There is little published literature to support the claim that a successful total knee replacement (TKR) is predictive of future good outcomes on the contralateral side. The objective was to identify whether outcome from the first of staged TKRs could be used to predict the outcome of the contralateral TKR. This was a retrospective cohort study of 1687 patients over a 25-year period undergoing staged bilateral TKRs in a UK arthroplasty centre. A control group of 1687 patients undergoing unilateral TKR with matched characteristics was identified. Primary outcomes were satisfaction and Knee Society Score (KSS) at one year. Preoperative status was comparable for pain, ROM and KSS (mean 41, 45, 43±14). At one year follow up, dissatisfaction was similar for all groups (4% first of staged TKR, 4% second of staged TKR, 5% controls). If the first TKR had a good outcome, the relative risk of a contralateral bad outcome was 20% less than controls (95% CI 0.6–1.2). If the first TKR had a poor outcome, the risk of a second poor outcome was 4 times higher (95% CI 2.8–6.1), increasing from 6% to 27% (absolute risk). Patients undergoing the second of staged TKRs with a previous good outcome are likely to do well in their second procedure (94 in 100 will go on to have a second good outcome). Of those with a previous poor outcome, 27 in 100 will have a second poor outcome. The trend was persistent despite correcting for gender, age, BMI, and diagnosis

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. Methods. A total of 34 boys and 22 girls aged 0 to ten years with a closed, completely displaced metaphyseal distal radial fracture presented between 1 November 2015 and 1 January 2020. After 2018, children aged ten or under were offered treatment in a straight plaster or manipulation under anaesthesia with Kirschner (K-)wire stabilization. Case notes and radiographs were reviewed to evaluate outcomes. In all, 16 underwent treatment in a straight cast and 40 had manipulation under anaesthesia, including 37 stabilized with K-wires. Results. Of the children treated in a straight cast, all were discharged with good range of mo (ROM). Five children were discharged at six to 12 weeks with no functional limitations at six-month follow-up. A total of 11 children were discharged between 12 and 50 weeks with a normal ROM and radiological evidence of remodelling. One child had a subsequent diaphyseal fracture proximal to the original injury four years after the initial fracture. Re-displacement with angulation greater than 10° occurred for 17 children who had manipulation under anaesthesia. Four had a visible cosmetic deformity at discharge and nine had restriction of movement, with four requiring physiotherapy. One child developed over- granulation at the pin site and one wire became buried, resulting in a difficult retrieval in clinic. No children had pin site infections. Conclusion. Nonoperative management of completely displaced distal radial fractures in appropriately selected cases results in excellent outcomes without exposing the child to the risks of surgery. This study suggests that nonoperative management of these injuries is a viable and potentially underused strategy. Cite this article: Bone Joint J 2021;103-B(5):902–907

The Poole Traction Splint (PTS) is a non-invasive technique that applies dynamic traction to the affected digit using materials readily available in the outpatient department. The primary aim of this study was to document the outcome of the PTS for hand phalangeal fractures. Over a four-year period (2017–2021), suitable patients were reviewed and referred for PTS to the hand physiotherapists. Functional outcome measures included range of motion (ROM), return to work, and a DASH score. In addition, a healthcare cost analysis was carried out. A total of 63 patients were treated with a PTS from 2017 to 2021. Data was analysed for 54 patients with 55 digits. The mean age was 43 years (17–72) and 53.7% (n=29) were female. There were 43 fractures involving the proximal phalanx and 12 involving the middle phalanx. The mean final composite range of movement averaged 209˚ (110–270°), classified as ‘good/excellent’ by ASSH criteria. The mean DASH score was 13.6 (0-43.2; n=45). All patients were able to return to work. Only two (3.7%) digits required conversion to surgical fixation. The PTS resulted in approximate savings of £2,452 per patient. The PTS is a cost-effective non-invasive low risk outpatient treatment method which provides a functional ROM and good functional outcomes in the treatment of complex phalangeal hand fractures, with minimal risk of surgical intervention being required

Introduction. Muscle stiffness and joint contractures are common complications of limb lengthening. Authors have demonstrated less permanent soft tissue complications with intramedullary lengthening than external fixation. Our aim was to evaluate the joint response following intramedullary femoral lengthening and need for physiotherapy and alteration to rate/rhythm of lengthening. Method. A retrospective review of documentation for all femoral Precice nails in our centre inserted between 2012 and 2017. This involved 98 nails (68 antegrade, 30 retrograde) in 88 patients (59 males, 29 females) with a mean age of 32 years (range 12–69 yrs). We excluded cases where there was no documentation regarding Range of Movement (ROM). Bilateral lengthenings were recorded as separate cases. This left 50 antegrade, 16 retrograde cases with hip ROM data and 55 antegrade, 26 retrograde cases with Knee ROM data. Results. Hip. In the antegrade group 20 cases (39%) developed no stiffness throughout treatment. ROM decreased in 61% (n=30) of cases and the median length at which this occurred was 3cm. Where a retrograde nail was inserted 62.5% of cases (n=10) maintained normal range of motion. The median length at which ROM decreased was 3.25cm, this occurred in 6 cases (37.5%). . Knee. Where the antegrade nail was inserted, 22 cases (40%) did not develop stiffness. There was reduced ROM in 33 cases (60%), occurring at a median distance of 2cm. The median distance at which reduced ROM occurred with the retrograde nails was 1.5cm, this occurred in 23 cases (88.5%). 3 cases did not develop stiffness. All cases regained full ROM. Conclusion. Although there was no permanent loss, Joint Stiffness still occurs with intramedullary limb lengthening and there remains the need for regular physiotherapy. There are no data from other institutions for comparison. Rehabilitation guidelines and a proforma to accurately monitor patients ROM throughout treatment have been developed

Aims. No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA. Methods. Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler’s angle and calcaneal width, and posterior facet reduction. Results. Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001). Conclusion. The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286–293

Aims. Tibial plateau fractures are serious injuries about the knee that have the potential to affect patients’ long-term function. To our knowledge, this is the first study to use patient-reported outcomes (PROs) with a musculoskeletal focus to assess the long-term outcome, as compared to a short-term outcome baseline, of tibial plateau fractures treated using modern techniques. Methods. In total, 102 patients who sustained a displaced tibial plateau fracture and underwent operative repair by one of three orthopaedic traumatologists at a large, academic medical centre and had a minimum of five-year follow-up were identified. Breakdown of patients by Schatzker classification is as follows: two (1.9%) Schatzker I, 54 (50.9%) Schatzker II, two (1.9%) Schatzker III, 13 (12.3%) Schatzker IV, nine (8.5%) Schatzker V, and 26 (24.5%) Schatzker VI. Follow-up data obtained included: Visual Analogue Scale (VAS) or Numeric Rating Scale (NRS) pain scores, Short Musculoskeletal Functional Assessment (SMFA), and knee range of movement (ROM). Data at latest follow-up were then compared to 12-month data using a paired t-test. Results. Patient-reported functional outcomes as assessed by overall SMFA were statistically significantly improved at five years (p < 0.001) compared with one-year data from the same patients. Patients additionally reported an improvement in the Standardized Mobility Index (p < 0.001), Standardized Emotional Index (p < 0.001), as well as improvement in Standardized Bothersome Index (p = 0.003) between the first year and latest follow-up. Patient-reported pain and knee ROM were similar at five years to their one-year follow-up. In total, 15 of the patients had undergone subsequent orthopaedic surgery for their knees at the time of most recent follow-up. Of note, only one patient had undergone knee arthroplasty following plateau fixation related to post-traumatic osteoarthritis (OA). Conclusion. Knee pain following tibial plateau fracture stabilizes at one year. However, PROs continue to improve beyond one year following tibial plateau fracture, at least in a statistical sense, if not also clinically. Patients displayed statistical improvement across nearly all SMFA index scores at their minimum five-year follow-up compared with their one-year follow-up. Cite this article: Bone Joint J 2020;102-B(5):632–637

Purpose. Surgical correction of upper limb deformities in severe osteogenesis imperfecta (OI) is technically difficult and less absolving, hence we aimed to analyse the surgical complications of rodding the humeri in severe OI. Methods and results. Retrospective analysis was carried out for consecutive humeral roddings for severe OI in last 3 years. Surgical technique for all humeri included retrograde telescopic nailing (female or both of FD or TST rods) with entry from olecranon fossa, exploration of radial nerve followed by osteotomies. Deformities were quantified and sub-classified as per level of deformity). Variables such as number of osteotomies, radiological union, intraoperative and postoperative complications, improvement in ROM and subjective patient satisfaction were recorded. Total 18 humeri in 12 patients with type III OI (except 1) with mean age of 8.9 years underwent nailing. All patients achieved radiological union at 6–10 weeks. Total 8 complications (44.4 %) were reported within mean 8.4 months follow up. Four segments (22.2 %) had intraoperative fractures at distal third of the humerus while negotiating the nail. Significantly higher intraoperative complications were encountered in humeri fixed with both components combined and upper third level deformities, deformities > 900 and more than 2 osteotomies. Other complications were prominent implant at upper end (2) with growth and one each of contralateral fracture and distal humeral varus. All patients reported improvement in ROM and functional status. Conclusion. Significant complications are associated with humeral nailing for severe OI. Quantification of the deformity with meticulous surgical planning and execution is advised. Despite these complications outcomes show benefits of the surgical treatment. Level of evidence. Therapeutic III

Aims

There has been an increasing use of early operative fixation for scaphoid fractures, despite uncertain evidence. We conducted a meta-analysis to evaluate up-to-date evidence from randomized controlled trials (RCTs), comparing the effectiveness of the operative and nonoperative treatment of undisplaced and minimally displaced (≤ 2 mm displacement) scaphoid fractures.

We report on the 5 year results of a randomized study comparing TKR performed using conventional instrumentation versus electromagnetic computer-assisted surgery. This study analysed patient reported outcome measures (PROMs) at 5 years utilising the American Knee Society Score (AKSS), Oxford Knee Score (OKS), the Short Form 36 score and range of motion (ROM). Of the 200 patients enrolled 125 completed 5 year follow up, 62 in the navigated group and 63 in the conventional group. There were 28 deceased patients, 29 withdrawals and 16 lost to follow-up. There was improvement in clinical function in most PROMs from 1-5 year follow up across both groups. OKS improved from a mean of 26.6 (12–55) to 35.1 (5–48). AKSS increased from 75.3 (0–100) to 78.4 (−10–100), SF36 from 58.9 (2.5–100) to 53.2 (0–100). ROM improved by an average 7 degrees from 110 degrees to 117 degrees (80–135). There was no statistically significant difference in PROMs between the groups at 5 years. Patients undergoing revision surgery were identified from the dataset and global PACS. There were no revisions within 5 years in the navigated group and 3 revisions in the conventional group, two for infection and one for mid-flexion instability, giving an all cause revision rate of 3.06% at 5 years for this group. There appears to be no significant advantage in clinical function for patients undergoing TKR for OA of the knee with electromagnetic navigation when compared to conventional techniques. There may be an advantage in reducing early revision rates using this technology

Introduction. Distal radius fractures (DRF) are a common injury in the A&E departments, being a major cause of disability of the upper extremity. The aim of this prospective study is to assess the possible association between objective physical variables such as wrist range of movement (ROM), radiological parameters, and upper extremity disability (measured by the DASH questionnaire), after conservative treatment of DRF. Patients and methods. 44 patients with non-operatively managed DRF were enrolled in a prospective cohort study from July 2007 till September 2009. Inclusion criteria: unilateral DRF in skeletally mature patients, treated non-operatively with closed reduction and cast. Patients who sustained a previous fracture of the wrist, or bilateral wrist fracture, or with dementia, were excluded. After the closed reduction and inmovilization of the fracture in the A&E department we asked the patients to complete the DASH questionnaire, referring to their baseline pre-fracture state. All fractures were classified according to the AO classification. After one year, 36 patients were still available for follow-up purposes. We assesed the following objective physical variables: ROM of both wrists: flexion/extension arc and pronation/supination arch. We recorded the following radiologic parameters: radial angulation, volar angulation and radial shortening. The patient-perceived results were measured by the DASH questionnaire, while pain was measured using the VAS scale. Statistical analysis was performed using the SPSS 15.0. Results. Average follow up: 13,39 months (range 12.3–16.43). Mean age: 62.5 years (18–91). 75% of the fractures were 23A and 24,1% 23B. Average pre-fracture DASH score was 19.6 and 42.1 at the end of follow-up. Radial tilt: 18.18°. Volar tilt: 3,35°. Radial shortening: 5,76mm. ROM for flexion/extension of the involved wrist: 103.6° and non-involved wrist: 131.2°. ROM for pronation/supination involved wrist: 145.7° and non-involved wrist: 173.8°. Post-fracture VAS score: 3.5. We didn't find any significant statistical correlation between the lost of ROM, neither with radiological malaligment nor with patient-perceived outcomes. But we found a significant association between items 24–28 of the DASH (except item 26) questionnaire and the VAS score. Conclusions. The results of the present study show that, conservative treatment of DRF seems to deteriorate the patient self-reported outcomes measured by the DASH questionnaire

This study aimed to determine the long-term functional, clinical and radiological outcomes in patients with Schatzker IV to VI fractures of the tibial plateau treated with an Ilizarov frame. Clinical, functional and radiological assessment was carried out at a minimum of one year post-operatively. A cohort of 105 patients (62 men, 43 women) with a mean age of 49 years (15 to 87) and a mean follow-up of 7.8 years (1 to 19) were reviewed. There were 18 type IV, 10 type V and 77 type VI fractures. All fractures united with a mean time to union of 20.1 weeks (10.6 to 42.3). No patient developed a deep infection. The median range of movement (ROM) of the knee was 110. o. and the median Iowa score was 85. . Our study demonstrates good long-term functional outcome with no deep infection; spanning the knee had no detrimental effect on the ROM or functional outcome. . High-energy fractures of the tibial plateau may be treated effectively with a fine wire Ilizarov fixator. Cite this article: Bone Joint J 2015;97-B:1693–7

Introduction. The degeneration of the adjacent segment in lumbar spine with spondylodesis is well known, though the exact incidence and the mechanism is not clear. Several implants with semi rigid or dynamic behavior are available to reduce the biomechanical loads and to prevent an adjacent segment disease (ASD). Randomized controlled trials are not published. We investigated the biomechanical influence of dynamic and semi rigid implants on the adjacent segment in cadaver lumbar spine with monosegmental fusion (MF). Materials and Methods. 14 fresh cadaver lumbar spines were prepared; capsules and ligaments were kept intact. Pure rotanional moments of ±7.5 Nm were applied with a Zwick 1456 universal testing machine without preload in lateral bending and flexion/extension. The intradiscal pressure (IDP) and the range of motion (ROM) were measured in the segments L2/3 and L3/4 in following situations: in the native spine, monosegmental fusion L4/5 (MF), MF with dynamic rod to L3/4 (Dynabolt), MF with interspinous implant L3/4 (Coflex), and semi rigid fusion with PEEK rod (CD Horizon Legacy) L3-L5. Results. Under flexion load all implants reduced the IDP of segment L2/L3, whereas the IDP in the segment L3/4 was increased using interspinous implants in comparison to the other groups. The IDP was reduced in extension in both segments for all semi rigid or dynamic implants. Compared under extension to the native spine the MF had no influence on the IDP of the adjacent disc. The rod instrumentation (Dynabolt, PEEK rod) lead to a decreased IDP in lateral bending tests. The ROM in L3 was reduced in all groups compared to the native spine. The dynamic and semi rigid stabilization in the segment L3/4 limited the ROM more than the MF. Discussion. The MF reduced the ROM in all directions, whereas the IDP of the adjacent segment remained unaffected. The support of the adjacent segment by semi rigid and dynamic implants decreased the IDP of both segments in extension mainly. This fact is an agreement with other studies. Compared to our data, no significant effect on the adjacent levels was observed. Interestingly, in our study, the IDP of the adjacent segment is unaffected by MF. The biomechanical influence in the view of an ASD could be comprehended, but is not completely clear. The fact of persistent IDP in the adjacent segment suggests that MF has a lower effect on the adjacent segment degeneration as presumed. Biomechanical studies with human cadaver lumbar spines are limited and depend on age and degenerative situation. The effect on supporting implants on adjacent segment disease in lumbar spine surgery has to be investigated in clinical long term studies

Introduction. Adequate exposure is a prerequisite for treatment of distal humeral fractures. In this study, we compared the clinico-radiological and functional outcome of TRAP approach with that of olecranon osteotomy for distal humerus fractures. Material & Methods. 27 patients with distal humerus fractures were randomized into 2 groups: Group 1 (n=14, TRAP approach), Group 2 (n=13, Olecranon osteotomy). All patients were operated with bi-columnar fixation. All patients were mobilized from day 2. Follow-up evaluation was done at 1, 3, 6 and 12 months. Results. All patients achieved union. The mean surgical time was higher in group 1 (120 min) as compared to group 2 (100 min). The final ROM was higher in group 1 (1160) as compared to group 2 (850). Two patients in group 2 needed posterior release. 5 patients in group 2 had hardware complications related to olecranon osteotomy and needed removal. Two patients in Group 1 had transient ulnar nerve paraesthesias. There was no difference in triceps power in both groups. Conclusion. Our results demonstrate that TRAP approach is extensile and safe enough in treating these complex fractures with better final ROM and fewer complications

Objective. High grade hallux rigidus is a forefoot deformity characterized by a limitation of dorsiflexion of the first toe associated with pain, and severe damage of the first metatarsophalangeal joint. Most authors recommended resection arthroplasty or arthrodesis of the first metatarsophalangeal joint. The aim of this study was to present the results of our series of 42 consecutive cases of severe hallux rigidus treated by resection of the first metatarsal head and implant of a poly D-L lactic (PDLLA) bioreabsorbable spacer to promote the interposition of fibrous tissue to preserve the range of motion of the joint. Material and methods. Forty-two feet in 27 patients affected by high grade hallux rigidus were included in the study. Surgical treatment consisted of resection of the first metatarsal head and positioning of a poly D-L lactic acid (PDLLA) bioreabsorbable implant. Post-operative care consisted in gauze bandage of the forefoot, and immediate weight-bearing with talus shoes for 3 weeks. All patients were clinically and radiographically evaluated preoperatively and checked at a mean 6 (5–7) year follow-up. Results. No intraoperative complication occurred. No sinus formation were observed. All implants resulted well tolerated by the patients. Mean AOFAS score was 42±14 preoperatively and 81±9 postoperatively. Mean preoperative metatarsophalangeal joint ROM was 27±17 degrees and mean postoperative metatarsophalangeal joint ROM was 75±8 degrees. Conclusions. First metatarsophalangeal joint arthroplasty using bioreabsorbable implant demonstrated to be an effective surgical option for treatment of high grade hallux rigidus, thank to its ability to promote fibrous tissue formation during its reabsorption

Introduction and objectives. Intramedullary nailing is indicated to stabilization of tibia shaft fractures. Intramedullary nailing through an infra-patellar incision is commonly the technique of choice. While intramedullary nailing of simple diaphyseal fracture patterns is relatively easy, proximal tibia fractures, extremely comminuted/segmental tibia fractures, politrauma with multiple fractures in both extremities and reconstruction of bone loss segment with stiffness of the knee joint can be very challenging to treat. A novel technique for intramedullary tibia nailing through the patella-femoral joint is described. This technique allow extension tibia during intervention time and it supplies easier reduction of the pattern of fracture above. The purpose of our investigation was to evaluate the use of this new technique in described above pattern fracture and patient situation; because we have thought that new technique can perform better outcomes in this situations. Materials and Methods. An observational study of tibia fractures or bone defect was performed for consecutive patients who presented: proximal tibia fractures, extremely comminuted/segmental tibia fractures, politrauma with multiple fractures in both extremities and reconstruction of bone loss segment in the Trauma unit of our institution from September 2009 to August 2010. A total of 32 were included in our study, which performed surgery intervention with Trigen tibia nail (Smith & Nephew, Memphis) with suprapatelar device. Demographic data, mechanism of injury, fracture classification, ROM (2 and 6 weeks, and 3 months), consolidation rate, reduction fracture quality and knee pain at 3 months were recorded. Results. Male was the gender most frequent (64%), the average age was 39,5 years and the main mechanism of injury was motor vehicle injury (30,6%). There were 7 proximal fractures, 1 bifocal fracture, 6 politrauma and 2 reconstruction bone loss segment, the others were comminuted and segmental tibia fracture. In all the patients, the fracture was consolidated between 8 to 14 weeks with average of 10,6 weeks. The quality of reduction was correct in all patients in different axis. The average of ROM at 2 weeks was (−2°/95°) at 3 months was (−0,4°/133°). The knee pain (VAS) average was 0,6 only in 2 patients were (4). Poller screw was used in 7 patients. Conclusion. The suprapatelar nailing is optimal technique to resolve complex fracture of the tibia (proximal, segmental conminution, politrauma) that perform correct consolidation rate without misalignment in the patients. Concerns about knee pain (VAS) from the technique not appear in our data. Prospective and clinical trials are needed to validate this approach

Electromagnetic navigation versus conventional Total Knee Arthroplasty: Clinical improvements Optical and electromagnetic (EM) tracking systems are widely used commercially. However in orthopaedic applications optical systems dominate the market. Optical systems suffer from deficiencies due to line of sight. EM trackers are smaller but are affected by metal. The accuracy of the two tracker systems has been seen to be comparable1. Recent advancements in optical navigated TKA have shown improved overall limb alignment, implant placement and reduce outliers when compared to conventional TKA2-4. This study is the first RCT to compare EM and conventional TKA. Two groups of 100 patients underwent TKA using either the EM navigation system or the conventional method. Frontal, sagittal and rotational alignment was analysed from a CT scan. Clinical scores including Oxford Knee Score (OKS) and Knee/Function American Knee Society Score (AKSS) were recorded pre-op, and at 3 and 12 months post-op. 3 month data presented includes 180 patients (n = 90). The 12 months data presented includes 140 (n = 70). The two groups had similar mean mechanical axis alignments (EM 0.31o valgus, conventional 0.15o valgus). The mechanical axis alignment was improved in the EM group with 92% within +/-3o of neutral compared to 84% of the conventional group (p = 0.90). The alignment of the EM group was improved in terms of frontal femoral, frontal tibial, sagittal femoral, sagittal tibial and tibial rotation alignment. However, only the sagittal femoral alignment was significantly improved in the EM group (p = 0.04). Clinically, both TKA groups showed significant improvements in OKS and AKSS scores between both pre-op to 3 month post-op and 3 months to 12 months post-op (p<0.001). The OKS and the AKSS knee score for the EM group was significantly better at 3 months post-op (OXS p = 0.02, AKSS knee p = 0.04). However there was no difference between the groups at 12 months. The mean pre-op range of motion (ROM) for both groups was 105o. This decreased to 102o in the EM group and 99o in the conventional group at 3 months. There was a significant improvement at 12 months post-op, EM = 113o (p = 0.012) and conventional = 112o (p = 0.026). There was no significant difference in ROM between the two groups at 3 or 12 months post-op. Therefore the alignment outcome of the EM TKA group was improved compared to the conventional group. The EM group also showed clinical improvements at 3 months post-op however these were not seen again at 12 months post-op. ROM was seen to decrease at 3 months post-op but then significantly improve by 12 month post-op

Background. The Schatzker classification is applied in the management of tibial plateau fractures. The unique pattern of Schatzker VI fractures requires recognition for proper fixation. Method:. We have treated 33 patients with Schatzker IV tibial plateau fractures including non-unions and mal-unions. Patients had a temporary spanning Ilizarov frame with intraoperative distraction, articular reconstruction and olive wires for indirect reduction. No open surgery was performed. Patients mobilised fully weight-bearing and underwent post-operative CT scan and regular outpatient reviews. At six weeks the femoral ring was removed, and patients underwent a staged dynamisation protocol prior to frame removal. Results:. Twenty seven patients have achieved union and completed at least 1-year follow-up. Of these, 25 were reviewed at a mean follow-up of 5.4 years. The mean IOWA score was 85 and the mean ROM was 119 degrees. Two patients were not contactable for final review. The remaining six patients are still undergoing treatment. The mean time to union was 145 days. Conclusion:. Shatzker IV fracture requires understanding of the axial/valgus pattern of injury so that appropriate fixation can be applied to produce good results

Aims

To compare operative and nonoperative treatment for displaced distal radius fractures in patients aged over 65 years.

There is a high rate of forearm deformity in patients with hereditary multiple exostoses (HME), and a quarter of patients acquire a dislocated radial head due to disproportionate ulnar shortening. One-hundred and six patients with HME aged 15 years or older were identified from a prospective database. Flexion and extension of the elbow and wrist, and supination and pronation of the forearm was measured. The number of exostoses affecting the proximal and distal radius and ulna were recorded. Proportional ulna length was calculated as a percentage of the patients measured height ([ulna length/height] × 100). More than 70% of patients were affected by exostoses of the forearm, of which the distal radius was the commonest site to be affected (73%). One in seven patients had a dislocated radial head, which was associated with proportional ulna shortening (p<0.001). Both radial head dislocation (p<0.001) and proportional ulna shortening (p<0.001) were confirmed to be independent predictors of forearm motion on multivariable regression analysis. In conjunction with other predictors these could be used to calculate ROM of the forearm. In addition proportional ulna length was also an independent predictor of radial head dislocation (p<0.001). Proportional ulna length could be used as a tool to identify patients at risk of diminished forearm motion and radial head dislocation during childhood, who could be monitored clinically and radiographically, and surgical intervention could be offered before deterioration in function and dislocation of the radial head occurs

Introduction. For the increasing number of frail elderly patients in Japan, mobility is crucial to stay independent and maintain quality of life. After failure reports with standard implants, a prospective multicentre study was performed to evaluate whether an implant designed for Asians enables rapid recovery after unstable trochanteric fractures. Materials and methods. Patients with an AO 31A2 or A3 fracture sustained less than 7 days before fracture fixation with the Asian version of the Proximal Femoral Nail Antirotation. Those with severe dementia and bedridden or confined to a wheelchair were excluded. Outcome parameters were quality of life (SF36v2, EQ5D), mobility (Parker Mobility score PMS) and range of motion (ROM). Results. Median age of the 176 pat. was 84 yrs; 88% had comorbidities, 25% were underweight/severely underweight. After 1 year, mean relative ROM was 90% for flex/ext, 88% for abd/add compared to the healthy side. Although the median PMS decreased from initial 9 to 6 points at 1 year, 42% returned to within 1 point of their pre-injury level. 60% and 76% returned to their pre-injury residential status at 6 and 12 months, resp. 43% and 65% of patients at 1-year had no problems with their mobility and self-care assessed with the EQ5D. All 8 SF36 dimensions were similar at pre-injury, 6 and 12 months. Discussion. Frail elderly patients can achieve good function and quality of life after a trochanteric fracture treated with a size and geometry adapted implant