Open talus fracture are notoriously difficult to manage and they are commonly associated with a high level of complications including non-union, avascular necrosis and infection. Currently, the management of such injuries is based upon BOAST 4 guidelines although there is no suggested definitive management, thus definitive management is based upon surgeon preference. The key principles of open talus fracture management which do not vary between surgeons, however, there is much debate over whether the talus should be preserved or removed after open talus fracture/dislocation and proceeded to tibiocalcaneal fusion. A review of electronic hospital records for open talus fractures from 2014-2021 returned foureen patients with fifteen open talus fractures. Seven cases were initially managed with ORIF, five cases were definitively managed with FUSION, while the others were managed with alternative methods. We collected patient's age, gender, surgical complications, surgical risk factors and post-treatment functional ability and pain and compliance with BOAST guidelines. The average follow-up of the cohort was four years and one month. EQ-5D-5L and FAAM-ADL/Sports score was used as a patient reported outcome measure. Data was analysed using the software PRISM. Comparison between FUSION and ORIF groups showed no statistically significant difference in EQ-5D-5L score (P = 0.13), FAAM-ADL (P = 0.20), FAAM-Sport (P = 0.34), infection rate (P = 0.55), surgical times (P = 0.91) and time to weight bearing (P = 0.39), despite a higher proportion of polytrauma and Hawkins III and IV fractures in the FUSION group. FUSION is typically used as second line to ORIF or failed ORIF. However, there are a lack of studies that directly compared outcome in open talus fracture patients definitively managed with FUSION or ORIF. Our results demonstrate for the first time, that FUSION may not be inferior to ORIF in terms of patient functional outcome, infection rate, and quality-of-life, in the management of patients with open talus fracture patients. Of note, as open talus fractures have increased risks of complications such as osteonecrosis and non-union, FUSION should be considered as a viable option to mitigate these potential complications in these patients

In our department, currently there is variation in the number of xrays that patients receive following ORIF of distal radius fractures. This audit investigated the use of xrays following ORIF of distal radius fractures. Patients were identified from daily trauma lists. Patients who had a primary ORIF or ORIF following failed conservative management were included in the study. PACS was used to identify the number of post-operative xrays performed. These were correlated with clinic letters to see if there was any change in management following xray review. Between July and November 2013, 102 patients were admitted with distal radius fracture. Of these, 35 (mean age:51 years) had an ORIF. Four were not followed-up in Scotland. Of the remaining 31 patients, eleven had one post-operative xray, seventeen had two and three had three xrays. Of the patients who had one xray, seven had the xray in the first three weeks, the rest at six weeks. Patients who had two xrays had an xray at two and 6 weeks. Of the three patients who had three xrays, two had comminuted fractures that required further CT investigation, one for a suspicion of an intra-articular screw, the other for possibility of non-union. The third patient had no apparent reason for requiring three xrays. Thus of the 31 patients in the study, 29 did not require any further investigations. The results show a variation in the frequency of post-operative xrays after fixation of distal radius fractures. In most cases the management plan was unchanged after plain xrays were undertaken. This suggests that a protocol driven approach to follow-up after fixation of distal radius fractures could reduce the burden on fracture clinic and radiology departments. We propose that unless indicated by intra-operative findings or post-operative concerns, patients should have xrays at the two week review appointment

Introduction: Treatment and outcome of patients with rheumatoid arthritis and distal humerus fractures is not well established. Methods: Between 1982 and 2002 twenty-four elbows in twenty-two patients (eleven men, eleven women) treated for acute distal humerus fractures were retrospectively reviewed. The average age at time of the fracture was 64 years. Eleven elbows were immediately treated with a total elbow arthroplasty (TEA) type Coonrad-Morrey (CM), six elbows had underwent open reduction and internal fixation (ORIF), and seven elbows were referred to our institution after failed ORIF elsewhere and were revised with an TEA (CM). Results: At an average follow-up of 52 months the Mayo Elbow Performance Score (MEPS) averaged in the eleven elbows with an immediate TEA 96 points and in the six elbows with ORIF 93 points (p=0.79). In the seven elbows with TEA after failed ORIF there was a trend towards a less favorable outcome (MEPS: 86 points) but the differences was not significant compared to immediate TEA (p=0.31) and ORIF (p=0.53). Patients with failed ORIF and a subsequent TEA had an average of 3 operation per elbow with one patient ending in elbow resection after an infected TEA. Patients with immediate TEA had an average of 1.3 operations and patients with successful ORIF 1.2 interventions. Discussion and Conclusion: Distal humerus fractures in patients with rheumatoid arthritis can be treated successfully with an immediate TEA or ORIF. There is a trend towards a poorer clinical outcome in patients with TEA after failed ORIF

Aim: To compare the outcome of open reduction and internal fixation with MUA and k-wire stabilisation of dorsally displaced distal radial fractures. Methods: A review of patients that had ORIF or MUA and k-wire stabilisation for dorsally displaced distal radial fractures was carried out and patients with a follow period of more than 6 months were selected for this study. The patient history and the management of the injury were obtained and the wrist examined. Each patient completed a patient-rated wrist evaluation form and the range of movement and strength of the wrist was determined by the senior occupational therapist. Standard radiographs were obtained and volar tilt, radial inclination and radial length were measured. Results: This study provides results on 24 patients, which were grouped according to the two different surgical procedures; ORIF and MUA and k-wire stabilisation. The procedure undertaken depended on consultant preferences and in the majority of cases patients were treated with MUA and k-wire stabilisation. Patients of both groups were of similar age and all sustained either a low or medium energy injury. All patients from each group received physiotherapy post operatively. There was no significant difference between both groups for range of movement and grip strength. There was also no difference between the patient’s perception of pain and function which was assessed using the patient rated wrist evaluation (PRWE). Radiologically, the k-wire stabilisation group averaged better volar tilt compared with the ORIF group. For radial height and inclination the outcome was similar. Conclusion: MUA and k-wire stabilisation has been the most popular surgical management for unstable dorsally displaced fractures of the distal radius. More recently ORIF with the locking compression plate has been used with good results. This study showed that the outcome of ORIF and MUA and k-wire stabilisation were similar and therefore either surgical management can be used with good results

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

Few will disagree that the best femoral head that a young patient can have is his or her own, native femoral head. In the active, healthy patient under age 60 with a displaced femoral neck fracture, well-done, timely ORIF presents the best chance of preserving the patient's native femoral head. Arthroplasty is generally reserved for older patients, over age 60, where attempts at ORIF in this setting have demonstrated failure rates over 40%. Recent studies have documented that approximately 80% of young patients with displaced femoral neck fractures treated with ORIF will keep their own femoral head for 10 years after injury. The variables under the surgeon's control include timing of fixation, quality of reduction, accurate implant placement and implant selection, and capsulotomy. All of these variables potentially affect outcomes. Fractures in this young age group are frequently high shear angle (vertical) Pauwels type 3 fractures, and benefit from fixed angle fixation. The author prefers anatomic reduction and stabilization with a sliding hip screw and a superiorly placed derotation screw. Careful attention to detail is important to obtain an anatomic reduction, which is the most important variable in the outcome of these challenging injuries

The proper management of radial head fractures is difficult and controversial. The radial head is intra-articular, part of the forearm ring and participates in both flexion and extension as well as in pronosupination. Our main goal in treating those fractures is anatomic restoration of the joint surface and early mobilization. Excision of the radial head, a well described procedure, may result in elbow instability and proximal migration of the radius. In this work we tried to avoid those complications by either conserving the head (ORIF) or by using a Radial head prosthesis. Material and Methods: 20 Patients were enrolled into the study between 2003–2004. They were divided into 2 groups. 10 patients had ORIF and in patients the Corin Radial head prosthesis was used. Post-op all patients started immediate CPM. All patients were followed-up for 12–28 months (average 18.6). XR were taken each time and clinical examination was done, ROM was noted as well as muscle strength. Elbow stability was tested only on the 2. nd. month post op. Patient satisfaction was noted based of their function ability, and the amount of pain. Pain was rated on a scale of 1–10. Results: Both groups passed the surgery uneventfully. No neurovascular damage nor infection were noted. In clinical examination the elbow was found to be stable in both groups. Decreased ROM in compare with the other elbow was found in both groups, but was more prominent in he ORIF group. One patient in the ORIF group in which biodegradable rod was used developed moderate synovitis that passed without intervention after 9 weeks. XR reveled that one patient in the ORIF group developed Heterotopic ossification, no dislocation or subluxation of the prosthesis was seen. Regarding to pain, in the ORIF group the patients rated their pain as milder in compare to those in the prosthetic group. Conclusions: Both methods result in stable elbow but the ORIF group showed tendency to experience less pains and the prosthesis group showed tendency to better ROM

Aims: In prospective study the author asked, what are the results of ORIF (open reduction, internal fixation) in displaced intraarticular fractures of the calcaneus, and whether type of fracture and/or congruity in the sub-talar joint influence these results. Methods: Forty-three displaced intraarticular fractures of the calcaneus (30 Type II, 10 Type III and 3 Type IV; Sanders) were operated through extensile lateral approach. After reduction of the subtalar joint and restoration of the calcaneus shape, the fracture was fixed with the calcaneal plate. Mostly, surgery was delayed (median: day 7). Motion was encouraged immediately, partial weight-bearing after 5–6 weeks, and full weight-bearing after 3–4 month. Following surgery subtalar joint was congruent in 33 (77%) and non-congruent (within 2mm) in ten fractures. Results: Thirtysix fractures were evaluated 12 to 61 months postinjury. Functional results were satisfactory in 31 fractures (86%) and not satisfactory in five. All fractures with unsatisfactory results were comminutive (Type III or IV). Four fractures with congruent subtalar joint had unsatisfactory, whereas eight of nine fractures with uncongruent joint had satisfactory result. Statistically, functional results of the comminuted fractures were significantly worse (p=0,002). However, functional results of fractures with non-congruent joint were comparable to the results of fractures with congruent joint. Conclusions: ORIF enables satisfactory results in majority of displaced intraarticular fractures of the calcaneus. Comminution in the subtalar joint is a negative prognostic factor; furthermore, comminution is a negative prognostic factor irrespectless of the postreduction congruity in the subtalar joint, if step-off is less than 2mm

The term os-acromiale denotes the failure of fusion of acromial apophysis to the scapular spine. The prevalence of os is considered to be about 8% in the general population with higher prevalence in African Americans and males. The treatment options for a symptomatic os acromiale range from arthroscopic excision to decompression to ORIF and bone grafting. In this study, we reviewed retrospectively patients who had undergone ORIF and bone grafting for a painful os acromiale. Patients surgically treated for os acromiale from 1998 to 2009 were included in the study. All patients were diagnosed to have a symptomatic os acromiale clinically and radiologically. A pre operative MRI of the affected shoulder was done in all patients. All patients had failed conservative management. The surgical technique was standard in all patients. The rotator cuff was repaired if it was torn. Patients were followed up at 3, 6 and 12 months postoperatively. Post operative X-rays were done at 3 months to assess healing. An ASES scoring was done at the final follow up at a mean of 30.5 months post op. 16 patients with 17 shoulders which included 10 males and 6 females were available for the last follow up. 11 shoulders involved dominant hand, 15 shoulders had a history of trauma. Surgery was performed after an average of 7.2 months of conservative management. 11 out of the 17 shoulders had associated rotator cuff tears. Out of the 6 patients with intact cuff, 2 had associated clavicle fractures and 1 patient had an Acromio clavicular joint dislocation. A clinical and radiographic union was achieved in all patients. Mean ASES score in patients without rotator cuff tear was 89 whereas patients with associated rotator cuff tear had an ASES score of 74. Pain score and percentage ADL score were better in patients without rotator cuff tear (92 and 1.3) as compared to those with a cuff tear (83 and 2.2). There was no significant difference in scores in patients who had second surgery at final follow up. 15 of the 16 patients were satisfied with the surgery and would have the surgery on the other side for a similar problem. Open reduction and internal fixation of symptomatic os acromiale yields predictable clinical outcome. Bigger studies randomising treatment methods in similar group of patients may be needed to find out the superiority of one method over the other

Introduction. Venous thromboembolism (VTE) represents a major cause of morbidity, mortality and financial burden to the NHS. Acquired risk factors are well documented, including immobilisation, lower limb plaster cast and surgery. NICE guidance on VTE prophylaxis within orthopaedics currently excludes operative ankle fracture fixation (ankle ORIF). Aims. Ascertain the local incidence of VTE; compare our local VTE rates with published data from other institutions; review guidelines, scientific literature and other hospitals policies; formulate a local policy for VTE prophylaxis. Method. Retrospective analysis of records of all patients undergoing ankle ORIF in our hospital over a continuous 5 year period, identifying cases of VTE, individual risk factors and surgical duration. Results. 380 patients underwent ankle ORIF; 3 developed VTE; no mortality. VTE incidence 0.79% (0.26%DVT; 0.53%PE). Operative duration 88 +/− 34mins (mean +/− 1S.D); in those with VTE, duration was 35, 90&85min. There is no statistically significant difference (p=0.18) observed between our local and national VTE incidence rates. Operative duration was not a significant factor in those developing VTE. Additional risk factors were identified in one patient with VTE. Discussion. The incidence of heparin induced thrombocytopenia is 0.5%, its associated mortality 10% (i.e. 1:2000). To prevent one fatal PE in foot & ankle surgery, 10,000 must receive VTE prophylaxis. Therefore, heparin associated mortality exceeds VTE associated mortality in foot & ankle surgery. Conclusion. Our local VTE rates are comparable to national rates. Risk of pharmacological prophylaxis exceeds benefit; therefore routine use not justified. Individual risk should be assessed; higher risk patients may benefit

Femoral neck fractures continue to be one of the most common orthopaedic injuries treated today. Owing to the increased longevity of patients, enduring activity of older patients, and widespread osteoporosis in the population, there are more femoral neck fractures treated nowadays than ever before. Over 1 million femoral neck fractures were treated in the >65-year-old population, in the United States, between the years 1991–2008. The treatment of femoral neck fractures is unique because some fractures are amenable to internal fixation, while others require endoprosthetic replacement, either with a hemiarthroplasty or total hip replacement. Traditionally, less displaced fractures are treated with internal fixation; however, in younger patients, an attempt to fix the displaced fractures may be performed, in order to avoid a joint replacement in this population. The age at which an attempt at internal fixation is performed is still controversial, and treatment must be individualised to each patient. In general, patients younger than 60 would likely have internal fixation of the femoral neck fracture, rather than joint replacement. The paradigm for the treatment of femoral neck fractures has been changing in the last 10 years, due to advances in implant technology, surgical technique, and scientific papers that have compared the results of all three treatment options. Larger diameter femoral heads in combination with highly crosslinked polyethylene, or dual mobility head options, provide greater joint stability today than was possible in the past, thus making THA a more appealing option. Furthermore, greater use of the direct anterior approach to THA may also reduce the postoperative dislocation rate, due to preservation of the posterior capsule and short external rotators. Therefore, the author will propose the use of arthroplasty for displaced femoral neck fractures in patients younger than 60 years of age, owing to the reliability and reproducibility of THA over ORIF. Furthermore, the advances in arthroplasty materials and surgical techniques can restore function in this group of younger patients, with greater longevity of the implant than in the past

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

Aims. The aim of this study was to determine both the incidence of, and the reoperation rate for, postoperative periprosthetic femoral fracture (POPFF) after total hip arthroplasty (THA) with either a collared cementless (CC) femoral component or a cemented polished taper-slip (PTS) femoral component. Methods. We performed a retrospective review of a consecutive series of 11,018 THAs over a ten-year period. All POPFFs were identified using regional radiograph archiving and electronic care systems. Results. A total of 11,018 THAs were implanted: 4,952 CC femoral components and 6,066 cemented PTS femoral components. Between groups, age, sex, and BMI did not differ. Overall, 91 patients (0.8%) sustained a POPFF. For all patients with a POPFF, 16.5% (15/91) were managed conservatively, 67.0% (61/91) underwent open reduction and internal fixation (ORIF), and 16.5% (15/91) underwent revision. The CC group had a lower POPFF rate compared to the PTS group (0.7% (36/4,952) vs 0.9% (55/6,066); p = 0.345). Fewer POPFFs in the CC group required surgery (0.4% (22/4,952) vs 0.9% (54/6,066); p = 0.005). Fewer POPFFs required surgery in males with a CC than males with a PTS (0.3% (7/2,121) vs 1.3% (36/2,674); p < 0.001). Conclusion. Male patients with a PTS femoral component were five times more likely to have a reoperation for POPFF. Female patients had the same incidence of reoperation with either component type. Of those having a reoperation, 80.3% (61/76) had an ORIF, which could greatly mask the size of this problem in many registries. Cite this article: Bone Joint J 2024;106-B(2):144–150

This is a case series report on the outcomes of patients that have received ORIF of their calcaneal fractures at Craigavon Hospital, Northern Ireland, for the first 2 years since it opened. It is a one surgeon series. Methods. Patients were identified from the theatre logbook. The patient recalled to clinic for interview and examination. Outcome was assessed using The Ankle-Hindfoot Scale devised by the American Orthopaedic Foot and Ankle Society. This was recorded with data for the patient's notes and CT scans. These data included age, date of surgery, mechanism of injury, associated injuries and previous function. The calcaneal fractures were classified according to the Sanders Classification. Results. Sixteen patients identified from the theatre register. Of these patients, 10 patients were contactable and attended for evaluation. The data from these 10 patients was then analysed. There 9 male patients and one female. Time from operation from 9.5 months to 33 months. All patients had fractures classified as Sanders Type IV. All implants were Variax calcaneal plates. One patient had metalwork removed at 15 months. All patients had commenced weightbearing at 3 months. Outcome scores ranged from 52–97 (mean 78.3, median 79). Six of the ten had returned to work at this review. Subtalar motion was universally affected. Discussion. This one surgeon case series reflects the current literature on calcaneal fractures, in that there is a variation in outcome which is multifactorial. There is also a difficulty in defining a classification system which can reflect outcome. The results of this series suggest that there is a trend of improving outcome scores as time from injury progresses, and that outcome score tends to decrease as age at injury increases

Aim: To present and analysis the neurological complications after ORIF with plates of bicondylar fractures of the humerus. Material and Methods: For the period 1996 – 2003 77 bicondylar fractures were operated with plates. All of them were followed up. 36 Man and 41 women. Dominant hand was affected in 43 patients. The AO types were C1- 25, C2 – 28, C3 – 24. There were 18 open fractures (I–II degree). High-energy trauma caused 19 fractures. 14 were with associated ipsilateral fractures of the upper limb. All patients were operated by the standard AO technique. In all patients the ulnar nerve was identified. There was no case where the radial nerve was exposed. In 36 patients the nerve was transposed anteriorly subcutaneosly and for the rest it was not. Results: We observed 20 postoperative ulnar and radial nerve disfunctions (19 ulnar nerve and 1 radial nerve disfunctions). Electromiography was performed in all cases. 7 of 36 (with transposition) cases finished with temporary ulnar nerve palsy. 3 of 41 (without transposition) cases finished with permanent ulnar nerve palsy and the other 9 of 41 finished with temporary disfunction. The disfunction of the radial nerve was temporary. The temporary neurological disfunctions recovered completely for 3–7 months. Neurolysis and anterior transposition of the ulnar nerve was performed in the cases with permanent ulnar nerve palsy. Conclusions: We suggest that ulnar nerve transposition is a method of choice in operative treatment of bicondylar fractures of the humerus. Careful management of the ulnar nerve is mandatory. Meticulous soft-tissue dissection and hemostasis help to prevent perineural fibrosis

Femoral neck fractures continue to be one of the most common orthopaedic injuries treated today. Owing to the increased longevity of patients, enduring activity of older patients, and widespread osteoporosis in the population, there are more femoral neck fractures treated nowadays than ever before. Over 1 million femoral neck fractures were treated in the >65 year old population, in the United States, between the years 1991–2008. The treatment of femoral neck fractures is unique because some fractures are amenable to internal fixation, while others require endoprosthetic replacement, either with a hemiarthroplasty or total hip replacement. Traditionally, less displaced fractures are treated with internal fixation; however, in younger patients, an attempt to fix the displaced fractures may be performed, in order to avoid a joint replacement in this population. The age at which an attempt at internal fixation is performed is still controversial, and treatment must be individualised to each patient. In general, patients younger than 60 would likely have internal fixation of the femoral neck fracture, rather than joint replacement. The paradigm for the treatment of femoral neck fractures has been changing in the last 10 years, due to advances in implant technology, surgical technique, and scientific papers that have compared the results of all three treatment options. Larger diameter femoral heads in combination with highly crosslinked polyethylene, or dual mobility head options, provide greater joint stability today than was possible in the past, thus making THA a more appealing option. Furthermore, greater use of the direct anterior approach to THA may also reduce the post-operative dislocation rate, due to preservation of the posterior capsule and short external rotators. Therefore, the author will propose the use of arthroplasty for displaced femoral neck fractures in patients younger than 60 years of age, owing to the reliability and reproducibility of THA over ORIF. Furthermore, the advances in arthroplasty materials and surgical techniques can restore function in this group of younger patients, with greater longevity of the implant than in the past

Introduction: An ankle fracture represents the most frequent osseous injury in both the elderly and non-elderly population. To date, only a limited number of retrospective studies have addressed medium-term outcome following ankle Open Reduction and Internal Fixation (ORIF). The purpose of this study was to assess residual pain and functional outcome 10 to 20 years after operative treatment of ankle fractures and to evaluate the incidence of symptomatic and radiographic ankle osteoarthritis (OA). Methods: We designed a retrospective study including all consecutive patients who underwent ankle ORIF between January 1988 and December 1997 in a University Hospital setting. Pilon and talus fracture as well as pediatric patients were excluded. Patients were seen by two senior residents 10–20 years after their index surgery. Residual pain was measured using the Visual Analog pain Scale. Function and general health status were assessed using the Olerud and Molander Ankle Score, the American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and the 12-item short-form health survey (SF-12). Ankle OA on standard radiographs was scored according to the revised Kellgren and Lawrence (K& L) scale. Results: 374 patients (56% men) underwent ankle surgery during the defined period. 10% of the patients had a Weber A fracture, 57% a Weber B and 33% a Weber C fracture. Mean age at the time of operation was 42.9 years (+/− 17.1; range 16–86 years). 10–20 years after surgery, 47 patients had died, 126 had left the country and were lost to follow-up, 99 did not respond or refused to participate, and 102 patients were seen at the follow-up visit. These patients did not differ in terms of age, gender distribution, BMI and type of fracture from those who were not seen. The mean duration of follow up was 17.3 years (+/− 3.3). Advanced radiographic OA (K& L grade 3 and 4) was present in 34.3 % of the patients. Symptomatic OA was reported by 34.3 % of the patients (AOFAS pain score < 40). Both clinically symptomatic and radiographic ankle OA was found in 18 patients (17.6%). Function was good in 85% of the cases (total AOFAS hindfoot score between 80 and 100 points; mean total AOFAS hindfoot score 89.9, +/−14.6). The mean Olerud and Molander ankle score was 86.5 (+/−18.7). The general health status (SF-12) was similar to representative values of the general population with a similar mean age. Conclusion: 10–20 years after operative treatment of an ankle fracture, the incidence of advanced radiographic post-traumatic ankle OA was 35%, symptomatic OA was present in one third of the patients and about one fifth had both. The majority of the patients reported good function

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

Objective. To identify risk factors for surgical site infections and to quantify the contribution of independent risk factors to the probability of developing infection after definitive fixation of tibial plateau fractures. Methods. A retrospective analysis was performed at a Level I trauma center between 2004 and 2010. A total of 251 consecutive patients (256 cases) were divided into two groups, those with and those without a surgical site infection. Preoperative and perioperative variables were compared between these groups and risk factors were determined by univariate analyses and multivariate logistic regression. Results. The overall rate of surgical site infection after tibial plateau ORIF was 7.8% (20 of 256). The most common causative pathogens was Staphylococcus aureus (n=15, 75%). Independent predictors of surgical site infection identified by multivariate analyses were open tibial plateau fracture (odds ratio =3.9; 95% confidence interval=1.3–11.6, p =0.015) and operative time (odds ratio=2.7; 95% confidence interval=1.6 − 4.4; p < 0.001). Conclusions. Both open fracture and operative time are independent risks factors for post operative infection

Aims. This systematic review and meta-analysis was conducted to compare open reduction and internal fixation (ORIF) with primary arthrodesis (PA) in the treatment of Lisfranc injuries, regarding patient-reported outcome measures (PROMs), and risk of secondary surgery. The aim was to conclusively determine the best available treatment based on the most complete and recent evidence available. Methods. A systematic search was conducted in PubMed, Cochrane Controlled Register of Trials (CENTRAL), EMBASE, CINAHL, PEDro, and SPORTDiscus. Additionally, ongoing trial registers and reference lists of included articles were screened. Risk of bias (RoB) and level of evidence were assessed using the Cochrane risk of bias tools and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool. The random and fixed-effect models were used for the statistical analysis. Results. A total of 20 studies were selected for this review, of which 12 were comparative studies fit for meta-analysis, including three randomized controlled trials (RCTs). This resulted in a total analyzed population of 392 patients treated with ORIF and 249 patients treated with PA. The mean differences between the two groups in American Orthopedic Foot and Ankle Society (AOFAS), VAS, and SF-36 scores were -7.41 (95% confidence interval (CI) -13.31 to -1.51), 0.77 (95% CI -0.85 to 2.39), and -1.20 (95% CI -3.86 to 1.46), respectively. Conclusion. This is the first study to find a statistically significant difference in PROMs, as measured by the AOFAS score, in favour of PA for the treatment of Lisfranc injuries. However, this difference may not be clinically relevant, and therefore drawing a definitive conclusion requires confirmation by a large prospective high-quality RCT. Such a study should also assess cost-effectiveness, as cost considerations might be decisive in decision-making. Level of Evidence: I. Cite this article: Bone Jt Open 2021;2(10):842–849

Purpose: The purpose of this study was to review our results in patients with pilon fractures treated with ORIF in which surgical planning involved multiple skin incisions, ensuring that the distance incisions overlapped was less than the distance between them. We hypothesized that soft-tissue complications would be minimal despite incisions placed < 7-cm apart. Method: A retrospective chart review identified 37 pilon fractures in 32 patients treated by three orthopedic traumatologists at The Ottawa Hospital between August 2000 and February 2007. Follow-up included measurements of incision placement and functional outcome measures. Results: There were nine OTA type B and 28 OTA type C fractures; 28 were closed and nine were open. The mean age was 46.5 ±14.5 years, and average follow-up was 3.2 ±1.7 years. Of the patients reviewed, the average number of incisions was 3.7 ±1.1. The average overlap between incisions was 4.6-cm ±1.9 and the average skin bridge between incisions was 5.9-cm ±1.9, with 80% of the skin bridges < 7-cm. Average ROM was 4.3° ±7.1 dorsiflexion and 39.1° ±11.6 plantarflexion. The mean AMA lower extremity impairment score was 18.9% ±12.4, and mean SIP ambulation score was 9.6 ±8.8. Complications included two superficial infections, one deep infection, and three non-unions. There were no cases of wound dehiscence or necrosis, or cases requiring revision soft-tissue coverage. These outcomes were comparable to recent reports with similar injuries. Conclusion: With careful planning and good soft-tissue management, incisions can be placed to maximize articular exposure based on fracture lines. It does not appear that the dogma of keeping incisions > 7-cm apart must be followed in most cases. Prudent surgical timing and meticulous soft-tissue handling can allow for multiple incisions to be placed as necessary for fracture reduction and optimal fixation while maintaining a low rate of complications

OBJECTIVES: In recent years the incidence of proximal humerus fractures increased strongly. The optimal treatment of displaced, unstable fractures is still controversial. One of the major problem seen in previous treatment options was implant failure with secondary dislocation, pseudarthrosis and AVN. New angular stable implants promise a stronger anchorage and allow early functional aftertreatment, especially in osteopenic bone. Aim of this prospective case-series was to assess complication risks and functional outcome after ORIF with an angular stable form plate. DESIGN: Prospective case-series. SETTING: Multicenter study in 8 European Trauma Units. PATIENTS: 157 patients were treated for 158 displaced proximal humerus fractures. INTERVENTION: ORIF with a PHILOS. ™. plate. RESULTS: According to the AO/ASIF classification 25%, 61% and 37% were classified as type A, B and C, respectively. One year follow-up rate was 84%, whereupon 6 patients had died in the mean time and 18 were lost to follow-up. Overall 71 complications were observed in 53 patients and led to 39 unplanned re-operations, whereupon most frequent were primary screw perforations (n=22), secondary screw perforations (n=13)–mostly with secondary impaction (n=11), and AVN (n=8). Increasing age and severity of fractures influenced the occurrence of complications, since the risk to obtain a complication was doubled in patients over 60 years compared to younger (Relative Risk 1.9; Fischer’s Exact, p=0.022) as well as in AO/ASIF B- and C-fractures compared to A-fractures (Relative Risk=1.8; Fischer’s Exact, p=0.05). Risks for complications related to the implant, surgical technique or fracture and bone were 9%, 20% and 13%, respectively. Within one year all fractures healed and 5 secondary dislocations were observed. The mean (SD) Constant score of the injured shoulder improved during follow-up period to 72 points (15.2) at 12 months follow-up, when 87% (16.6%) of the contralateral shoulder was reached. Across all follow-up examinations the Constant score in relation to the contralateral shoulder impaired with increasing severity of the fracture (ANOVA, p=0.006). The mean (SD) DASH score after one year was with 16 points (21.1) worser (T-test, p< 0.001) than before the accident [5.2 (11.4)]. CONCLUSIONS: Fixation with a Philos plate provides high stability to preserve achieved reduction, which benefits the good functional outcome. However surgical technique related complication risks are high, particularly due to screw perforations into the joint. Augmented awareness and improvement of surgical technique should reduce these risks. Complex fracture types and higher age increases the risk to sustain complications, where as only severity of fractures impairs the functional outcome

The Failed Femoral Neck Fracture

For the young patient: Attempt to preserve patient's own femoral head. Clinical results reasonably good even if there are patches of avascular necrosis. Preferred methods of salvage: valgus-producing intertrochanteric femoral osteotomy: puts the nonunion under compression. Other treatment option: Meyer's vascularised pedicle graft.

For the older patient: Most reliable treatment is prosthetic replacement. Decision to use hemiarthroplasty (such as bipolar) or THA based on quality of articular cartilage, perceived risk of instability problem. In most patients THA provides higher likelihood of excellent pain relief. Specific technical issues: (1) hardware removal: usually remove after hip has first been dislocated (to reduce risk of femur fracture); (2) Hip stability: consider methods to reduce dislocation risk: larger diameter heads/dual mobility/anteriorly-based approaches; (3) Acetabular bone quality: poor because it is not sclerotic from previous arthritis; caution when impacting a pressfit cup; low threshold to augment fixation with screws; don't overdo reaming; just expose the bleeding subchondral bone. A reasonable alternative is a cemented cup.

Aims

The purpose of this study was to compare reoperation and revision rates of double plating (DP), single plating using a lateral locking plate (SP), or distal femoral arthroplasty (DFA) for the treatment of periprosthetic distal femur fractures (PDFFs).

Two stainless steel ‘TriMed’ distal radial fracture reduction techniques were tested to compare the relative stability of the two in vitro for a pre-determined fracture pattern. The movement of the bony segments were plotted over time using an ARAMIS 3 dimensional non-contacting displacement mapping system (GOM mbH, Braunschweig, Germany) to give quantitative data. The data was used to calculate the relative motion of the bony segments with the aim of investigating regions of compression across the fracture line, which is thought to accelerate fracture healing, and shear between bony segments, which is detrimental to fracture healing.

Ten third generation adult radius biomechanical model Sawbones (Sawbones, Malmö, Sweden) were cut to simulate AO type C2 fractures with dorsal comminution. Five bones were plated using the TriMed fixed angle volar bearing plate and five were plated using the TriMed radius and ulnar plating technique. Samples were potted and loaded cyclically at 1 Hz via a floating scaphoid-lunate bearing onto the end of the radius at incrementally increasing loads of 100 N – 500 N with 1000 load cycles applied for each load level.

The results showed the radius and ulnar pin-plate configuration allowed greater movement of the articular surface, with relative shear motion and separation between the two segments, although the relative shear movement between the two distal segments was below 2mm, which is considered the definition of failed fixa-tion. With the volar bearing plate the two distal segments moved as single unit and compression with minimal shear was applied across the fracture line to the proximal radius. Thus the radius and ulnar plates allowed shear across all three fracture lines, while the volar plate held the two distal segments fixed relative to each other and allowed compression across the interface with the proximal radius. The ARAMIS system allowed the three dimensional motion of the bony segments to be followed, in particular the relative motion between the segments, indicating the type of healing to be expected clinically. The study demonstrated the value of ARAMIS in investigating the stability of wrist fractures fixations and can easily be adapted to investigate other orthopaedic fixation systems.

Background: The purpose of the presented study was to evaluate the longterm outcome of surgically treated complex fractures of the proximal humerus including fractures with initial humeral head ischemia. The study was focused on the assessment of the functional outcome as well as on the occurence of avascular necrosis.

Methods: 100 shoulders (98 patients/60y/21–88) with intracapsular fractures of the proximal humerus were included in a prospective surgical evaluation protocol (Binary [LEGO] description system: 48/100 4-, 46/100 3-, 6/100 2-fragment fractures). Humeral head perfusion was assessed intraoperatively by means of laser-Doppler flowmetry and borehole judgement. 51/100 fractures were treated with osteosynthesis (group A). 49/100 were treated with hemiarthroplasty (group B). In group A 41/51 heads were perfused at the index procedure (A1) and 10/51 were ischemic (A2). The patients were re-evaluated at a mean follow-up of 5.0 years (3.3–7.3) using the Constant-Murley-Score (CMS), the Subjective Shoulder Value (SSV) and conventional x-ray imaging.

Results: The median total CMS was 76 (37–98) in group A, 70 (39–84) (group B) (p=0.02). The median SSV was 92 (40–100) (group A) and 90 (40–100) in group B (p=0.93). In group A1 6/30 heads were structurally alterated but not collapsed; 4/30 were collapsed. In group A2 6/10 were structurally alterated but not collapsed; 3/10 were collapsed. The median CMS for patients without structural alterations was 80 (37–98), for those with structural alterations 84 (53–93) and for those with collapsed heads 63 (48–74). The median SSV was 95 (50–100), 92 (50–100) and 60 (40–80), respectively.

Conclusions: Revascularization of the humeral head after initial ischemia is possible and occured in 7/10 patients. Their functional results were comparable to those of patients with initially perfused heads. When feasible, osteosynthesis is a viable option even for ischemic heads. The indication for osteosynthesis should be weighed against the fact that Osteosynthesis and Arthroplasty showed comparable long-term results.

The use of tourniquets in lower limb trauma surgery to control bleeding and improve the surgical field is a long established practice. In this article, we review the evidence relating to harms and benefits of tourniquet use in lower limb fracture fixation surgery and report the results of a survey on current tourniquet practice among trauma surgeons in the UK.

Objectives. To investigate the differences of open reduction and internal fixation (ORIF) of complex AO Type C distal radius fractures between two different models of a single implant type. Methods. A total of 136 patients who received either a 2.4 mm (n = 61) or 3.5 mm (n = 75) distal radius locking compression plate (LCP DR) using a volar approach were followed over two years. The main outcome measurements included motion, grip strength, pain, and the scores of Gartland and Werley, the Short-Form 36 (SF-36) and the Disabilities of the Arm, Shoulder, and Hand (DASH). Differences between the treatment groups were evaluated using regression analysis and the likelihood ratio test with significance based on the Bonferroni corrected p-value of < 0.003. Results. The groups were similar with respect to baseline and injury characteristics as well as general surgical details. The risk of experiencing a complication after ORIF with a LCP DR 2.4 mm was 18% (n = 11) compared with 11% (n = 8) after receiving a LCP DR 3.5 mm (p = 0.45). Wrist function was also similar between the cohorts based on the mean ranges of movement (all p > 0.052) and grip strength measurements relative to the contralateral healthy side (p = 0.583). In addition, DASH and SF-36 component scores as well as pain were not significantly different between the treatment groups throughout the two-year period (all p ≥ 0.005). No patient from either treatment group had a step-off > 2 mm. Conclusions. Differences in plate design do not influence the overall final outcome of fracture fixation using LCP.

Introduction

Intraarticular calcaneal fractures often need open reduction and internal fixation (ORIF) with plate osteosynthesis. The wound complication is one of the common problems encountered following this and affects the outcome adversely. Our study was done to assess how far postoperative slab/cast can avert wound complications.

In light of the growing number of elderly osteopenic patients with distal humeral fractures, we discuss the history of their management and current trends. Under most circumstances operative fixation and early mobilisation is the treatment of choice, as it gives the best results. The relative indications for and results of total elbow replacement versus internal fixation are discussed.

Most fractures of the radial head are stable undisplaced or minimally displaced partial fractures without an associated fracture of the elbow or forearm or ligament injury, where stiffness following non-operative management is the primary concern. Displaced unstable fractures of the radial head are usually associated with other fractures or ligament injuries, and restoration of radiocapitellar contact by reconstruction or prosthetic replacement of the fractured head is necessary to prevent subluxation or dislocation of the elbow and forearm. In fractures with three or fewer fragments (two articular fragments and the neck) and little or no metaphyseal comminution, open reduction and internal fixation may give good results. However, fragmented unstable fractures of the radial head are prone to early failure of fixation and nonunion when fixed. Excision of the radial head is associated with good long-term results, but in patients with instability of the elbow or forearm, prosthetic replacement is preferred.

This review considers the characteristics of stable and unstable fractures of the radial head, as well as discussing the debatable aspects of management, in light of the current best evidence.

Cite this article: Bone Joint J 2013;95-B:151–9.

The ideal form of fixation for displaced, extra-articular fractures of the distal tibia remains controversial. In the UK, open reduction and internal fixation with locking-plates and intramedullary nailing are the two most common forms of treatment. Both techniques provide reliable fixation but both are associated with specific complications. There is little information regarding the functional recovery following either procedure.

We performed a randomised pilot trial to determine the functional outcome of 24 adult patients treated with either a locking-plate (n = 12) or an intramedullary nailing (n = 12). At six months, there was an adjusted difference of 13 points in the Disability Rating Index in favour of the intramedullary nail. However, this was not statistically significant in this pilot trial (p = 0.498). A total of seven patients required further surgery in the locking-plate group and one in the intramedullary nail group.

This study suggests that there may be clinically relevant, functional differences in patients treated with nail versus locking-plate fixation for fractures of the distal tibia and differences in related complications. Further trials are required to confirm the findings of this pilot investigation.

Aims. The aim of this study was to compare open reduction and internal fixation (ORIF) with revision surgery for the surgical management of Unified Classification System (UCS) type B periprosthetic femoral fractures around cemented polished taper-slip femoral components following primary total hip arthroplasty (THA). Methods. Data were collected for patients admitted to five UK centres. The primary outcome measure was the two-year reoperation rate. Secondary outcomes were time to surgery, transfusion requirements, critical care requirements, length of stay, two-year local complication rates, six-month systemic complication rates, and mortality rates. Comparisons were made by the form of treatment (ORIF vs revision) and UCS type (B1 vs B2/B3). Kaplan-Meier survival analysis was performed with two-year reoperation for any reason as the endpoint. Results. A total of 317 periprosthetic fractures (in 317 patients) with a median follow-up of 3.6 years (interquartile range (IQR) 2.0 to 5.4) were included. The fractures were type B1 in 133 (42.0%), B2 in 170 (53.6%), and B3 in 14 patients (4.4%). ORIF was performed in 167 (52.7%) and revision in 150 patients (47.3%). The two-year reoperation rate (15.3% vs 7.2%; p = 0.021), time to surgery (4.0 days (IQR 2.0 to 7.0) vs 2.0 days (IQR 1.0 to 4.0); p < 0.001), transfusion requirements (55 patients (36.7%) vs 42 patients (25.1%); p = 0.026), critical care requirements (36 patients (24.0%) vs seven patients (4.2%); p < 0.001) and two-year local complication rates (26.7% vs 9.0%; p < 0.001) were significantly higher in the revision group. The two-year rate of survival was significantly higher for ORIF (91.9% (standard error (SE) 0.023%) vs 83.9% (SE 0.031%); p = 0.032) compared with revision. For B1 fractures, the two-year reoperation rate was significantly higher for revision compared with ORIF (29.4% vs 6.0%; p = 0.002) but this was similar for B2 and B3 fractures (9.8% vs 13.5%; p = 0.341). The most common indication for reoperation after revision was dislocation (12 patients; 8.0%). Conclusion. Revision surgery has higher reoperation rates, longer surgical waiting times, higher transfusion requirements, and higher critical care requirements than ORIF in the management of periprosthetic fractures around polished taper-slip femoral components after THA. ORIF is a safe option providing anatomical reconstruction is achievable. Cite this article: Bone Joint J 2023;105-B(2):124–134

Aims. The objectives of this study were to investigate the patient characteristics and mortality of Vancouver type B periprosthetic femoral fractures (PFF) subgroups divided into two groups according to femoral component stability and to compare postoperative clinical outcomes according to treatment in Vancouver type B2 and B3 fractures. Methods. A total of 126 Vancouver type B fractures were analyzed from 2010 to 2019 in 11 associated centres' database (named TRON). We divided the patients into two Vancouver type B subtypes according to implant stability. Patient demographics and functional scores were assessed in the Vancouver type B subtypes. We estimated the mortality according to various patient characteristics and clinical outcomes between the open reduction internal fixation (ORIF) and revision arthroplasty (revision) groups in patients with unstable subtype. Results. The one-year mortality rate of the stable and unstable subtype of Vancouver type B was 9.4% and 16.4%. Patient demographic factors, including residential status and pre-injury mobility were associated with mortality. There was no significant difference in mortality between patients treated with ORIF and Revision in either Vancouver B subtype. Patients treated with revision had significantly higher Parker Mobility Score (PMS) values (5.48 vs 3.43; p = 0.00461) and a significantly lower visual analogue scale (VAS) values (1.06 vs 1.94; p = 0.0399) for pain than ORIF in the unstable subtype. Conclusion. Among patients with Vancouver type B fractures, frail patients, such as those with worse scores for residential status and pre-injury mobility, had a high mortality rate. There was no significant difference in mortality between patients treated with ORIF and those treated with revision. However, in the unstable subtype, the PMS and VAS values at the final follow-up examination were significantly better in patients who received revision. Based on postoperative activities of daily life, we therefore recommend evision in instances when either treatment option is feasible. Cite this article: Bone Jt Open 2023;4(1):38–46

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Fractures of the humeral diaphysis occur in a bimodal distribution and represent 3-5% of all fractures. Presently, the standard treatment of isolated humeral diaphyseal fractures is nonoperative care using splints, braces, and slings. Recent data has questioned the effectiveness of this strategy in ensuring fracture healing and optimal patient function. The primary objective of this randomized controlled trial (RCT) was to assess whether operative treatment of humeral shaft fractures with a plate and screw construct provides a better functional outcome than nonoperative treatment. Secondary objectives compared union rates and both clinical and patient-reported outcomes. Eligible patients with an isolated, closed humeral diaphyseal fracture were randomized to either nonoperative care (initial sugar-tong splint, followed by functional coaptation brace) or open reduction and internal fixation (ORIF; plate and screw construct). The primary outcome measure was the Disability Shoulder, Arm, Hand (DASH) score assessed at 2-, 6-, 16-, 24-, and 52-weeks. Secondary outcomes included the Short Musculoskeletal Functional Assessment (SMFA), the Constant Shoulder Score, range of motion (ROM), and radiographic parameters. Independent samples t-tests and Chi-squared analyses were used to compare treatment groups. The DASH, SMFA, and Constant Score were modelled over time using a multiple variable mixed effects model. A total of 180 patients were randomized, with 168 included in the final analysis. There were 84 patients treated nonoperatively and 84 treated with ORIF. There was no significant difference between the two treatment groups for age (mean = 45.4 years, SD 16.5 for nonoperative group and 41.7, SD 17.2 years for ORIF group; p=0.16), sex (38.1% female in nonoperative group and 39.3% female in ORIF group; p=0.87), body mass index (mean = 27.8, SD 8.7 for nonoperative group and 27.2, SD 6.2 for ORIF group; p=0.64), or smoking status (p=0.74). There was a significant improvement in the DASH scores at 6 weeks in the ORIF group compared to the nonoperative group (mean=33.8, SD 21.2 in the ORIF group vs. mean=56.5, SD=21.1 in the nonoperative group; p < 0 .0001). At 4 months, the DASH scores were also significantly better in the ORIF group (mean=21.6, SD=19.7 in the ORIF group vs. mean=31.6, SD=24.6 in the nonoperative group; p=0.009. However, there was no difference in DASH scores at 12-month follow-up between the groups (mean=8.8,SD=10.9 vs. mean=11.0, SD=16.9 in the nonoperative group; p=0.39). Males had improved DASH scores at all timepoints compared with females. There was significantly quicker time to union (p=0.016) and improved position (p < 0 .001) in the ORIF group. There were 13 (15.5%) nonunions in the nonoperative group and four (4.7%) combined superficial and deep infections in the ORIF group. There were seven radial nerve palsies in the nonoperative group and five (a single iatrogenic) radial nerve palsies in the ORIF group. This large RCT comparing operative and nonoperative treatment of humeral diaphyseal fractures found significantly improved functional outcome scores in patients treated surgically at 6 weeks and 4 months. However, the early functional improvement did not persist at the 12-month follow-up. There was a 15.5% nonunion rate, which required surgical intervention, in the nonoperative group and a similar radial nerve palsy rate between groups

Aims. We report the long-term outcomes of the UK Heel Fracture Trial (HeFT), a pragmatic, multicentre, two-arm, assessor-blinded, randomized controlled trial. Methods. HeFT recruited 151 patients aged over 16 years with closed displaced, intra-articular fractures of the calcaneus. Patients with significant deformity causing fibular impingement, peripheral vascular disease, or other significant limb injuries were excluded. Participants were randomly allocated to open reduction and internal fixation (ORIF) or nonoperative treatment. We report Kerr-Atkins scores, self-reported difficulty walking and fitting shoes, and additional surgical procedures at 36, 48, and 60 months. Results. Overall, 60-month outcome data were available for 118 patients (78%; 52 ORIF, 66 nonoperative). After 60 months, mean Kerr-Atkins scores were 79.2 (SD 21.5) for ORIF and 76.4 (SD 22.5) for nonoperative. Mixed effects regression analysis gave an estimated effect size of -0.14 points (95% confidence interval -8.87 to 8.59; p = 0.975) in favour of ORIF. There were no between group differences in difficulty walking (p = 0.175), or on the type of shoes worn (p = 0.432) at 60 months. Additional surgical procedures were conducted on ten participants allocated ORIF, compared to four in the nonoperative group (p = 0.043). Conclusion. ORIF of displaced intra-articular calcaneal fractures, not causing fibular impingement, showed no difference in outcomes at 60 months compared to nonoperative treatment, but with an increased risk of additional surgery. Cite this article: Bone Joint J 2021;103-B(6):1040–1046

Proximal humerus fractures (PHF) are common, accounting for approximately 5% of all fractures. Approximately 30% require surgical intervention which can range from open reduction with internal fixation (ORIF) to shoulder arthroplasty (including hemiarthroplasty, total shoulder arthroplasty, (TSA) or reverse total shoulder arthroplasty (RTSA)). The aim of this study was to assess trends in operative interventions for PHF in an Australian population. Data was retrospectively collected for patients diagnosed with a PHF and requiring surgical intervention between January 2001 and December 2020. Data for patients undergoing ORIF were extracted from the Medicare database, while data for patients receiving arthroplasty for PHF were obtained from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Across the study period, ORIF was the most common surgical procedure for management of PHFs. However, since 2019, RTSA has surpassed ORIF as the most common surgical procedure to treat PHFs, accounting for 51% of operations. While the number of RTSA procedures for PHF has increased, ORIF and shoulder hemiarthroplasty has significantly reduced since 2007 (p < 0.001). TSA has remained uncommon across the follow-up period, accounting for less than 1% of all operations. Patients younger than 65 years were more likely to receive ORIF, while those aged 65 years or greater were more likely to receive hemiarthroplasty or RTSA. While the number of ORIF procedures has increased during the period of interest, it has diminished as a proportion of overall procedure volume. RTSA is becoming increasingly popular, with decreasing utilization of hemiarthroplasty, and TSA for fracture remaining uncommon. These trends provide information that can be used to guide resource allocation and health provision in the future. A comparison to similar data from other nations would be useful

Aims. The aim of this study was to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter). Methods. This retrospective cohort study assessed 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems; 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Mean follow-up was 6.5 years (SD 2.6; 3.2 to 12.1). The primary outcome measure was revision of at least one component. Kaplan–Meier survival analysis was performed. Regression analysis was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay, and mortality. Results. Fractures (B1 n = 74 (49%); B2 n = 50 (33%); and B3 n = 28 (18%)) occurred at median of 4.2 years (interquartile range (IQR) 1.2 to 9.2) after primary total hip arthroplasty (THA) (n = 138) or hemiarthroplasty (n = 14). Rates of revision and reoperation were significantly higher following revision arthroplasty compared to ORIF for B2 (p = 0.001) and B3 fractures (p = 0.050). Five-year survival was significantly better following ORIF: 92% (95% confidence interval (CI) 86.4% to 97.4%) versus 63% (95% CI 41.7% to 83.3%), p < 0.001. ORIF was associated with reduced blood transfusion requirement and reoperations, but there were no differences in medical complications, hospital stay, or mortality between surgical groups. No independent predictors of revision following ORIF were identified: where the bone-cement interface was intact, fixation of B2 or B3 fractures was not associated with an increased risk of revision. Conclusion. When the bone-cement interface was intact and the fracture was anatomically reducible, all Vancouver B fractures around Exeter stems could be managed with fixation as opposed to revision arthroplasty. Fixation was associated with reduced need for blood transfusion and lower risk of revision surgery compared with revision arthroplasty. Cite this article: Bone Joint J 2021;103-B(2):309–320

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

Abstract. Objectives. The outcomes from patella fracture have remained dissatisfactory despite advances in treatment, especially from operative fixation1. Frequently, reoperation is required following open reduction and internal fixation (ORIF) of the patella due to prominent hardware since the standard technique for patella ORIF is tension band wiring (TBW) which inevitably leaves a bulky knot and irritates soft tissue given the patella's superficial position2. We performed a systematic review to determine the optimal treatment of patella fractures in the poor host. Methods. Three databases (EMBASE/Medline, ProQuest and PubMed) and one register (Cochrane CENTRAL) were searched. 476 records were identified and duplicates removed. 88 records progressed to abstract screening and 73 were excluded. Following review of complete references, 8 studies were deemed eligible. Results. Complication rates were shown to be high in our systematic review. Over one-fifth of patients require re-operation, predominantly for removal of symptomatic for failed hardware. Average infection rate was 11.95% which is higher than rates reported in the literature for better hosts. Nevertheless, reported mortality was low at 0.8% and thromboembolic events only occurred in 2% of patients. Average range of movement achieved following operative fixation was approximately 124 degrees. Upon further literature review, novel non-operative treatment options have shown acceptable results in low-demand patients, including abandoning weight-bearing restrictions altogether and non-operatively treating patients with fracture gaps greater than 1cm. Regarding operative management, suture/cable TBW has been investigated as a viable option with good results in recent years since the materials used show comparable biomechanics to stainless steel. Additionally, ORIF with locking plates have shown favourable results and have enabled aggressive post-operative rehabilitation protocols. TBW with metallic implants has shown higher complication rates, especially for anterior knee pain, reoperation and poor functional outcomes. Conclusion. There is sparse literature regarding patella fracture in the poor host. Nevertheless, it is clear that ORIF produces better outcomes than conservative treatment but the optimal technique for patella ORIF remains unclear. TBW with metallic implants should not remain the standard technique for ORIF; low-profile plates of suture TBW are more attractive solutions. Non-operative treatment may be considered for low-demand individuals however any form of patellectomy should be avoided if possible. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Introduction. Distal Femoral Fractures around a Total Knee Replacement have a reported incidence of 0.25–2.3% of primary TKRs. Literature suggests that these fractures have high complication rates such as non union and revision. Methodology. A retrospective case note review was undertaken of all patients who sustained a distal femoral fracture around a TKR from April 2014-April 2021. Data parameters collected included patient demographics, classification of fracture, management, post op mobility, fracture union and mortality. Results. 52 distal femoral fractures were recorded, out of which 5 patients had bilateral fractures. The average age was 83.6 years (61–101). 41 fractures were managed operatively with 61% undergoing ORIF, 37% undergoing Distal Femoral Replacement & 2% undergoing a retrograde IM Nail. The median LOS was 22 days (11–85) for patients treated with DFR versus 10 (3–75) for those undergoing an ORIF. 60% of DFR patients were discharged home compared to 56% of those who underwent an ORIF. All the DFR patients were FWB post op compared to ORIF 24%. Conclusion. Over a 7 year study period, 52 distal femoral fractures were reviewed. Despite FWB status post op, patients undergoing a DFR had a longer length of stay and less were discharged home compared to the ORIF group. Given the cost of a distal femoral replacement (£4485-6500) compared to £212-297 for a locking plate, in order to get patients FWB post operatively potentially dual plating (medial and lateral) may need to be considered if the fracture is amenable to improve stability & allow FWB

Abstract. Introduction. We aimed to compare the outcomes of elderly patients with periarticular distal femur or supracondylar periprosthetic fractures treated with either open reduction internal fixation or distal femoral replacement. Methods. A retrospective review of patients over 65 years with AO Type B and C fractures of the distal femur or Su type I and II periprosthetic fractures treated with either a DFR or ORIF was undertaken. Outcomes including Length of Stay, PROMs (Oxford Knee Score and EQ 5D), infection, union, mortality, complication and reoperation rates were assessed. Data on confounding variables were also collected for multivariate analysis. Patients below 65 years and extra articular fractures were excluded. Results. 23 patients (11 in DFR group and 12 in ORIF group) fulfilled inclusion criteria and were included in the analysis. There was no difference between the DFR and ORIF groups with respect to SDI, demographic variables, ASA grade, FCI, preoperative Hb and renal function. There was no difference in 30 day mortality, reoperation rates, 30 day readmission rates and LOS between the two groups. Mean follow up was 12.7 and 15.9 months respectively in the DFR and ORIF groups. At final follow up after accounting for all confounding variables on multivariate analysis, functional outcomes using OKS (adjusted mean: 29.5 vs 15.8) and Health related Quality of Life outcomes using EQ 5D (adjusted mean: 0.453 vs −0.07) were significantly better in the DFR group. Conclusion. DFR for periarticular and periprosthetic distal femoral fractures in the elderly are associated with better patient reported outcomes

Introduction. The condition of the soft tissues surrounding an ankle fracture influences timing and treatment of injuries. Conventional treatment used an open approach to facilitate anatomical reduction and rigid internal fixation. Intramedullary devices for fibular fractures provide a safe alternative in patients in which the condition of the soft tissue envelope or the patient's co-morbidities may benefit from a less invasive approach. We compared outcomes for patients treated with open reduction internal fixation (ORIF) with those undergoing treatment with fibular nails (FN). Methods. 13 consecutive patients treated with fibular nails (FN) were compared with 13 age-matched patients that underwent open reduction and internal fixation (ORIF). All patients were followed to union. Study outcomes were time from admission to surgery, length of stay, wound failure, implant failure, revision surgery, OMAS and SF-36. Results. There was no difference in age or sex distribution between groups. There was no difference in OMAS at 1 year (83 ± 9 in FN group; 80± 21 in ORIF group) and SF-36 (94 ± 11 and 90 ± 20). There were 2 implant failures in the ORIF group and none in the FN group. There was one wound failure in the ORIF group and none in the FN group. Patients treated with FN had a shorter time to surgery (1 day ± 24 hours vs 3 days ± 24 hours) and shorter length of stay (1 day ± 24 hours vs 4 days ± 96 hours). Conclusion. FN is a safe method to treat patients with displaced distal fibular fractures that may have a poor soft tissue envelope and risk factors for wound healing. FN reduces the time to surgery and overall length of stay compared with similar patients treated with conventional ORIF

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

Abstract. Introduction. In our quality improvement project we implemented a novel pathway, performing acute fixation in mid-third clavicle fractures with >15% shortening. Patients with <15% shortening reviewed at 6 weeks, non-union risk identified as per Edinburgh protocol and decision to operate made accordingly. Methods. Retrospective pre-pathway analysis of patients presenting 04/2017–04/2019. Prospective post-pathway analysis of patients presenting 10/2020–10/2021. Fracture shortening measured using Matsumura technique. QuickDASH and recovery questionnaires posted to >15% shortening patients and done post-pathway at 3 months. Results. Pre-pathway retrospective cohort included 141 patients; 69 <15%, 72 >15% shortening. Acute ORIF performed in 15(22%) <15% and 34(47%) >15%. In those conservatively managed, non-union occurred in 2 patients with <15% shortening, and 5 with >15% shortening. Union time was significantly longer in >15% treated non-operatively compared to those requiring ORIF and <15% (18.4 vs 13.4 vs 12.0 weeks; p<0.05). QuickDASH significantly worse in >15% managed conservatively than operatively (17.6 vs 2.8; p<0.05). >15% ORIF had significantly fewer number of weeks until undisturbed sleep than those treated non-operatively (2.3 vs 10.1; p<0.05). Post-pathway prospective cohort included 37 patients; 17 <15% (of which 1 underwent delayed ORIF), 20 >15% shortening (of which 15 underwent acute ORIF). No significant increase in proportion ORIF performed (43% vs 38%). No non-unions occurred. Conclusion. Acute fixation in >15% shortening was associated with better QuickDash scores and reduced union times than those treated non-operatively. Implementation of our pathway resulted in no nonunions compared to 5% pre-implementation and thus identifies patients benefitting from acute fixation

Determine the infection risk of nonoperative versus operative repair of extraperitoneal bladder ruptures in patients with pelvic ring injuries. Pelvic ring injuries with extraperitoneal bladder ruptures were identified from a prospective trauma registry at two level 1 trauma centers from 2014 to 2020. Patients, injuries, treatments, and complications were reviewed. Using Fisher's exact test with significance at P value < 0.05, associations between injury treatment and outcomes were determined. Of the 1127 patients with pelvic ring injuries, 68 (6%) had a concomitant extraperitoneal bladder rupture. All patients received IV antibiotics for an average of 2.5 days. A suprapubic catheter was placed in 4 patients. Bladder repairs were performed in 55 (81%) patients, 28 of those simultaneous with ORIF anterior pelvic ring. The other 27 bladder repair patients underwent initial ex-lap with bladder repair and on average had pelvic fixation 2.2 days later. Nonoperative management of bladder rupture with prolonged Foley catheterization was used in 13 patients. Improved fracture reduction was noted in the ORIF cohort compared to the closed reduction external fixation cohort (P = 0.04). There were 5 (7%) deep infections. Deep infection was associated with nonoperative management of bladder rupture (P = 0.003) and use of a suprapubic catheter (P = 0.02). Not repairing the bladder increased odds of infection 17-fold compared to repair (OR 16.9, 95% CI 1.75 – 164, P = 0.01). Operative repair of extraperitoneal bladder ruptures substantially decreases risk of infection in patients with pelvic ring injuries. ORIF of anterior pelvic ring does not increase risk of infection and results in better reductions compared to closed reduction. Suprapubic catheters should be avoided if possible due to increased infection risk later. Treatment algorithms for pelvic ring injuries with extraperitoneal bladder ruptures should recommend early bladder repair and emphasize anterior pelvic ORIF

Aims. To compare complication-related reoperation rates following primary arthroplasty for proximal humerus fractures (PHFs) versus secondary arthroplasty for failed open reduction and internal fixation (ORIF). Patients and Methods. We identified patients aged 50 years and over, who sustained a PHF between 2004 and 2015, from linkable datasets. We used intervention codes to identify patients treated with initial ORIF or arthroplasty, and those treated with ORIF who returned for revision arthroplasty within two years. We used multilevel logistic regression to compare reoperations between groups. Results. We identified 1624 patients who underwent initial arthroplasty for PHF, and 98 patients who underwent secondary arthroplasty following failed ORIF. In total, 72 patients (4.4%) in the primary arthroplasty group had a reoperation within two years following arthroplasty, compared with 19 patients (19.4%) in the revision arthroplasty group. This difference was significantly different (p < 0.001) after covariable adjustment. Conclusion. The number of reoperations following arthroplasty for failed ORIF of PHF is significantly higher compared with primary arthroplasty. This suggests that primary arthroplasty may be a better choice for patients whose prognostic factors suggest a high reoperation rate following ORIF. Prospective clinical studies are required to confirm these findings. Cite this article: Bone Joint J 2019;101-B:1272–1279

Abstract. Introduction. Intra-articular distal humerus OTA type C fractures are challenging to treat. When osteosynthesis is not feasible one can choose to do a primary arthroplasty of elbow or manage non-operatively. The indications for treatment of this fracture pattern are evolving. Objectives. We present our outcomes and complications when this cohort of patients was managed with either open reduction internal fixator (ORIF), elbow arthroplasty or non-operatively. Methods. Retrospective study to include OTA type C2 and C3 fracture distal humerus of 36 patients over the age of 50 years managed with all the three modalities. Patient's clinical notes and radiographs were reviewed. Results. Between 2016 and 2022, 21 patients underwent ORIF – group 1, 10 patients were treated with arthroplasty – group 2 and 5 were managed conservatively- group 3. The mean age of patients was 62 years in group 1, 70 years in group 2 and 76 years in group 3. The mean range of movement (ROM) arc achieved in the group 1 & 2 was 103 while group 3 was 68. At least follow up was 6 months. 5 patients in group 1 underwent metalwork removal and 2 patients in group 3 under arthroplasty. Conclusion. The outcomes of arthroplasty and ORIF are comparable, but reoperation rates and stiffness were higher in ORIF and conservative group. Surgeon choice and patient factors play important role in decision towards choosing treatment modality. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project