SD 3.2%) in the dual plating group (p = 0.051); representing a mean decrease in arterial contribution of 4.2%. The only significant difference found between both experimental groups was regionally, at the lateral aspect of the distal femur with a mean drop in arterial contribution in the lateral plating group of 18.9% (SD 2.6%) versus 24.0% (SD 3.2%) in the dual plating group (p = 0.048), representing a mean decrease in arterial contribution of 5.1%. Gross dissection revealed complete destruction of periosteal vessels underneath either medial or lateral plates in both groups. The network of genicular branches contributing to the posterior and distal femoral condyles was preserved in all specimens. A medial vascular pedicle was found dividing from the superficial femoral artery at a mean 12.7 cm (SD 1.7) proximal to the medial epicondyle and was undisrupted in the dual plating group. Conclusion. Lateral locking-plate application resulted in mean 21.2% reduction in distal femur vascularity. Addition of medial plates did not further markedly decrease vascularity. As such, the majority of the vascular insult occurred with lateral plating alone. Supplemental medially based fixation did not lead to marked devascularization of the distal femur, and should therefore be considered in the setting of comminution and poor bone stock in distal femoral fractures. Further clinical research is required to confirm the results of this study. Cite this article: Bone Joint J 2020;102-B(4):530–538

The June 2023 Trauma Roundup. 360. looks at: Aspirin or low-molecular-weight heparin for thromboprophylaxis?; Lateral plating or retrograde nailing for distal femur fractures?; Sciatic nerve palsy after acetabular fixation: what about patient position?; How reliable is the new OTA/AO classification for trochanteric hip fractures?; Young hip fractures: is a medial buttress the answer?; When is the best time to ‘flap’ an open fracture?; The mortality burden of nonoperatively managed hip fractures

It is unclear whether there is a limit to the amount of distal bone required to support fixation of supracondylar periprosthetic femoral fractures. This retrospective multicentre study evaluated lateral locked plating of periprosthetic supracondylar femoral fractures and compared the results according to extension of the fracture distal with the proximal border of the femoral prosthetic component. Between 1999 and 2008, 89 patients underwent lateral locked plating of a supracondylar periprosthetic femoral fracture, of whom 61 patients with a mean age of 72 years (42 to 96) comprising 53 women, were available after a minimum follow-up of six months or until fracture healing. Patients were grouped into those with fractures located proximally (28) and those with fractures that extended distal to the proximal border of the femoral component (33). Delayed healing and nonunion occurred respectively in five (18%) and three (11%) of more proximal fractures, and in two (6%) and five (15%) of the fractures with distal extension (p = 0.23 for delayed healing; p = 0.72 for nonunion, Fisher’s exact test). Four construct failures (14%) occurred in more proximal fractures, and three (9%) in fractures with distal extension (p = 0.51). Of the two deep infections that occurred in each group, one resolved after surgical debridement and antibiotics, and one progressed to a nonunion. Extreme distal periprosthetic supracondylar fractures of the femur are not a contra-indication to lateral locked plating. These fractures can be managed with internal fixation, with predictable results, similar to those seen in more proximal fractures

Introduction: Weber B fractures are one of the most common fractures of the ankle. Unstable fractures are treated with lateral plating and a lag screw. Another method of fixation is antiglide plating, this concept was first introduced by Brunner and Weber in 1982. Manoli and Schaeffer in 1987, showed that fixation by antiglide plate demonstrated superior static biomechanical properties compared to lateral plating. However there are some shortcomings in their study and hence we decided to perform our biomechanical study. The shortcomings of the Manoli study are. They did not use an interfragmentary lag screw for lateral plate fixation. It was a cadaveric study where the bone does not accurately represent the live bone. The quality of the bone ranging from normal to osteoporotic bone varies from cadaver to cadaver and hence there is no uniformity between the samples. Materials and Methods: We used 4th generation composite bone models validated to closely simulate human bone characteristics for fracture toughness, tensile strength, compressive strength, fatigue crack resistance and implant subsidence. 4th generation composite bone model provides uniformity of test samples which is not achievable in cadaveric studies. These bones were custom made for the experiment. We used two sets of bones, one representative of normal bone (Set A n=10) and the other of osteoporotic bone quality (Set B n=10). Each of the sets A & B will have two types of fixations for artificially created Weber B Fractures. Lateral plate with interfragmentary lag screw. Antiglide plate with interfragmentary lag screw. The strength of the fixation was measured by restressing the bone until the fixation failed using an Instron machine which simultaneously applied torque and compressive forces to the fibular construct. The resulting data was analysed on a computer and statistical analysis was performed. Results: When the two fixation constructs were stressed to failure, the lateral plate construct demonstrated less stiffness (3–5Nm/degree) and failed at lower energy levels (250Nm). Similar values obtained for the antiglide system were, stiffness of 12–16Nm/degree and energy absorbed to failure 350–450Nm. Antiglide plating was significantly more stable in the osteoporotic fibula. Conclusion: Antiglide plating with lag screw is much more stable than lateral plating. It is suitable for treatment without plaster cast post operatively. It results in a more stable fixation in osteoporotic bone

The objective of this study was to use patient-specific finite element modeling to measure the 3D interfragmentary strain environment in clinically realistic fractures. The hypothesis was that in the early post-operative period, the tissues in and around the fracture gap can tolerate a state of strain in excess of 10%, the classical limit proposed in the Perren strain theory. Eight patients (6 males, 2 females; ages 22–95 years) with distal femur fractures (OTA/AO 33-A/B/C) treated in a Level I trauma center were retrospectively identified. All were treated with lateral bridge plating. Preoperative computed tomography scans and post-operative X-rays were used to create the reduced fracture models. Patient-specific materials properties and loading conditions (20%, 60%, and 100% body weight (BW)) were applied following our published method.[1]. Elements with von Mises strains >10% are shown in the 100% BW loading condition. For all three loading scenarios, as the bridge span increased, so did the maximum von Mises strain within the strain visualization region. The average gap closing (Perren) strain (mean ± SD) for all patient-specific models at each body weight (20%, 60%, and 100%) was 8.6% ± 3.9%, 25.8% ± 33.9%, and 39.3% ± 33.9%, while the corresponding max von Mises strains were 42.0% ± 29%, 110.7% ± 32.7%, and 168.4% ± 31.9%. Strains in and around the fracture gap stayed in the 2–10% range only for the lowest load application level (20% BW). Moderate loading of 60% BW and above caused gap strains that far exceeded the upper limit of the classical strain rule (<10% strain for bone healing). Since all of the included patients achieved successful unions, these findings suggest that healing of distal femur fractures may be robust to localized strains greater than 10%

Dual plating of the medial and lateral distal femur has been proposed to reduce angular malunion and hardware failure secondary to delayed union or nonunion. This strategy improves the strength and alignment of the construct, but it may compromise the vascularity of the distal femur paradoxically impairing healing. This study investigates the effect of dual plating versus single plating on the perfusion of the distal femur. Ten matched pairs of fresh-frozen cadaveric lower extremities were assigned to either isolated lateral plating or dual plating of a single limb. The contralateral lower extremity was used as a matched control. A distal femoral locking plate was applied to the lateral side of ten legs using a standard sub-vastus approach. Five femurs had an additional 3.5mm reconstruction plate applied to the medial aspect of the distal femur using a medial sub-vastus approach. The superficial femoral artery and the profunda femoris were cannulated at the level of the femoral head. Gadolinium MRI contrast solution (3:1 gadolinium to saline ration) was injected through the arterial cannula. High resolution fat-suppressed 3D gradient echo sequences were completed both with and without gadolinium contrast. Intra-osseous contributions were quantified within a standardized region of interest (ROI) using customized IDL 6.4 software (Exelis, Boulder, CO). Perfusion of the distal femur was assessed in six different zones. The signal intensity on MRI was then quantified in the distal femur and comparison was made between the experimental plated limb and the contralateral, control limb. Following completion of the MRI protocol, the specimens were injected with latex medium and the extra-osseous vasculature was dissected. Quantitative MRI revealed that application of the lateral distal femoral locking plate reduced the perfusion of the distal femur by 21.7%. Within the dual plating group there was a reduction in perfusion by 24%. There was no significant difference in the perfusion between the isolated lateral plate and the dual plating groups. There were no regional differences in perfusion between the epiphyseal, metaphyseal or meta-diaphyseal regions. Specimen dissection in both plating groups revealed complete destruction of any periosteal vessels that ran underneath either the medial or lateral plates. Multiple small vessels enter the posterior condyles off both superior medial and lateral geniculate arteries and were preserved in all specimens. Furthermore, there was retrograde flow to the distal most aspect of the condyles medially and laterally via the inferior geniculate arteries. The medial vascular pedicle was proximal to the medial plate in all the dual plated specimens and was not disrupted by the medial sub-vastus approach in any specimens. Fixation of the distal femur via a lateral sub-vastus approach and application of a lateral locking plate results in a 21% reduction in perfusion to the distal femur. The addition of a medial 3.5mm reconstruction plate does not significantly compromise the vascularity of the distal femur. The majority of the vascular insult secondary to open reduction, internal fixation of the distal femur occurs with application of the lateral locking plate

The extended lateral L-shaped approach for the treatment of displaced intra-articular fractures of the calcaneum may be complicated by wound infection, haematoma, dehiscence and injury to the sural nerve. In an effort to reduce the risk of problems with wound healing a technique was developed that combined open reduction and fixation of the joint fragments and of the anterior process with percutaneous reduction and screw fixation of the tuberosity. A group of 24 patients with unilateral isolated closed Sanders type II and III fractures was treated using this technique and compared to a similar group of 26 patients managed by the extended approach and lateral plating. The operation was significantly shorter (p < 0.001) in the first group, but more minor secondary procedures and removal of heel screws were necessary. There were no wound complications in this group, whereas four minor complications occurred in the second group. The accuracy and maintenance of reduction, and ultimate function were equivalent

Peri-prosthetic fractures above a TKA are becoming increasingly more common, and typically occur at the junction of the anterior flange of the femoral component and the osteopenic metaphyseal distal femur. In the vast majority of cases, the TKA is well fixed and has been functioning well prior to fracture. For fractures above well-fixed components, internal fixation is preferred. Fixation options include retrograde nailing or lateral plating. Nails are typically considered in arthroplasties that allow intercondylar access (“open box PS” or CR implants) and have sufficient length of the distal fragment to allow multiple locking screws to be used. This situation is rare, as most distal fragments are quite short. If a nail is chosen, use of a long nail is preferred, since it allows the additional fixation and alignment that diaphyseal fill affords. Short nails should be discouraged since they can “toggle” in the meta-diaphysis and do not engage the diaphysis to improve coronal alignment. Plates can be used with any implant type and any length of distal fragment. The challenge with either fixation strategy is obtaining stable fixation of the distal fragment while maintaining length, alignment, and rotation. Fixation opportunities in the distal fragment can be limited due to obstacles caused by femoral component lugs, boxes, stems, cement mantles, and areas of stress shielding or osteolysis. Modern lateral locked plates can be inserted in a biologically friendly submuscular extra-periosteal fashion. The goal of fixation is to obtain as many long locked screws in the distal fragment as possible. High union rates have been reported with modern locked plating and nailing techniques, however, biplanar fluoroscopic vigilance is required to prevent malalignments, typically valgus, distraction, and distal fragment hyperextension. For certain fractures, distal femoral replacement (DFR) is a wise choice. The author reserves DFR for situations where internal fixation is likely to fail (severe distal osteolysis, severe osteopenia) or for cases where it has already failed (nonunion). Obviously, if the implant is loose, revision is indicated, and typically the distal bone loss is so severe that a distal femoral replacement is indicated. The author prefers cemented constructs and routinely adds antibiotics to the cement mixture. Careful attention to posterior dissection of the distal fragment is recommended to avoid neurovascular injury. Cementing the femoral component in the proper amount of external rotation is important to allow central patellar tracking. The available literature demonstrates excellent functional results with these reconstructions, however, complications are not uncommon. Infection and extensor mechanism complications are the most frequent complications and are best avoided. In summary, ORIF remains the treatment of choice for these fractures, however, for cases where ORIF is likely to fail, or has failed, DFR remains a predictable salvage option

Peri-prosthetic fractures above a TKA are becoming increasingly more common, and typically occur at the junction of the anterior flange of the femoral component and the osteopenic metaphyseal distal femur. In the vast majority of cases the TKA is well fixed and has been functioning well prior to fracture. For loose components, revision is typically indicated. Typically a megaprosthesis is required. Well-fixed components, internal fixation is preferred. Fixation options include retrograde nailing or lateral plating. Nails are typically considered in arthroplasties that allow intercondylar access (“open box PS” or CR implants) and have sufficient length of the distal fragment to allow multiple locking screws to be used. This situation is rare, as most distal fragments are quite short. If a nail is chosen, use of a long nail is preferred, since it allows the additional fixation and alignment that diaphyseal fill affords. Short nails should be discouraged since they can “toggle” in the meta-diaphysis and do not engage the diaphysis to improve coronal alignment. Plates can be used with any implant type and any length of distal fragment. The challenge with either fixation strategy is obtaining stable fixation of the distal fragment while maintaining length, alignment, and rotation. Fixation opportunities in the distal fragment can be limited due to obstacles caused by femoral component lugs, boxes, stems, cement mantles, and areas of stress shielding or osteolysis. Modern lateral locked plates can be inserted in a biologically friendly submuscular extra-periosteal fashion. More recent developments with polyaxial locked screws (that allow angulation prior to end-point locking) may offer even more versatility when distal fragment fixation is challenging. The goal of fixation is to obtain as many long locked screws in the distal fragment as possible. High union rates have been reported with modern locked plating techniques, however, biplanar fluoroscopic vigilance is required to prevent malalignments, typically valgus, distraction, and distal fragment hyperextension

The April 2023 Trauma Roundup³⁶⁰ looks at: Displaced femoral neck fractures in patients aged 55 to 70 years: internal fixation or total hip arthroplasty?; Tibial plateau fractures: continuous passive motion approves range of motion; Lisfranc fractures: to fuse or not to fuse, that is the question; Is hardware removal after clavicle fracture plate fixation beneficial?; Fixation to coverage in Grade IIIB open fractures – what’s the time window?; Nonoperative versus locking plate fixation in the proximal humerus; Retrograde knee nailing or lateral plate for distal femur fractures?

Peri-prosthetic fractures above a total knee arthroplasty (TKA) are becoming increasingly more common, and typically occur at the junction of the anterior flange of the femoral component and the osteopenic metaphyseal distal femur. In the vast majority of cases the TKA is well-fixed and has been functioning well prior to fracture. For loose components, revision is typically indicated. Typically a megaprosthesis is required. For well-fixed components, internal fixation is preferred. Fixation options include retrograde nailing or lateral plating. Nails are typically considered in arthroplasties that allow intercondylar access (“open box PS” or CR implants) and have sufficient length of the distal fragment to allow multiple locking screws to be used. This situation is rare, as most distal fragments are quite short. If a nail is chosen, use of a long nail is preferred, since it allows the additional fixation and alignment that diaphyseal fill affords. Short nails should be discouraged since they can “toggle” in the meta-diaphysis and do not engage the diaphysis to improve coronal alignment. Plates can be used with any implant type and any length of distal fragment. The challenge with either fixation strategy is obtaining stable fixation of the distal fragment while maintaining length, alignment, and rotation. Fixation opportunities in the distal fragment can be limited due to obstacles caused by femoral component lugs, boxes, stems, cement mantles, and areas of stress shielding or osteolysis. Modern lateral locked plates can be inserted in a biologically friendly submuscular extra-periosteal fashion. More recent developments with polyaxial locked screws (that allow angulation prior to end-point locking) may offer even more versatility when distal fragment fixation is challenging. The goal of fixation is to obtain as many long locked screws in the distal fragment as possible. High union rates have been reported with modern locked plating techniques, however, biplanar fluoroscopic vigilance is required to prevent malalignments, typically valgus, distraction, and distal fragment hyperextension

The August 2023 Trauma Roundup³⁶⁰ looks at: A comparison of functional cast and volar-flexion ulnar deviation for dorsally displaced distal radius fractures; Give your stable ankle fractures some AIR!; Early stabilization of rib fractures – an effective thing to do?; Locked plating versus nailing for proximal tibia fractures: A multicentre randomized controlled trial; Time to flap coverage in open tibia fractures; Does tranexamic acid affect the incidence of heterotropic ossification around the elbow?; High BMI – good or bad in surgical fixation of hip fractures?

Periprosthetic femoral shaft fractures are a significant complication of total hip arthroplasty. Plate osteosynthesis with or without onlay strut allograft has been the mainstay of treatment around well-fixed stems. Nonunions are a rare, challenging complication of this fixation method. The number of published treatment strategies for periprosthetic femoral nonunions are limited. In this series, we report the outcomes of a novel orthogonal plating surgical technique for addressing nonunions in the setting of Vancouver B1 and C-type periprosthetic fractures that previously failed open reduction internal fixation (ORIF). A retrospective chart review of all patients from 2010 to 2014 with Vancouver B1/C total hip arthroplasty periprosthetic femoral nonunions was performed. All patients were treated primarily with ORIF. Nonunion was defined as no radiographic signs of fracture healing nine months post-operatively, with or without hardware failure. Exclusion criteria included open fractures and periprosthetic infections. The technique utilised a mechanobiologic strategy of atraumatic exposure, resection of necrotic tissue, bone grafting with adjuvant recombinant growth factor and revision open reduction internal fixation. Initially, compression was achieved using an articulated tensioning device and application of an anterior plate. This was followed by locked lateral plating. Patients remained non-weight bearing for eight weeks. Six Vancouver B1/C periprosthetic femoral nonunions were treated. Five patients were female with an average age of 80.3 years (range 72–91). The fractures occurred at a mean of 5.8 years (range 1–10) from their initial arthroplasty procedure. No patients underwent further revision surgery; there were no wound dehiscence, hardware failures, infections, or surgical complications. All patients had a minimum of nine months follow up (mean 16.6, range 9–36). All fractures achieved osseous union, defined as solid bridging callus over at least two cortices and pain free, independent ambulation, at an average of 24.4 weeks (range 6.1–39.7 weeks). To our knowledge, this is the first case series describing 90–90 locked compression plating using modern implants for periprosthetic femoral nonunions. This is a rare but challenging complication of total hip arthroplasty and we present a novel solution with satisfactory preliminary outcomes. Orthogonal locked compression plating utilising an articulated tensioning device and autograft with adjuvant osteoinductive allograft should be considered in periprosthetic femur fractures around a well-fixed stem. Further biomechanical and clinical research is needed to improve our treatment strategies in this population

The April 2024 Trauma Roundup³⁶⁰ looks at: The infra-acetabular screw in acetabular fracture surgery; Is skin traction helpful in patients with intertrochanteric hip fractures?; Reducing pain and improving function following hip fracture surgery; Are postoperative splints helpful following ankle fracture fixation?; Biomechanics of internal fixation in Hoffa fractures: a comparison of four different constructs; Dual-plate fixation of periprosthetic distal femur fractures; Do direct oral anticoagulants necessarily mean a delay to hip fracture surgery?; Plate or retrograde nail for low distal femur fractures?.

The October 2023 Trauma Roundup³⁶⁰ 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.

Background. To establish relative fixation strengths of a single lateral locking plate, a double locking plate, and a tibial nail in treatment of proximal tibial extra-articular fractures. Methods. Three groups of composite tibial synthetic bones consisting of 5 specimens per group were included; lateral plating (LP) using a LCP-PLT (locking compression plate-proximal lateral tibia), double plating (DP) using a LCP-PLT and a LCP-MPT (locking compression plate-medial proximal tibia), and intramedullary nailing (IN) using an ETN (expert tibial nail). To simulate a comminuted fracture model, a gap osteotomy measuring 1 cm was cut 8 cm below the joint. For each tibia, a minimal preload of 100N was applied before loading to failure. A vertical load was applied at 25mm/min until tibia failure. Results. For axial loading, fixation strength of DP (14387.3N, SD=1852.1) was 17.5% greater than that of LP (12249.3N, SD=1371.6), and 60% less than that of IN (22879.6N, SD=1578.8) (p<0.001). For ultimate displacement in axial loading, similar results were observed for LP (5.74mm, SD=1.01) and DP (4.45mm, SD=0.96), with a larger displacement for IN (5.84mm, SD=0.99). Conclusion. In biomechanical testing of a comminuted proximal tibial fracture model, DP proved stronger than LP in terms of ultimate strength. IN proved strongest; however, DP may be an acceptable alternative for minimally invasive osteosynthesis, which may be technically difficult to fix using a nail

Practice variation may occur when there is no standardised approach to specific clinical problems and there is a lack of scientific evidence for alternative treatments. Practice variation suggests that a segment of the patient population may be managed sub-optimally, and indicates a need for further research in order to establish stronger evidence-based practice guidelines. We surveyed Australian orthopaedic surgeons to examine practice variation in common orthopaedic presentations. In February 2009, members of the Australian Orthopaedic Association were emailed an online survey, which collected information regarding experience level (number of years as a consultant), sub-specialty interests, state where the surgeon works, on- call participation, as well as five common (anecdotally controversial) orthopaedic trauma cases with a number of management options. Surgeons were asked to choose their one most likely management choice from the list provided, which was either surgical or non-surgical in nature. A reminder was sent two weeks later. Exploratory regression was modeled to examine the predictors of choosing surgical management for each case and overall. Of 760 surgeons, 358 (47%) provided responses. For undisplaced scaphoid fractures, respondents selected short-arm cast (53%), ORIF (22%), percutaneous screw (22%) and long-arm cast (3%). Less experienced (0 to 5 years) (p=0.006) and hand surgeons (p=0.008) were more likely to operate. For a displaced mid-shaft clavicle fracture, respondents selected non-operative (62%), plating (31%) and intramedullary fixation (7%). Shoulder surgeons were more likely to operate (p<0.001). For an undisplaced Weber B lateral malleolus fracture, respondents selected plaster cast or boot (59%), lateral plating (31%), posterior plating (9%) and no splinting (2%). For a displaced Colles fracture in an older patient, respondents selected plating (47%), Kirschner wires (28%), cast/splint (23%) and external fixation (1%). Less experienced (p<0.001) and hand surgeons (p=0.024) were more likely to operate. For a two-part neck of humerus fracture in an older patient, respondents selected non-operative (74%), locking plate (14%), and hemiarthroplasty (7%). Shoulder surgeons were more likely to operate (p<0.001). Accounting for all answers in multiple regression modeling, it was found that more experienced surgeons (>15 years) were 25% less likely to operate (p=0.001). Overall, there was no difference among sub-specialties, or whether a surgeon participated in an on-call roster. Considerable practice variation exists among orthopaedic surgeons in the approach to common orthopaedic problems. Surgeons who identify with a sub-specialty are more likely to manage conditions in their area of interest operatively, and more experienced surgeons are less likely to recommend surgical management

Peri-prosthetic fractures above a TKA are becoming increasingly more common, and typically occur at the junction of the anterior flange of the femoral component and the osteopenic metaphyseal distal femur. In the vast majority of cases the TKA is well fixed and has been functioning well prior to fracture. For loose components, revision is typically indicated. Often, distal femoral mega prostheses are required to deal with metaphyseal bone loss. Good results have been reported in small series, however, complications, including infection remain concerning, and these implants are incredibly expensive. Although performing a mega prosthesis in the setting of a well fixed TKA is not unreasonable due to immediate full weight bearing, in my opinion, prosthetic replacement should be limited to cases of failed ORIF (rare), or in cases where fixation is likely to fail (i.e., severe osteolysis distally). For the majority of fractures above well fixed components, internal fixation is preferred for the main reason that the overwhelming majority of these fractures will heal. Fixation options include retrograde nailing or lateral locked plating. Nails are typically considered in arthroplasties that allow intercondylar access (“open box PS” or CR implants) and have sufficient length of the distal fragment to allow multiple locking screws to be used. This situation is rare, as most distal fragments are quite short. If a nail is chosen, use of a long nail is preferred, since it allows the additional fixation and alignment that diaphyseal fill affords. Short nails should be discouraged since they can “toggle” in the meta-diaphysis and do not engage the diaphysis to improve coronal alignment. Plates can be used with any implant type and any length of distal fragment. The challenge with either fixation strategy is obtaining stable fixation of the distal fragment while maintaining length, alignment, and rotation. Fixation opportunities in the distal fragment can be limited due to obstacles caused by femoral component lugs, boxes, stems, cement mantles, and areas of stress shielding or osteolysis. Modern lateral locked plates can be inserted in a biologically friendly submuscular extra-periosteal fashion. More recent developments with polyaxial locked screws (that allow angulation prior to end-point locking) may offer even more versatility when distal fragment fixation is challenging. The goal of fixation is to obtain as many long locked screws in the distal fragment as possible. High union rates have been reported with modern locked plating techniques, however, biplanar fluoroscopic vigilance is required to prevent malalignments, typically valgus, distraction, and distal fragment hyperextension

Lateral malleolar plating is associated with complication rates of up to 30%. The fibular nail is an alternative fixation technique, requiring a minimal incision and tissue dissection, with the potential to reduce the incidence of complications. We reviewed our results of 105 unstable ankle fractures fixed with the Acumed fibular nail between 2002 and 2010. The mean age was 65 years and 72% of patients had significant systemic medical comorbidities. A number of different locking screw configurations were assessed over the study period. A proximal blocking screw resulted in satisfactory stability in 93%, single locking screws in 86%, but nailing without locking in only 66%, leading to the development of our current technique. Of the twenty-one patients treated with this technique there have been no significant complications, and only two superficial wound infections. Good fracture reduction was achieved in all of these patients. The mean physical component SF12, Olerud and Molander and Foot and Ankle Outcome scores were 46, 65 and 83 respectively. The outcomes of unstable ankle fractures managed with the fibular nail are encouraging, with good radiographic and functional outcomes and minimal complications. This technique should be considered in the management of debilitated patients with unstable ankle fractures

Aims

Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients’ long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques.

Peri-prosthetic fractures above a TKA are becoming increasingly more common, and typically occur at the junction of the anterior flange of the femoral component and the osteopenic metaphyseal distal femur. In the vast majority of cases the TKA is well-fixed and has been functioning well prior to fracture. For loose components, revision is typically indicated. Often, distal femoral mega prostheses are required to deal with metaphyseal bone loss. Good results have been reported in small series, however, complications, including infection remain concerning, and these implants are incredibly expensive. Although performing a mega prosthesis in the setting of a well-fixed TKA is not unreasonable due to immediate full weight bearing, in my opinion, prosthetic replacement should be limited to cases of failed ORIF (rare), or in cases where fixation is likely to fail (i.e., severe osteolysis distally). For the majority of fractures above well-fixed components, internal fixation is preferred for the main reason that the overwhelming majority of these fractures will heal. Fixation options include retrograde nailing or lateral locked plating. Nails are typically considered in arthroplasties that allow intercondylar access (“open box PS” or CR implants) and have sufficient length of the distal fragment to allow multiple locking screws to be used. This situation is rare, as most distal fragments are quite short. If a nail is chosen, use of a long nail is preferred, since it allows the additional fixation and alignment that diaphyseal fill affords. Short nails should be discouraged since they can “toggle” in the meta-diaphysis and do not engage the diaphysis to improve coronal alignment. Plates can be used with any implant type and any length of distal fragment. The challenge with either fixation strategy is obtaining stable fixation of the distal fragment while maintaining length, alignment, and rotation. Fixation opportunities in the distal fragment can be limited due to obstacles caused by femoral component lugs, boxes, stems, cement mantles, and areas of stress shielding or osteolysis. Modern lateral locked plates can be inserted in a biologically friendly submuscular extra-periosteal fashion. More recent developments with polyaxial locked screws (that allow angulation prior to end-point locking) may offer even more versatility when distal fragment fixation is challenging. The goal of fixation is to obtain as many long locked screws in the distal fragment as possible. High union rates have been reported with modern locked plating techniques, however, biplanar fluoroscopic vigilance is required to prevent malalignments, typically valgus, distraction, and distal fragment hyperextension

We describe the technique and results of medial submuscular plating of the femur in paediatric patients and discuss its indications and limitations. Specifically, the technique is used as part of a plate-after-lengthening strategy, where the period of external fixation is reduced and the plate introduced by avoiding direct contact with the lateral entry wounds of the external fixator pins. The technique emphasises that vastus medialis is interposed between the plate and the vascular structures.

A total of 16 patients (11 male and five female, mean age 9.6 years (5 to 17)), had medial submuscular plating of the femur. All underwent distraction osteogenesis of the femur with a mean lengthening of 4.99 cm (3.2 to 12) prior to plating. All patients achieved consolidation of the regenerate without deformity. The mean follow-up was 10.5 months (7 to 15) after plating for those with plates still in situ, and 16.3 months (1 to 39) for those who subsequently had their plates removed. None developed a deep infection. In two patients a proximal screw fractured without loss of alignment; one patient sustained a traumatic fracture six months after removal of the plate.

Placing the plate on the medial side is advantageous when the external fixator is present on the lateral side, and is biomechanically optimal in the presence of a femoral defect. We conclude that medial femoral submuscular plating is a useful technique for specific indications and can be performed safely with a prior understanding of the regional anatomy.

Cite this article: Bone Joint J 2014;96-B:137–42.

Aims

Computer hexapod assisted orthopaedic surgery (CHAOS), is a method to achieve the intra-operative correction of long bone deformities using a hexapod external fixator before definitive internal fixation with minimally invasive stabilisation techniques.

The aims of this study were to determine the reliability of this method in a consecutive case series of patients undergoing femoral deformity correction, with a minimum six-month follow-up, to assess the complications and to define the ideal group of patients for whom this treatment is appropriate.

Objectives

This study tests the biomechanical properties of adjacent locked plate constructs in a femur model using Sawbones. Previous studies have described biomechanical behaviour related to inter-device distances. We hypothesise that a smaller lateral inter-plate distance will result in a biomechanically stronger construct, and that addition of an anterior plate will increase the overall strength of the construct.

Techniques for fixation of fractures of the lateral malleolus have remained essentially unchanged since the 1960s, but are associated with complication rates of up to 30%. The fibular nail is an alternative method of fixation requiring a minimal incision and tissue dissection, and has the potential to reduce the incidence of complications.

We reviewed the results of 105 patients with unstable fractures of the ankle that were fixed between 2002 and 2010 using the Acumed fibular nail. The mean age of the patients was 64.8 years (22 to 95), and 80 (76%) had significant systemic medical comorbidities. Various different configurations of locking screw were assessed over the study period as experience was gained with the device. Nailing without the use of locking screws gave satisfactory stability in only 66% of cases (4 of 6). Initial locking screw constructs rendered between 91% (10 of 11) and 96% (23 of 24) of ankles stable. Overall, seven patients had loss of fixation of the fracture and there were five post-operative wound infections related to the distal fibula. This lead to the development of the current technique with a screw across the syndesmosis in addition to a distal locking screw. In 21 patients treated with this technique there have been no significant complications and only one superficial wound infection. Good fracture reduction was achieved in all of these patients. The mean physical component Short-Form 12, Olerud and Molander score, and American Academy of Orthopaedic Surgeons Foot and Ankle outcome scores at a mean of six years post-injury were 46 (28 to 61), 65 (35 to 100) and 83 (52 to 99), respectively. There have been no cases of fibular nonunion.

Nailing of the fibula using our current technique gives good radiological and functional outcomes with minimal complications, and should be considered in the management of patients with an unstable ankle fracture.

Although gradual bone transport may permit the restoration of large-diameter bones, complications are common owing to the long duration of external fixation. In order to reduce such complications, a new technique of bone transport involving the use of an external fixator and a locking plate was devised for segmental tibial bone defects.

A total of ten patients (nine men, one woman) with a mean age at operation of 40.4 years (16 to 64) underwent distraction osteogenesis with a locking plate to treat previously infected post-traumatic segmental tibial defects. The locking plate was fixed percutaneously to bridge proximal and distal segments, and was followed by external fixation. After docking, percutaneous screws were fixed at the transported segment through plate holes. At the same time, bone grafting was performed at the docking site with the external fixator removed.

The mean defect size was 5.9 cm (3.8 to 9.3) and mean external fixation index was 13.4 days/cm (11.8 to 19.5). In all cases, primary union of the docking site and distraction callus was achieved, with an excellent bony result. There was no recurrence of deep infection or osteomyelitis, and with the exception of one patient with a pre-existing peroneal nerve injury, all achieved an excellent or good functional result.

With short external fixation times and low complication rates, bone transport with a locking plate could be recommended for patients with segmental tibial defects.

Cite this article: Bone Joint J 2013;95-B:1667–72.

The operative treatment of displaced fractures of the tibial plateau is challenging. Recent developments in the techniques of internal fixation, including the development of locked plating and minimal invasive techniques have changed the treatment of these fractures. We review current surgical approaches and techniques, improved devices for internal fixation and the clinical outcome after utilisation of new methods for locked plating.

The October 2014 Foot & Ankle Roundup360 looks at: multilayer compression bandaging superior for post-traumatic ankle oedema; compression stockings for ankle fractures; weight bearing ok in Achilles tendon ruptures; MRI findings can predict ankle sprain symptoms; salvage for malreduced ankle fractures; locking fibular plates are more expensive; is fixation better early or late in pilon fractures?; and calcaneal fracture fixation not for subtalar arthropathy

We investigated the stability of seven Schatzker type II fractures of the lateral tibial plateau treated by subchondral screws and a buttress plate followed by immediate partial weight-bearing. In order to assess the stability of the fracture, weight-bearing inducible displacements of the fracture fragments and their migration over a one-year period were measured by differentially loaded radiostereometric analysis and standard radiostereometric analysis, respectively. The mean inducible craniocaudal fracture fragment displacements measured −0.30 mm (−0.73 to 0.02) at two weeks and 0.00 mm (−0.12 to 0.15) at 52 weeks. All inducible displacements were elastic in nature under all loads at each examination during follow-up. At one year, the mean craniocaudal migration of the fracture fragments was −0.34 mm (−1.64 to 1.51).

Using radiostereometric methods, this case series has shown that in the Schatzker type II fractures investigated, internal fixation with subchondral screws and a buttress plate provided adequate stability to allow immediate post-operative partial weight-bearing, without harmful consequences.

Heterotopic ossification occurring after the use of commercially available bone morphogenetic proteins has not been widely reported. We describe four cases of heterotopic ossification in patients treated with either recombinant bone morphogenetic protein 2 or recombinant bone morphogenetic protein 7. We found that while some patients were asymptomatic, heterotopic ossification which had occurred around a joint often required operative excision with good results.