We compared the outcome of closed intramedullary nailing with minimally invasive plate osteosynthesis using a percutaneous locked compression plate in patients with a distal metaphyseal fracture in a prospective study. A total of 85 patients were randomised to operative stabilisation either by a closed intramedullary nail (44) or by minimally invasive osteosynthesis with a compression plate (41). Pre-operative variables included the patients’ age and the side and pattern of the fracture. Peri-operative variables were the operating time and the radiation time. Postoperative variables were wound problems, the time to union of the fracture, the functional American Orthopaedic Foot and Ankle surgery score and removal of hardware. We found no significant difference in the pre-operative variables or in the time to union in the two groups. However, the mean radiation time and operating time were significantly longer in the locked compression plate group (3.0 vs 2.12 minutes, p < 0.001, and 97.9 vs 81.2 minutes, p < 0.001, respectively). After one year, all the fractures had united. Patients who had intramedullary nailing had a higher mean pain score, but better function, alignment and total American Orthopaedic Foot and Ankle surgery scores, although the differences were not statistically significant (p = 0.234, p = 0.157, p = 0.897, p = 0.177 respectively). Three (6.8%) patients in the intramedullary nailing group and six (14.6%) in the locked compression plate group showed delayed wound healing, and 37 (84.1%) in the former group and 38 (92.7%) in the latter group expressed a wish to have the implant removed. We conclude that both closed intramedullary nailing and a percutaneous locked compression plate can be used safely to treat Orthopaedic Trauma Association type-43A distal metaphyseal fractures of the tibia. However, closed intramedullary nailing has the advantage of a shorter operating and radiation time and easier removal of the implant. We therefore prefer closed intramedullary nailing for patients with these fractures

Aims. The aim of this study was to determine the immediate post-fixation stability of a distal tibial fracture fixed with an intramedullary nail using a biomechanical model. This was used as a surrogate for immediate weight-bearing postoperatively. The goal was to help inform postoperative protocols. Methods. A biomechanical model of distal metaphyseal tibial fractures was created using a fourth-generation composite bone model. Three fracture patterns were tested: spiral, oblique, and multifragmented. Each fracture extended to within 4 cm to 5 cm of the plafond. The models were nearly-anatomically reduced and stabilized with an intramedullary nail and three distal locking screws. Cyclic loading was performed to simulate normal gait. Loading was completed in compression at 3,000 N at 1 Hz for a total of 70,000 cycles. Displacement (shortening, coronal and sagittal angulation) was measured at regular intervals. Results. The spiral and oblique fracture patterns withstood simulated weight-bearing with minimal displacement. The multifragmented model had early implant failure with breaking of the distal locking screws. The spiral fracture model shortened by a mean of 0.3 mm (SD 0.2), and developed a mean coronal angulation of 2.0° (SD 1.9°) and a mean sagittal angulation of 1.2° (SD 1.1°). On average, 88% of the shortening, 74% of the change in coronal alignment, and 75% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. The oblique fracture model shortened by a mean of 0.2 mm (SD 0.1) and developed a mean coronal angulation of 2.4° (SD 1.6°) and a mean sagittal angulation of 2.6° (SD 1.4°). On average, 44% of the shortening, 39% of the change in coronal alignment, and 79% of the change in sagittal alignment occurred in the first 2,500 cycles. No late acceleration of displacement was noted. Conclusion. For spiral and oblique fracture patterns, simulated weight-bearing resulted in a clinically acceptable degree of displacement. Most displacement occurred early in the test period, and the rate of displacement decreased over time. Based on this model, we offer evidence that early weight-bearing appears safe for well reduced oblique and spiral fractures, but not in multifragmented patterns that have poor bone contact. Cite this article: Bone Joint J 2021;103-B(2):294–298

The results of the treatment of 31 open femoral fractures (29 patients) with significant bone loss in a single trauma unit were reviewed. A protocol of early soft-tissue and bony debridement was followed by skeletal stabilisation using a locked intramedullary nail or a dynamic condylar plate for diaphyseal and metaphyseal fractures respectively. Soft-tissue closure was obtained within 48 hours then followed, if required, by elective bone grafting with or without exchange nailing. The mean time to union was 51 weeks (20 to 156). The time to union and functional outcome were largely dependent upon the location and extent of the bone loss. It was achieved more rapidly in fractures with wedge defects than in those with segmental bone loss. Fractures with metaphyseal defects healed more rapidly than those of comparable size in the diaphysis. Complications were more common in fractures with greater bone loss, and included stiffness of the knee, malunion and limb-length discrepancy. Based on our findings, we have produced an algorithm for the treatment of these injuries. We conclude that satisfactory results can be achieved in most femoral fractures with bone loss using initial debridement and skeletal stabilisation to maintain length, with further procedures as required

Clinical Problem. Pilon fractures and distal metaphyseal fractures of the tibia are associated with a high rate of soft tissue and bone healing problems. We started to use the XS and XS nail as minimal invasive procedure for the management of these fractures in July 2000 first for the fibula and since for the fibula and pilon itself but extended metaphseal comminution are contraindication for the XS nail. Because of soft tissue problems and higher loading capacity of intramedullary implants the XS Nail was also used for ankle fracture osteosynthesis but as in all articular fractures with open reduction,. Material and Methods. the XS nail is a 4.5mm or the XXS a 3.5mm straight nail witch is locked by threaded wires witch are placed with an aiming device and allows also dynamic fracture site compression with a set screw. The Fibula is fixed percutaneusly and after distal locking with traction of the aiming device also tibia length and axis can be restored and fixed with the proximal locking. From july 2000 to july2006 54 pilon fractures where treated. The mean age was 54 years (range 25–92). In all cases except one referred after 4 weeks the fibula and joint dislocations where stabilised primarily. The tibia XS nail osteosynthesis or limited invasive plate fixation was performed after 5–8 days except two fixed primarily. Up to now 43 patients could be re-examined more than 12 months after surgery. The results were classified according to the Ovadia Score. In a second study: from 05/2000 to 03/2002 214 ankle fractures were stabilised with a XS or XXS nail. The mean age was 51 year, 59% were woman. 35% were Weber B and 25% type C fractures. The re-examination after 6 months could be performed in 91 Patients and was evaluated according to the Ovadia score (clinical and radiological). Results. All articular pilon fractures and fibula fractures healed without problems but in 3 metaphyseal fractures delayed union required bone grafting. According to the Ovadia Score after one year the results were very good or good in the subjective criteria in 69% of the patients and 61% in the objective criteria. In the ankle fractures study in 2 patients haematoma revisions and in 2 patients with the primary used oblique insertion of the nail a proximal fibula fracture occured. At re-examination 71% showed an excellent and 25% a good result. Conclusion. the minimal invasive stabilisation of pilon fractures with the XS nail and the absence of plates on the bone surface reduces significantly the healin. The Xs nail is also a new option for ankle stabilisation. It improves the stability and reduces the complication of ankle osteosynthesis due to the lack of implant under the skin on the bone surface and due to the higher biomechanical stability of intramedullary implants

Aims

Several previously identified patient-, injury-, and treatment-related factors are associated with the development of nonunion in distal femur fractures. However, the predictive value of these factors is not well defined. We aimed to assess the predictive ability of previously identified risk factors in the development of nonunion leading to secondary surgery in distal femur fractures.

Background. Locking internal fixation through a relatively small surgical dissection presents an innovative technique for managing distal tibial extra-articular fractures. The aim of this study is to evaluate the biomechanical properties of one locking internal fixation plate used to treat these injuries. Method. An AO/OTA43-A3 fracture was created in synthetic composite tibiae. Locking internal fixation was achieved with an anatomically pre-contoured medial distal tibial locking plate. Comparisons were made between different screw configurations in holes proximal to the fracture and monocortical versus bicortical fixation. Axial stiffness was measured using a universal materials testing machine. Finite element analysis (FEA) was used to model the elastic deformation of the constructs. Outcome measures were axial stiffness under physiological loading conditions and compression load to failure. Results. A trend towards reduced mean axial stiffness from the bicortical to the monocortical fixation constructs was observed. The physical model demonstrated no difference in measured mean axial stiffness between constructs with all screw holes filled and constructs with 2 screws in the holes closest and furthest from the fracture site. There was a 19% reduction in mean measured axial stiffness between constructs with all holes filled and in constructs with 2 screws in adjacent holes furthest from the fracture site (p<0.05). FEA predicted increased plate deflection and reduced construct axial stiffness with increasing distance of screw placement from the osteotomy site. Conclusion. Axial stiffness of distal tibial extra-articular metaphyseal fractures stabilized by locking internal fixation is dependent upon the configuration of the screw in the plate

Background. Distal tibial metaphyseal fractures pose many complexities. This study assessed the outcomes of distal tibial fractures treated with percutaneously inserted medial locking plates. Methods. Eighteen patients were selected based on the fracture pattern and classified using the AO classification and stabilised with an AO medial tibial locking plate. Time to fracture union, complications and outcomes were assessed with the American Orthopaedic Foot and Ankle Society ankle score at 12 months. Results. Sixteen of the 18 patients achieved fracture union, with 1 patient lost to follow up. Twelve fractures united within 24 weeks, with an average union time of 23.1 weeks. Three delayed unions, two at 28 weeks and one at 56 weeks. The average time to union was 32 weeks in the smokers and 15.3 weeks in the non-smokers. Five of the 18 patients (27%) developed complications. One superficial wound infection and one chronic wound infection, resulting in non-union at 56 weeks, requiring revision. Two patients required plate removal, one after sustaining an open fracture at the proximal end of the plate 6 months after surgery (post fracture union) and the other for painful hardware. One patient had implant failure of three proximal diaphyseal locking screws at the screw head/neck junction, but successful fracture union. The average AOFAS ankle score was 88.8 overall, and 92.1 in fractures that united within 24 weeks. Conclusions. Distal tibial locking plates have high fracture union rates, minimum soft tissue complications, and good functional outcomes. The literature shows similar fracture union and complication rates in locking and non-locking plates

Intramedullary nailing of metaphyseal fractures may be associated with deformity as a result of instability after fixation. Our aim was to evaluate the clinical use of Poller screws (blocking screws) as a supplement to stability after fixation with statically locked intramedullary nails of small diameter. We studied, prospectively, 21 tibial fractures, 10 in the proximal third and 11 in the distal third in 20 patients after the insertion of Poller screws over a mean period of 18.5 months (12 to 29). All fractures had united. Healing was evident radiologically at a mean of 5.4 ± 2.1 months (3 to 12) with a mean varus-valgus alignment of −1.0° (−5 to 3) and mean antecurvatum-recurvatum alignment of 1.6° (−6 to 11). The mean loss of reduction between placement of the initial Poller screw and follow-up was 0.5° in the frontal plane and 0.4° in the sagittal plane. There were no complications related to the Poller screw. The clinical outcome, according to the Karström-Olerud score, was not influenced by previous or concomitant injuries in 18 patients and was judged as excellent in three (17%), good in seven (39%), satisfactory in six (33%), fair in one (6%), and poor in one (6%)

Aims

The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of ‘off-ended’ fractures in children with at least two years of potential growth remaining.

Introduction. Locking compression plate (LCP) fixation is an established method of treatment of distal third tibial fractures. No biomechanical data exists in the literature regarding their use. Additionally no data exists on the biomechanical advantage of locking screw fixation over non-locking screw fixation for these fractures. In this study the axial and torsional stiffness, axial load to failure and fatigue performance of a 3.5 mm LCP medial distal tibia Synthes plate was evaluated for the stabilisation of distal third tibial fractures. Additionally the performance of the plate in uni and bicortical locked mode as well as non-locked mode was evaluated. Methods. A standardized oblique fracture pattern was created in the tibial metaphysis of 3rd generation composite tibias, 40 mm from the distal end of the tibia (AO 43-A2.3). A 10mm fracture gap was used to model a comminuted metaphyseal fracture. A 3.5 mm medial distal tibia LCP was applied with bi or unicortical locking or bicortical non-locking screws to 5 tibias respectively. All the bio-mechanical tests were performed on a Bose 3510 Electroforce material testing machine. A ramp to load, loading profile was used to determine the static axial and torsional performance of the construct. Fatigue testing simulated a 6 week gradual weight bearing régime with the load increasing every two weeks by 400N until either 250,000 cycles were completed or the construct failed. Results. The non-locked plate demonstrated a significantly higher load to failure than both the bicortical and unicortical locked plates, 683N vs. 575N vs. 483N respectively(p<0.01). The non locked plate also demonstrated significantly higher mean axial stiffness than the bicortical locked plate and unicortical locked plate 632±13 N/mm, 337±12N/mm and 266±6 N/mm respectively (p <0.01). The non locked plate demonstrated the highest torsional stiffness followed by the bi and unicortical locking plates 1.16 ±.08 Nmm vs. 0.79 ± .06 Nmm vs.0.40 ± 0.02 Nmm respectively (p < 0.01). The non locked plate demonstrated higher endurance than the bi and unicortical locking plates over a 6 week simulated fatigue cycle with 1.75mm, 2.10mm and 2.3mm residual displacement at 1600N respectively (p < 0.01). Discussion. This is the first study that has examined the biomechanical properties of the LCP when used for distal third tibial fractures. A review of the literature suggests LCPs outperform dynamic compression plates in osteoporotic bone but demonstrates no clear biomechanical advantage in using a locking construct in non-osteoporotic bone. In our study the non locked construct outperformed the locked constructs in all parameters assessed. We conclude there is no advantage in using a locking construct for distal third tibial fractures in good quality bone

Aims

Osteopetrosis (OP) is a rare hereditary disease that causes reduced bone resorption and increased bone density as a result of osteoclastic function defect. Our aim is to review the difficulties, mid-term follow-up results, and literature encountered during the treatment of OP.

AIMS. Pure tibial plafond traumatic pathology (excluding trimalleolar fractures) is rare but troublesome, considering the surgical challenges and the long term disability perspective. Treatment involves a wide variety of implants and techniques, and the procedures choice and timing is highly dictated by the soft tissue damage. We designed this study to assess the status of our patients operated with internal, external or combined procedures. METHODS. In a retrospective study, between July 2008 and July 2010 we reviewed 24 patients with available follow-up data. We reviewed the pre- and post-operative imaging available and the immediate follow-up data. A form is currently mailed to the patients to self-evaluate the general physical, mental and employment status, and also the affected limb, using general approved questionnaires. Data from this form is still in process. RESULTS. In this clinic we recorded 24 patients with tibial plafond fractures (17 male, 7 female, 2.43 sex ratio), with ages between 18 and 82 years (average 46.5, median 39 years). According to AO/OTA classification, we noted 8 type A (2 A1, 3 A2, 3 A3) extra-articular tibial fractures, 9 type B (4 B1, 4 B2, 1 B3) intra-articular pilon fractures and 7 type C (3 C1, 1 C2, 3 C3) both epi- and metaphyseal tibial fractures, usually with peroneus fractures at various levels. 10 of these fractures were open, from them 3 type IIIA and 2 IIIB Gustilo-Anderson, and 3 of the patients were politrauma (1 L1 lumbar fracture and distal radius fracture, 1 cranio-cerebral trauma and type I open distal radius fracture and 1 cranio-cerebral trauma). We performed a large array of surgical procedures, usually in emergency, based mainly on the local soft tissue status and both the age and recovery needs of the patient. In old debilitated patients we preferred to use minimal internal osteosynthesis, usually applying a supplementary external fixator or cast. In young active patients we used MIPO techniques in tibial fractures, both with regular or locking-screw plates, repairing also the peroneus in order to preserve the limb length in diaphyseal fractures, and to reconstruct the ankle in lateral malleolus fractures. In cases with severe soft tissue impairment we delayed the definitive osteosynthesis using an external fixator. The short term outcome was good, noting only one septic nonunion, which healed with the appropriate treatment, one calcaneus pin track infection and one deterioration of the external fixator in an alcoholic patient. Data for the mid-term outcome is still under evaluation. CONCLUSIONS. Choosing the appropriate procedure is vital for the outcome. Timing is important, especially in high energy trauma, when the proper surgery performed in emergency allowed us to overcome most of the possible complications. Short term results are encouraging, and the mid-term results will let us know if our attitude was correct

Aims

Type IIIB open tibial fractures are devastating high-energy injuries. At initial debridement, the surgeon will often be faced with large bone fragments with tenuous, if any, soft-tissue attachments. Conventionally these are discarded to avoid infection. We aimed to determine if orthoplastic reconstruction using mechanically relevant devitalized bone (ORDB) was associated with an increased infection rate in type IIIB open tibial shaft fractures.

Objectives

We aimed to further evaluate the biomechanical characteristics of two locking screws versus three standard bicortical screws in synthetic models of normal and osteoporotic bone.

Although the use of constrained cemented arthroplasty to treat distal femoral fractures in elderly patients has some practical advantages over the use of techniques of fixation, concerns as to a high rate of loosening after implantation of these prostheses has raised doubts about their use. We evaluated the results of hinged total knee replacement in the treatment of 54 fractures in 52 patients with a mean age of 82 years (55 to 98), who were socially dependent and poorly mobile.

Within the first year after implantation 22 of the 54 patients had died, six had undergone a further operation and two required a revision of the prosthesis. The subsequent rate of further surgery and revision was low.

A constrained knee prosthesis offers a useful alternative treatment to internal fixation in selected elderly patients with these fractures, and has a high probability of surviving as long as the patient into whom it has been implanted.

In order to achieve satisfactory reduction of complex distal humeral fractures, adequate exposure of the fracture fragments and the joint surface is required. Several surgical exposures have been described for distal humeral fractures. We report our experience using the anconeus pedicle olecranon flip osteotomy approach. This involves detachment of the triceps along with a sliver of olecranon, which retains the anconeus pedicle. We report the use of this approach in ten patients (six male, four female) with a mean age of 38.4 years (28 to 51). The mean follow-up was 15 months (12 to 18) with no loss to follow-up. Elbow function was graded using the Mayo Score. The results were excellent in four patients, good in five and fair in one patient. The mean time to both fracture and osteotomy union was 10.6 weeks (8 to 12) and 7.1 weeks (6 to 8), respectively. We found this approach gave reliably good exposure for these difficult fractures enabling anatomical reduction and bicondylar plating without complications.

Cite this article: Bone Joint J 2014;96-B:1252–7.

We reviewed 59 bone graft substitutes marketed by 17 companies currently available for implantation in the United Kingdom, with the aim of assessing the peer-reviewed literature to facilitate informed decision-making regarding their use in clinical practice. After critical analysis of the literature, only 22 products (37%) had any clinical data. Norian SRS (Synthes), Vitoss (Orthovita), Cortoss (Orthovita) and Alpha-BSM (Etex) had Level I evidence. We question the need for so many different products, especially with limited published clinical evidence for their efficacy, and conclude that there is a considerable need for further prospective randomised trials to facilitate informed decision-making with regard to the use of current and future bone graft substitutes in clinical practice.

Cite this article: Bone Joint J 2013;95-B:583–97.

Percutaneous stabilisation of tibial fractures by locking plates has become an accepted form of osteosynthesis. A potential disadvantage of this technique is the risk of damage to the neurovascular bundles in the anterior and peroneal compartments. Our aim in this anatomical study was to examine the relationship of the deep peroneal nerve to a percutaneously-inserted Less Invasive Stabilisation System tibial plate in the lower limbs of 18 cadavers. Screws were inserted through stab incisions. The neurovascular bundle was dissected to reveal its relationship to the plate and screws.

In all cases, the deep peroneal nerve was in direct contact with the plate between the 11th and the 13th holes. In ten specimens the nerve crossed superficial to the plate, in six it was interposed between the plate and the bone and in the remaining two specimens it coursed at the edge of the plate.

Percutaneous insertion of plates with more than ten holes is not recommended because of the risk of injury to the neurovascular structures. When longer plates are required we suggest distal exposure so that the neurovascular bundle may be displayed and protected.