Introduction. Our unit has extensive experience with the use of Ilizarov circular frames for acute fracture and nonunion surgery. We have observed and analysed fracture healing patterns which question the role of relative stability in fracture healing and we offer limb mechanical axis restoration as a more important determinant. Aim. To assess for the presence of external callus, when only relative stability has been achieved but with anatomical restoration of the mechanical axis (ARMA). Methods. We retrospectively reviewed diametaphyseal proximal and distal tibial fractures treated with Ilizarov frame fixation in our unit between 2009 and 2017. We also reviewed cases where the Ilizarov frame technique had been used for complex femoral and humeral non-unions. Radiographs in 4 views were reviewed to assess bone healing, the presence of external callus and correction of lower limb mechanical axis. Results. 45 tibial plateau fractures, 42 distal tibial fractures and 20 humeral and 3 femoral non-unions were reviewed. Where ARMA was achieved, bone healing was observed to occur without external callus. ARMA proved more challenging in the distal tibia and where ARMA was not achieved external callus was visible during fracture healing. Conclusion. ARMA bone healing is reliable and occurs without formation of external callus, despite relative stability. This would suggest that external callus is produced not in response to just the magnitude of strain but also the direction of strain. Restoration of the mechanical axis is an important step in achieving union and needs to be considered when fixing fractures or treating non-unions

Restoration of native Coronal Plane Alignment of the Knee (CPAK) phenotype is a strategy suggested to achieve better satisfaction. The aim of this study was to investigate the influence of changes in CPAK classification on patient-reported outcome measures (PROMs) and survivorship in a large cohort of manual mechanically aligned (MA) cemented TKAs. A retrospective analysis of 1062 consecutive cemented TKAs using MA philosophy at a single institution. Pre- and post-operative hip-knee-ankle radiographs were classified using the CPAK classification. Oxford Knee Score (OKS) and patient satisfaction (4-point-Likert scale) were collected prospectively. Implant survival data was obtained from our national arthroplasty database. We compared the outcomes of patients who maintained or changed their CPAK classification following TKA. Satisfaction was analysed using chi-square test, and OKS was analysed using Mann-Whitney test. Pre-operatively, most patients were CPAK type-I (38.8%). 85.5% of patients changed their CPAK type post-operatively, with CPAK type-V observed in 41.2% of these. Significantly better satisfaction (p=0.033) and OKS (p=0.021) were observed at one-year follow-up in patients who changed CPAK type, although the difference was below OKS minimally important clinical difference. There was no difference in satisfaction (p=0.73) and OKS (p=0.26) at one year between CPAK-V and non-V classifications. Post-operative CPAK type had no correlation with satisfaction and OKS. 12 TKAs (1.1%) were revised within 10 years (3 septic). In this large cohort of MA-TKA, excellent survivorship was observed at 10 years, with no demonstrable difference in outcome related to the final CPAK phenotype or change in phenotype

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

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Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures.

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Fracture-related infections (FRIs) are a devastating complication of fracture management. However, the impact of FRIs on mental health remains understudied. The aim of this study was a longitudinal evaluation of patients’ psychological state, and expectations for recovery comparing patients with recurrent FRI to those with primary FRI.

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The aims of this study were to identify means to quantify coronal plane displacement associated with distal radius fractures (DRFs), and to understand their relationship to radial inclination (RI).

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Acetabular fractures are associated with long-term morbidity. Our prospective cohort study sought to understand the recovery trajectory of this injury over five years.

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Despite multiple trials and case series on hip hemiarthroplasty designs, guidance is still lacking on which implant to use. One particularly deficient area is long-term outcomes. We present over 1,000 consecutive cemented Thompson’s hemiarthroplasties over a ten-year period, recording all accessible patient and implant outcomes.

A total of 56 male patients with a displaced intracapsular fracture of the hip and a mean age of 81 years (62 to 94), were randomised to be treated with either a cemented hemiarthroplasty (the Exeter Trauma Stem) or reduction and internal fixation using the Targon Femoral Plate. All surviving patients were reviewed one year after the injury, at which time restoration of function and pain in the hip was assessed. There was no statistically significant difference in mortality between the two groups (7/26; 26.9% for hemiarthroplasty vs 10/30; 33.3% for internal fixation). No patient treated with a hemiarthroplasty required further surgery, but eight patients treated by internal fixation did (p = 0.005), five requiring hemiarthroplasty and three requiring total hip arthroplasty. Those treated by internal fixation had significantly more pain (p = 0.02). The restoration of mobility and independence were similar in the two groups. These results indicate that cemented hemiarthroplasty gives better results than internal fixation in elderly men with a displaced intracapsular fracture of the hip. Cite this article: Bone Joint J 2015;97-B:992–6

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Postoperative malalignment of the femur is one of the main complications in distal femur fractures. Few papers have investigated the impact of intraoperative malalignment on postoperative function and bone healing outcomes. The aim of this study was to investigate how intraoperative fracture malalignment affects postoperative bone healing and functional outcomes.

Background. Humerus fracture non-union is a challenge for which a wide range of treatments exist. We present our experience of managing these by hybrid Ilizarov frame fixation, without bone graft or debridement of the non-union site. Methods. Case notes review of a consecutive series of 20 patients treated for aseptic humeral non-union between 2004 and 2016. Eighteen patients had previous plate or intramedullary nail fixations, and 2 had no prior surgery. During Ilizarov application, any existing metalwork preventing dynamisation of the fracture site was removed through minimal incisions before compression of the fracture site was then achieved. Only 3 patients had open debridement or osteotomy of the non-union site, otherwise all other patients had no debridement of their non-union. Results. Bony union was achieved in 17 patients (85%), with a further 2 achieving a functional fibrous union. The remaining patient subsequently had successful open surgery. Union rates were 66% (2/3) and 88% (15/17) for the debridement/osteotomy and non-debridement groups respectively. Mean frame duration was 193 days. One patient was treated for pin-site infection. The Chertsey Outcome Score for Trauma was used to assess patient reported outcomes. Conclusions. Simple changes to the physical properties acting upon a humeral non-union, such as adequate control of its strain environment and restoration of the mechanical axis, are enough on their own to initiate healing. In our practice, this eliminates any morbidity associated with extensive fracture debridements or donor harvest sites

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Our objective was to conduct a systematic review and meta-analysis, to establish whether differences arise in clinical outcomes between autologous and synthetic bone grafts in the operative management of tibial plateau fractures.

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

We treated 108 patients with a pertrochanteric femoral fracture using either the dynamic hip screw or the proximal femoral nail in this prospective, randomised series. We compared walking ability before fracture, intra-operative variables and return to their residence. Patients treated with the proximal femoral nail (n = 42) had regained their pre-operative walking ability significantly (p = 0.04) more often by the four-month review than those treated with the dynamic hip screw (n = 41). Peri-operative or immediate post-operative measures of outcome did not differ between the groups, with the exception of operation time. The dynamic hip screw allowed a significantly greater compression of the fracture during the four-month follow-up, but consolidation of the fracture was comparable between the two groups. Two major losses of reduction were observed in each group, resulting in a total of four revision operations. Our results suggest that the use of the proximal femoral nail may allow a faster postoperative restoration of walking ability, when compared with the dynamic hip screw

We present the results of 13 patients who suffered severe injuries to the lower leg. Five sustained a traumatic amputation and eight a Gustilo-Anderson type IIIC open fracture. All were treated with debridement, acute shortening and stabilisation of the fracture and vascular reconstruction. Further treatment involved restoration of tibial length by callus distraction through the distal or proximal metaphysis, which was commenced soon after the soft tissues had healed (n = 8) or delayed until union of the fracture (n = 5). All patients were male with a mean age of 28.4 years (17 to 44), and had sustained injury to the leg only. Chen grade II functional status was achieved in all patients. Although the number of patients treated with each strategy was limited, there was no obvious disadvantage in the early lengthening programme, which was completed more quickly

We carried out a retrospective review of 47 intra-articular fractures of the calcaneum treated by open reduction and internal fixation in 45 patients by a single surgeon between 1993 and 2001. The fractures were evaluated before operation by plain radiographs and a CT scan using Sanders’ classification. Osteosynthesis involved a lateral approach and the use of the AO calcaneal plate. The mean follow-up was for ten years (7 to 15). Clinical assessment included the American Orthopaedic Foot and Ankle Society Score (AOFAS), the Creighton-Nebraska Score, the Kerr, Prothero, Atkins Score and the SF-36 Health Questionnaire. The radiological evaluation consisted of lateral and axial views of the os calcis. Arthritic changes in the subtalar joint were assessed with an internal oblique view and were graded using the Morrey and Wiedeman scale. There were 18 excellent (38.3%), 17 good (36.2%), three fair (6.3%) and nine poor (19.2%) results. Five patients had a superficial wound infection and five others eventually had a subtalar arthrodesis because of continuing pain. Restoration of Böhler’s angle was associated with a better outcome. The degree of arthritic change in the subtalar joint did not correlate with the outcome scores or Sanders’ classification. Prompt osteosynthesis should be considered for intra-articular fractures of the calcaneum in order to restore the shape of the hindfoot and Böhler’s angle

A total of 179 adult patients with displaced intra-articular fractures of the distal radius was randomised to receive indirect percutaneous reduction and external fixation (n = 88) or open reduction and internal fixation (n = 91). Patients were followed up for two years. During the first year the upper limb musculoskeletal function assessment score, the SF-36 bodily pain sub-scale score, the overall Jebsen score, pinch strength and grip strength improved significantly in all patients. There was no statistically significant difference in the radiological restoration of anatomical features or the range of movement between the groups. During the period of two years, patients who underwent indirect reduction and percutaneous fixation had a more rapid return of function and a better functional outcome than those who underwent open reduction and internal fixation, provided that the intra-articular step and gap deformity were minimised

The most important issue in the assessment of fracture healing is to acquire information about the restoration of the mechanical integrity of bone. Echo tracking (ET) can noninvasively measure the displacement of a certain point on the bone surface under a load. Echo tracking has been used to assess the bone deformation angle of the fracture healing site. Although this method can be used to evaluate bending stiffness, previous studies have not validated the accuracy of bending stiffness. The purpose of the present study is to ensure the accuracy of bending stiffness as measured by ET. A four-point bending test of the gap-healing model in rabbit tibiae was performed to measure bending stiffness. Echo tracking probes were used to measure stiffness, and the results were compared with results of stiffness measurements performed using laser displacement gauges. The relationship between the stiffness measured by these two devices was completely linear, indicating that the ET method could precisely measure bone stiffness

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The primary aim of this study was to address the hypothesis that fracture morphology might be more important than posterior malleolar fragment size in rotational type posterior malleolar ankle fractures (PMAFs). The secondary aim was to identify clinically important predictors of outcome for each respective PMAF-type, to challenge the current dogma that surgical decision-making should be based on fragment size.

The most important issue in the assessment of fracture healing is to acquire information about the restoration of the mechanical integrity of bone. Many researchers have attempted to monitor stiffness either directly or indirectly for the purpose of assessing strength, as strength has been impossible to assess directly in clinical practice. The purpose of this study was thus to determine the relationship between bending stiffness and strength using mechanical testing at different times during the healing process. Unilateral, transverse, mid-tibial osteotomies with a 2-mm gap were performed in 28 rabbits. The osteotomy site was stabilized using a double-bar external fixator. The animals were divided into four groups (n=7/group/time point; 4, 6, 8 and 12 weeks). A series of images from micro-computed tomography of the gap was evaluated to detect the stage of fracture healing and a 4-point bending test was performed to measure stiffness and strength. Formation of cortex and medullary canal at the gap was seen in the 12-week group and would represent the remodeling stage. In addition, the relationship between stiffness and strength remained almost linear until at least 12 weeks. However, stiffness recovered much more rapidly than strength. Strength was not fully restored until the later stages of fracture healing. However, the current study demonstrated that stiffness could be monitored as a surrogate marker of strength until at least the remodeling stage