Introduction. Through the paediatric LCP Hip plating system, the highly successful technique of the locking compression plate used in adult surgery, has been incorporated in a system dedicated to paediatrics. The purpose of this study was to review the outcome of the paediatric LCP Hip plate use in children, both with and without neuromuscular disease, for fixation of proximal femoral osteotomy for a variety of indications. Materials and methods. We retrospectively reviewed the notes and radiographs of all those children who have had Paediatric LCP Hip Plate for the fixation of proximal femoral osteotomy and proximal femur fractures in our institution, between October 2007 and July 2010, for their clinical progress, mobilization status, radiological healing and any complications. Results. Forty-three Paediatric LCP hip plates were used in forty patients for the fixation of proximal femoral osteotomies (n=40) and proximal femur fractures (n=3). The osteotomies were performed for a variety of indications including Perthes disease, DDH, Cerebral Palsy, Down's syndrome, coxa vara, Leg length discrepancy and previous failed treatment of SUFE. Twenty-five children were allowed touch to full weight bearing post operatively. Two were kept non-weight bearing for 6 weeks. The remaining 13 children were treated in hip spica due to simultaneous pelvic osteotomy or multilevel surgery for cerebral palsy. All osteotomies and fractures radiologically healed within 6 months (majority [n=40] within 3 months). There was no statistically significant difference (p = 0.45) in the neck shaft angle between the immediately postoperative and final x-rays after completion of bone healing. There were no implant related complications. Conclusion. The Paediatric LCP Hip Plate provides a stable and reliable fixation of the proximal femoral osteotomy performed for a variety of paediatric hip conditions in children with and without neuromuscular disease

Through the paediatric LCP Hip plating system (Synthes GmBH Eimattstrasse 3 CH- 4436 Oberdorff), the highly successful technique of the locking compression plate used in adult surgery, has been incorporated in a system dedicated to pediatrics. We are presenting the outcome of the paediatric LCP hip plating system used for a variety of indications in our institution. We retrospectively reviewed the notes and radiographs of all those children who have had Paediatric LCP Plate for the fixation of proximal femoral osteotomy and proximal femur fractures in our institution, between October 2007 and July 2010, for their clinical progress, mobilization status, radiological healing and any complications. Forty-three Paediatric LCP hip plates were used in forty patients (24 males and 13 females) for the fixation of proximal femoral osteotomies (n=40) and proximal femur fractures (n=3). The osteotomies were performed for a variety of indications including Perthes disease, developmental dysplasia of hip, Cerebral Palsy, Down's syndrome, coxa vara, Leg length discrepancy and previous failed treatment of Slipped Upper Femoral Epiphysis. Twenty-five children were allowed touch to full weight bearing post operatively. Two were kept non-weight bearing for 6 weeks. The remaining 13 children were treated in hip spica due to simultaneous pelvic osteotomy or multilevel surgery for cerebral palsy. All osteotomies and fractures radiologically healed within 6 months (majority [n=40] within 3 months). There was no statistically significant difference (p= 0.45) in the neck shaft angle between the immediately postoperative and final x-rays after completion of bone healing. Among the children treated without hip spica, 1 child suffered a periprosthetic fracture. Of the children treated in hip spica, 2 had pressure sores, 3 had osteoporotic distal femur fractures and 2 had posterior subluxations requiring further intervention. There were no implant related complications. The Paediatric LCP Hip Plate provides a stable and reliable fixation of the proximal femoral osteotomy performed for a variety of paediatric orthopaedic conditions

Introduction. Coxa vara is an uncommon orthopaedic condition. Problems associated with the definition, radiological appearance, classification and surgical treatment are discussed. Methods. A clinical and radiological review of 11 patients (14 hips) treated with a LCP plate (Synthes) in our paediatric orthopaedic unit from 2010 to 2013 was performed. These hips were classified as congenital (6), developmental (3) and acquired (5). The Hilgenreiner Epiphyseal (HE) angle, the head/shaft angle and the neck/shaft angle were all assessed and examples shown why one measurement does not address every case. Results. A mean radiological improvement of 45 degrees (20–75 +/−16.5 degrees) was obtained. There was no loss of position in any of our patients from initial surgery until union. Complications included over-correction (1 case), under-correction (2 cases) and a peri-prosthetic fracture in a patient with Osteogenesis imperfecta. Conclusions. Limitations of the LCP system include a demanding surgical technique and, in South Africa at least, a limited plate selection. Advantages include excellent proximal control with precise correction, and in our experience provide the best fixation for valgizing proximal femoral osteotomies in the paediatric coxa vara patient. NO DISCLOSURES

INTRODUCTION. Childhood diseases involving the proximal femoral epiphysis often cause abnormalities that can lead to end-stage arthritis at a relatively young age and the need for total hip arthroplasty (THA). The young age of these patients makes hip resurfacing arthroplasty (HRA) an alternative and favorable option due to the ability to preserve femoral bone. Patients presenting with end-stage hip arthritis as sequelae of childhood diseases such as Legg-Calves-Perthes (LCP) and slipped capital femoral epiphysis (SCFE) pose altered femoral anatomy, making HRA more technically complicated. LCP patients can result in coxa magna, coxa plana and coxa breva causing altered femoral head-to-neck ratio. There can also be acetabular dysplasia along with the proximal femoral abnormalities. SCFE patients have altered femoral head alignment. In particular, the femoral head is rotated medially and posteriorly, reducing the anterior and lateral offset. Additionally, many of these patients have retained hardware, making resurfacing more complicated. We report findings of a cohort of patients, with history of either LCP or SCPE who underwent HRA to treat end-stage arthritis. METHODS. Data was retrospectively collected for patients who had HRA for hip arthritis as a result of either LCP (n=67) or SCFE (n=21) between 2004 and 2014 performed by two surgeons. Demographic information, clinical examination and improvement was collected pre and postoperatively. Improvement was determined using Harris Hip Scores (HHS) and UCLA activity scores. Anteroposterior radiographs were measured pre and postoperatively to determine leg length discrepancy. Radiographs were inspected postoperatively for radiolucent lines, implant loosening and osteolysis. Kaplan-Meier survivorship for freedom from reoperation for any reason was calculated. Paired student t-tests were used to compare groups. RESULTS. The average age at the time of surgery was 44 years (11.8–68), with an average follow-up of 3.7 years (.22–11.2). Retained hardware was present in a total of 5 patients, 1 LCP and 4 SCFE. Preoperative HHS was 58.3 (33–83), which increased significantly to 94.9 (55–100) at the most recent postoperative timepoint (p<.0001). The most recent UCLA activity score was 7 (1–10). Average leg length discrepancy preoperatively was 7.5mm (0–20), which significantly improved to 0.6mm (0–7.5) postoperatively (p<.0001). At most recent follow-up, metal ion testing revealed median chromium level of 2.3 parts per billion (ppb, 1–7.7) and median cobalt level of 1.5 (0–9.2). There were three failures in the group with 1 LCP due to instability at 2.7 years, and 2 SCFE due to femoral neck fracture at 1 month in one and clinical failure due to unexplained pain at 5.5 years in one. Revision surgery was done in 2 patients, 1 LCP and 1 SCFE. Radiographic examination of all non-failure HRA patients revealed implants to be in good alignment with no indication of implant loosening at the most recent postoperative timepoint. Kaplan-Meier survivorship for freedom from revision was 96.2 at 5 years. CONCLUSION. The findings demonstrated increase in functional outcomes in patients who underwent HRA for osteoarthritis associated with LCP and SCFE. There was no increase in complications including femoral neck fracture or implant loosening despite technical challenges of the procedure

Distal femur fractures (DFF) are common, especially in the elderly and high energy trauma patients. Lateral locked osteosynthesis constructs have been widely used, however non-union and implant failures are not uncommon. Recent literature advocates for the liberal use of supplemental medial plating to augment lateral locked constructs. However, there is a lack of proprietary medial plate options, with some authors supporting the use of repurposing expensive anatomic pre-contoured plates. The aim of this study was to investigate the feasibility of a readily available cost-effective medial implant option. A retrospective analysis from January 2014 to June 2022 was performed on DFF (primary or revision) managed with supplemental medial plating with a Large Fragment Locking Compression Plate (LCP) T-Plate (~$240 AUD) via a medial sub-vastus approach. The T-plate was contoured and placed superior to the medial condyle. A combination of 4.5mm cortical, 5mm locking and/or 6.5mm cancellous screws were used, with oblique screw trajectories towards the distal lateral cortex of the lateral condyle. All extra-articular fractures and revision fixation cases were allowed to weight bear immediately. The primary outcome was union rate. This technique was utilised on sixteen patients; 3 acute, 13 revisions; mean age 52 years (range 16-85), 81% male, 5 open fractures. The union rate was 100%, with a median time to union of 29 weeks (IQR 18-46). The mean follow-up was 15 months. There were two complications: a deep infection requiring two debridements and a prominent screw requiring removal. The mean range of motion was 1–108. o. . Supplemental medial plating of DFF with a Large Fragment LCP T-Plate is a feasible, safe, and economical option for both acute fixation and revisions. Further validation on a larger scale is warranted, along with considerations to developing a specific implant in line with these principles

Purpose. To promote rapid bone healing, an adequate stable fixation implant with a percutaneous reduction instrument should be used for Vancouver type B1 or C fractures. The objective of this study was to describe radiographic and clinical outcomes of patients with periprosthetic fracture (PPF) around a stable femoral stem, treated with a distal femoral locking plate alone or with a cerclage cable. Materials and Methods. A total of 21 patients with PPF amenable to either a reverse distal femoral locking plate (LCP DF. ®. ) alone or with a cerclage cable, with a mean age of 75.7 years, were included. In these patients, 10 fractures were treated with a reverse LCP DF. ®. alone and were classified as group I, and 11 additionally received a cerclage cable and were classified as group II.[Fig.1]. Results. Group I was not inferior to group II, as reflected by HHS evaluations. Additionally, group II had a significantly longer operation time (P = 0.019) than group I and included one patient with nonunion at the final 24-month follow-up visit after the initial fracture reduction.[Fig. 2]. Conclusion. Use of reverse LCP DF. ®. alone appears to provide advantages in the biological healing process compared with the use of reverse LCP DF. ®. with a cerclage cable. When comparing the stability of the fractures in both groups, there was no statistically significant difference, which might be attributed to the stable fixed-angle implant. For figures/tables, please contact authors directly.

Introduction. Patients presenting with osteoarthritis as late sequelae following pediatric hip trauma have few options aside from standard Total Hip Replacement (THR). For younger more active patients, Hip Resurfacing Arthroplasty (HRA) can be offered as an alternative. HRA has been performed in the United States over the past decade and allows increased bone preservation, decreased hip dislocation rates versus THR, and potential to return to full activities. Patients presenting with end-stage hip arthritis as following prior pediatric trauma or disease often have altered hip morphology making HRA more complicated. Often Legg-Calve-Perthes (LCP) patients present with short, wide femoral necks, and femoral head distortion including coxa magna or coxa plana. There often can be acetabular dysplasia in conjunction with the proximal femoral abnormalities. Slipped Capital Femoral Epiphysis (SCFE) patients have an alteration of the femoral neck and head alignment, which can make reshaping the femoral head difficult. In particular, the femoral head is rotated medially and posteriorly, reducing the anterior and lateral offset. We present a cohort of 20 patients, with history of a childhood hip disorder (SCFE or LCP), who underwent HRA to treat end-stage arthritis. Fifty percent had prior pediatric surgical intervention at an average age of 11. Method. After Institutional Review Board approval, data was reviewed retrospectively on patients with pediatric hip diseases of SCFE and LCP who underwent HRA using the Birmingham Hip Resurfacing (BHR) by a single orthopaedic surgeon at a teaching institution. Harris Hip Scores (HHS), plain radiographs and blood metal ion levels were reviewed at routine intervals (12 months and annually thereafter). Those who had not returned for recent follow-up were contacted via telephone survey for a modified HHS. Results. Twenty patients had mean follow up of 2.8 years (range 1–7 years). Twelve had LCP and 8 SCFE. Median implant duration was 2.4 years. One-year metal ion testing revealed median chromium level of 2.3 ppb and median Cobalt level of 1.5 ppb. At one-year follow up, plain radiographs demonstrated all patient implants to be well-fixed, without radiolucent lines or osteolysis. Two patients at three and five-year follow-up exhibited heterotopic ossification. Mean HHS for LCP at 6 weeks post-operative was 88, and 98 at one year. Mean HHS for SCFE at 6 weeks post-operative was 77.5, and 98.6 at one year. LLD was significantly improved with an average pre-operative LLD of 12.6 mm and post op of 2.6 mm (p-value <0.001). At most recent follow-up, all retained their implants with overall average HHS of 98. Conclusion. At minimum of one-year following HRA, an increase in functional outcomes is found in patients who underwent HRA for osteoarthritis associated with LCP and SCFE with a mean HHS of 98. No increase was found in complications including femoral neck fracture or implant loosening despite technical challenges of the procedure related to proximal femoral morphologic abnormalities, or presence of acetabular dysplasia [Fig 1]

Distal radius fractures are the most common upper extremity injury, and are increasingly being treated surgically with pre-contoured volar-locking plates. These plates are favored for their low-profile template while allowing for rigid anatomic fixation of distal radius fractures. The geometry of the distal radius is extremely complex, and little evidence within the medical literature suggests that current implant designs are anatomically accurate. The main objective of this study is to determine if anatomic alignment of the distal radii corresponds accurately with modern volar-locking plate designs. Additionally, this study will examine sex-linked differences in morphology of the distal radius. Segmented CT models of ten female cadaver (mean age, 88.7 ± 4.57 years, range, 82 – 97) arms, and ten male cadaver (mean age, 86 ± 3.59 years, range, 81 – 91) arms were created. Micro CT models were obtained for the DePuy Synthes 2.4mm Extra-articular (EA) Volar Distal Radius Plate (4-hole and 5-hole head), and 2.4mm LCP Volar Column (VC) Distal Radius Plate (8-hole and 9-hole head). Plates were placed onto the distal radii models in a 3D visualization software by a fellowship-trained orthopaedic hand surgeon. The percent contact, volar cortical angle (VCA), border and overlap of the watershed line (WSL) were measured. Both sexes showed an increase in the average VCA measure from medial to lateral columns which was statistically significant. Female VCA ranged from 28 – 36 degrees, and 38 – 45 degrees for males. WSL overlap ranged from 0 – 34.7629% for all specimens without any statistical significance. The average border distance for females was 2.58571 mm, compared to 3.52411 mm for males, with EA plates having a larger border than VC plates. The border distances had statistically significant differences between the plate types, and was approaching significance between sexes. Lastly, a maximum percent contact of 21.966 % was observed in specimen F4 at a 0.3 mm threshold. No statistical significance between plate or sex populations was observed. This study investigated the incoherency between the volar cortical angle of the distal radius, and the pre-contoured angle of volar locking plates. It was hypothesized that if the VCA measures between plate and bone were unequal then there would be an increase in watershed line overlap, and decrease in percent contact between the surfaces. Our results agreed with literature, indicating that the VCA of bone was larger than that of the EA and VC pre-contoured plates examined in this study. With distal radius fracture incidences and prevalence on the rise for elderly female patients, it is a necessity that volar locking plates be re-designed to factor in anatomical features of individual patients with a particular focus on sex differences. New designs should focus on providing smaller head sizes that are more accurately tailored to the natural contours of the volar distal radius. It is recommended that future studies incorporate expertise from multiple surgeons to diversify and further understand plate placement strategies

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

INTRODUCTION. In total knee arthroplasty (TKA), the effectiveness of the mechanical alignment (MA) within 0°±3° has been recently questioned. A novel implantation approach, i.e. the kinematic alignment (KA), emerged recently, this being based on the pre-arthritic lower-limb alignment. In KA, the trans-cylindrical axis is used as the reference, instead of the trans-epicondylar one, for femoral component alignment. This axis is defined as the line passing through the centres of the posterior femoral condyles modeled as cylinders. Recently, patient specific instrumentation (PSI) has been introduced in TKA as an alternative to conventional instrumentation. This provides a tool for preoperative implant planning also via KA. Particularly, KA using PSI seems to be more effective in restoring normal joint kinematics and muscle activity. The purpose of this study was to report preliminarily joint kinematic and electromyography results of two patient groups operated via conventional MA or KA, the latter using PSI. PATIENT AND METHODS. Twenty patients recruited for TKA were implanted with Triathlon® prosthesis (Stryker®-Orthopaedics, Mahwah, NJ-USA). Seventeen patients, eleven operated targeting MA using the convention instrumentation (group A) and six targeting KA (group B) using PSI (Stryker®-Orthopaedics), were assessed at 6 month follow-up clinically via IKSS and biomechanically. Knee kinematics during stair-climbing, chair-rising, and extension-against-gravity were evaluated using three-dimensional mono-planar video-fluoroscopy (CAT® Medical-System, Monterotondo, Italy) synchronised with electromyography (Wave-Wireless, Cometa®, Milan, Italy). Component pose was reconstructed to calculate knee flexion/extension (FE), ad/abduction (AA), internal/external-rotation (IE), together with the rotation of the contact-line (CLR), i.e. line connecting the medial (MCP) and lateral (LCP) tibio-femoral contact points. MCP and LCP antero-posterior translations were calculated and reported in percentage (%) of the tibial base-plate length. RESULTS. Postoperative clinical scores were better in group B. Knee/functional scores were 78±20/80±23 in group A and 91±12/90±15 in group B. AA range was found smaller than 3°, and physiological ranges of FE and IE were found in both groups. From extension to flexion, MCP translations were all anterior of about 13.8±5.6% anterior, 17.0±6.6% posterior and 15.4±6.6.9% posterior in group A, and 13.0±3.4%, 16.6±5.3% and 16.6±5.6% in group B; corresponding values for LCP were all posterior of about 9.5±3.6%, 11.1±4.3% and 8.7±2.6% in group A, and 102±2.1%, 13.7±8.6% and 14.6±9.8% in group B. These resulted in a CLR equal to 8.2°±3.2°, 10.2°±3.7° and 8.8°±5.3° in group A, and 7.3°±3.5°, 12.6°±2.6° and 12.5°±4.2° group B. Much more consistent patterns of motion were observed in group B. A prolonged activation of the vastus medialis and lateralis was observed in group A. DISCUSSION. These preliminary results show that better scores can be expected using PSI via KA. Although not relevant kinematic differences were observed between groups, more consistent patterns were observed in using PSI via KA. Furthermore, the observed less prolonged activation of the knee extensor muscles suggest that a more natural soft tissue balance is experienced in this group. These findings show a good efficacy of KA using PSI in TKA. The clinical/functional analysis of more patients and a longer follow-up are necessary to establish the claimed superiority of the novel approach

The distal femur fracture is a difficult injury that affects young men andelderly women. The tissue stripping that occurs with the traditional approach has been a factor in the development of complications like infection and nonunion. This study addresses the issue of minimally invasive approach. Does the LISS system really improve the results of such fracture?. Fifty-two patients were included in the trial from six academic trauma centres. Twenty-eight fractures had been randomised to be fixed with the LISS device, while twenty-four had the DCS implant. Type C3 fractures were excluded as they were not amenable for fixation with DCS system. All procedures were performed via minimally invasive technique. The LISS system had the targeter that helped with plate insertion and distal diaphyseal screws placement. Radiography was utilised in the case of the DCS distal screws insertion. All fractures went onto union, except two participants in LISS group who had to be revised due to loss of reduction, in the early post-operative peroid. There were three nonunions in the same group. These required a re-operation. Further more, a LISS participant who had re-injured his distal femur (unrelated to LISS plate), was fixed with different implant. There was a single nonunion with the DCS group that needed revision surgery. There was one participant from each group who had drifted into varus. Neither required a re-operation. This translated into a 21% re-operation rate in the LISS system compared to 4% with the DCS device. Our data supports the use of the DCS system in the fixation of distal femur fractures (except Type C3} via a minimally invasive approach. The LISS implant seems to be technique dependent. In our centre, the LISS plate had been discontinued in favour of the DCP and LCP systems

Background. Periprosthetic fracture fixation can be a difficult and complex procedure. The incidence of such fractures is increasing relative to the high prevalence of elderly patients with joint arthroplasty and osteoporosis. Locking plates were introduced for the management of complex periarticular fractures in osteoporotic bone, but there is little information on the use of these plates for the management of periprosthetic fractures. The purpose of this study was to review the early experience with these plates in managing complex Vancouver B1 and C periprosthetic fractures at our academic centre to determine the effectiveness in achieving union, and to identify any potential complications associated with their use. Methods. We evaluated the results of Vancouver B1 and type C periprosthetic fractures treated with Synthes LCP. The mean age of the patients at the time of surgery was 76 years. 5 patients were men and 10 were women. There were 8 Vancouver B1 and 7 Vancouver C fractures. 6 fractures had failed previous operative treatment. No patient was lost to follow-up. We assessed time to union, complications, and identified criteria for cortical fixation using these plates. Results. At the time of the most recent follow-up, all patients had gone on to radiographic union. Time to union was 6 months. All patients continue to have pain, and all continue to use walking aids. We discuss technical considerations, plate length, fixation and use of allograft. Conclusion. The Synthes Locking Plate system has been shown to provide good results for use in Type C and B1 periprosthetic fractures. Complications were surprisingly low considering the age group involved and associated co-morbidities. Surgery is complex requiring approximately 4 hours with expected blood loss of > 1 litre. Rehabilitation can be slow and prolonged but all patients were ambulatory at 1 year