Aims. In our unit, we adopt a two-stage surgical reconstruction approach using internal fixation for the management of infected Charcot foot deformity. We evaluate our experience with this functional limb salvage method. Methods. We conducted a retrospective analysis of prospectively collected data of all patients with infected Charcot foot deformity who underwent two-stage reconstruction with internal fixation between July 2011 and November 2019, with a minimum of 12 months’ follow-up. Results. We identified 23 feet in 22 patients with a mean age of 56.7 years (33 to 70). The mean postoperative follow-up period was 44.7 months (14 to 99). Limb salvage was achieved in all patients. At one-year follow-up, all ulcers have healed and independent full weightbearing mobilization was achieved in all but one patient. Seven patients developed new mechanical skin breakdown; all went on to heal following further interventions. Fusion of the hindfoot was achieved in 15 of 18 feet (83.3%). Midfoot fusion was achieved in nine of 15 patients (60%) and six had stable and painless fibrous nonunion. Hardware failure occurred in five feet, all with broken dorsomedial locking plate. Six patients required further surgery, two underwent revision surgery for infected nonunion, two for removal of metalwork and exostectomy, and two for dynamization of the hindfoot nail. Conclusion. Two-stage reconstruction of the infected and deformed Charcot foot using internal fixation and following the principle of ‘long-segment, rigid and durable internal fixation, with optimal bone opposition and local antibiotic elusion’ is a good form of treatment provided a multidisciplinary care plan is delivered. Cite this article: Bone Joint J 2021;103-B(10):1611–1618

Aims. In contrast to operations performed for other fractures, there is a high incidence rate of surgical site infection (SSI) post-open reduction and internal fixation (ORIF) done for tibial plateau fractures (TPFs). This study investigates the effect of induced membrane technique combined with internal fixation for managing SSI in TPF patients who underwent ORIF. Methods. From April 2013 to May 2017, 46 consecutive patients with SSI post-ORIF for TPFs were managed in our centre with an induced membrane technique. Of these, 35 patients were included for this study, with data analyzed in a retrospective manner. Results. All participants were monitored for a mean of 36 months (24 to 62). None were subjected to amputations. A total of 21 patients underwent two-stage surgeries (Group A), with 14 patients who did not receive second-stage surgery (Group B). Group A did not experience infection recurrence, and no implant or cement spacer loosening was noted in Group B for at least 24 months of follow-up. No significant difference was noted in the Lower Extremity Functional Scale (LEFS) and the Hospital for Special Surgery Knee Score (HSS) between the two groups. The clinical healing time was significantly shorter in Group B (p＜0.001). Those with longer duration of infection had poorer functional status (p＜0.001). Conclusion. Management of SSI post-ORIF for TPF with induced membrane technique combined with internal fixation represents a feasible mode of treatment with satisfactory outcomes in terms of infection control and functional recovery. Cite this article: Bone Joint Res 2021;10(7):380–387

We report a prospective single-blind controlled study of the incidence of early wound infection after internal fixation for trauma in 609 patients, of whom 132 were HIV-positive. Wounds were assessed for healing using the ASEPSIS score. There was no significant difference in the rate of infection between HIV-positive and HIV-negative patients undergoing clean surgery (4.2% vs 6%, respectively; p = 0.65). HIV-positive patients did not receive additional antibiotic prophylaxis or antiretroviral therapy as part of their management. The difference in the rate of infection between HIV-positive and HIV-negative patients with an open fracture or other contamination was not significant (33% vs 15%, respectively; p = 0.064). There was no relationship between CD4 count and infection rate. HIV status did not significantly influence the number of secondary surgical procedures (p = 0.183) or the likelihood of developing chronic osteomyelitis (p = 0.131). Although previous contamination from the time of injury was a risk factor for infection in mal- and nonunions, it was not significantly increased in HIV-positive patients (p = 0.144). We conclude that clean implant surgery in HIV-positive patients is safe, with no need for additional prophylaxis

Objectives. The aim of this study was to compare the biomechanical stability and clinical outcome of external fixator combined with limited internal fixation (EFLIF) and open reduction and internal fixation (ORIF) in treating Sanders type 2 calcaneal fractures. Methods. Two types of fixation systems were selected for finite element analysis and a dual cohort study. Two fixation systems were simulated to fix the fracture in a finite element model. The relative displacement and stress distribution were analysed and compared. A total of 71 consecutive patients with closed Sanders type 2 calcaneal fractures were enrolled and divided into two groups according to the treatment to which they chose: the EFLIF group and the ORIF group. The radiological and clinical outcomes were evaluated and compared. Results. The relative displacement of the EFLIF was less than that of the plate (0.1363 mm to 0.1808 mm). The highest von Mises stress value on the plate was 33% higher than that on the EFLIF. A normal restoration of the Böhler angle was achieved in both groups. No significant difference was found in the clinical outcome on the American Orthopedic Foot and Ankle Society Ankle Hindfoot Scale, or on the Visual Analogue Scale between the two groups (p > 0.05). Wound complications were more common in those who were treated with ORIF (p = 0.028). Conclusions. Both EFLIF and ORIF systems were tested to 160 N without failure, showing the new construct to be mechanically safe to use. Both EFLIF and ORIF could be effective in treating Sanders type 2 calcaneal fractures. The EFLIF may be superior to ORIF in achieving biomechanical stability and less blood loss, shorter surgical time and hospital stay, and fewer wound complications. Cite this article: M. Pan, L. Chai, F. Xue, L. Ding, G. Tang, B. Lv. Comparisons of external fixator combined with limited internal fixation and open reduction and internal fixation for Sanders type 2 calcaneal fractures: Finite element analysis and clinical outcome. Bone Joint Res 2017;6:433–438. DOI: 10.1302/2046-3758.67.2000640

A consecutive series of 320 patients with an intracapsular fracture of the hip treated with a dynamic locking plate (Targon Femoral Neck (TFN)) were reviewed. All surviving patients were followed for a minimum of two years. During the follow-up period 109 patients died.

There were 112 undisplaced fractures, of which three (2.7%) developed nonunion or re-displacement and five (4.5%) developed avascular necrosis of the femoral head. Revision to an arthroplasty was required for five patients (4.5%). A further six patients (5.4%) had elective removal of the plate and screws.

There were 208 displaced fractures, of which 32 (15.4%) developed nonunion or re-displacement and 23 (11.1%) developed avascular necrosis. A further four patients (1.9%) developed a secondary fracture around the TFN. Revision to a hip replacement was required for 43 patients (20.7%) patients and a further seven (3.3%) had elective removal of the plate and screws.

It is suggested that the stronger distal fixation combined with rotational stability may lead to a reduced incidence of complications related to the healing of the fracture when compared with other contemporary fixation devices but this needs to be confirmed in further studies.

Cite this article: Bone Joint J 2013;95-B:1402–5.

Aims

The objective of this study was to investigate bone healing after internal fixation of displaced femoral neck fractures (FNFs) with the Dynamic Locking Blade Plate (DLBP) in a young patient population treated by various orthopaedic (trauma) surgeons.

We compared a new fixation system, the Targon Femoral Neck (TFN) hip screw, with the current standard treatment of cannulated screw fixation. This was a single-centre, participant-blinded, randomised controlled trial. Patients aged 65 years and over with either a displaced or undisplaced intracapsular fracture of the hip were eligible. The primary outcome was the risk of revision surgery within one year of fixation.

A total of 174 participants were included in the trial. The absolute reduction in risk of revision was of 4.7% (95% CI 14.2 to 22.5) in favour of the TFN hip screw (chi-squared test, p = 0.741), which was less than the pre-specified level of minimum clinically important difference. There were no significant differences in any of the secondary outcome measures.

We found no evidence of a clinical difference in the risk of revision surgery between the TFN hip screw and cannulated screw fixation for patients with an intracapsular fracture of the hip.

Cite this article: Bone Joint J 2014;96-B:652–7.

Introduction. Circular external fixators are fundamental to lower limb reconstruction, primarily in situations with a high risk of infection such as open fractures. During the Covid-19 pandemic, use of circular frames in our unit decreased, following departmental approval, due to resource management and in keeping with BOA guidelines as we opted to “consider alternative techniques for patients who require soft tissue reconstruction to avoid multiple operations”. These alternatives included the use of internal fixation (plate osteosynthesis and intramedullary nailing) as a measure to reduce the number of hospital attendances for patients and to conserve resources. This change in practice has continued in part following the pandemic with the increased use of internal fixation in cases previously deemed unsuitable for such techniques. We present our experience of this treatment strategy in the management of complex lower limb injuries, focusing on outcomes and consider the lessons learnt. Materials & Methods. Data of patients with complex lower limb injuries treated before, during and after the pandemic were collected from our in-house trauma database, theatre records and follow up clinics. The rationale for choosing other techniques over a circular frame, the type of alternative technique used, the cost of such alternatives, the need for soft tissue reconstruction, time to recovery, complications and amputation rates were compared among groups. Results. These data suggest comparable outcomes between circular frames and alternative techniques can be achieved. A notable reduction in the number of circular frames applied during the review period was observed. Furthermore, frame fixation was associated with more frequent outpatient review and the associated implications for resource management. Conclusions. Conclusion: The Covid-19 pandemic has posed great challenges to the Trauma and Orthopaedic community, forcing us to be flexible by adopting alternative treatment methods to traditional circular external fixation. These alternatives have proven feasible and potentially more cost effective, prompting their adoption in the post pandemic era. However, this change of practice is not without potential consequences and continued investigation is warranted

Introduction and Objective. Postoperative management regimes vary following open reduction and internal fixation of unstable ankle fractures. There is an evolving understanding that poorer outcomes could be associated with non-weight bearing protocols and immobilisation. Traditional non-weight bearing cast immobilisation may prevent loss of fixation, and this practice continues in many centres. The aim of this systematic review and meta-analysis is to compare the complication rate and functional outcomes of early weight-bearing (EWB) versus late weight-bearing (LWB) following open reduction and internal fixation of ankle fractures. Materials and Methods. We performed a systematic review with a meta-analysis of controlled trials and comparative cohort studies. MEDLINE (via PubMed), Embase and the Cochrane Library electronic databases were searched inclusive of all date up to the search time. We included all studies that investigated the effect of weight-bearing following adults ankle fracture fixation by any means. All ankle fracture types, including isolated lateral malleolus fractures, isolated medial malleolus fractures, bi-malleolar fractures, tri-malleolar fractures and Syndesmosis injuries, were included. All weight-bearing protocols were considered in this review, i.e. immediate weight-bearing (IMW) within 24 hours of surgery, early weight-bearing (EWB) within three weeks of surgery, non-weight-bearing for 4 to 6 weeks from the surgery date (or late weight-bearing LWB). Studies that investigated mobilisation but not weight-bearing, non-English language publications and tibial Plafond fractures were excluded from this systematic review. We assessed the risk of bias using ROB 2 tools for randomised controlled trials and ROBINS-1 for cohort studies. Data extraction was performed using Covidence online software and meta-analysis by using RevMan 5.3. Results. After full-text review, fourteen studies (871 patients with a mean age ranged from 35 to 57 years) were deemed eligible for this systematic review; ten randomised controlled trials and four comparative cohort studies. Most of the included studies were rated as having some concern with regard to the risk of bias. There is no important difference in the infection rate between protected EWB and LWB groups (696 patients in 12 studies). The risk ratio (RR) is 1.30, [95% CI 0.74 to 2.30], I. 2. = 0%, P = 0.36). Other complications were rare. The Olerud-Molander Ankle Score (OMAS) was the widely used patient-reported outcome measure after ankle fracture fixation among the studies. The result of the six weeks OMAS analysis (three RCTs) was markedly in favour of the early weight-bearing group (MD = 10.08 [95% CI 5.13 to 15.02], I. 2. = 0%P = <0.0001). Conclusions. The risk of postoperative complications is an essential factor when considering EWB. We found that the overall incidence of surgical site infection was 6%. When comparing the two groups, the incidence was 5.2% and 6.8% for the LWB and EWB groups. This difference is not clinically important. On the other hand, significantly better early functional outcome scores were detected in the EWB group. These results are not without limitations. Protected early weight-bearing following open reduction and internal fixation of ankle fractures is potentially safe and improve short-term functional outcome. Further good-quality randomised controlled trials would be needed before we could draw a more precise conclusion

Aims. Monocyte-lymphocyte ratio (MLR) or neutrophil-lymphocyte ratio (NLR) are useful for diagnosing periprosthetic joint infection (PJI), but their diagnostic values are unclear for screening fixation-related infection (FRI) in patients for whom conversion total hip arthroplasty (THA) is planned after failed internal fixation for femoral neck fracture. Methods. We retrospectively included 340 patients who underwent conversion THA after internal fixation for femoral neck fracture from January 2008 to September 2020. Those patients constituted two groups: noninfected patients and patients diagnosed with FRI according to the 2013 International Consensus Meeting Criteria. Receiver operating characteristic (ROC) curves were used to determine maximum sensitivity and specificity of these two preoperative ratios. The diagnostic performance of the two ratios combined with preoperative CRP or ESR was also evaluated. Results. The numbers of patients with and without FRI were 19 (5.6%) and 321 (94.4%), respectively. Areas under the ROC curve for diagnosing FRI were 0.763 for MLR, 0.686 for NLR, 0.905 for CRP, and 0.769 for ESR. Based on the Youden index, the optimal predictive cutoffs were 0.25 for MLR and 2.38 for NLR. Sensitivity and specificity were 78.9% and 71.0% for MLR, and 78.9% and 56.4% for NLR, respectively. The combination of CRP with MLR showed a sensitivity of 84.2% and specificity of 94.6%, while the corresponding values for the combination of CRP with NLR were 89.5% and 91.5%, respectively. Conclusion. The presence of preoperative FRI among patients undergoing conversion THA after internal fixation for femoral neck fracture should be determined. The combination of preoperative CRP with NLR is sensitive tool for screening FRI in those patients. Cite this article: Bone Joint J 2021;103-B(9):1534–1540

The results of meta-analysis show a revision rate of 33% for internal fixation of displaced fractures of the femoral neck, mostly because of nonunion. Osteopenia and osteoporosis are highly prevalent in elderly patients. Bone density has been shown to correlate with the intrinsic stability of the fixation of the fracture in cadaver and retrospective studies. We aimed to confirm or refute this finding in a clinical setting. We performed a prospective, multicentre study of 111 active patients over 60 years of age with a displaced fracture of the femoral neck which was eligible for internal fixation. The bone density of the femoral neck was measured pre-operatively by dual-energy x-ray absorptiometry (DEXA). The patients were divided into two groups namely, those with osteopenia (66%, mean T-score −1.6) and those with osteoporosis (34%, mean T-score −3.0). Age (p = 0.47), gender (p = 0.67), delay to surgery (p = 0.07), the angle of the fracture (p = 0.33) and the type of implant (p = 0.48) were similar in both groups. Revision to arthroplasty was performed in 41% of osteopenic and 42% of osteoporotic patients (p = 0.87). Morbidity (p = 0.60) and mortality were similar in both groups (p = 0.65). Our findings show that the clinical outcome of internal fixation for displaced fractures of the femoral neck does not depend on bone density and that pre-operative DEXA is not useful

The incidence of hip fractures in the elderly is increasing. Minimally displaced and un-displaced hip fractures can be treated with either internal fixation or hemiarthroplasty. The aim was identifying the revision rate of internal fixation and hemiarthroplasty in patients 60 years or older with Garden I or II hip fractures and to identify risk factors associated with each method. A retrospective analysis was conducted from 2 Major Trauma Centres and 9 Trauma Units between 01/01/2015 and 31/12/2020. Patients managed conservatively, treated with a total hip replacement and missing data were excluded from the study. 1273 patients were included of which 26.2% (n=334) had cannulated hip fixation (CHF), 19.4% (n=247) had a dynamic hip screw (DHS) and 54.7% (n=692) had a hemiarthroplasty. 66 patients in total (5.2%) required revision surgery. The revision rates for CHF, DHS and hemiarthroplasty were 14.4%, 4%, 1.2% (p<0.001) respectively. Failed fixation was the most common reason for revision with the incidence increasing by 7-fold in the CHF group [45.8% (n=23) vs. 33.3% (n=3) in DHS; p<0.01]. The risk factors identified for CHF revision were age >80 (p<0.05), female gender (p<0.05) and smoking (p<0.05). The average length of hospital stay was decreased when using CHF compared to DHS and hemiarthroplasty (12.6 days vs 14.9 days vs 18.1 days respectively, p<0.001) and the 1 year mortality rate for CHF, DHS and hemiarthroplasty was 2.5%, 2% and 9% respectively. Fixation methods for Garden I and II hip fractures in elderly patients are associated with a higher revision rate than hemiarthroplasty. CHF has the highest revision rate at 14.4% followed by DHS and hemiarthroplasty. Female patients, patients over the age of 80 and patients with poor bone quality are considered high risk for fixation failure with CHF. When considering a fixation method in such patients, DHS is more robust than a screw construct, followed by hemiarthroplasty

Abstract. Background. The incidence of periprosthetic fractures of the femur around a total knee arthroplasty (TKA) is rising and this is owed to the increased longevity that today's TKA implants allow for, as well as an aging population. These injuries are significant as they are related to increased morbidity and mortality. Methods. We retrospectively reviewed all periprosthetic fractures around a TKA that presented to our NHS Trust between 2011 to 2020. Medical records were reviewed. Treatment, complications and mortality were noted. Results. 37 patients (34 females) with an average age of 84 (range 65–99) met the inclusion criteria for this study. 17 patients (45.9%) underwent open reduction and internal fixation (ORIF), eight patients (21.6%) underwent revision arthroplasty to a distal femoral replacement (DFR) and 12 patients (32.4%) were treated non-operatively. 10 (58.8%) of the 17 patients that were treated with ORIF were discharged from hospital to a rehabilitation facility rather than their usual residence. In comparison, 3 (37.5%) of the patients that were treated with a DFR were discharged to a rehabilitation facility. one-year mortality rate in the ORIF group was 29.4 compared to 12.5% in those that had a DFR. Conclusion. Revision arthroplasty using a DFR should be considered in patients with periprosthetic fractures around a TKR, as it is associated with lower mortality rates and higher immediate post-operative function

Internal fixation remains the treatment of choice for non-displaced femoral neck fractures in elderly patients, whereas, arthroplasty is preferred for displaced fracture patterns. Given technological advancements in implant design and excellent long-term outcomes, arthroplasty may provide improved outcomes for the treatment of non-displaced femoral neck fractures. The aim of our study was to conduct a systematic review of the orthopaedic literature (1) to investigate the outcomes of internal fixation for the treatment of non-displaced and minimally displaced femoral neck fractures in elderly patients and (2) to compare the outcomes of patients treated with internal fixation to arthroplasty in this patient population. Relevant articles were identified using PubMed, Embase, and CENTRAL databases. Manuscripts were included only if they contained (1) patients 60 years or older with (2) nondisplaced or minimally displaced (Garden I or II) femoral neck fractures (3) treated with internal fixation or arthroplasty or (4) separately reported outcomes in this patient population. The primary outcome was reoperation. Secondary outcomes included mortality, patient reported outcomes, length of hospital stay, infection, and transfusions. An a priori decision was made to classify studies into comparative or non-comparative groups. Comparative studies directly compared arthroplasty to internal fixation in the specific study population while the non-comparative studies included separate cohorts of patients treated with arthroplasty or internal fixation. A fixed-effects model was used to quantitatively pool study outcomes. Twenty-five non-comparative studies were identified with a total of 22,020 patients, all of which were treated with internal fixation. The pooled incidence of reoperation after internal fixation was 14.4% (95% CI: 10.8 – 18.8). The incidence of mortality within one-year of injury was 14.4% (95% CI: 6.7 – 28.3), based on the reporting in 14 studies. Three comparative studies were identified with a total of 360 patients (128 treated with arthroplasty and 232 treated with internal fixation). All three studies reported reoperation rates. The overall risk of reoperation was 3.1% in the arthroplasty group compared to 9.5% in the internal fixation group (relative risk: 0.30, 95% CI: 0.10 – 0.84, p= 0.02). Only two studies reported mortality. The relative risk of mortality in patients treated with arthroplasty compared to internal fixation was 2.54 (95% CI: 1.38 – 4.70, p= 0.003). Internal fixation of minimally displaced femoral neck fractures in the elderly is associated with a risk of reoperation and mortality that exceeds 14%. Treatment with arthroplasty may reduce the risk of reoperation by 70%. However, this benefit maybe tempered by a potential increased risk of mortality associated with arthroplasty in this patient population

Introduction. Ankle fractures in the elderly have been increasing with an ageing but active population and bring with them specific challenges. Medical co-morbidities, a poor soft tissue envelope and a requirement for early mobilisation to prevent morbidity and mortality, all create potential pitfalls to successful treatment. As a result, different techniques have been employed to try and improve outcomes. Total contact casting, both standard and enhanced open reduction internal fixation, external fixation and most recently tibiotalocalcaneal (TTC) nailing have all been proposed as suitable treatment modalities. Over the past five years popular literature has begun to herald TTC nailing as an appropriate and contemporary solution to the complex problem of high-risk ankle fragility fractures. We sought to assess whether, within our patient cohort, the outcomes seen supported the statement that TTC has equal outcomes to more traditional open reduction internal fixation (ORIF) when used to treat the high-risk ankle fragility fracture. Materials & Methods. Results of ORIF versus TTC nailing without joint preparation for treatment of fragility ankle fractures were evaluated via retrospective cohort study of 64 patients with high-risk fragility ankle fractures without our trauma centre. We aimed to assess whether results within our unit were equal to those seen within other published studies. Patients were matched 1:1 based on gender, age, Charlson Comorbidity Index (CCI) and ASA score. Patient demographics, AO/OTA fracture classification, intra-operative and post-operative complications, discharge destination, union rates, FADI scores and patient mobility were recorded. Results. There were 32 patients within each arm. Mean age was 78.4 (TTC) and 78.3 (ORIF). The CCI was 5.9 in each group respectively with mean ASA 2.9 (TTC) and 2.8 (ORIF). There were two open fractures within each group. Median follow up duration was 26 months. Time to theatre from injury was 8.0 days (TTC) versus 3.3 days (ORIF). There was no statistically significant difference in 30-day, one year or overall mortality at final follow up. Kaplan-Meier survivorship analysis did however demonstrate that of those patients who died post-operatively the mean time to mortality was significantly shorter in those treated with TTC nailing versus ORIF (20.3 months versus 38.2 months, p=0.013). There was no statistical difference in the overall complication rate between the two groups (46.9% versus 25%, p=0.12). The re-operation rate was twice as high in patients treated with TTC nailing however this was not statistically significant. There was no statistical difference in the FADI scores at final follow up, 72.1±12.9 (TTC) versus 67.9±13.9 (ORIF) nor post-operative mobility status. Conclusions. Within our study TTC nailing with an unprepared joint demonstrated broadly equivalent results to ORIF in the management of high-risk ankle fragility fractures; this replicates findings of previous studies. We did however observe that mean survival was significantly shorter in the TTC group than those treated with ORIF. We believe this may have been contributed to by a delay to theatre due to TTC stabilisation being treated as a sub-specialist operation in our unit at the time. We propose that both TTC and ORIF are satisfactory techniques to stabilise the frail ankle fracture however, similarly to the other fragility fractures, the priority should be on an emergent operation in a timely fashion in order to minimise the associated morbidity and mortality. Further randomised control studies are needed within the area to establish definitive results and a working consensus

Introduction. Femoral shaft fractures in children is a serious injury that needs hospitalization, with a high prevalence in the age group 6–8 years old. Various treatment options are available and with a comparable weight of evidence. Submuscular plating provides a dependable solution, especially in length-unstable fractures and heavier kids. We present a novel technique to facilitate and control the reduction intraoperatively, which would allow for easier submuscular plate application. Materials and Methods. We have retrospectively reviewed four boys and three girls; all were operated in one centre. Polyaxial clamps and rods were applied to the sagittally-oriented bone screws, the reduction was done manually, and the clamps were tightened after achieving the proper alignment in the anteroposterior and lateral fluoroscopy views. The submuscular plate was applied as described, then clamps and bone screws were removed. Results. The mean age at surgery was 13 years (range, 9–14). The mean body weight was 43.3 kg (range, 30–66). There were five mid-shaft fractures, one proximal third and one distal third. There were Four type A fractures, two type B and one type C. Four patients had road traffic accidents while three had direct trauma. The mean preoperative haemoglobin concentration 12.5 g/dl (range 11.3–13 g/dl). No blood transfusion was needed intraoperatively or postoperatively. The operative time averaged 122 minutes, and the mean hospital stay was one (range 1–4 days). The patients reported no pain at a mean of 1.5 weeks (range, one-three weeks). All fractures united at a mean of 8.7 weeks (range 6–12 weeks). No wound healing problems nor deep infections happened. The knee joint range of motion was full in all patients at six weeks postoperatively. There was no mechanical irritation from the inserted plate. At the final follow-up, all fractures united without malalignment nor length discrepancy. Conclusions. External fixator-assisted internal fixation of pediatric femoral fractures would facilitate the accuracy and control of fracture reduction and allow minimally invasive percutaneous osteosynthesis. Our study has shown a decrease in operative time, and an accompanying reduction in length of inpatient stay, prolonged need for analgesia and post-operative rehabilitation

Distal radius fractures are the most common adult fractures, yet there remains some uncertainty surrounding optimal treatment modalities. Recently, the rate of operative treatment of these injuries has been increasing, however, predictors of outcomes in patients treated surgically remain poorly understood. The purpose of this study was to evaluate independent predictors of 30-day readmission and complications following internal fixation of distal radius fractures. Patients ≥18 years who underwent surgical intervention for distal radius fractures between 2005 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) using procedural codes. Patient demographics, as well as 30-day readmission, complication, and mortality rates were ascertained. Multivariable logistic regression was used to determine independent predictors of 30-day outcomes while adjusting for patient age, sex, American Society of Anaesthesiologists (ASA) class, functional status, smoking status, comorbidities, and Body Mass Index (BMI). A total of 10,051 patients were identified (average age 58 ±16). All patients received open reduction and internal fixation with no cases of external fixation identified in the data set. Included fractures were 37% extraarticular and 63% intraarticular. Within 30-days of initial fixation 143 (1.42%) patients were readmitted to the hospital, 71 patients experienced a complication, and 18 (0.18%) patients died. After adjusting for relevant covariables, current smoking increased the odds of readmission by 1.73 (95%Confidence interval [95%CI] 1.15 – 2.50), ASA class III/IV vs. I/II increased the odds of readmission by 2.74 (95%CI 1.85 – 4.06), and inpatient surgery vs. outpatient surgery increased the odds of readmission by 2.10 (95%CI 1.46 – 3.03). Current smoking also increased the odds of complications by 2.26 (95%CI 1.32 – 3.87), while ASA class III/IV increased it by 2.78 (95%CI 1.60 – 4.85), inpatient surgery increased it by 2.26 (95%CI 1.37 – 3.74), and dependent functional status increased it by 2.55 (1.16 – 5.64). In conclusion, patients with severe systemic disease, current smokers and patients undergoing inpatient surgery are at risk for 30-day readmissions and complications following operative treatment of distal radius fractures. In addition, patients with dependent functional statuses are more likely to experience a complication within 30-days

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. Patients and Methods. Between 2008 and 2014, distraction osteogenesis followed by arthrodesis using internal fixation was performed in 12 patients with complex conditions of the ankle due to trauma or infection. There were eight men and four women: their mean age was 35 years (23 to 51) at the time of surgery. Bone healing and functional recovery were evaluated according to the criteria described by Paley. Function was assessed using the ankle-hindfoot scale of the American Orthopedic Foot and Ankle Society (AOFAS). Results. A solid fusion of the ankle and eradication of infection was achieved in all patients. A mean lengthening of 6.1 cm (2.5 to 14) was achieved at a mean follow-up of 25.2 months (14 to 37). The mean external fixation index (EFI) was 42 days/cm (33.3 to 58). The function was judged to be excellent in six patients and good in six patients. Bone results were graded as excellent in ten patients and good in two patients. The mean AOFAS score was 37.3 (5 to 77) preoperatively and 75.3 (61 to 82) at the final follow-up. Minor complications, which were treated conservatively, included pain, pin-tract infection, loosening of wires, and midfoot stiffness. Major complications, which were treated surgically included grade V pin-tract infection with inflammation and osteolysis, poor consolidation of the regenerate bone, and soft-tissue invagination. The reoperations required to treat the major complications included the exchange of pins and wires, bone grafting and invagination split surgery. Conclusion. The technique of distraction osteogenesis followed by arthrodesis using internal fixation is an effective form of treatment for the management of complex conditions of the ankle. It offers a high rate of union, an opportunity to remove the frame early, and a reduced EFI without infection or wound dehiscence. Cite this article: Bone Joint J 2018;100-B:755–60

Failed internal fixation of a fracture of the proximal humerus produces many challenges with limited surgical options. The aim of this study was to evaluate the clinical outcomes after the use of a reverse shoulder arthroplasty under these circumstances. Between 2007 and 2012, 19 patients (15 women and four men, mean age 66 years; 52 to 82) with failed internal fixation after a proximal humeral fracture, underwent implant removal and reverse shoulder arthroplasty (RSA). The mean follow-up was 36 months (25 to 60). The mean American Shoulder and Elbow Score improved from 27.8 to 50.1 (p = 0.019). The mean Simple Shoulder Test score improved from 0.7 to 3.2 (p = 0.020), and the mean visual analogue scale for pain improved from 6.8 to 4.3 (p = 0.012). Mean forward flexion improved from 58.7° to 101.1° (p < 0.001), mean abduction from 58.7° to 89.1° (p = 0.012), mean external rotation from 10.7° to 23.1° (p = 0.043) and mean internal rotation from buttocks to L4 (p = 0.034). A major complication was recorded in five patients (26%) (one intra-operative fracture, loosening of the humeral component in two and two peri-prosthetic fractures). A total of 15 patients (79%) rated their outcome as excellent or good, one (5%) as satisfactory, and three (16%) as unsatisfactory. . An improvement in outcomes and pain can be expected when performing a RSA as a salvage procedure after failed internal fixation of a fracture of the proximal humerus. Patients should be cautioned about the possibility for major complications following this technically demanding procedure. Cite this article: Bone Joint J 2015;97-B:967–72

Aim. Previous studies of primary internal fixation of infected non-unions have reported high failure rates. Local antibiotic carriers and coatings have been advocated to reduce infection around implants and allow bone healing. We evaluated the effect of a calcium sulphate/hydroxyapatite antibiotic-loaded composite on bone healing and the eradication of infection in combination with internal fixation. Method. Twelve cases of established infected non-union, with segmental bone loss of up to 1cm were treated using a multidisciplinary protocol. This included; excision, deep sampling, stabilisation, local and systemic antibiotics, and soft-tissue closure. We treated 5 femurs, 4 humeri, 1 tibia and 2 periarticular non-unions at the ankle. Mean age was 59.8 years (34–75) and 9 patients had systemic co-morbidities (C-M Type B hosts). 9 patients had single stage surgery, with 5 IM Nails and 4 plates. Three patients had planned second stage internal fixation after external fixation to correct deformity. Staph. aureus was the commonest pathogen (5 cases) with polymicrobial infection in 3 cases. Results. All 12 patients were infection-free at a mean follow-up of 23 months (range 13–34 months). Union was achieved in 11/12 (92%) with the primary surgery alone. The single failure was the tibial case, who remains with an infection-free, stiff non-union. Conclusion. This protocol offered good results, mainly with a single stage treatment. Primary internal fixation was possible in 9 cases, without recurrent infection. The combination of excision of infected dead bone and a high level of local antibiotics above the Minimum Inhibitory Concentration and Minimum Biofilm Eradication Concentration levels for common bacteria, allowed a high success rate in these difficult cases

Aims. Displaced, comminuted acetabular fractures in the elderly are increasingly common, but there is no consensus on whether they should be treated non-surgically, surgically with open reduction and internal fixation (ORIF), or with acute total hip arthroplasty (THA). A combination of ORIF and acute THA, an approach called ’combined hip procedure’ (CHP), has been advocated and our aim was to compare the outcome after CHP or ORIF alone. Patients and Methods. A total of 27 patients with similar acetabular fractures (severe acetabular impaction with or without concomitant femoral head injury) with a mean age of 72.2 years (50 to 89) were prospectively followed for a minimum of two years. In all, 14 were treated with ORIF alone and 13 were treated with a CHP. Hip joint and patient survival were estimated. Operating times, blood loss, radiological outcomes, and patient-reported outcomes were assessed. Results. No patient in the CHP group required further hip surgery, giving THA a survival rate of 100% (95% confidence interval (CI) 100 to 100) after three years, compared with 28.6% hip joint survival in the ORIF group (95% CI 12.5 to 65.4; p = 0.001). No dislocations or deep infections occurred in the CHP group. No patient died within the first year after index surgery, but patient survival was lower in the CHP group after three years. There were no relevant differences in patient-reported outcomes. Conclusion. The CHP confers a considerably reduced need of further surgery when compared with ORIF alone in elderly patients with complex acetabular fractures. These findings encourage both further use of, and larger prospective studies on, the CHP. Cite this article: Bone Joint J 2019;101-B:478–483

1. Eighty consecutive open fractures of the tibial shaft were treated by primary internal fixation and wound closure. Wound healing was complicated by deep infection in eight patients (10 per cent) and by skin loss of varying degree in ten (l2·5 per cent). 2. Careful selection of patients on the basis of associated soft-tissue injuries is urged. A simple method of grading open fractures by the appearance of the wound and adjacent skin and the effectiveness of wound closure is suggested. If internal fixation is indicated on mechanical grounds, the nature of the soft-tissue injury should be the deciding factor in the choice of the method of treatment. In the less severe (Grade 1) fractures internal fixation and wound closure may be safely employed. In the severe (Grade 3) injuries, primary wound closure with or without internal fixation should be avoided. Moderately severe (Grade 2) fractures should be carefully assessed and treated by internal fixation and wound closure only if primary wound healing is confidently expected. 3. Wound healing by first intention requires, in addition to adequate debridement of the deep layers of the wound, careful approximation of healthy wound edges without excessive tension. An adequate knowledge of skin-plastic procedures is essential to achieve this. 4. A combination of systemic penicillin and streptomycin in adequate doses is a safe and effective prophylactic antibiotic for use in the treatment of open fractures

Purpose of the study:. To determine the outcomes of cases converted from an external fixator to an internal fixation device in the management of limb reconstructions and deformity corrections. Method:. A retrospective review of 18 patients, that underwent a conversion procedure to internal fixation following long term external fixation use, was done. This comprised 24 limbs. Inclusion criteria: All cases of long term external fixator use converted to internal fixation over a 5 year period. Average external fixation time, pin site care, conversion timing, surgical device used as well as outcome were documented. Results:. The mean treatment time in an external fixator was 185 days (61–370). The reasons for conversion included patient dissatisfaction, pin tract sepsis and a refracture. The conversion procedures included 8 intramedullary nail fixations and 16 plate and screw fixations. An acute conversion was identified as an internal fixation that was done in the same sitting as external fixator removal. A delayed conversion was any internal stabilisation that was done thereafter. In total, the complication rate associated with conversion to internal fixation following long term external fixation was 25%, mainly due to persistent non-union or sepsis. In the 8 conversions to intramedullary nails, 7 were acute: 4 had good outcomes with sepsis free union being achieved. 3 had poorer outcomes with a non-union and 2 amputations being documented. The single delayed nailing achieved union. In the 16 conversions to plate fixation, 13 achieved union. 10 were acute conversions and 3 were delayed. The remaining 3 that developed complications included 2 acute conversions with septic non-unions and a single delayed conversion which resulted in sepsis. Conclusion:. Conversion of an external fixator to an internal fixator in a non-acute reconstructive setting has a 75% success rate. In the acute conversion group (19 cases), plate and screw fixation had a superior outcome. In the delayed conversion group (5 cases), intramedullary fixation was favoured

We compared the reoperation rate after internal fixation for minimally displaced or impacted intracapsular fractures of the femoral neck in patients aged 80 years and above with that in similar patients aged 65 to 79 years. We also compared the results of internal fixation with those of hemiarthroplasty for displaced intracapsular fracture in an age- and sex-matched group of elderly patients. We found that a significantly greater proportion of the older patients treated by internal fixation required reoperation than either the younger group or the age-matched group treated by hemiarthroplasty. Our results indicate that internal fixation may not be the best treatment for extremely elderly patients with minimally displaced or impacted intracapsular fractures of the femoral neck

1. The results of internal fixation are described in 470 tibial shaft fractures. 2. The immediate internal fixation of compound fractures was followed by so high an incidence of serious complications that the use of this method is not recommended. The immediate internal fixation of fresh closed fractures was also followed by many complications. 3. Delayed rigid internal fixation proved satisfactory for difficult fractures in which an acceptable reduction could not be obtained by closed means ; skeletal traction was of value in such fractures until the skin was soundly healed. 4. Delayed internal fixation reduced both the healing time and the complications

Triple arthrodesis is the most effective treatment resource for restoring shape and stability to the hind-foot. It is used in order to achieve a plantigrade foot, aligned, stable and painless, in the treatment of various pathologies. However, it has the effect of changing the dynamic mobility of the foot and diminishes the adapting ability to uneven ground, influencing the outcome. Opinions differ on the necessity of internal fixation to maintain the proper alignment of the hind-foot and improve consolidation, influencing the results. The authors reviewed the patients who underwent triple arthrodesis between 01/01/1998 and 31/12/2008. Of a total of 46 patients 28 were reviewed, corresponding to 29 feet that underwent 36 interventions (7 recurrences). Patients were divided into two groups according to whether or not the placement of internal fixation. They were evaluated according to the AOFAS ankle and hindfoot score and correlated with the radiologic result. The most frequent indications for surgery were osteoarthrosis of the tarsus and sequelae of fractures of the calcaneus. In the group without fixation 68% had radiological signs of consolidation. 24% required revision for non consolidation. In the group with internal fixation there was 72.7% consolidation and 9.1% required revision surgery. Bone graft was more often used in internal fixation group (72.7% vs 40%). Group without fixation vs group with internal fixation:. AOFAS mean score: 74.5% vs 61.6%, patients without pain: 50% vs 20%; plantigrade foot with good alignment: 66.7% vs 40% without pain: 50% vs 20%; tibiotarsal arthritis: 48% vs 63.6%; Lisfranc arthrosis: 44% vs 63.6%. There is a higher rate of consolidation in the group setting. However, the functional outcome seems to be better in the group without fixation. Fixation seems to be associated with better consolidation. The functional outcome is related to a plantigrade and well aligned foot

Background: The importance of HIV in trauma has been poorly investigated. There’re few reports in the literature on the effects of HIV on fracture healing, those that there are involve small numbers. Many surgeons have concerns about both internal and external fixation in these patients. Some of the most recent published studies have suggested a 4 fold increase in infection rates in internal fixation of open fractures (small series 39 patients, 12 of whom HIV positive). In our hospital we have prospectively reviewed the outcomes of our open fractures treated by internal fixation, to see if HIV is a significant risk factor for wound infection and non union. Methods: All patients undergoing internal fixation for open fractures were entered into a database. Patients were managed along predesigned protocols, under the care of one consultant to try and standardise care. Patients were followed up in a dedicated clinic. 96% 2 month follow up and 84% 3 month follow up was obtained. Results: Over a 9 month period 102 open fractures were treated with internal fixation. 23% of patients were HIV positive and 14% declined to be tested. CD4 counts ranged from 131–862, mean of 387. The superficial wound infection rate was 13% in HIV positive patients and 15% in HIV negative patients. Sub group analysis suggested that HIV positive patients with low CD4 counts and grade 1 injuries were significantly more likely to develop wound infections (50%) than controls (12%), p value=0.02. Grade 1 injuries were not managed with urgent debridement, under hospital guidelines, and had an average delay to theatre of 4 days. Rates of non union were 4% and 2% in the HIV positive/negative groups respectively. Conclusions: This series is the largest prospective study in the literature. Our data suggests that:. The risks of acute infection in open fractures fixed by internal fixation in HIV positive individuals may not be as high as some previous studies have suggested;. Open fractures in HIV positive patients can be managed to union with internal fixation;. That in may not be appropriate to leave grade 1 injuries in HIV positive patients for non urgent debridement/fixation, as previous studies have suggested. Discussion: We feel that the current dogma of denying such patients internal fixation, is no longer appropriate. Although this study does not provide a direct comparison between differing Methods: of fixation, it provides the strongest evidence available in the literature, that internal fixation should be considered as a treatment option in these patients. We are currently awaiting the result of long term follow up looking at rates of delayed sepsis in these patients

Background. Studies have compared open reduction internal fixation (ORIF) with fibular nail fixation (FNF) and shown reduced wound complications with minimal difference to PROMS in the short term. Our aim is to compare long-term outcomes for unstable ankle fractures at 10 year follow up. Methods. Patients from a previously conducted RCT were contacted at a minimum of 10 years post intervention at a single study centre. Case notes were reviewed, and patient reported outcome measures acquired at 10 years. Results. Ninety-nine patients were included (48 FNF and 51 ORIF). After 10 years 75% (33/44) of patients in the FNF group required no further follow up versus 81% (39/48) in the ORIF group. Radiographically at 2 years post-injury, there was no statistically significant difference between groups for development of osteoarthritis (p=0.851). There was one tibio-talar fusion in each group secondary to osteoarthritis, but no statistically significant difference in overall re-operation rate (p=0.518). Fifty-one percent (n=50) of patients have so far returned patient reported outcome measures at a minimum of 10 years (Fibular nail n=23, plate fixation n=27). No significant difference was found between groups for the mean scores of Olerud and Molander Ankle Score (FNF 84.78 vs ORIF 84.07; p=0.883), the Manchester-Oxford Foot Questionnaire (MOXFQ) (FNF 89.54 vs ORIF 96.47; p=0.112), Euroqol-5D Index (FNF 0.88 vs ORIF 0.87; p=0.701) and Euroqol-5D Visual Analogue Score (FNF 77.30 vs ORIF 77.52; p=0.859). Conclusion. The current study illustrates that both methods of treatment result in a satisfactory long-term outcome with no difference in late complications or PROM scores at up to 10 years in patients under 65 years old, although the study is currently under powered

Objective. Failures of internal fixation after intertrochanteric fractures pose great challenge to orthopaedic surgeons. Hip arthroplasty can be a remedy for such failures, however, the selection of femoral stem length is controversial. This study aims to report our experience of managing failed internal fixation after intertrochanteric fractures with standard femoral stem arthroplasty. Methods. A retrospective review of patients who were managed with hip arthroplasty for failed internal fixation after intertrochanteric fractures in the First Affiliated Hospital of Fujian Medical University, P.R. China between January 2001 to December 2013 was performed. Patients’ age, gender, pre- and postoperative Harris Hip Score (HHS), femoral stem types and surgical outcomes were traced and analyzed. Results. 14 patients were included. The average age at the time of internal fixation and hip arthroplasty was 74.6 years old (Range, 56–89) and 75.8 years old (Range, 58–90), respectively. The time duration between internal fixation and hip arthroplasty ranged from 3 to 26 months. 5 were total hip arthroplasty while 9 were hemiarthroplasty. 4 were implanted with long femoral stems while 10 with standard stems, including 4 cementless (SL-PLUS, Smith & Nephew)and 6 cemented stems. Standard femoral stems were defined as ones that are designed to be used in primary hip replacement, with the length of which ranging from 120 to 140mm. The distal ends of these stems did not exceed the distal screw hole levels of 2 cortical diameters. After a mean follow-up time of 6.4 years (Range, 1–13), 2 patients lost to follow-up and 2 died of non-surgically related diseases. For the 8 cases with standard stems, at the latest follow-up, no periprosthetic fractures or periprosthetic joint infections were observed. A total of 3 hip dislocations happened in 2 patients but were managed successfully with manipulative reduction followed by hip brace. The HHS score increased from an average of 35.6 preoperatively to 79.4 after surgery. Conclusions. Hip arthroplasty can be performed as revision for failed internal fixation after intertrochanteric fractures. Use of standard femoral stems is less invasive, reduces expenditure and can also achieve similar satisfactory clinical outcomes as long femoral stems. However, the long-term clinical outcomes required further follow-up

We studied 60 patients with an acute displaced fracture of the femoral neck and with a mean age of 84 years. They were randomly allocated to treatment by either internal fixation with cannulated screws or hemiarthroplasty using an uncemented Austin Moore prosthesis. All patients had severe cognitive impairment, but all were able to walk independently before the fracture. They were reviewed at four, 12 and 24 months after surgery. Outcome assessments included complications, revision surgery, the status of activities of daily living (ADL), hip function according to the Charnley score and the health-related quality of life (HRQOL) according to the Euroqol (EQ-5D) (proxy report). General complications and the rate of mortality at two years (42%) did not differ between the groups. The rate of hip complications was 30% in the internal fixation group and 23% in the hemiarthroplasty group; this was not significant. There was a trend towards an increased number of re-operated patients in the internal fixation group compared with the hemiarthroplasty group, 33% and 13%, respectively (p = 0.067), but the total number of surgical procedures which were required did not differ between the groups. Of the survivors at two years, 54% were totally dependent in ADL functions and 60% were bedridden or wheelchair-bound regardless of the surgical procedure. There was a trend towards decreased mobility in the hemiarthroplasty group (p = 0.066). All patients had a very low HRQOL even before the fracture. The EQ-5D. index. score was significantly worse in the hemiarthroplasty group compared with the internal fixation group at the final follow-up (p < 0.001). In our opinion, there is little to recommend hemiarthroplasty with an uncemented Austin Moore prosthesis compared with internal fixation, in patients with severe cognitive dysfunction

A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar. Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p < 0.0001), lower operative blood loss (28 ml versus 177 ml, p < 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p < 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004). We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail

Open reduction and internal fixation (ORIF) with trans-articular screws or dorsal plating is the standard surgical technique for displaced Lisfranc injuries. This aim of this study is to compare the clinical outcomes of percutaneous reduction and internal fixation (PRIF) of low energy Lisfranc injuries with a matched, control group of patients treated with ORIF. Over a seven-year period (2012–2019), 16 consecutive patients with a low energy Myerson B2-type injury were treated with PRIF. Patient demographics were recorded within a prospectively maintained database at the institution. This study sample was matched for age, sex and mechanism of injury to a control group of 16 patients with similar Myerson B2-type injuries treated with ORIF. Clinical outcome was compared using the American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Manchester Oxford Foot Questionnaire (MOXFQ). At a mean follow up of 43.0 months (95% CI 35.6 – 50.4), both the AOFAS and MOXFQ scores were significantly higher in the PRIF group compared to the control ORIF group (AOFAS 89.1vs 76.4, p=0.03; MOXFQ 10.0 vs 27.6, p=0.03). There were no immediate postoperative complications in either group. At final follow up, there was no radiological evidence of midfoot osteoarthritis in any patient in the PRIF group. Three patients in the ORIF group developed midfoot osteoarthritis, one of whom required midfoot fusion. PRIF is a technically simple, less invasive method of operative stabilisation of low energy Lisfranc injures which also appears to be associated with better mid-term clinical outcomes compared to ORIF

Aim: This retrospective study presents the results of humeral pseudarthrosis management, in our clinic, during the period 1997–2002. Material: 21 patients with humeral pseudarthrosis were treated during this period. 7 were men, with an average age of 48, 6 (range 22–63) and 14 were women, with an average age of 63, 3 (range 42–80). The initial treatment in 19 cases was conservative and in 2 cases surgical (internal fixation with plate – screws or intramedullary nailing). The average time of the humeral pseudarthrosis management was 5,9 months (4–10 months).3 pseudarthrosis were oligotrophic and 18 atrophic. Method: All patients underwent an open reduction, internal fixation and bone grafting (autografts and/or allografts).In humeral shaft pseudarthrosis a wide plate was applied, while in superior humeral metaphysis pseudarthrosis, a T-plate. In all cases impaction of the fracture edges was achieved. Results: The average follow-up was 40,2 months (range 4–68 months).Union was achieved in all cases in an average of 2,8 months (range 2–8 months). Direct postoperative mobilisation and physical therapy was applied in 20 cases and only in 1 case a “Sarmiento” splint was applied for 3 weeks. In 2 cases a postoperative haematoma presented. In 1 case a pre-existed paresis of the radial nerve after the initial treatment of the fracture with internal fixation, came back 3 months after the management of pseudarthrosis and the release of the nerve. All patients’ revealed good functional rehabilitation, about 85–90% compared with the normal arm. Arm shortening in no case was greater than 2 cm. Conclusion: Open reduction and internal fixation is the treatment of choice in the management of the humeral pseudarthrosis. The impaction of the fracture edges into each other strengthens significantly the stability of the fracture and promotes union

Purpose. To compare the clinical and radiological results between internal fixation using the proximal femoral nail system and bipolar hemiarthroplasty in reverse oblique intertrochanteric hip fracture in elderly patients. Materials and Methods. From January 2005 to July 2012, we reviewed 53 patients who had been treated surgically for reverse oblique intertrochanteric fracture and been followed up on for a minimum of 2 years. The patients, all over 70 years old, were divided into two groups for retrospective evaluation: one group was treated with open reduction and internal fixation using the proximal femoral nail system (31 cases), and the other group was treated with bipolar hemiarthroplasty (22 cases). Results. Early ambulation postoperatively and less pain at postoperative three months were significantly superior in the bipolar hemiarthroplasty group. However, by 24 months postoperatively, the open reduction and internal fixation group had higher Harris scores and correspondingly less pain than the bipolar hemiarthroplasty group. There were no significant differences in union rate, duration of hospitalization or lateral wall fracture healing between the two groups. Four patients in the open reduction and internal fixation group underwent reoperation. Conclusions. In the treatment of intertrochanteric fracture of the reverse oblique type, if the patient's health and bone quality are good, open reduction and internal fixation is considered to be the better choice. However, in cases of severe communition of fracture and poor bone quality along with high risk of early reduction failure, bipolar hemiarthroplasty is an alternative offering advantages in terms of early ambulation, less pain at early stages, and lower risk of reoperation

Management of acetabular fractures in the elderly population remains somewhat controversial in regards to when to consider is open reduction internal fixation (ORIF) versus acute primary total hip. study aims to (1) describe outcome of this complex problem and investigate predictors of successful outcome. This retrospective study analyzes all acetabular fractures in patients over the age of 60, managed by ORIF at a tertiary trauma care centre between 2007 and 2018 with a minimum follow up of one year. Of the 117 patients reviewed, 85 patients undergoing ORIF for treatment of their acetabular fracture were included in the analysis. The remainder were excluded based management option including acute ORIF with THA (n=10), two-stage ORIF (n=2), external fixator only (n=1), acute THA (n=1), and conservative management (n=1). The remainder were excluded based on inaccessible medical records (n=6), mislabelled diagnosis (n=6), associated femoral injuries (n=4), acetabular fracture following hemiarthroplasty (n=1). The mean age of the cohort is 70±7 years old with 74% (n=62) of patients being male. Data collected included: demographics, mechanism of injury, Charlson Comorbidity Index (CCI), ASA Grade, smoking status and reoperations. Pre-Operative Radiographs were analyzed to determine the Judet and Letournel fracture pattern, presence of comminution and posterior wall marginal impaction. Postoperative radiographs were used to determine Matta Grade of Reduction. Outcome measures included morbidity-, mortality- rates, joint survival, radiographic evidence of osteoarthritis and patient reported outcome measures (PROMs) using the Oxford Hip Score (OHS) at follow-up. A poor outcome in ORIF was defined as one of the following: 1) conversion to THA or 2) the presence of radiographic OA, combined with an OHS less than 34 (findings consistent with a hip that would benefit from a hip replacement). The data was analyzed step-wise to create a regression model predictive of outcome following ORIF. Following ORIF, 31% (n=26) of the cohort had anatomic reduction, while 64% (n=54) had imperfect or poor reduction. 4 patients did not have adequate postoperative radiographs to assess the reduction. 31 of 84 patients undergoing ORIF had a complication of which 22.6% (n=19) required reoperation. The most common reason being conversion to THA (n=14), which occurred an average of 1.6±1.9 years post-ORIF. The remainder required reoperation for infection (n=5). Including those converted to THA, 43% (n=36) developed radiographic OA following acetabular fracture management. The mean OHS in patients undergoing ORIF was 36 ± 10; 13(16%) had an OHS less than 34. The results of the logistic regression demonstrate that Matta grade of reduction (p=0.017), to be predictive of a poor outcome in acetabular fracture management. With non-anatomic alignment following fixation, patients had a 3 times greater risk of a poor outcome. No other variables were found to be predictive of ORIF outcome. The ability to achieve anatomic reduction of fracture fragments as determined by the Matta grade, is predictive of the ability to retain the native hip with acceptable outcome following acetabular fracture in the elderly. Further research must be conducted to determine predictors of adequate reduction in order to identify candidates for ORIF

Aim. Unexpected positive infections are distinct entity in prosthetic revision surgery. The prevalence and characteristics of unexpected positive cultures in internal fixation are however less established. The aim of this study was to describe the prevalence and characteristics of unexpected diagnosis of infection in a prospective cohort of revision surgeries following internal fixation. Method. We reviewed the microbiological results following 356 surgeries that included partial or complete removal of internal fixation, performed in 328 patients (54% male, mean age 53 ± 17 years), in which infection was not initially suspected. This prospective study was performed in a large single center for musculoskeletal surgery from 2013–2017. The implants most commonly removed were plate and/or screws (281 cases, 78,9%), followed by intramedullary nails (64 cases, 18,0%). The main indications for surgery were nonunion (89 cases, 25%) and symptomatic hardware (70 cases, 19,7%). All removed implants were sonicated, and tissue cultures were obtained depending on the surgeon's criteria. Diagnosis of infection was established by the presence of 2 or more positive tissue cultures (1 with a highly virulent microorganism), or ≥ 50 colony-forming units found in the sonication fluid. Results. Infection was confirmed in 47 cases (13,2%); diagnosis was obtained with tissue cultures in 5 cases (1,4%), sonication in 14 cases (3,9%) and a combination of both sonication and tissue samples in 28 cases (7,9%). In another 24 cases (6,7%), ≥ 50 CFU of low-virulence microorganisms were isolated in the sonication fluid, but no tissue samples were available to confirm the diagnosis. Low-virulent microorganisms such as Propionibacterium acnes (22 cases / 46,8%) or coagulase-negative Staphycoccci (13 cases, 27,7%) were most commonly isolated. Sonication was key for the diagnosis of 61,7% of unexpected-positive surgeries. Nearly half of the patients received a new implant (internal fixation in 40,4%; arthroplasty in 6,4%), but only 34% of the patients were treated with antibiotics on discharge. Conclusions. Unexpected diagnosis of infection occurs in approximately 13,2% of revision surgeries following internal fixation, most commonly due to low-virulent microorganisms. Sonication was key for the diagnosis of the majority of these infections. The clinical relevance of these infections remains unclear, though the insertion of new implants raises concern. We recommend sonication of all internal fixation devices removed, especially if new implants are inserted in the revision surgery

In a series of 450 patients over 70 years of age with displaced fractures of the femoral neck sustained between 1995 and 1997 treatment was randomised either to internal fixation or replacement. Depending on age and level of activity the latter was either a total hip replacement or a hemiarthroplasty. Patients who were confused or bed-ridden were excluded, as were those with rheumatoid arthritis. At ten years there were 99 failures (45.6%) after internal fixation compared with 17 (8.8%) after replacement. The rate of mortality was high at 75% at ten years, and was the same in both groups at all times. Patient-reported pain and function were similar in both groups at five and ten years. Those with successfully healed fractures had more hip pain and reduction of mobility at four months compared with patients with an uncomplicated replacement, and they never attained a better outcome than the latter patients regarding pain or function. Primary replacement gave reliable long-term results in patients with a displaced fracture of the femoral neck

Two hundred and thirty-two ankle fractures were treated in the orthopaedic department of the Royal Portsmouth Hospital between 1959 and 1960. Seventy-one fractures treated by internal fixation with screws have been seen at follow-up examination. Results show that open reduction, secure and accurate internal fixation and early movement without plaster or other splintage is a treatment which in most cases has been followed by a short convalescence, few post-operative complications, and a painless ankle and with good function

The Orthofix acute correction template has been developed for multiplanar deformity corrections, with or without lengthening, using a monolateral external fixation system such as the limb reconstruction system (LRS). Pin placement is achieved by marrying the template onto the particular deformity in the frontal, sagittal and rotational planes, so that after the osteotomy the pins can be rearranged by manipulating the fragments to permit application of the standard Orthofix fixation system. The options of compression, dynamisation or lengthening through the osteotomy sites remain available should they be required in the reconstructive procedure. We have found the template useful in correcting multiplanar deformities intra-operatively. This is followed by internal fixation and removal of the external fixator at the end of the procedure. Internal fixation of diaphyseal and metaphyseal osteotomies is achieved with intramedullary nailing and blade fixation respectively. This technique simplifies complex procedures, following careful planning by accurate pin placement. The fragments are compressed before definitive internal fixation. The correct mechanical axis is checked radiologically before stable fixation

Lisfranc injuries are uncommon and can be challenging to manage. There is considerable variation in opinion regarding the mode of operative treatment of these injuries, with some studies preferring primary arthrodesis over traditional open reduction and internal fixation (ORIF). We aim to assess the clinical and radiological outcomes of the patients treated with ORIF in our unit. This is a retrospective study, in which all 27 consecutive patients treated with ORIF between June 2013 and October 2018 by one surgeon were included with an average follow-up of 2.4 years. All patients underwent ORIF with joint-sparing surgery by a dorsal bridging plate (DBP) for the second and third tarsometatarsal (TMT) joint, and the first TMT joint was fixed with trans-articular screws. Patients had clinical examination and radiological assessment, and completed American Orthopaedic Foot and Ankle Society (AOFAS) midfoot score and Foot Function Index (FFI) questionnaires. Our early results of 22 patients (5 lost to follow-up) showed that 16 (72%) patients were pain free, walking normally without aids, and wearing normal shoes and 68% were able to run or play sports. The mean AOFAS midfoot score was 78.1 (63–100) and the average FFI was 19.5 (0.6–34). Radiological assessment confirmed that only three patients had progression to posttraumatic arthritis at the TMT joints though only one of these was clinically symptomatic. Good clinical and radiological outcomes can be achieved by ORIF in Lisfranc injuries with joint-sparing surgery using DBP

Over a seven-year period we treated a consecutive series of 58 patients, 20 men and 38 women with a mean age of 66 years (21 to 87) who had an acute complex anterior fracture-dislocation of the proximal humerus. Two patterns of injury are proposed for study based upon a prospective assessment of the pattern of soft-tissue and bony injury and the degree of devascularisation of the humeral head. In 23 patients, the head had retained capsular attachments and arterial back-bleeding (type-I injury), whereas in 35 patients the head was devoid of significant soft-tissue attachments with no active arterial bleeding (type-II injury). Following treatment by open reduction and internal fixation, only two of 23 patients with type-I injuries developed radiological evidence of osteonecrosis of the humeral head, compared with four of seven patients with type-II injuries. A policy of primary treatment by open reduction and internal fixation of type-I injuries is justified, whereas most elderly patients (aged 60 years or over) with type-II injuries are best treated by hemiarthroplasty. The best treatment for younger patients (aged under 60 years) who sustain type-II injuries is controversial and an individualised approach to their management is advocated

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

In a meta-analysis of fourteen trials (N=1901 patients) in patients with displaced hip fractures, we identified significant reductions in the risk of revision surgery with internal fixation compared to arthroplasty. A trend towards increased mortality with arthroplasty was identified. The purpose of this study was to determine the effect of arthroplasty (hemi-arthroplasty, bipolar arthroplasty and total hip arthroplasty) in comparison to internal fixation for displaced femoral neck fractures on rates of mortality and revision surgery. Arthroplasty for displaced femoral neck fractures, in comparison to internal fixation, significantly reduces the risk of revision surgery at the cost of greater infection rates, blood loss and operative time, and a possible increase in early mortality. Over 220,000 fractures of hip occur per year in North America representing an annual seven billion dollar cost to the health care system. Current evidence suggests internal fixation may reduce mortality risk at the consequence of increased revision rates. A large trial is needed to resolve this issue. We searched computerized databases (MEDLINE, COCHRANE and SCISEARCH) for published clinical studies from 1969–2002 and identified additional studies through hand searches of major orthopaedic journals, bibliographies of major orthopaedic texts and personal files. We found a non-significant trend toward an increase in the relative risk of dying with arthroplasty when compared to internal fixation (relative risk=1.27, 95% confidence interval, 0.84–1.92, p = 0.25; homogeneity p= 0.45). Arthroplasty appeared to increase the risk of dying when compared to pin and plate, but not in comparison to internal fixation using screws (relative risk= 1.75 vs 0.86, respectively, p< 0.05). Fourteen trials provided data on revision surgery (n=1901 patients). The relative risk of revision surgery with arthroplasty was 0.23 (95% confidence interval, 0.13–0.42, p = 0.0003, homogeneity p = < 0.01)

The treatment of infected exposed implants which have been used for internal fixation usually involves debridement and removal of the implant. This can result in an unstable fracture or spinal column. Muscle flaps may be used to salvage these implants since they provide soft-tissue cover and fresh vascularity. However, there have been few reports concerning their use and these have concentrated on the eradication of the infection and successful soft-tissue cover as the endpoint. There is no information on the factors which may influence the successful salvage of the implant using muscle flaps. We studied the results and factors affecting outcome in nine pedicled muscle flaps used in the treatment of exposed metal internal fixation with salvage of the implant as the primary endpoint. This was achieved in four cases. Factors predicting success were age < 30 years, the absence of comorbid conditions and a favourable microbiological profile. The growth of multiple organisms, a history of smoking and the presence of methicillin-resistant Staphylococcus aureus on wound cultures indicated a poor outcome. The use of antibiotic beads, vacuum-assisted closure and dressing, the surgical site, the type of flap performed and the time from primary surgery to flap cover were not predictive of outcome

Introduction. Intracapsular hip fractures in young adults are treated with internal fixation, often as a surgical emergency to reduce the vascular insult to the femoral head. Avascular necrosis and non-union often require revision surgery. Methods. A prospective trauma database was retrospectively searched from 1. st. August 2008 to 31. st. December 2010. Intracapsular hip fracture admissions to the Regional Trauma Centre, in adults under sixty-five years, were studied. Ninety-eight intracapsular fractures internally fixed with sliding hip screw underwent radiographic review for quality of fixation, and evidence of complications at a mean of thirteen months. Co-morbid medical conditions and quality of fixation were assessed for association with revision rates. Results. Avascular necrosis developed in eighteen fractures, and seven proceeded to non-union. Seventeen of ninety-eight fractures underwent revision to total hip arthroplasty. Three individuals were deceased at final review. Six of thirty-four fractures (18%) fixed within twelve hours of injury required revision, compared with eleven of sixty-four (17%) fixed after twelve hours. None of the four fractures fixed within six hours required revision, although this was not statistically significant (p=0.32). Revision was required for three of six individuals with chronic respiratory disease (50%) excluding asthma, one of two with rheumatoid arthritis (50%), and three of six with varus reduction (50%), and each were significant on multiple regression. Residual translation and eccentric screw placement approached significance on chi-squared analysis. Only two of twenty (10%) fractures fixed using an additional anti-rotation screw required revision. Conclusions. Internal fixation of intracapsular hip fractures within twelve hours in young adults did not statistically reduce revision rates. Accurate reduction and internal fixation is paramount, and anti-rotation screws may reduce complication rates. Certain co-morbid conditions predict revision, and should be taken into consideration when selecting the primary operative procedure

We present the management and outcome of patients who presented following internal fixation of primary malignant tumours of the femur. This is a retrospective study of eleven patients. All underwent internal fixation of pathological or impending fractures of the femur in the assumption of metastatic disease, or prior to diagnosis of primary malignancy. Data was collected from database records and case notes. The mean age was 47 years (range 13 – 73). Six patients were male and five female. Tumour type was osteosarcoma (3), MFH (3), chondrosarcoma (2), Ewing’s sarcoma (1), fibrosarcoma (1) and liposarcoma (1). The site of the lesion was proximal in six cases and distal in five. Nine patients presented initially with pathological fractures and two with lytic lesions. The mode of fixation was DHS (3), AO screws (1), antegrade IM nailing (2), retrograde IM nailing (3), Blade plate (1) and DCS fixation (1). No patients underwent biopsy prior to fixation. Surgical treatment at the Bone Tumour Unit was excision and segmental endoprosthetic replacement (5), total femoral replacement (2), hip disarticulation (2), above knee amputation (1) with one patient dying prior to surgery. Eight patients also received chemotherapy and three radiotherapy. Four patients had local recurrences, three presented with metastatic disease and five more went on to develop metastases. Two patients died within one year of initial surgery, three more within two years and none have so far survived five years. Three patients are still alive. We believe that internal fixation of primary malignant tumours has a detrimental effect on limb salvage and survival, emphasising the absolute necessity of pre-operative investigation of solitary bone lesions

The place of internal fixation in the treatment of fractures of the shafts of the radius and ulna in adults is discussed, and the results in 130 fractures treated by internal fixation are reviewed. Non-union was found to be the most frequent and serious complication after internal fixation. The incidence of non-union can be greatly reduced if operation is delayed for at least one week, and preferably two to three weeks after injury. Evidence is presented to support the value of delayed operation in the promotion of union of fractures

1. The results in 211 fractures of the shaft of the femur in adults treated by internal fixation have been reviewed. 2. A comparison has been made between the effects of early internal fixation within the first six days of injury and delayed fixation. 3. Eighty-five fractures treated by early fixation gave a rate of non-union of 23 per cent; in 126 fractures treated by delayed fixation the rate was 0·8 per cent. 4. Delayed operation is therefore advocated for the majority of femoral shaft fractures for which internal fixation is indicated

Failed internal fixation of hip fracture is a problem with varied aetiology. This becomes more complex when associated with infection. Total hip arthroplasty (THA) remains the only option to restore hip biomechanics when there is partial/complete head destruction associated with it. A retrospective review was performed for 22 consecutive patients of THA following failed infected internal fixation between Sept. 2001 and Nov. 2007. There were 11 dynamic hip screw failures for intertrochanteric fractures, six failed osteotomies following proximal femoral fractures and five failed screw fixations for transcervical fractures. The average age of the patients was 48.5 years and average follow up period was 3.5 years (16 months–7.5 years). All the patients have undergone two stage revision surgeries. The average Harris Hip Score improved from 35.5 to 82.8 at the latest follow up. None of the patients had recurrence of infection. One patient developed sciatic nerve palsy, recovered partially at one year following surgery. The results were comparable to primary arthroplasty in femoral neck fractures. THA is a useful salvage procedure for failed infected internal fixation of hip fractures. Extreme care must be taken to avoid fracture and penetration of femoral shaft in such cases. Auto graft, allograft and special components like multihole cup, narrow stem should be available for reconstruction in difficult cases

Background: Complex anterior fracture-dislocations of shoulder are rare injuries and little is known about the functional outcomes following operative treatment. The aim of our study was to evaluate the functional outcomes following open reduction and internal fixation for these injuries. Methods: Over a ten and a half year period, we studied thirty-two consecutive patients who presented to shoulder injury clinic at the Royal Infirmary of Edinburgh with an acute Type-I complex anterior fracture-dislocation of the shoulder. The average age of the 19 men and 13 women was 58 years (range 21–81 years). All patients were treated with open reduction and internal fixation and were followed up for at least two years. The functional outcomes were assessed by three scoring systems (Disabilities of the Arm, Shoulder and Hand questionnaire, the Constant questionnaire, and the Short Form-36 general health questionnaire). Results: At two years post injury, the median DASH score was 26 points and the median Constant score was 83.5 points. The range of motion of the shoulder joint showed significant improvement throughout the two year period and degree of forward flexion and abduction continued to show significant improvement at five years. At two years, the mean forward flexion was 162°, mean extension was 152°, mean internal rotation was 109° and mean external rotation was 73°. All but one patient returned to their job at two years. Conclusions: Type I complex anterior fracture-dislocations of the shoulder are rare and occur in the middle age and elderly group of population. Following open reduction and internal fixation, the functional outcomes have been shown to be satisfactory. We recommend that open reduction and internal fixation should be the first choice of treatment in Type-I complex anterior fracture-dislocation of shoulder